Graduate Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- 1526 Lombard Street, Philadelphia, Pennsylvania 19146
- CMS Provider Number
- 395485
- Inspections on file
- 45
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 29
Citation history
Health deficiencies cited at Graduate Post Acute during CMS and state inspections, most recent first.
A resident with cognitive impairment and a history of falls exited the facility unsupervised after staff failed to recognize her as a resident and did not follow LOA and visitor sign-out protocols. The resident left through the front entrance while the receptionist was distracted, and was later found over a mile away. This lapse in supervision and protocol adherence placed the resident at high risk for injury.
A resident with a history of falls and cognitive deficits, requiring staff assistance for ambulation and without a physician order for leave, was able to exit the facility unsupervised. The resident left through the front entrance after being mistaken for a visitor by the receptionist, who did not follow sign-out or visitor badge protocols. The resident was found two hours later, 1.2 miles away, after staff realized the resident was missing.
A resident with moderate cognitive impairment and a history of falls exited a facility unsupervised, walking 1.2 miles away. The receptionist, distracted by personal activities, mistook the resident for a visitor and allowed them to leave without following protocol. The resident was found two hours later, highlighting a failure in supervision and adherence to facility policies.
A resident with a history of falls and cognitive deficits left an LTC facility unsupervised due to inadequate management and protocol lapses. The resident exited behind visitors, with the receptionist failing to recognize them as a resident. The resident was found 1.2 miles away, highlighting non-compliance with leave of absence and visitation protocols, resulting in Immediate Jeopardy.
The facility did not ensure an effective pest control program, as evidenced by a rodent observed in a resident room and confirmation from an LPN who reported frequent rodent sightings. Two residents also reported seeing rodents and expressed concerns about ongoing infestation, with mouse traps proving ineffective.
A resident with multiple medical conditions did not receive several scheduled medications at the prescribed time, as a nurse administered them over two hours late. The nurse confirmed the delay, which resulted in noncompliance with physician orders.
A resident with a diagnosis requiring supplemental oxygen was observed receiving oxygen at 6 L/min via nasal cannula, despite a physician order specifying 2 L/min. This deviation from the prescribed oxygen flow rate was confirmed by an RN and did not align with facility policy requiring adherence to physician orders.
A resident with a recent hip fracture, requiring staff assistance for ADLs, was not provided or offered a scheduled shower as indicated in the care plan. Review of documentation and resident interview confirmed the omission, with no evidence of bathing assistance being given on the scheduled day.
A resident with a physician's order for Cannabidiol Oral Solution for pain and seizures was not informed prior to admission that the facility prohibited cannabis administration. As a result, the resident did not receive the prescribed medication, and the order was discontinued due to facility policy. Staff and the resident's representative confirmed that the no-cannabis policy was not communicated before or at admission, and the facility could not provide documentation of the policy.
A resident with cognitive impairments and a history of schizophrenia eloped from an LTC facility due to inadequate supervision and failure to properly check the functionality of a wander management device. The resident was missing for over 24 hours, highlighting deficiencies in the facility's elopement prevention policy and procedures.
A resident with a history of stroke and schizophrenia eloped from an LTC facility due to inadequate supervision and management by the Nursing Home Administrator and DON. Despite having an elopement care plan, the resident exited the facility and was missing for over 24 hours. A wander guard was applied but not properly tested, contributing to the incident.
A facility failed to document a prescribed wound care regimen for a resident who underwent foot surgery. Despite a physician's order for daily wound care, there was no record of the care being performed, as confirmed by the facility administrator. This lack of documentation indicates a failure to maintain accurate medical records.
The facility failed to employ a qualified Food Service Director (FSD) as required. The FSD, responsible for food service operations, lacked necessary certifications and did not receive frequent consultations from a qualified dietician. A corporate RD covered the facility part-time, but there was no evidence of regular guidance for the FSD.
The facility was found to be non-compliant as it lacks a qualified professional to direct the activities program. Interviews with the NHA and the Director of Guest Services confirmed the absence of an activities director. Resident council meeting minutes from June and July indicated discussions on activities, but no qualified oversight was mentioned.
The facility failed to ensure nursing staff had necessary competencies, as three employees lacked documented training in key areas such as resident rights, person-centered care, and infection control. This deficiency was confirmed with the facility's administration.
The facility's pest control program on the fifth floor was ineffective, as evidenced by multiple mice and pest sightings. Despite a policy requiring a pest-free environment, interviews with staff and residents, along with documentation, revealed ongoing issues. The pest control company's reports and a log book recorded numerous sightings, and residents reported frequent encounters with mice and other pests.
The facility did not provide a Notice Of Medicare Non-Coverage (NOMNC) to a resident transitioning from Medicare to Medicaid pending status. Despite multiple requests during a survey, the facility could not produce the NOMNC, confirmed by the facility's Social Services.
A nurse aide in an LTC facility misappropriated funds from two residents by using their EBT and debit cards to purchase food for herself. The residents, one with moderate cognitive impairment and the other with intact cognition but communication difficulties, admitted to giving their cards to the aide. Despite receiving training on the facility's abuse policy, the aide claimed ignorance of her actions being misappropriation. The facility's investigation confirmed the allegations, but the extent of the misappropriation remains unknown.
A facility failed to thoroughly investigate the misappropriation of funds involving two residents and a nurse aide. The aide used residents' EBT and debit cards to purchase items for herself and at the residents' request. Despite residents admitting consent, the investigation lacked comprehensive evidence, including staff statements and interviews with other residents. One resident had moderate cognitive impairment, highlighting the need for a thorough investigation.
A resident with HIV, paraplegia, and a stage 4 pressure ulcer experienced a decline in ROM and ADL, requiring more assistance. The facility failed to conduct a significant change MDS assessment despite these changes, as confirmed by the RN Assessment Coordinator.
A facility failed to develop a baseline care plan within 48 hours for a resident with COPD and a tracheostomy requiring oxygen therapy. The resident was observed on oxygen via a tracheostomy collar, but the care plan was not initiated until several days after admission, contrary to facility policy.
A facility failed to develop and implement a comprehensive care plan for a resident with an indwelling urinary catheter. Despite having a physician's order for catheter management, there was no documented care plan addressing the resident's urinary catheter. The resident, with diagnoses including hemiplegia and urinary retention, had a catheter in place, confirmed by observation and interview, yet lacked a documented care plan.
The facility failed to update care plans for three residents, leading to deficiencies in addressing their specific medical needs. One resident's care plan did not reflect the need for supervision of a visitor providing unauthorized medical care. Another resident experienced significant weight loss and abnormal bleeding without care plan updates. A third resident was signed onto hospice care, but their care plan was not updated to reflect this change, including the updated advance directive.
A resident with COPD and a tracheostomy was not receiving the prescribed oxygen level of 6 liters per minute, as the concentrator was set to 3 liters per minute. This discrepancy was observed on two occasions and confirmed by a nurse, who then adjusted the oxygen level to the correct setting.
A facility failed to follow infection control practices for a resident with multiple pressure injuries. The resident's room lacked EBP signage and a PPE disposal bin. A nurse performed wound care without a gown, despite drainage from the wounds. Staff interviews revealed a misunderstanding of the EBP policy, leading to non-compliance with CDC guidelines.
The facility failed to provide palatable food and drink at appropriate temperatures for residents. Resident council minutes and interviews revealed dissatisfaction with food quality and service. A test tray evaluation showed food temperatures did not meet standards, and the presentation was unappealing, confirmed by the Food Service Director.
The facility failed to maintain an effective pest control program, with multiple sightings of mice and other pests across all nursing units. Despite a policy for a pest-free environment, logs and resident notes reported frequent pest sightings, including mice and roaches. Staff interviews confirmed the inadequacy of pest control measures, with missed treatments contributing to the issue.
A resident, who was at high risk for falls and moderately cognitively impaired, experienced falls on two occasions. The facility failed to notify the resident's representative as required by their policy. Documentation errors led to the resident being incorrectly listed as their own responsible party, and staff interviews confirmed the oversight.
A facility failed to update a resident's care plan to include fall risk precautions despite the resident's high fall risk and history of falls. The resident, with moderate cognitive impairment and a history of falls, experienced two unwitnessed falls without new interventions being developed. The Interim DON confirmed the lack of fall risk precautions.
The facility did not provide the required transfer notices to the State Office of the LTC Ombudsman for three months. This was confirmed through a review of clinical records and staff interviews, revealing that the facility failed to send copies of transfer or discharge notices to the Ombudsman as required.
The facility failed to maintain a comfortable temperature in the dialysis center, affecting residents receiving dialysis treatment. The cooling system was in disrepair, leading to temperatures above the recommended range. Temporary cooling units were insufficient, and the issue persisted due to delays in obtaining necessary parts for repair. Residents and staff reported discomfort, and the facility was non-compliant with CMS temperature requirements.
The facility failed to report allegations of abuse and neglect for four residents to the state survey agency. Grievances included a resident left in feces, another not receiving care over a weekend, a third experiencing disrespectful behavior from a nurse aide, and a fourth not receiving toileting assistance. These grievances were not reported as required by the facility's policy.
The facility failed to conduct thorough investigations into allegations of abuse and neglect for four residents. Grievances included reports of inadequate care, confrontational behavior by staff, and lack of assistance with toileting. Despite the facility's policy requiring prompt reporting and investigation, no evidence of complete investigations was provided, as confirmed by discussions with the DON and Regional Nurse.
The facility failed to provide dialysis care consistent with professional standards for two residents. There were no physician orders or person-centered care plans for dialysis, and post-dialysis monitoring was not documented. Interviews confirmed the residents received dialysis, but necessary documentation and monitoring were absent.
The facility failed to maintain an effective pest control program, as evidenced by resident reports of frequent mice sightings and pest logs documenting numerous instances of mice and roaches across all nursing units. Pest management reports confirmed structural issues allowing mice access, with droppings accumulating under furniture and radiators.
A resident with diabetes, a fractured mandible, and malnutrition was not properly supervised, resulting in a 3 1/2 hour absence. The resident was last seen by an LPN at 2:00 p.m. and was not in his room when checked by a Nurse's Aide at 3:30 p.m. The facility's policy requires staff to conduct rounds every two hours, which was not followed.
The facility failed to serve food at safe and appetizing temperatures on the 5th floor Nursing Unit. A test tray observation revealed that food temperatures did not meet the required standards, and mashed potatoes were improperly prepared. Residents expressed dissatisfaction with the food's temperature and quality, and multiple grievances were filed. The Dietary Manager confirmed the deficiencies during the observation.
A resident with a complex medical history, including a recent hospitalization for pneumonia and sepsis, was admitted to the facility with a PICC line for IV antibiotic therapy. The facility failed to verify and obtain the necessary order for the antibiotics, resulting in the resident not receiving the required medication for several days. Despite requests from the resident and their family member, the facility did not administer the antibiotics, leading to the resident's readmission to the hospital.
The facility failed to complete a discharge summary for a resident, including necessary details such as the course of illness, treatment, and post-discharge care plan. The discharge document was incomplete, lacking critical information for a safe transition home, as confirmed by the social worker.
The facility failed to provide bathing assistance to a resident who required set up assistance for shower/bath and personal hygiene, as indicated by their MDS assessment and care plan. Documentation from October 5, 2023, through October 15, 2023, showed no evidence of a shower being provided, which was confirmed by the Infection Control Nurse.
The facility failed to promptly obtain lab studies as ordered by a physician for a resident with hematuria. Despite orders for a CBC and BMP on a specific date, the lab work was not completed until several days later, after the physician had to re-request it. This deficiency was confirmed by the Assistant Director of Nursing.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Protocol Lapses
Penalty
Summary
A deficiency occurred when a resident with a history of repeated falls, difficulty walking, pelvic fracture, and cognitive impairment was able to leave the facility without a physician's order for a leave of absence (LOA) and without staff supervision. The resident, who required one-person assistance for ambulation and had a moderately impaired cognitive status as indicated by a BIMS score of 10, exited the third floor via elevator and walked out the front entrance using a walker. The resident was not identified as having an LOA order in the clinical records, and there was no documentation of staff being notified or a sign-out process being followed. Facility policy required that residents at risk for wandering or elopement have care plans with specific interventions and that staff intervene if a resident attempts to leave. However, the receptionist on duty did not recognize the resident as a facility resident, mistaking her for a visitor due to her appearance. The receptionist was distracted by personal computer use and failed to follow the protocol of ensuring all residents and visitors sign out and wear visitor badges. Surveillance footage confirmed that the receptionist opened the door for the resident, who then left the premises unchallenged. Staff interviews revealed that the assigned nursing assistant was aware the resident wanted to walk but did not clarify the resident's intentions or monitor her whereabouts. The resident was later found approximately 1.2 miles away in a busy area after being missing for about two hours. The failure to provide adequate supervision and to follow established LOA and visitation protocols resulted in the resident leaving the facility unsupervised, placing her at high risk for injury.
Removal Plan
- Resident was assisted back to the Center and assessed by RN Supervisor for injuries.
- The Center completed a headcount of all residents and compared it to the midnight census to ensure all residents were accounted for.
- The Nursing Administration held huddles with staff to discuss residents who go on frequent LOAs and signs and symptoms that may indicate risk for leaving the Center without staff notification.
- Shift RN Supervisor provided immediate education to receptionist on duty.
- RN Supervisors were educated on the completion of headcount of all residents compared to midnight census and the immediate reporting of any discrepancy to the Director of Nursing/designee.
- Staff were educated on signs and symptoms that may indicate a risk of elopement.
- Reception/security staff were educated on the process of each visitor receiving a badge that must be returned prior to door being opened and visitor leaving the premise.
- Staff educated on elopement/missing person policy and procedure including code yellow announcement to notify staff in Center, search both on the premises and the surrounding areas, notification processes including local police department.
- Staff educated on elopement drills including how often and expected response.
- All the training above will be added to our general orientation schedule for all new future employees.
- Residents with a current unsupervised LOA order were re-educated on the LOA policy/agreement and understood the sign out process with both the nursing staff on the unit.
- Auditing census compared to headcount every 4 hours for 3 days then every shift for 14 days then daily. All variances will be reported to the QAPI Committee monthly.
- Random audit of five visitors to ensure compliance with the visitor pass system two times daily for 14 days then daily for two months. All variances will be reported to the QAPI Committee monthly.
- Daily audit of LOA log to ensure reception/security staff are checking for clearance to leave the Center. The audit will be completed daily for three weeks with all variances reported during the clinical meeting.
- The QAPI Committee will make recommendations to ensure continued compliance. Upon sustained compliance, the QAPI Committee will recommend the reduction or resolution of the audits and the reception/security staff.
Failure to Supervise Resident Results in Unsupervised Exit and Elopement
Penalty
Summary
The Nursing Home Administrator (NHA) and Director of Nursing (DON) failed to effectively manage the facility to ensure adequate supervision for a resident with a history of repeated falls, difficulty walking, pelvic fracture, and cognitive communication deficit. The resident's care plan required one-person staff assistance for ambulation, and there was no physician order for a leave of absence. Despite these requirements, the resident was able to exit the third floor via elevator, leave through the front entrance, and was not noticed missing until later in the shift. Facility documentation and staff interviews revealed that the nursing assistant assigned to the resident was told by the resident that they needed to walk, but the assistant assumed this meant walking on the unit. When the resident was later found missing, a Code Yellow was announced. Surveillance footage showed the resident, dressed appropriately and using a walker, leaving the building behind a group of visitors. The receptionist, who was distracted by personal activities on the computer, did not recognize the resident as a resident and allowed them to exit without following sign-out or visitor badge protocols. The resident was located approximately 1.2 miles away in a busy area after being missing for about two hours. The facility's investigation confirmed that the resident did not have a physician order for a leave of absence and should not have been allowed to leave unaccompanied. The failure to follow established protocols for supervision, leave of absence, and visitor management directly contributed to the resident's unsupervised exit and subsequent elopement.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to a resident who did not have a leave of absence (LOA) order, resulting in the resident exiting the third floor via elevator and walking out the front entrance of the facility. The resident was located two hours later, approximately 1.2 miles away from the facility in a busy urban area. This incident was identified as an Immediate Jeopardy past non-compliance, placing the resident at high risk for injury. The resident, who was admitted with a history of repeated falls, difficulty walking, fracture of the pelvic bone, and cognitive communication deficit, had a BIMS score indicating moderate cognitive impairment. The resident's care plan required one-person staff assistance for ambulation, and there was no documented evidence of a physician order for a leave of absence. Despite this, the resident managed to leave the facility without staff intervention, as the receptionist mistook the resident for a visitor and allowed them to exit. The facility's policies on wandering and elopements, as well as resident leaves of absence, were not followed. The receptionist, distracted by personal activities on the computer, failed to recognize the resident and did not adhere to the protocol of ensuring visitors and residents sign out and wear visitor badges. This oversight, combined with the lack of supervision and failure to identify the resident's risk of elopement, led to the resident's unsupervised departure from the facility.
Removal Plan
- Resident left the Center to take a walk. The resident had walked to her previous address and was visiting neighbors. The Center staff spoke with her friend, and she was assisted back to the Center. Upon return, RN Supervisor assessed, and no injuries were noted.
- The Center completed a headcount of all residents and compared it to the midnight census to ensure all residents were accounted for and resting comfortably.
- The Nursing Administration held huddles on all floors with staff on duty to discuss the current residents which go on frequent LOAs as well as the signs and symptoms that may indicate the risk for leaving the Center without staff notification. No variances were noted, and no current residents were identified as an elopement risk.
- Shift RN Supervisor provided immediate education to receptionist on duty.
- RN Supervisors were educated on the completion of headcount of all residents compared to midnight census and the immediate reporting of any discrepancy to the Director of Nursing/designee.
- Staff were educated on signs and symptoms that may indicate a risk of elopement. 100% completion.
- Reception/security staff were educated on the process of each visitor receiving a badge that must be returned prior to door being opened and visitor leaving the premise. 100% completion.
- Staff educated on elopement/missing person policy and procedure including code yellow announcement to notify staff in Center, search both on the premises and the surrounding areas, notification processes including local police department. 100% completed.
- Staff educated on elopement drills including how often and expected response. 100% completion.
- All the training above will be added to our general orientation schedule for all new future employees.
- Residents with a current unsupervised LOA order were re-educated on the LOA policy/agreement and understood the sign out process with both the nursing staff on the unit.
- Auditing census compared to headcount every 4 HRS (hours) for 3 days then every shift for 14 days then daily. All variances will be reported to the QAPI (Quality Assurance Improvement Program) Committee monthly.
- Random audit of five visitors to ensure compliance with the visitor pass system two times daily for 14 days then daily for two months. All variances will be reported to the QAPI Committee monthly.
- Daily audit of LOA log to ensure reception/security staff are checking for clearance to leave the Center. The audit will be completed daily for three weeks with all variances reported during the clinical meeting.
- The QAPI Committee will make recommendations to ensure continued compliance. Upon sustained compliance, the QAPI Committee will recommend the reduction or resolution of the audits.
Resident Elopement Due to Inadequate Supervision and Protocol Lapses
Penalty
Summary
The deficiency involved the failure of the Nursing Home Administrator and Director of Nursing to effectively manage the facility, resulting in a resident, identified as Resident R1, exiting the facility unsupervised. Resident R1, who had a history of repeated falls, difficulty walking, and cognitive communication deficit, was admitted to the facility with a care plan indicating the need for one-person staff assistance for ambulation. Despite this, Resident R1 was able to leave the facility without a physician order for leave of absence, which was not documented in the resident's records. On the day of the incident, a nursing assistant was informed by Resident R1 of the need to walk, but the assistant assumed it was within the unit. Later, the resident was found missing, prompting a Code Yellow for elopement. Surveillance footage showed Resident R1 leaving the facility behind a group of visitors, with the receptionist, Employee E9, failing to recognize the resident and allowing the exit without intervention. The receptionist was distracted by personal activities on the computer and did not follow the facility's protocol for visitor sign-out and badge return, contributing to the oversight. The resident was located 1.2 miles away in a busy urban area, having walked to a friend's apartment. The facility's investigation confirmed that the resident should not have been allowed to leave without supervision or a physician order. Interviews with facility staff, including the Regional Vice President of Operations, confirmed the non-compliance with leave of absence and visitation protocols, placing the resident at risk for serious injury. This situation was identified as an Immediate Jeopardy of past non-compliance.
Plan Of Correction
This Plan of correction constitutes this facility's written allegation of compliance for the deficiencies cited. This submission of this plan of correction is not an admission or agreement with the deficiencies or conclusions contained in the Department's inspection report. Resident has been re-educated on the LOA on the process and is not currently at risk of elopement from the center. A full house audit was completed to identify any other residents similarly affected. All variances were updated and discussed with the physician. Care plans were updated to address safety and supervision. RDO reviewed with NHS/DON respective job descriptions. The job descriptions state that they will maintain and develop written policies and procedures that govern the operations of the center to include Resident Leave of Absence, Wandering and Elopements Procedure - Missing Resident. RDO reviewed with LNHA and DON his/her respective job description which includes that the purpose of the position was to plan, organize, develop and direct the overall operation of the nursing services department in accordance with the current federal, state, and local standards, guidelines and regulations that govern our center and as may be directed by the NHA and MD to ensure the highest degree of quality care is maintained at all times. The NHA and DON delegate the administrative authority, responsibility and accountability necessary for carrying out assigned duties. RDO will complete weekly audits for 12 weeks to ensure administrative enforcement of visitor badge process is being adhered to.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its own policy, resulting in the presence of rodents on the 2nd floor unit. During an observation, a rodent was seen in a resident room, and this finding was confirmed by a licensed nurse. The nurse reported observing rodents one to two times during each working shift. Additionally, interviews with two residents revealed that they had seen rodents in their rooms and expressed concerns about a persistent rodent infestation, noting that mouse traps placed in the room were ineffective.
Failure to Administer Medications Timely According to Physician Orders
Penalty
Summary
A deficiency was identified when a registered nurse failed to administer scheduled medications to a resident at the prescribed time. According to the resident's physician orders and Medication Administration Record (MAR), several medications, including acetaminophen, allopurinol, amiodarone, apixaban, gabapentin, ferrous sulfate, and a multivitamin, were scheduled to be given at 9:00 a.m. However, observation revealed that these medications were not administered until 11:12 a.m. The nurse involved confirmed during an interview that the medications were not given at the scheduled time. The resident in question had multiple medical conditions, including atrial fibrillation, gout, neuropathy, and anemia, for which the medications were prescribed. The failure to administer medications as ordered constituted noncompliance with physician orders and facility policy.
Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
A deficiency was identified when a resident, who was diagnosed with dependence on supplemental oxygen, did not receive respiratory care in accordance with the physician's orders. The resident had a documented order for oxygen administration at 2 liters per minute via nasal cannula to be provided continuously for shortness of breath. However, during an observation, the resident was found to be receiving oxygen at 6 liters per minute via nasal cannula, which was not consistent with the physician's order. This discrepancy was confirmed by a registered nurse at the time of the observation. The facility's policy requires nurses to follow physician orders when administering oxygen, but this was not adhered to in this instance.
Failure to Provide Scheduled Bathing Assistance to Dependent Resident
Penalty
Summary
A deficiency was identified when a resident, who was alert, oriented, and required assistance with activities of daily living (ADLs) due to a recent hip fracture, did not receive the necessary support for personal hygiene. The resident's care plan specified the need for one-staff assistance with bathing, transferring, dressing, and toileting, and the facility maintained a shower schedule indicating the resident was to receive a shower on Saturdays. On the scheduled shower day, the resident reported not being offered or provided a shower. Review of the nursing kardex and the resident's clinical record showed no documentation that a shower or bathing was provided or offered as per the care plan. The lack of documentation and the resident's statement confirmed that the required assistance with bathing was not delivered as scheduled.
Failure to Inform Resident of No-Cannabis Policy Resulted in Missed Medication
Penalty
Summary
The facility failed to inform a resident and their representative of its policy prohibiting the administration of cannabis products prior to admission. The admission documentation did not include any information regarding the facility's stance on medical cannabis use. The resident, who had a physician's order for Cannabidiol Oral Solution to manage pain and seizures, was admitted without being notified that the facility would not permit the administration of this medication. As a result, the prescribed medication was not administered from the time of admission, and the order was later discontinued due to facility policy. Interviews with facility staff and the resident's representative confirmed that neither the resident nor their representative was made aware of the no-cannabis policy before or at the time of admission. The staff member responsible for reviewing medication lists at admission did not ensure that only medications permitted by facility policy were included. Additionally, when requested, the facility administrator was unable to provide a copy of the no-cannabis use policy during the survey.
Resident Elopement Due to Inadequate Supervision and Device Checks
Penalty
Summary
The facility failed to provide adequate supervision to a resident at risk for elopement, resulting in the resident exiting the third floor via elevator and leaving through the front entrance doors. The resident was not located for over 24 hours, which placed them at high risk for injury. The facility's policy on 'Wander Management and Elopement Prevention' was not effectively implemented, as routine checks for placement and functionality of the wander management system devices were not conducted as required. The resident, who was admitted with a history of stroke, schizophrenia with prior psychosis, and cognitive dysfunction, was determined not to have decisional capacity and was assigned a legal guardian. Despite these conditions, the admission evaluation incorrectly indicated that the resident was not at risk for elopement. A care plan identifying the resident as at risk for elopement was only developed after admission, highlighting a delay in recognizing and addressing the resident's needs. Interviews with staff revealed that the wander guard device was not properly tested for functionality, and there was no documented evidence of its placement or functionality checks. The facility lacked a 'tester box' to verify the device's operation, and there was no order for the wander guard in the resident's clinical record. These oversights contributed to the resident's ability to leave the facility undetected, leading to an Immediate Jeopardy situation.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The deficiency involved the failure of the Nursing Home Administrator and Director of Nursing to effectively manage the facility, resulting in inadequate supervision of a resident at risk for elopement. The resident, who had a history of stroke, schizophrenia with prior psychosis, and cognitive dysfunction, was admitted to the facility and identified as being at risk for elopement. Despite the development of an elopement care plan, the resident managed to exit the facility and was missing for over 24 hours. The resident was last seen by staff in the afternoon and was discovered missing later that evening. The facility's search efforts were unsuccessful, and the resident was eventually located at another center 2.2 miles away, in a busy urban area. The resident was returned to the facility and assessed for respiratory concerns, which required a visit to the emergency room. Upon return, the resident was placed under one-to-one supervision. Interviews with staff revealed that a wander guard was applied to the resident upon admission, but there was no documented order for it, nor evidence that it was tested for functionality. The facility lacked a tester box to verify the wander guard's operation, which was on order. This oversight contributed to the resident's ability to elope, highlighting a significant lapse in the facility's management and adherence to federal and state guidelines.
Plan Of Correction
This Plan of Correction constitutes this facility's written allegation of compliance for the deficiencies cited. This submission of this plan of correction is not an admission of or agreement with the deficiencies or conclusions contained in the Department's inspection report. Resident has been assessed and identified as elopement risk. Resident is being maintained on 1:1 supervision 24/7. A full house audit was completed to identify any other residents similarly affected. All variances were updated and discussed with the physician. Care plans were updated to address safety and supervision. RDO reviewed with the NHA his respective job description that includes "Equipment and Supply Function" section stated that the NHA are to ensure that the Center is maintained in a clean and safe manner for residents' comfort and convenience by assuring that necessary equipment and supplies are maintained to perform such duties/services. Ensure that adequate supplies and equipment are on hand to meet the day-to-day operations needs of the Center and residents. NHA reviewed with DON her respective job description which includes that the purpose of the position was to plan, organize, develop and direct the overall operation of the nursing service department in accordance with current federal, state and local standards, guidelines and regulations that govern our Center and as may be directed by the Administrator and the Medical Director, to ensure that the highest degree of quality care is maintained at all times. The Director of Nursing Services delegates the administrative authority, responsibility and accountability necessary for carrying out assigned duties.
Incomplete Documentation of Wound Care
Penalty
Summary
The facility failed to maintain complete and accurately documented clinical records for a resident who was admitted for skilled nursing care following a surgical procedure on the right plantar foot. The resident's clinical record included a physician's order dated December 25, 2024, which specified a wound care regimen to be performed daily during the night shift. However, upon review, there was no documentation in the resident's clinical record to confirm that the wound care was carried out as ordered by the primary care physician. An interview with the facility administrator on January 23, 2025, confirmed the absence of both electronic and written documentation verifying the completion of the prescribed wound care. This lack of documentation indicates a failure to adhere to the physician's orders and maintain accurate medical records, as required by regulatory standards. The deficiency was identified during a review of clinical records and interviews with residents and staff.
Plan Of Correction
The resident no longer resides in the facility. An audit was completed to identify residents with physician orders for wound treatments to ensure accurate documentation. Variances were addressed and recorded on the audit. The licensed nurses were educated on The Wound Treatment Policy with emphasis on adherence to physician's orders and documenting accordingly. DON/Designee will perform 10 random weekly audits for 4 weeks, then monthly for 3 months to ensure that physician's orders are being followed, and wound treatments are being adhered to and documented on. Trends will be reported to the QAPI committee for recommendations as warranted.
Failure to Employ Qualified Food Service Director
Penalty
Summary
The facility failed to employ a qualified director of food and nutrition services, as required by regulations. During an observation tour, the Food Service Director (FSD), who had been working at the facility for one and a half years, stated his responsibilities included oversight of ordering, receiving, storing, preparation, and service of food. However, upon interview, the FSD confirmed that he was not a certified dietary manager, certified food manager, nor did he have a national certification for food service management and safety, or an associate's or higher degree in food service management or hospitality from an accredited institution. Additionally, the FSD had not received frequently scheduled consultations from a qualified dietician. A review of the FSD's credentials confirmed that he did not meet the statutory qualifications for his role. Further interviews revealed that a corporate Registered Dietician (RD) covered the building two days per week, but the facility was unable to provide evidence that the FSD was receiving the necessary frequent consultations from a qualified dietician to ensure adequate guidance for the dietary department.
Lack of Qualified Activities Program Director
Penalty
Summary
The facility was found to be non-compliant with the requirement to have a qualified professional directing the activities program. During an interview with the nursing home administrator on November 19, 2024, it was revealed that the facility currently lacks an activities program director. This was further confirmed by the Director of Guest Services on November 20, 2024, who stated that the facility does not have a qualified activities director. Additionally, a review of resident council meeting minutes from June and July 2024 indicated discussions on activities such as outdoor engagements and birthday celebrations, but there was no mention of a qualified professional overseeing these activities.
Deficiency in Nursing Staff Competency Training
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies and skills to adequately care for residents, as evidenced by the review of personnel files and staff interviews. Specifically, three out of five personnel files reviewed showed deficiencies in skill competency training. Employee E9, a licensed nurse hired on October 1, 2024, lacked documented training in critical areas such as resident rights, person-centered care, communication, basic nursing skills, restorative services, skin and wound care, medication management, pain management, infection control, identification of changes in condition, and cultural competency. Similarly, Employee E18, a nurse aide hired on August 21, 2024, and Employee E16, a nurse aide hired on June 21, 2024, also did not have documented competency training in the same essential areas. These findings were confirmed with the facility's Nursing Home Administrator and Director of Nursing, indicating a systemic issue in ensuring that staff are adequately trained to meet the needs of residents, as required by the relevant Pennsylvania Code sections.
Deficiency in Pest Control Program on Fifth Floor
Penalty
Summary
The facility failed to maintain an effective pest control program on the fifth floor, as evidenced by multiple mice and pest sightings. The facility's policy, revised in January 2024, mandates a pest-free environment through a contract with a pest control vendor for periodic services. Despite this, interviews with staff and residents, along with a review of facility documentation, revealed ongoing pest issues. Employee E14, the Unit Manager of the fifth floor, confirmed multiple mice sightings and the existence of a log to document these occurrences, which the pest control company uses to treat affected areas. The pest control company's reports indicated thirteen sightings from mid-October to the end of October 2024, and fourteen sightings from early November to mid-November 2024. Additionally, the pest sighting log book recorded 32 sightings from May to November 2024. Interviews with several residents revealed frequent sightings of mice and other pests, with one resident reporting seeing a large roach in their room. These findings demonstrate a significant deficiency in the facility's pest control measures, impacting the living conditions on the fifth floor.
Failure to Provide NOMNC to Resident
Penalty
Summary
The facility failed to provide a Notice Of Medicare Non-Coverage (NOMNC) to one of the three residents reviewed, specifically Resident R20. The review of facility documentation titled 'Medicare A Patients Cut from Skilled Care with Benefits Days Remaining' indicated that Resident R20 was transitioning from Medicare to Medicaid pending status effective August 19, 2024. Despite multiple requests during the survey conducted from November 20, 2024, through November 22, 2024, the facility was unable to produce the NOMNC for Resident R20. This deficiency was confirmed through an interview with the facility's Social Services, Employee E11, and is a violation of 28 Pa Code 201.29(f) regarding resident rights.
Misappropriation of Resident Funds by Nurse Aide
Penalty
Summary
The facility failed to protect residents from misappropriation and exploitation of property, specifically involving the unauthorized use of residents' funds. Two residents, identified as R1 and R22, were involved in incidents where a nurse aide, Employee E16, used their EBT and debit cards to purchase food items for herself. The residents admitted to giving their cards to Employee E16, with Resident R1 having moderate cognitive impairment and Resident R22 having intact cognition but with communication difficulties due to a stroke. The facility's policy on abuse prohibition, last revised in October 2022, clearly defines exploitation and misappropriation of resident property. Despite this, Employee E16, who had received training on the facility's abuse policy, claimed to be unaware that her actions constituted misappropriation. The facility's investigation confirmed that the allegations were substantiated, as the residents had given consent for the purchases, but the aide's actions still fell under misappropriation. The Director of Nursing reported the incident to the State Agency, and the facility's investigation revealed that the extent of the misappropriation, including the duration and total amount spent, was unknown. The residents involved had varying levels of cognitive function, with Resident R1 having a BIMS score indicating moderate cognitive impairment, while Resident R22 had a BIMS score indicating intact cognition but with some communication challenges due to aphasia.
Inadequate Investigation of Misappropriation of Resident Funds
Penalty
Summary
The facility failed to conduct a thorough investigation into the alleged misappropriation of resident funds involving two residents. The facility's policy on abuse prohibition, which includes the prevention and investigation of misappropriation of resident property, was not adequately followed. The investigation did not include pertinent information such as staff statements, interviews with other residents cared for by the implicated employee, or the amount of funds used. This lack of thoroughness in the investigation process led to the deficiency. The incident involved a nurse aide, Employee E16, who was reported by two staff members for using residents' EBT and debit cards to purchase food items for herself and at the residents' request. The residents involved, identified as Resident R1 and Resident R22, admitted to giving their cards to Employee E16 and consenting to her purchasing items for herself. Despite this admission, the facility's investigation was incomplete, as it did not gather comprehensive evidence or assess the full extent of the misappropriation. Resident R1, who was cognitively assessed with a BIMS score of 12, indicating moderate cognitive impairment, was one of the residents involved. The facility's failure to conduct a complete investigation, including the lack of interviews with other residents and staff statements, resulted in a deficiency in addressing the misappropriation of resident funds. The facility's actions were insufficient to rule out the possibility of misappropriation, as required by their abuse prohibition policy.
Failure to Conduct Significant Change MDS Assessment
Penalty
Summary
The facility failed to conduct a significant change Minimum Data Set (MDS) assessment for a resident who experienced a deterioration in range of motion (ROM) and activities of daily living (ADL). The resident, identified as R67, was admitted with diagnoses including HIV, paraplegia, and a stage 4 pressure ulcer. Initially, the resident's MDS assessments indicated no impairment in both upper and lower extremities and required limited assistance for bed mobility and transfers. However, subsequent assessments showed a need for extensive assistance in these areas, indicating a significant decline in the resident's condition. Despite these changes, the facility did not complete a significant change assessment as required. The Resident Assessment Instrument (RAI) Manual specifies that a significant change in a resident's status, which impacts more than one area of health and requires interdisciplinary review, necessitates such an assessment. An interview with the Registered Nurse Assessment Coordinator confirmed that a significant change assessment should have been conducted when the changes were identified during the quarterly MDS assessment.
Failure to Develop Timely Baseline Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident requiring oxygen therapy. The resident, who was admitted with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and a tracheostomy, was observed receiving oxygen via a tracheostomy collar connected to an oxygen concentrator. The physician's orders specified that the oxygen concentrator should be set to 6 liters per minute, but the baseline care plan was not developed and initiated until more than 48 hours after the resident's admission. Observations conducted during a tour of the unit revealed that the resident was on oxygen therapy, yet there was no documented evidence of a baseline care plan being developed within the required timeframe. The facility's policy mandates the creation of a person-centered care plan within 48 hours of admission, but this was not adhered to, as evidenced by the care plan for COPD being initiated several days post-admission.
Failure to Develop Comprehensive Care Plan for Urinary Catheter
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with an indwelling urinary catheter. The facility's policy requires a comprehensive individualized care plan to be developed within seven days after the completion of a comprehensive assessment and to be reviewed and revised after each assessment. However, there was no documented evidence that a care plan addressing the resident's urinary catheter was developed and implemented, despite the resident having a physician's order for an indwelling urinary catheter and specific instructions for its management. The resident, who was admitted with diagnoses including hemiplegia, hemiparesis, chronic kidney disease, and urinary retention, had a physician's order dated March 13, 2024, for a 16 F indwelling urinary catheter with a 10cc balloon. The order also specified that the urinary catheter drainage bag should be emptied at least once every eight hours or when it becomes 1/2 to 2/3 full. An observation conducted on November 19, 2024, confirmed the presence of the urinary catheter, with the urine bag containing 350 cc of yellowish clear liquid. An interview with the resident at the time of observation confirmed the presence of the urinary catheter, yet no care plan was documented in the resident's clinical record.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update care plans for three residents, leading to deficiencies in addressing their specific medical needs. For one resident, the care plan did not reflect the need for supervision of a visitor who was providing unauthorized medical care, such as administering over-the-counter medications and performing oral hygiene, which posed risks of aspiration and tube occlusion. Despite repeated education and counseling, the visitor continued these interventions, and the care plan was not updated to address this issue. Another resident experienced significant weight loss and had a history of abnormal bleeding, yet their care plan lacked updates and interventions to address these conditions. The resident's medical records indicated a decrease in weight from 120 pounds to 101 pounds over several months, and there was no evidence that the care plan was revised to manage these health concerns. A third resident, who was admitted with heart failure, end-stage renal disease, and intestinal obstruction, was signed onto hospice care, but their care plan was not updated to reflect this significant change, including the updated advance directive. The resident's care plan did not include the transition to hospice care, and the resident eventually expired at the facility without these updates being made.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to administer oxygen as ordered by the physician for a resident diagnosed with Chronic Obstructive Pulmonary Disease (COPD) with a tracheostomy. The resident was admitted with a physician's order for an oxygen concentrator set to 6 liters per minute, to be administered during both day and night shifts. However, during observations conducted on two separate occasions, it was found that the resident's oxygen concentrator was set to only 3 liters per minute, contrary to the physician's order. The deficiency was confirmed during an interview with a licensed nurse, who acknowledged that the oxygen was running at a lower rate than prescribed. The nurse reviewed the physician's order and confirmed the discrepancy, subsequently adjusting the oxygen level to the correct setting of 6 liters per minute. This failure to adhere to the physician's order for oxygen administration was a violation of the facility's policy and the resident's care plan, which specified the need to administer oxygen as ordered.
Inadequate Infection Control Practices for Resident with Pressure Injuries
Penalty
Summary
The facility failed to maintain effective infection control practices related to barrier precautions and personal protective equipment (PPE) for a resident with multiple pressure injuries. The facility's policy on Enhanced Barrier Precautions (EBP) was not followed, as there was no signage indicating EBP outside the resident's room, and no bin was available for discarding used PPE. During an observation, a licensed nurse performed wound care on the resident without donning a gown, despite the presence of drainage from the wounds, which contradicts the facility's policy and CDC guidelines. The resident in question was admitted with several medical conditions, including cervical disc disorders and type 2 diabetes with diabetic neuropathy. The resident had multiple stage 4 pressure injuries with moderate serous drainage, requiring specific wound care orders. Interviews with staff, including the infection preventionist and the director of nursing, revealed a misunderstanding or misapplication of the facility's EBP policy, as they believed gowns were not necessary for wounds without drainage, despite evidence to the contrary.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to provide food and drink that was palatable and served at appropriate temperatures for five residents. Resident council minutes from June and August 2024 indicated complaints about the quality and temperature of food, as well as issues with beverage availability and service delays. An interview with a resident revealed dissatisfaction with the food, particularly for a diabetic resident receiving regular ginger ale and finding the pork chops too hard to chew. A test tray evaluation conducted with the Dietary Director showed that the food temperatures did not meet the required standards, with hot foods below 135 degrees Fahrenheit and cold beverages above 41 degrees Fahrenheit. Additionally, the presentation of the food was unappealing due to a lack of color variety, which was confirmed by the Food Service Director.
Ineffective Pest Control Program in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program across all four nursing units, as evidenced by multiple sightings of mice and other pests. The facility's pest control policy, revised in January 2024, mandates a pest-free environment, yet pest logs and resident council notes indicate frequent sightings of mice and roaches in various rooms and hallways on the 2nd, 3rd, 4th, and 5th floors. Specific incidents include mice sightings in rooms and hallways, with reports of mice running under furniture and into air conditioning units. Additionally, there were reports of bedbugs, with a resident bitten on the neck, and roaches seen running in certain areas. Interviews with facility staff, including the Assistant Maintenance Director and the Interim Director of Nursing, confirmed the presence of pests and acknowledged the inadequacy of the current pest control measures. The pest control company was scheduled to provide treatments twice a week, but records show that several treatments were missed or only partially completed during August and September 2024. This lapse in regular pest control treatments contributed to the ongoing pest issues, as documented in the pest logs and corroborated by staff interviews.
Failure to Notify Resident's Representative of Falls
Penalty
Summary
The facility failed to ensure that a resident's representative was informed of falls sustained by the resident. The facility's policy, titled 'Change in Condition: Notification,' requires immediate notification of the patient's representative in the event of a change in condition. However, for Resident R1, who was at high risk for falls and had a history of repeated falls, the facility did not notify the resident's representative after falls occurred on two separate occasions. Resident R1, who was moderately cognitively impaired with a BIMS score of 12, experienced falls on August 28, 2024, and September 4, 2024. Despite having two representatives listed in their profile, the facility's documentation incorrectly noted the resident as their own responsible party. Interviews with facility staff, including the Social Worker and Interim Director of Nursing, confirmed that the representatives should have been informed of the falls, but were not.
Failure to Update Care Plan for Fall Risk Precautions
Penalty
Summary
The facility failed to update and revise a resident's care plan to reflect specific care needs, particularly concerning fall risk precautions. The resident, who was moderately cognitively impaired with a BIMS score of 12, had a history of difficulty walking, repeated falls, dementia, restlessness, and agitation. Despite being identified as high risk for falls with a score of 16 on a risk assessment, the care plan did not include specific fall risk precautions. The resident experienced an unwitnessed fall on August 28, 2024, and another on September 3, 2024, yet no new interventions were developed to address the increased fall risk. The Interim Director of Nursing confirmed that fall risk precautions were neither developed nor implemented for the resident. A care conference was held on September 6, 2024, to discuss the recent falls, but the family requested the resident be transferred to the hospital. The facility's failure to develop and implement appropriate fall risk precautions for the resident was a deficiency noted in the report.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide the required transfer notices to the State Office of the Long-Term Care Ombudsman for three consecutive months: July, August, and September 2024. This deficiency was identified through a review of clinical records and staff interviews. On September 18, 2024, a request was made for evidence of all residents' transfer notices provided to the Ombudsman for the specified months. However, during an interview with the Interim Director of Nursing and the Regional Clinical Lead Nurse, it was confirmed that the facility did not send a copy of the transfer or discharge notices to the Ombudsman as required by regulations.
Failure to Maintain Comfortable Temperature in Dialysis Center
Penalty
Summary
The facility failed to maintain a comfortable air temperature in the dialysis center, affecting four residents receiving dialysis treatment. The Home Hemodialysis Coordination Agreement indicated that the facility was responsible for providing a safe and sanitary environment, including maintaining the HVAC system. However, the cooling system in the dialysis center, located in the basement, was in disrepair, leading to high temperatures. Observations and interviews revealed that the temperatures in the dialysis center were consistently above the recommended range of 72 to 75 degrees Fahrenheit, with recorded temperatures reaching as high as 97 degrees Fahrenheit. Temporary cooling units were used but were insufficient to maintain the appropriate temperature. The issue with the cooling system was first reported in June 2024, but temperature monitoring did not begin until July 17, 2024. The Director of Maintenance confirmed that the cooling system required parts that were unavailable and had to be manufactured, with an estimated repair date set for September 9, 2024. During this period, residents and staff reported discomfort due to the high temperatures, and the dialysis nurse noted that maintaining the room at the appropriate temperature range was crucial for the effectiveness of dialysis solutions. The facility's failure to address the cooling system issue promptly resulted in non-compliance with the CMS requirement for maintaining a comfortable temperature for dialysis patients.
Failure to Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to report allegations of abuse and neglect to the state survey agency for four residents. The facility's policy requires immediate reporting of suspected abuse, mistreatment, or neglect to the appropriate authorities within specified timeframes, depending on the severity of the incident. However, grievances submitted on behalf of Residents R1, R2, R3, and R4 were not reported as required. Resident R1's grievance, dated August 14, 2024, stated that he was left sitting in feces all day without assistance from the nurse aides. Resident R2's grievance, submitted by her daughter on July 22, 2024, alleged that the resident did not receive care over a weekend, was left in the same clothes, and experienced confrontational behavior from nurse aides. Resident R3's grievance, dated July 28, 2024, described an incident where a nurse aide was allegedly disrespectful and did not properly assist the resident. Resident R4's grievance, dated August 14, 2024, claimed that aides were not assisting with toileting, forcing the resident to manage independently. The facility's failure to report these grievances to the state survey agency was confirmed during a discussion with the Director of Nursing and the Regional Nurse. The facility's reporting system showed no evidence of notification or investigation results being reported to the state survey agency, as required by the facility's policy and state regulations.
Failure to Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to conduct a complete and thorough investigation regarding allegations of abuse and neglect for four residents. The facility's policy requires that upon receiving information about suspected abuse, the Administrator or designee must report the allegations to the appropriate authorities within specified timeframes and initiate an investigation within 24 hours. However, the facility did not provide evidence of thorough investigations for the grievances submitted on behalf of Residents R1, R2, R3, and R4. Resident R1's grievance reported that he had been left sitting in feces all day without assistance, and the morning nurse aides told him he had to wait for the next shift. Although the Director of Nursing (DON) ensured that staff provided care, no further investigation details were documented. Resident R2's grievance, submitted by her daughter, alleged that the resident did not receive care over two days, had unchanged clothes, and experienced confrontational behavior from nurse aides. An undated statement from a nurse aide was obtained, but no additional investigation information was provided. Resident R3's grievance included allegations of inappropriate behavior by a nurse aide and missing medication, with no further investigation details documented. Resident R4's grievance alleged that aides were not assisting with toileting, forcing the resident to manage independently. The facility did not provide evidence of a complete investigation to rule out abuse or neglect for any of these residents. Discussions with the DON and Regional Nurse confirmed the lack of thorough investigations.
Failure to Ensure Proper Dialysis Care and Documentation
Penalty
Summary
The facility failed to provide dialysis care and services consistent with professional standards for two residents requiring dialysis treatment. The facility's policy required communication with the dialysis center and monitoring of the resident's condition before and after dialysis treatments. However, for both residents, there was no evidence of physician orders for dialysis treatment, nor was there a person-centered care plan developed to address their dialysis needs. Additionally, the clinical records lacked documentation of post-dialysis monitoring for complications such as blood pressure, temperature, and weight, as well as assessment and observation of the dialysis access site. Interviews with the dialysis center's Regional Operations Manager and the facility's Director of Nursing confirmed that the residents had been receiving dialysis treatments at the facility. Despite this, the necessary documentation and monitoring were not present in the clinical records. This deficiency was identified during a review of the residents' clinical records and interviews with facility staff, highlighting a failure to adhere to the facility's own policy and professional standards of dialysis care.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program across all four nursing units, as evidenced by multiple resident interviews and pest log reviews. Residents reported frequent sightings of mice, with one resident expressing concern about mice getting into their bed. The pest logs from the second to fifth floors documented numerous instances of mice and roaches, with sightings in resident rooms, common areas, and even in a social worker's office. These logs were confirmed by the maintenance director, indicating a widespread issue. The pest management company reports further corroborated the deficiency, detailing the removal of mice from various locations within the facility and noting structural issues such as broken radiators that allowed mice access. The reports highlighted ongoing problems with mice droppings accumulating under furniture and radiators, and mice chewing through drywall. The Nursing Home Administrator confirmed the accuracy of these reports, underscoring the facility's failure to effectively address the pest problem.
Failure to Supervise Resident Leading to Extended Absence
Penalty
Summary
The facility failed to ensure proper supervision for a resident, identified as Resident R1, who was alert, oriented, and capable of making life decisions. Resident R1 was admitted with diagnoses including diabetes, a fractured mandible, and malnutrition. On May 28, 2024, a Nurse's Aide (NA) working the 3-11 pm shift noticed at 3:30 p.m. that Resident R1 was not in his room, and his lunch tray was untouched. By dinner time, around 5:30 p.m., the NA inquired about the resident's whereabouts with a Licensed Practical Nurse (LPN), who last saw the resident at approximately 2:00 p.m. propelling himself in his wheelchair towards the elevator. The facility's investigation revealed that 3 1/2 hours had passed since Resident R1 was last seen. The Director of Nursing confirmed that nursing staff are required to conduct rounds every two hours to ensure resident safety and report any issues promptly to the unit manager or nursing directors. This lapse in supervision and failure to adhere to the facility's policy on resident safety rounds contributed to the deficiency identified in the report.
Food Temperature and Quality Deficiency
Penalty
Summary
The facility failed to ensure that food was served at a safe and appetizing temperature during a lunch meal on the 5th floor Nursing Unit. The facility's food temperature protocol requires cold food to be at or below 41 degrees Fahrenheit and hot food to be at or above 135 degrees Fahrenheit. However, during a test tray observation, the temperatures of the three beans salad, mashed potatoes, and chicken were recorded at 53.2, 114.2, and 129.0 degrees Fahrenheit, respectively, all of which did not meet the required standards. Additionally, the mashed potatoes were found to contain large solid pieces, indicating improper preparation. Interviews with residents revealed dissatisfaction with the temperature and quality of the food. One resident reported that the food was not always served hot and was often delayed, and another resident expressed dissatisfaction with both the temperature and quality of the food. Multiple grievances were filed by residents, expressing concerns about the food's temperature, quality, and appearance. The Dietary Manager, Employee E3, confirmed during the test tray observation that the food temperatures did not meet the standards and acknowledged the improper preparation of the mashed potatoes.
Failure to Administer IV Antibiotic Therapy
Penalty
Summary
The facility failed to ensure that intravenous antibiotic therapy was ordered and administered for a resident admitted for antibiotic therapy. The resident, who had a complex medical history including diabetes, liver cirrhosis, a liver transplant, COPD, and recent hospitalization for pneumonia resulting in sepsis, was admitted to the facility with a PICC line for IV antibiotic therapy. However, the hospital discharge instructions did not include the antibiotic therapy in the medication list, and the facility did not verify or obtain the necessary order for the antibiotics. As a result, the resident did not receive the required IV antibiotics upon admission and for the following two days, despite requests from the resident and their family member. The resident was eventually readmitted to the hospital due to the lack of antibiotic administration at the facility. Interviews with the resident, their family member, and facility staff confirmed that the antibiotic therapy was not administered as required. The facility's licensed nurse and the Director of Nursing acknowledged the medication error, and the Nursing Home Administrator believed it was due to a miscommunication with the hospital. There was no documented evidence that the facility contacted the hospital to review the resident's medication list to ensure the IV antibiotic therapy was included. This failure to administer the necessary medication led to a significant lapse in the resident's care.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to complete a discharge summary for a resident, which included a recapitulation of the resident's stay, the course of illness, corresponding treatment, discharge instructions, and a post-discharge care plan. The resident, who had been admitted with diagnoses including joint replacement surgery and post-traumatic stress disorder, was discharged home. However, the discharge documentation titled 'My Transition Home' was incomplete, with only the activities and appointment sections initiated, leaving out critical information necessary for a safe transition home. During the survey, it was confirmed by the social worker that the 'My Transition Home' document for the resident was not fully completed. This lack of a comprehensive discharge summary meant that there was no accurate and current description of the resident's clinical status or sufficiently detailed, individualized care instructions provided to ensure the resident's safe transition from the facility to home. The facility's policy required a complete Discharge Transition Plan to be given to the patient, family member, or legal representative and placed in the patient's medical record, which was not adhered to in this case.
Failure to Provide Bathing Assistance
Penalty
Summary
The facility failed to provide care and services regarding bathing for one of three residents. Resident R1's MDS assessment dated October 5, 2023, indicated that the resident required set up assistance for shower/bath and personal hygiene. The care plan initiated on the same date indicated that the resident had altered musculoskeletal status and was at fall risk, requiring transfer and ambulation assistance as needed. However, a review of the shower and bed bath documentation from October 5, 2023, through October 15, 2023, showed no evidence that a shower was provided to Resident R1. During an interview on December 19, 2023, the Infection Control Nurse confirmed that the facility offered showers to all residents twice a week but acknowledged the lack of documented evidence for Resident R1.
Failure to Promptly Obtain Laboratory Studies
Penalty
Summary
The facility failed to ensure that laboratory studies were promptly obtained as ordered by the physician for Resident R2. On December 8, 2023, the physician ordered lab work for a CBC and BMP to be conducted in the morning due to the resident's hematuria. However, by December 11, 2023, the lab work had not been sent over the weekend, and the results were still pending. The clinical record showed no evidence that the lab work was completed until December 12, 2023, after the physician re-requested it. This deficiency was confirmed by the Assistant Director of Nursing on December 19, 2023.
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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