Hickory House Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Honey Brook, Pennsylvania.
- Location
- 3120 Horseshoe Pike, Honey Brook, Pennsylvania 19344
- CMS Provider Number
- 395436
- Inspections on file
- 19
- Latest survey
- June 18, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Hickory House Nursing Home during CMS and state inspections, most recent first.
A resident filed a grievance alleging that a CNA was verbally disrespectful, threw a shirt at the resident, refused to assist with socks, and left the room without returning. The DON confirmed that this abuse allegation was not reported to the State agency as required by facility policy and state regulations.
A resident reported that a CNA spoke disrespectfully, threw a shirt at the resident, refused to help with socks, and left the room without returning. The DON confirmed that this abuse allegation was not fully investigated, as required by facility policy.
Surveyors found that three residents did not receive care according to physician orders, including administration of Midodrine and Metoprolol outside of specified blood pressure parameters and failure to adhere to a prescribed fluid restriction for a resident with CHF. These deficiencies were confirmed through record review and staff interviews.
A resident with a physician's order for oxygen therapy via nasal cannula did not have their equipment changed as directed, with observations showing the cannula was not replaced weekly and was visibly soiled, contrary to facility policy and medical orders.
The facility failed to thoroughly investigate incidents involving three residents. A resident with dementia was found with a bleeding wrist, but the incident report lacked key details. Another resident with severe cognitive impairment reported feeling unsafe and alleged abuse, but no staff statements were taken. A third resident had a pen found in their rectum, but the investigation did not include interviews or contact with the hospital. The facility's investigations were confirmed to be incomplete.
The facility failed to follow physician's orders and notify the physician of missed medications for three residents. One resident missed doses of Vancomycin due to unavailability, another received Coreg despite a low heart rate, and a third was given Midodrine outside of ordered parameters. The DON confirmed these deficiencies.
A resident with severe cognitive impairment and a history of dementia and CVA experienced two falls in one day due to inadequate supervision and assistance. The resident, requiring two-person assistance for transfers, fell while attempting to enter a family van without proper assessment and later during a one-person transfer from a wheelchair to a bed, contrary to their care plan.
A resident with COPD and other respiratory conditions was receiving supplemental oxygen without a physician's order, contrary to the facility's policy. The resident had been on continuous oxygen since admission, but the order was only documented after several days, following confirmation by the DON.
A resident was given antibiotics for a probable UTI without a proper nursing assessment or lab confirmation. The decision was made after a phone call with a doctor, and the resident received antibiotics for five days without microbiological evidence. The DON and Nursing Home Administrator confirmed the lack of assessment and lab study.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving one resident. According to facility policy, any alleged violations involving neglect, abuse, or misappropriation of resident property must be reported immediately to the administrator and as required by state law. A grievance was filed by a resident stating that a CNA spoke to him disrespectfully, threw a shirt at him, told him to put it on, refused to help him put on socks, and then left the room without returning. The Director of Nursing confirmed that this abuse allegation was not reported to the State agency as required by policy and regulation.
Failure to Investigate Alleged Abuse
Penalty
Summary
The facility failed to investigate an allegation of abuse involving one resident. According to facility policy, any reported or suspected incident of abuse, neglect, or exploitation requires an investigation by the administrator or designee, with protective measures implemented as needed. Documentation review showed that a resident filed a grievance stating that a CNA spoke to him disrespectfully, threw a shirt at him, told him to put it on, refused to assist with putting on socks, and then left the room without returning. An interview with the Director of Nursing confirmed that this abuse allegation was not fully investigated, contrary to facility policy and regulatory requirements.
Failure to Follow Physician Orders for Medication and Fluid Restriction
Penalty
Summary
The facility failed to follow physician orders for three residents, resulting in deficiencies related to medication administration and fluid restriction. For one resident with hypotension, Midodrine was administered multiple times despite blood pressure readings exceeding the physician-ordered threshold for withholding the medication. Documentation showed that the medication was given on several occasions when the systolic blood pressure was above 125 mm/Hg, contrary to the order. Another resident with acute congestive heart failure and malnutrition had a physician order for a strict fluid restriction, but records indicated that the resident consistently received fluids in excess of the prescribed daily limit over several days. Additionally, a third resident with hypertensive chronic kidney disease received Metoprolol Succinate ER outside of the specified blood pressure and heart rate parameters on four occasions. These findings were confirmed through review of clinical records, medication administration records, and staff interviews.
Failure to Follow Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to follow a physician's order for oxygen therapy for one resident. According to the clinical record, the resident had a current order to receive oxygen via nasal cannula, with instructions for the cannula to be changed every night shift on Wednesdays. Facility policy also required oxygen supplies, including cannulas, to be changed weekly and when visibly soiled, and to be labeled with the resident's name and the date of setup or change. Observations on two consecutive days revealed that the resident's nasal cannula was dated from several weeks prior and was visibly soiled, with red-tinged nasal prongs and brownish-red dots on the wrapping. The resident confirmed regular use of the oxygen equipment while in the facility.
Failure to Investigate Incidents Thoroughly
Penalty
Summary
The facility failed to thoroughly investigate incidents involving three residents, as required by their policy on reducing the threat of abuse and neglect. For Resident 2, who has a history of dementia, anxiety disorder, and major depressive disorder, an incident occurred where the resident was found with a bleeding cut on the wrist. The incident report lacked documentation identifying the nurse who treated the wound and did not include any witness statements. The Nursing Home Administrator confirmed that the investigation was incomplete. Resident 95, who has severe cognitive impairment, reported feeling unsafe and alleged physical abuse by two men, described as EMT staff. The facility's documentation did not include statements from staff who had contact with the resident, and the Director of Nursing confirmed the lack of a comprehensive investigation into the allegation of physical abuse. For Resident 155, admitted after a hip fracture repair, an incident was reported where a pen was found in the resident's rectum. The facility's investigation did not include interviews with staff or residents, nor did it contact the hospital or transport company involved in the resident's admission. The Nursing Home Administrator and Director of Nursing confirmed the investigation was not thorough.
Failure to Follow Physician's Orders and Notify of Missed Medications
Penalty
Summary
The facility failed to follow physician's orders and notify the physician of missed medications for three residents. Resident 9 had a physician's order for Vancomycin to treat C-diff, but the medication was not administered until the morning of the last day of the order, missing three doses due to unavailability. The physician was not notified of the missed doses until several days later. Resident 51 received Coreg, a beta blocker, despite having a heart rate below the ordered parameter on multiple occasions over several months. The clinical records indicated that the medication was administered with a heart rate of less than 60, contrary to the physician's order. Resident 95 was administered Midodrine, a medication for low blood pressure, outside of the ordered parameters, as it was given 13 times with a systolic blood pressure above 130. The Director of Nursing confirmed that the medication was administered outside of the ordered parameters. These deficiencies indicate a failure to adhere to physician's orders and to communicate effectively with physicians regarding medication administration issues.
Failure to Provide Adequate Supervision and Assistance Leads to Resident Falls
Penalty
Summary
The facility failed to provide appropriate assessment and supervision to prevent falls for a resident with severe cognitive impairment and a history of dementia and cerebral vascular accident. The resident required extensive assistance with two persons for transfers using a hemi walker, as documented in their care plan. On January 1, 2024, the resident was found on the floor outside the facility after attempting to transfer into a family van without the necessary assistance. The rehabilitation department was not notified to assess the resident's safety with car transfers, which contributed to the incident. Later that same day, the resident experienced another fall when an aide attempted a one-person pivot transfer from a wheelchair to a bed, despite the care plan indicating the need for a two-person assist. The aide lowered the resident to the floor after the resident slipped during the transfer. Interviews with the Director of Nursing confirmed that the resident was not provided with the required two-person assistance, leading to two falls in one day.
Lack of Physician Order for Oxygen Use
Penalty
Summary
The facility failed to ensure a physician order for oxygen use was in place for a resident, identified as Resident 205, who was receiving supplemental oxygen. The facility's policy on oxygen administration, revised in February 2024, requires a written order specifying the liter flow needed by the resident. Resident 205, diagnosed with Chronic Obstructive Pulmonary Disease (COPD), bronchiectasis with an acute lower respiratory infection, and pleural effusion, was observed receiving supplemental oxygen at two liters per minute (LPM) via nasal cannula. Despite the resident's need for continuous supplemental oxygen since admission, there was no active physician's order documented in the clinical records. Interviews with Resident 205 revealed that they had been using supplemental oxygen as needed at home and required continuous oxygen since being admitted to the facility. The Director of Nursing confirmed the absence of a physician's order for the resident's supplemental oxygen from the time of admission. It was only on May 31, 2024, that a physician's order was documented, specifying oxygen administration at two to four LPM, with instructions to titrate to maintain saturation above 90% and notify the physician if needs could not be met at four liters.
Unnecessary Antibiotic Administration Due to Lack of Assessment
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. Specifically, Resident 79 was administered an antibiotic without a proper nursing assessment or laboratory confirmation of a urinary tract infection (UTI). The resident had reported symptoms of dysuria and was noted to have blood on his penis and in his brief. Despite these symptoms, there was no documented nursing assessment to confirm the signs and symptoms reported by the CNA, nor was there any laboratory testing conducted to confirm a UTI before the administration of antibiotics. The decision to prescribe antibiotics was made after a phone call with the doctor's office, where it was noted that it was a Friday afternoon and the resident was symptomatic. The resident was subsequently given Amoxicillin-Pot Clavulanate for five days based on a diagnosis of probable UTI, without any microbiological evidence to support this diagnosis. The Director of Nursing and the Nursing Home Administrator confirmed the lack of a nursing assessment and laboratory study to confirm the infection and its sensitivity prior to the administration of the antibiotics.
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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