Ivy Park Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Pittsburgh, Pennsylvania.
- Location
- 5609 Fifth Avenue, Pittsburgh, Pennsylvania 15232
- CMS Provider Number
- 395251
- Inspections on file
- 34
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 37 (1 serious)
Citation history
Health deficiencies cited at Ivy Park Post Acute during CMS and state inspections, most recent first.
The facility failed to follow its resident fund management policy requiring closure of discharged residents’ trust accounts and release of funds within 30 days. Two residents, one transferred for psychiatric evaluation and another who died with physician authorization to release the body, both had ongoing open trust accounts with balances documented on a later fund trial balance. Review of their clinical records showed no evidence that their monies were provided within 30 days of discharge, and the Business Office Manager confirmed that the accounts were not closed or funds conveyed as required.
A resident with chronic kidney disease, adult failure to thrive, and HTN had an active physician order for full code and no advance directives limiting resuscitation, yet the care plan did not address full code status. One morning, an LPN found the resident unresponsive, with eyes open and skin pale and cool, and notified an RN supervisor and the MD but did not start CPR, believing there were signs of irreversible death. Later, an RN assessed the resident as pulseless, apneic, pale, cool, and mottled, judged these as signs of irreversible death, and also did not initiate CPR. Review of the clinical record confirmed that no CPR was provided despite the full code order, while interviews with other LPNs and RNs showed they understood that CPR should be started for full code residents found pulseless, leading surveyors to cite a failure to provide consistent CPR in accordance with orders and guidelines.
Facility leadership, including the NHA and DON, failed to ensure that staff consistently initiated CPR for an unresponsive resident, despite job descriptions requiring them to direct day-to-day operations and oversee resident care in accordance with federal and state regulations. Review of job descriptions, clinical records, and staff interviews showed that CPR was not initiated when the resident became unresponsive, and surveyors determined that the NHA and DON did not fulfill their essential duties to ensure compliance with applicable guidelines, resulting in an Immediate Jeopardy situation for one of the facility’s residents.
Surveyors found that 3rd floor shower rooms had visible buildup of red grime and black debris where the walls met the floors, and the DON confirmed these areas were not clean or sanitary, contrary to facility policy. On the 4th floor, an air temperature log completed by the DOM showed multiple resident rooms and the dining room with temperatures between 83°F and 88°F, above the facility’s stated comfort range of 71°F to 81°F. The NHA acknowledged that the environment on the 3rd floor was not clean and that air temperatures on the 4th floor were not maintained at comfortable levels.
A resident with complex neurological diagnoses refused ordered bloodwork, and staff did not notify the physician of this change in condition. The DON confirmed that the required notification was not made.
Surveyors observed that food items such as bread, bagels, deli ham, salads, and sandwiches were stored in the kitchen coolers without proper labels or dates, contrary to facility policy. The Dietary Manager confirmed that these practices failed to maintain sanitary conditions and created the potential for cross contamination.
The facility did not ensure that necessary resident information was communicated to receiving health care providers during transfers for two residents, and failed to provide written notification of the bed-hold policy to a resident or their representative during a hospital transfer. Additionally, a physician discharge order was not obtained for a resident discharged home. These deficiencies were confirmed through record review and staff interviews.
Surveyors found that the facility did not include specific, individualized interventions in the care plans for three residents, including missing care plan details for a wound vac, a trapeze bar used for mobility, and a wander guard device for elopement risk. Staff and the DON confirmed these omissions after review of clinical records, observations, and interviews.
The facility did not consistently follow physician orders for blood glucose monitoring and insulin administration, failed to document physician notifications and interventions for abnormal blood glucose levels, and did not provide required lab monitoring for a resident on Lithium. Additionally, the process for scheduling and communicating physician appointments was inconsistent, leading to missed and delayed follow-ups.
The facility did not consistently identify or reassess residents with cognitive impairment and exit-seeking behaviors for elopement risk, nor did it ensure care plans and physician orders addressed these risks. For example, a resident with dementia and moderate cognitive impairment was not reassessed despite ongoing exit-seeking behavior, another resident with a high elopement risk score had no further assessments, and a third resident was observed without a required wanderguard device. Staff and leadership confirmed these lapses in assessment and intervention.
The facility did not consistently maintain required dialysis communication forms for two residents with renal conditions, resulting in missing or incomplete documentation over several months. Additionally, current contracts with dialysis vendors were not in place for two residents, as confirmed by the administrator and DON. These deficiencies were identified through record review and staff interviews.
The facility did not complete required annual performance evaluations for three nurse aides, with some evaluations missing for multiple years and one aide lacking any evaluation since hire. This was confirmed by personnel file review and staff interview.
Two outside dumpsters were found with lids left open and liquid collecting in the disposal area, in violation of facility policy requiring proper containment and disposal of garbage to minimize infection risks and deter pests.
Three nurse aides did not receive the required 12 hours of annual in-service education, as confirmed by a review of training records and facility policy. The facility could not provide documentation to show that these staff members completed the mandated training, and this was acknowledged by Human Resources.
Seven residents were found to have beds with stained, dirty, or damaged linens, including fitted sheets with holes, thin and see-through sheets, and dirty blankets. These issues were confirmed by an LPN and the Nursing Home Administrator, indicating a failure to provide a clean and comfortable environment as required by facility policy.
A resident with multiple medical conditions, including a pressure ulcer, did not receive care in a manner that maintained dignity when an RN wrote on a dressing after it was applied to the resident's heel, contrary to facility policy.
A resident with heart failure, high blood pressure, and coronary artery disease, who was dependent on staff for personal hygiene, was repeatedly observed with significant facial hair and debris under fingernails. Staff and nursing leadership confirmed that required ADL assistance was not provided, contrary to facility policy.
The facility did not provide an ongoing program of activities to meet the interests and support the physical, mental, and psychosocial well-being of residents on one floor. Observations showed that an activity aide failed to interact with or engage residents during scheduled activities, and this was confirmed by staff interviews.
The facility did not accurately assess or document pressure ulcers for two residents, including one with a right foot amputation site and another with a coccyx ulcer, as required by policy and physician orders. Clinical records lacked necessary wound measurements over an extended period, and this deficiency was confirmed by nursing leadership.
A resident with PTSD did not have specific trauma triggers identified or addressed in their care plan, despite facility policy requiring individualized trauma-informed care. The Social Services Director confirmed that the facility failed to identify and mitigate triggers that could cause re-traumatization.
Surveyors found that two medication carts contained opened medications that were either undated or past their use-by date, including ipratropium nebulizer medication, an Ellipta inhaler, and Ketotifen Fumarate eye drops. LPNs and the DON confirmed that these medications were not stored or labeled according to policy.
A resident with dysphagia and physician orders for nectar thick liquids and no straw was given a thin liquid with a straw, contrary to their care plan and dietary orders. Staff confirmed the error occurred because the nursing assistant did not check the resident's prescribed diet before providing the drink, and facility leadership acknowledged the failure to meet the resident's dietary needs.
Two residents with severe cognitive impairment, as evidenced by low BIMS scores and dementia diagnoses, were allowed to sign binding arbitration agreements without confirmation of their capacity to understand the terms. The facility administrator confirmed this failure to ensure resident understanding.
A RN failed to follow infection control protocols during a wound dressing change for a resident with multiple diagnoses requiring pressure ulcer care. The RN did not clean the supply surface, failed to use a barrier under the resident's foot, used unclean scissors, and placed soiled dressings on the floor, resulting in a failure to prevent cross contamination.
The facility did not assign a qualified individual to oversee infection prevention and control activities while the Infection Preventionist was on leave, as confirmed by the DON and absence of meeting documentation.
Two residents with diabetes, high blood pressure, and dementia did not receive routine podiatry care as required by facility policy. Observations by nursing staff revealed both had thick, elongated, and curved toenails, and the DON confirmed that podiatry services had not been provided since admission.
The facility failed to provide timely access to personal funds for three residents, leading to grievances and frustration. One resident waited 13 days for Social Security funds, another did not receive a personal allowance despite having a sufficient balance, and a third experienced delays due to a transition in account management. The Nursing Home Administrator acknowledged the issue.
A resident with quadriplegia and Multiple Sclerosis, requiring two-person assistance for bed mobility, fell from bed when a nurse aide provided care alone and left the resident unattended. The resident experienced spasms and fell, but no injuries were noted. The facility failed to follow the care plan, resulting in neglect.
A resident with quadriplegia and Multiple Sclerosis, requiring two-person assistance for bed mobility, fell from bed when left unattended by a nurse aide who was providing incontinence care alone. The resident experienced spasms and fell, highlighting a failure in supervision and adherence to care plans.
A resident with MS and quadriplegia experienced a delay in receiving emergency care due to the facility's failure to ensure timely physician services. Despite the resident's repeated requests for emergency care, staff did not act promptly, and the resident was eventually admitted to the ICU with sepsis. The delay was partly due to confusion about procedures when a physician could not be reached.
A resident with aphasia, depression, and cerebral infarction had Flexeril ordered without proper authorization by an LPN, who did not consult the physician or NP. The RN noticed the unauthorized order and confirmed the LPN's actions. The NP and physician were not contacted for the reorder, and the facility failed to notify the family. Management acknowledged the failure to follow procedures.
A facility failed to dispose of discontinued medication for a resident in a timely manner, as required by their policy. The resident, with conditions including aphasia and cerebral infarction, had a prescription for Flexeril that was discontinued, yet the medication was still found in the medication room. The DON confirmed the medication should have been returned or destroyed.
A resident with a history of aphasia, depression, and cerebral infarction was improperly administered Flexeril after an LPN ordered it without consulting a physician or NP. The medication had been previously discontinued, and the error was discovered by an RN. The facility's management confirmed the failure to follow proper procedures for obtaining medication orders.
A facility failed to ensure a safe and orderly discharge for a resident with Conversion Disorder and Shortness of Breath. The discharge plan included returning to North Carolina with home care arrangements, but the facility lacked the resident's home address, personal provider's name, and contact information. Despite confirming a bus ticket and medication delivery, the facility could not verify the resident's destination or care arrangements, as confirmed by the Nursing Home Administrator and DON.
The facility failed to properly label and date food products, monitor food temperatures, and maintain kitchen cleanliness, leading to potential foodborne illness risks. Observations revealed improperly stored kitchenware, unlabeled and expired food items, and inconsistent temperature monitoring, confirmed by dietary staff.
The facility failed to maintain an adequate linen supply on two units, leading to residents being cleaned with paper towels and new admissions waiting for linens. Observations and interviews with residents and staff confirmed the shortage, with linen rooms often found barren or insufficiently stocked. The Nursing Home Administrator acknowledged the issue, which affected the second and third floors.
The facility failed to communicate necessary resident information during transfers for four residents, as required by policy. The residents, who had various medical conditions, were transferred to a hospital and returned without documented evidence of communicated care plan goals, advanced directives, or specific care instructions. The Nursing Home Administrator confirmed this deficiency.
The facility failed to notify the LTC Ombudsman of hospital transfers for four residents, as required by policy. The residents, with various medical conditions, were transferred without documented notification to the Ombudsman. The Director of Social Services was unaware of this requirement, confirmed by the Nursing Home Administrator.
The facility failed to notify residents or their representatives about the bed-hold policy during hospital transfers, as required by their policy. This deficiency was identified for four residents with various medical conditions, who were transferred to hospitals without receiving the necessary information. Staff interviews revealed that the policy was only communicated to private pay residents, which was confirmed by the Nursing Home Administrator.
The facility did not develop baseline care plans within 48 hours for 17 new residents admitted in the past 30 days, as required by their policy. The policy mandates a person-centered care plan to be created within 48 hours of admission, but a review showed no such plans were documented. The Nursing Home Administrator confirmed the oversight, acknowledging the failure to initiate these plans.
The facility failed to maintain consistent and complete communication with the dialysis center for three residents requiring dialysis services. Facility policy required licensed nurses to complete a Hemodialysis Communication Record before and after each dialysis session. However, records for a resident were incomplete for several dialysis days, and interviews with staff confirmed the lack of completed forms. This deficiency was identified through a review of clinical records, facility policy, and staff interviews.
The facility failed to store drugs and biologicals safely and orderly in two medication rooms. On the third floor, an opened and undated tuberculin solution was found, along with slime and sticky substances in the refrigerator. On the fourth floor, expired supplies were discovered, including glucose control solutions and a viral transport swab kit. These issues were confirmed by an RN and an LPN, respectively.
The facility failed to coordinate hospice services for two residents, as required by policy. Both residents, with diagnoses including dementia and cerebral atherosclerosis, were admitted to hospice care, but the facility lacked hospice communication binders and did not include hospice coordination in the care plans. This was confirmed by staff and violated state regulations.
The facility did not conduct Quality Assessment and Assurance (QAA) meetings quarterly with all required members for three consecutive quarters. The policy requires the QAA committee to include the Administrator, DON, Medical Director, Infection Preventionist, consultant pharmacist, patient/family representatives, and three additional staff. The facility could not provide attendance records for the specified periods, and the NHA confirmed the failure to hold these meetings.
The facility failed to prevent cross-contamination during medication administration for two residents, as an LPN handled medications without gloves. Additionally, Enhanced Barrier Precautions were not implemented for residents with medical devices, as confirmed by the Infection Preventionist, who was unaware of the updated guidelines.
The facility failed to offer influenza and pneumococcal vaccinations to four residents, as required by their policies. Residents with various diagnoses, including seizure disorder, high blood pressure, depression, Alzheimer's, and anxiety, were not provided these vaccinations or related education. The lack of documentation and offering of vaccines was confirmed by the Infection Preventionist.
The facility failed to maintain an effective training program for its staff, as three personnel records lacked documentation of required annual in-service training. A nurse aide hired in 2005 was missing training in several areas, including effective communication and resident rights. Another aide hired in 2018 lacked training in resident rights and compliance, while a third aide hired in 2003 was missing training in communication and QAPI. This was confirmed by a scheduler.
A facility failed to notify a resident's representative of a change in condition and hospital transfer due to missing contact information. The resident was found unresponsive with low oxygen levels, and emergency services were called. The oversight occurred because the admission employee did not enter emergency contact numbers from hospital paperwork into the system.
A resident with specific dietary needs due to dysphagia was served a meal that did not meet the required mechanically altered diet. The meal included inappropriate items such as a link sausage and red skin potatoes, contrary to the resident's meal ticket instructions. Staff interviews confirmed the oversight, and the DON acknowledged the facility's failure to provide the correct diet texture.
The facility failed to provide a dignified dining experience for residents on the 4th Floor Nursing Unit, as meals were served in Styrofoam containers due to a shortage of plates. This was confirmed through observations and staff interviews, violating the facility's policy and residents' rights.
Failure to Timely Convey Resident Trust Funds After Discharge or Death
Penalty
Summary
The deficiency involves the facility’s failure to convey resident funds and close resident trust accounts within 30 days of discharge, as required by its own resident fund management policy and applicable regulations. The facility policy, last reviewed on 5/20/25, stated that discharged resident accounts are to be closed following reconciliation and that funds are to be released after completion of an audit and reconciliation. Review of the resident fund trial balance dated 3/18/26 showed that two discharged residents still had open accounts with balances: one with $384.68 and another with $7,430.63. The clinical records for these residents did not contain documentation that their monies were provided within 30 days after discharge. The first closed record (CR1) was for a resident with diabetes, schizophrenia, and hypertension, whose progress note on 1/4/26 documented acute psychiatric distress, including refusal of medications and repeated verbalizations to be killed, leading to a 302 involuntary commitment and transfer from the facility with EMT and police escort. The second closed record (CR2) was for a resident with diabetes, hypertension, and Alzheimer’s dementia, whose progress note on 1/25/26 documented that she was found without pulse or respirations, the physician was notified, and an order was given to release the body to the funeral home, with a nephew notified. Despite these discharges—one due to transfer for psychiatric evaluation and one due to death—there was no indication in either clinical record that their funds were conveyed within 30 days, and the Business Office Manager confirmed that the facility failed to close these accounts and release the funds as required.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to initiate CPR for a resident who was a documented full code. The resident, identified as CR1, had diagnoses including chronic kidney disease, adult failure to thrive, and hypertension, and had a physician’s order indicating full code status current through the time of the incident. The resident’s advance directive form showed no advance directives, no living will, and no Power of Attorney, and there was no documentation that the resident had opted out of resuscitative efforts. The resident’s care plan, although current, did not include goals, plans, or interventions related to the resident’s full code status. On the morning of the incident, an LPN (E3) documented that at approximately 7:45 a.m. the resident was found lying in bed on her right side, not responding to her name, with eyes open and skin pale and cool. The call bell was within reach, and the RN supervisor and physician were notified of a change in condition. In a written statement, the LPN reported that CPR was not started because the nurse believed the resident showed signs of irreversible death. There is no indication in the clinical record that the resident’s code status was unclear or that any conclusive signs of irreversible death, such as rigor mortis or other criteria described in the facility’s CPR policy and AHA guidelines, were present or documented at that time. An RN (E4) later documented, in a late entry, that she was informed that the resident ceased to breathe at 7:56 a.m. and that the physician was notified and the resident pronounced deceased. In her statement, the RN reported that when she assessed the resident after being alerted by the LPN that there was no pulse, the resident’s eyes were open, the resident was pale and cool, and there was mottling of the extremities. The RN described these findings, along with the absence of pulse and respirations, as “obvious signs of death” and concluded that the resident had signs of irreversible death and that CPR would not have helped. The clinical record review confirmed that CPR was not administered despite the existing full code order, and staff interviews with other LPNs and RNs indicated that their understanding of procedure was to check code status and initiate CPR for full code residents found pulseless or without respirations. Surveyors determined that the facility failed to ensure consistent care by not initiating CPR for this unresponsive, pulseless full code resident, resulting in an immediate jeopardy situation.
Removal Plan
- Resident R1 no longer resides in facility.
- All professional nursing staff (LPN/RN) will be re-educated on the CPR procedure.
- Agency staff will be educated on the CPR procedure prior to the start of their next shift.
- All professional nursing staff (LPN/RN) will be re-educated on the definition of irreversible death and that it must be documented in the clinical record.
- Agency staff will be educated on the definition of irreversible death and documentation requirements prior to the start of their next shift.
- Whole-house audit will be conducted by the DON/designee to ensure that every resident has a completed POLST order form, the code status order in EHR, and the care plan updated accordingly.
- Policies related to CPR have been reviewed by NHA and DON and updated to include signs of irreversible death.
- Facility will review the incident in QAPI (Quality Assurance/Process Improvement) meeting.
- New admissions will be audited by DON/designee to ensure that the POLST is located in the resident chart and the DNR or Full Code status is in EHR.
- Findings of audits will be submitted through the facility QAPI program.
- All new hires will be educated on CPR procedures and signs of irreversible death.
Failure of Facility Leadership to Ensure CPR Initiation for Unresponsive Resident
Penalty
Summary
The deficiency involves the failure of the Nursing Home Administrator (NHA) and the Director of Nursing (DON) to effectively manage the facility so that consistent care was provided to initiate cardiopulmonary resuscitation (CPR) for an unresponsive resident (Resident R1). The NHA’s job description dated 2/2024 required directing the day-to-day functions of the facility in accordance with federal, state, and local regulations to assure the highest degree of quality care at all times, and the DON’s job description dated 2/2024 required overseeing and supervising the care of all residents and providing direct resident care. Based on review of job descriptions, clinical records, and staff interviews, surveyors determined that the facility failed to ensure that CPR was initiated for Resident R1 when the resident was unresponsive, and this failure was attributed to the NHA and DON not fulfilling their essential job duties to ensure that applicable federal and state guidelines and regulations were followed. During an interview, the NHA and DON were informed that their failure to effectively manage the facility and ensure consistent initiation of CPR for the unresponsive resident resulted in an Immediate Jeopardy situation for one of 131 residents, in violation of 28 Pa. Code 201.14(a), 201.18(b)(1)(3)(e)(1), and 211.12(d)(1)(2)(3)(5).
Unclean Shower Areas and Excessive Temperatures on Upper Floors
Penalty
Summary
Surveyors identified that the facility failed to maintain a clean, safe, comfortable, and homelike environment on the 3rd floor. During an observation conducted with the DON, both the low hallway and high hallway shower rooms on the 3rd floor were found to have a buildup of red grime and black debris where the wall meets the floor, indicating the shower areas were not clean and sanitary. The DON confirmed during interview that these 3rd floor shower areas failed to be clean and sanitary, which did not comply with the facility’s Safe and Homelike Environment policy requiring a clean, sanitary, and orderly environment. The facility also failed to ensure comfortable air temperature levels on the 4th floor. Review of an air temperature log completed by the DOM showed that multiple resident rooms and the dining room on the 4th floor had temperatures ranging from 83.0°F to 88.0°F, exceeding the facility’s policy range of 71°F to 81°F for comfortable and safe temperatures. The DOM confirmed that comfortable air temperature levels were not maintained for 11 resident rooms and the dining room on the 4th floor. The NHA later confirmed that the facility failed to provide a clean, safe, comfortable, and homelike environment on the 3rd floor and failed to ensure comfortable air temperature levels on the 4th floor as required.
Failure to Notify Physician of Resident's Refusal of Lab Work
Penalty
Summary
The facility failed to notify the physician of a change in condition for one resident who refused ordered bloodwork. The resident, admitted with diagnoses including seizures, moyamoya disease, and cerebral infarction, had a physician order for valproic acid and laboratory tests. Documentation showed that the resident refused the required bloodwork, but there was no evidence in the clinical progress notes that the physician was informed of this refusal. The Director of Nursing confirmed during an interview that staff did not notify the physician about the resident's refusal of lab work.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to properly store food products in both the walk-in and reach-in coolers in the main kitchen, as observed during a survey. Specifically, multiple food items including cinnamon bread, bagels, deli ham, salads, and sandwiches were found without required labels or dates. The facility's policy on food receiving and storage requires that foods be received and stored in compliance with safe food handling practices, but these procedures were not followed. The Dietary Manager confirmed that these lapses in food storage and labeling created unsanitary conditions and the potential for cross contamination in the kitchen. No information about specific residents or their medical conditions was provided in the report.
Failure to Communicate Resident Information and Provide Bed-Hold Notification During Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider during facility-initiated transfers for two residents. Specifically, the clinical records for these residents did not contain documentation that care plan goals and all information necessary to meet the residents' specific needs were provided to the receiving facility at the time of transfer. Additionally, for one resident who was transferred to the hospital and later returned, there was no documented evidence that the resident or their representative was provided with written information about the facility's bed-hold policy at the time of transfer. Furthermore, the facility failed to obtain a physician discharge order for one resident who was discharged home. These deficiencies were confirmed through review of facility policy, clinical records, and staff interviews, which indicated that required notifications and documentation were not completed as per regulatory requirements. The residents involved had significant medical histories, including dementia, major depressive disorder, urinary tract infection, high blood pressure, anemia, and renal insufficiency.
Failure to Develop Comprehensive, Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans for three of five residents reviewed, as required by policy. For one resident with coronary artery disease, hypertension, and acute osteomyelitis of the right foot, the care plan did not include interventions for the use of a wound vac, despite physician orders and direct observation confirming its use. Another resident with anemia, diabetes, and a right leg above-the-knee amputation had a trapeze bar above the bed for mobility, but the care plan did not address interventions related to the trapeze, even though staff confirmed its use for transfers. A third resident with high blood pressure, diabetes, and dementia had physician orders for a wander guard device due to poor safety awareness, but the care plan lacked interventions and goals for elopement risk management. Staff interviews, clinical record reviews, and direct observations confirmed these omissions. The Director of Nursing and other staff acknowledged that the care plans did not include the necessary individualized interventions and goals to address these residents' specific care needs.
Failure to Follow Physician Orders and Ensure Monitoring for Diabetic and Medically Complex Residents
Penalty
Summary
The facility failed to follow physician orders and provide appropriate monitoring and documentation for residents with diabetes and other medical conditions. For one resident, blood glucose levels were not obtained for an extended period despite physician orders, and the order itself lacked parameters for when to notify the physician. Additionally, several residents had physician orders for blood glucose monitoring and insulin administration that either lacked clear notification parameters or were not followed when abnormal blood glucose readings occurred. In multiple cases, there was no documentation that the physician was notified of blood glucose results outside of the ordered parameters, and interventions for hypoglycemia were not documented. The review also found that for one resident prescribed Lithium, there were no physician orders for the required therapeutic lab monitoring, and the resident did not receive routine lab work to monitor Lithium levels. This omission was confirmed by the Director of Nursing. Furthermore, the facility failed to ensure timely follow-up physician appointments for another resident. The process for scheduling appointments and transportation was inconsistent, with staff interviews revealing a lack of communication and a standardized process, resulting in missed appointments and delays in rescheduling. These deficiencies were identified through a review of facility policies, clinical records, and staff interviews. The issues included failures in following physician orders, lack of documentation for critical interventions, absence of required monitoring, and inadequate processes for scheduling and communication regarding resident care. The findings were confirmed by interviews with the Director of Nursing and other staff members, who acknowledged the lapses in care and documentation.
Failure to Identify and Address Elopement Risk in Residents with Cognitive Impairment
Penalty
Summary
The facility failed to identify and address elopement risks for several residents as required by policy. Specifically, residents with cognitive impairments and behaviors such as exit-seeking and wandering were not consistently assessed for elopement risk upon admission, quarterly, or when there were significant changes in condition. For one resident with dementia and a BIMS score indicating moderate impairment, only one elopement risk screen was found in the record, and it was not updated despite ongoing behaviors such as fixating on going home and independently moving about the unit in a wheelchair. Staff interviews confirmed that these behaviors were not recognized as triggers for reassessment, and the required quarterly elopement risk screens were not completed. Another resident, also with dementia and a high elopement risk score on admission, did not have further elopement assessments completed as required. A third resident with dementia and a physician order for a wanderguard was observed without the device, and staff were unable to account for its absence. The Director of Nursing confirmed that the facility did not timely identify residents with behaviors triggering elopement risk, failed to assess them on an ongoing basis, and did not provide appropriate care plans or physician orders for interventions related to exit-seeking behaviors.
Failure to Maintain Dialysis Communication and Vendor Contracts
Penalty
Summary
The facility failed to ensure consistent communication and documentation regarding dialysis care for two of three residents requiring such services. Specifically, for one resident with diagnoses including high blood pressure, anemia, and renal insufficiency, dialysis communication forms were either missing or incomplete for several months, as confirmed by staff review. Another resident with high blood pressure, diabetes, and end-stage renal disease also had incomplete or missing dialysis communication forms, with staff acknowledging that the documentation process had only recently been initiated. These lapses were identified through review of clinical records and staff interviews, which confirmed the absence and incompleteness of required documentation. Additionally, the facility did not maintain current dialysis contracts with the dialysis vendors for two residents as required by facility policy. Review of facility-provided dialysis agreements revealed that contracts were missing for these residents, a fact confirmed by the Nursing Home Administrator. The lack of proper agreements and incomplete communication forms were in violation of facility policy and state regulations regarding clinical records and nursing services.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance evaluations for three of five nurse aides, as required by regulation. Personnel file reviews showed that one nurse aide had not received a performance evaluation since 2019, another since 2021, and a third had no performance evaluation on file since their hire date. During an interview, the Human Resources employee confirmed that up-to-date performance appraisals were not completed for these nurse aides. This deficiency was identified through review of personnel records and staff interviews.
Improper Containment and Disposal of Garbage in Dumpsters
Penalty
Summary
The facility failed to properly contain and dispose of garbage in two of three outside dumpsters, as observed during a review of the outdoor trash receptacles. The lids or covers on dumpster one and two were not closed, and liquid from the dumpster area was found collecting in the disposal area. These conditions were confirmed by the Dietary Manager during the observation. The facility's policy requires the dumpster area to be clean, safe, and compliant with infection control and sanitation regulations, but these standards were not met in this instance.
Failure to Provide Required Annual In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that three out of five sampled nurse aides received the required minimum of 12 hours of in-service education within the past year. Review of facility policy indicated that all staff must participate in both initial orientation and annual in-service training. However, examination of nurse aide training records showed that the identified nurse aides did not meet the annual in-service training requirement. The facility was unable to provide documentation confirming that these nurse aides had completed the mandated training hours. This was confirmed during an interview with a Human Resources employee, who acknowledged the lack of evidence for the required in-service education.
Failure to Maintain Homelike Environment Due to Unsanitary and Damaged Linens
Penalty
Summary
The facility failed to maintain a homelike environment for seven of eight residents, as evidenced by observations during a unit tour. Specific deficiencies included beds with stained fitted sheets and pillowcases, holes in fitted sheets, thin and stretched see-through fitted sheets, and dirty, stained blankets. These conditions were confirmed by both an LPN and the Nursing Home Administrator. Facility policies on linen management and maintaining a homelike environment were reviewed, indicating expectations for cleanliness and comfort that were not met for the affected residents. No information was provided regarding the medical history or condition of the residents at the time of the deficiency.
Failure to Maintain Resident Dignity During Wound Care
Penalty
Summary
A deficiency was identified when a registered nurse (RN) failed to maintain a resident's dignity during wound care. Specifically, the RN wrote on the dressing after it had already been placed on the resident's right heel. This action was observed during a wound care procedure and was later confirmed by the RN in an interview. The facility's policy on dignity requires that each resident be cared for in a manner that promotes their sense of well-being and self-worth. The resident involved had a medical history including high blood pressure, diabetes, and dementia, and was admitted with a pressure ulcer on the right heel. Physician orders specified a detailed wound care regimen for the pressure ulcer, but the deficiency occurred when the RN wrote on the dressing post-application, which did not align with the facility's dignity policy. This incident was cited as a failure to provide care in a manner that maintains resident dignity.
Failure to Provide ADL Assistance for Dependent Resident
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident who was unable to perform these tasks independently. According to the facility's policy, residents who cannot carry out ADLs on their own are to receive services to maintain good nutrition, grooming, and personal and oral hygiene. Review of the resident's clinical record indicated diagnoses of high blood pressure, heart failure, and coronary artery disease, and the Minimum Data Set assessment documented that the resident was dependent for personal hygiene needs. Multiple observations over three consecutive days revealed that the resident remained in bed with a large amount of facial hair on the upper lip and chin, and black debris under the fingernails of both hands. These findings were confirmed by both a nurse aide and the Assistant Director of Nursing during separate interviews and observations. The Director of Nursing also confirmed that the facility did not provide the required ADL assistance for this resident.
Failure to Provide Ongoing Resident Activity Program
Penalty
Summary
The facility failed to provide an ongoing program of activities to meet the interests and support the physical, mental, and psychosocial well-being of each resident on the fourth floor. Review of the activity calendar showed scheduled activities, including 'Moovin and Groovin' and 'Connect Four.' However, during observations, the activity aide was present but did not engage with the residents. For example, during the 'Moovin and Groovin' activity, the aide sat at a table, played music, and did not interact with the group, instead eating a lollipop and resting her head on her hand. Similarly, during the 'Connect Four' activity, the aide sat at a table with the game present but did not encourage or facilitate resident participation. Interviews with the activity aide and the Activity Director confirmed that the aide did not interact with residents or attempt to involve them in the scheduled activities. The Activity Director acknowledged that the aide should have been engaging residents, such as encouraging movement or participation, but this did not occur. As a result, the facility did not meet the requirement to provide an ongoing program of activities tailored to the needs and interests of residents on the fourth floor.
Failure to Accurately Assess and Document Pressure Ulcers
Penalty
Summary
The facility failed to accurately assess and document pressure ulcers for two residents, as required by facility policy and nationally accepted guidelines. For one resident with a history of coronary artery disease, hypertension, and acute osteomyelitis of the right foot and ankle, there were no documented wound measurements for the right foot amputation site from late May through late June, despite physician orders for wound vac application and care. The Director of Nursing confirmed the absence of weekly wound measurements for this site. Another resident, admitted with diagnoses including surgical aftercare of the digestive system, peritonitis, and alcoholic cirrhosis of the liver, had a pressure ulcer on the coccyx. The clinical admission assessment and subsequent clinical records from late April through late June showed no documented measurements of the pressure ulcer, despite physician orders for daily wound care. The Assistant Director of Nursing confirmed that the facility did not accurately assess pressure ulcers for these two residents as required.
Failure to Identify and Address PTSD Triggers in Trauma-Informed Care
Penalty
Summary
The facility failed to provide trauma-informed care to a resident with a diagnosis of post-traumatic stress disorder (PTSD). The facility's policy on trauma-informed and culturally competent care requires staff to develop individualized care plans that address past trauma, identify triggers, and minimize exposure to those triggers in collaboration with the resident and family. However, review of the resident's care plan showed that while it acknowledged the risk for decreased psychosocial well-being and adjustment issues related to a history of assault with a weapon, it did not identify specific PTSD triggers or outline strategies to avoid them. Further review of the resident's clinical record confirmed the diagnosis of PTSD, along with anemia and a hip fracture. During an interview, the Social Services Director acknowledged that the facility did not identify or address the resident's PTSD triggers, which is necessary to eliminate or mitigate potential re-traumatization. This deficiency was cited under the relevant state codes for responsibility of the licensee and management.
Failure to Properly Store and Label Medications in Medication Carts
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications in two of three medication carts, as required by facility policy and professional standards. During an observation of the Second floor Low Cart, surveyors found three opened packages of ipratropium nebulizer medication and one Ellipta inhaler that were not dated as required. An LPN confirmed that these medications were opened and lacked the necessary dates. On a separate observation of the Third floor Low Cart, a vial of Ketotifen Fumarate eye drops was found opened and dated January 28, 2025, which was past its use-by date. Another LPN confirmed that this eye medication was opened and expired. The DON acknowledged that the facility did not properly and securely store medications in these two medication carts, in violation of facility policy and state regulations.
Failure to Provide Prescribed Thickened Liquids to Resident with Dysphagia
Penalty
Summary
A deficiency occurred when a resident with a physician-ordered diet of nectar thick liquids and no straws, due to diagnoses including dysphagia, was provided with a clear thin liquid and a straw. The resident's care plan, physician's orders, and Kardex all specified the need for nectar thick liquids and no straw, in accordance with the resident's medical needs and facility policy on therapeutic diets. During an observation, the resident was found in bed with a Styrofoam cup containing thin liquid and a straw within reach. Staff interviews confirmed that the resident should not have received this type of drink and that the nursing assistant responsible did not check the resident's ordered diet before providing the drink. The Director of Nursing acknowledged that the facility failed to provide drinks in the form required to meet the resident's individual needs.
Failure to Ensure Resident Capacity for Binding Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents had the capacity to understand the terms of a binding arbitration agreement prior to signing. Specifically, two residents were identified as having signed such agreements despite documented severe cognitive impairment. For one resident, the clinical record showed a diagnosis of dementia and a Brief Interview for Mental Status (BIMS) score of six, indicating severe impairment, at the time the agreement was signed. For the second resident, the record also showed a diagnosis of dementia and a BIMS score of three, again indicating severe impairment, at the time of signing. These findings were confirmed through review of facility documents, resident clinical records, and staff interviews. The Nursing Home Administrator acknowledged that the facility did not ensure these residents had the capacity to understand the binding arbitration agreements they signed. The deficiency was cited under 28 Pa. Code: 201.18(e)(1) Management.
Failure to Prevent Cross Contamination During Wound Dressing Change
Penalty
Summary
A deficiency was identified when a Registered Nurse (RN) failed to follow infection prevention and control protocols during a wound dressing change for a resident with diagnoses including high blood pressure, diabetes, and dementia, who required pressure ulcer care. The RN did not clean the surface used to hold wound care supplies before or after the dressing change, did not place a barrier under the resident's foot, and used scissors taken from a pocket without cleaning them prior to use. Additionally, after removing the soiled dressing, the RN placed the dirty dressing and empty packaging on the floor. These actions were observed during a dressing change and later confirmed by the RN in an interview. The facility's policy on wound care was not followed, resulting in a failure to prevent cross contamination during the procedure. The deficiency was cited under the relevant Pennsylvania Codes for resident care policies and nursing services.
Failure to Designate Qualified Infection Preventionist During Staff Absence
Penalty
Summary
The facility failed to designate a qualified individual onsite to be responsible for implementing infection prevention and control programs and activities during a specified period. Review of the Infection Control Committee meeting records for the third quarter revealed that the facility did not provide signatures of attendees for the July, August, and September meetings. During staff interviews, the DON stated that the Infection Preventionist was on leave of absence during these months and was unable to provide documentation of a qualified replacement fulfilling the Infection Preventionist role. The DON confirmed that no qualified individual was designated to oversee infection prevention and control during this time frame.
Failure to Provide Routine Podiatry Care
Penalty
Summary
The facility failed to provide appropriate foot care to two residents, both of whom had significant medical histories including diabetes, high blood pressure, and dementia. According to the facility's Podiatry Services Policy, podiatry services should be provided routinely every six to eight weeks, coordinated by nursing staff. However, review of clinical records and staff interviews confirmed that neither resident had received podiatry care since admission. Observations revealed that both residents had thick, elongated, and curved toenails, with lengths extending up to one inch beyond the ends of their toes. One resident was observed in bed with exposed feet, and a nurse confirmed the condition of the toenails. The other resident, who also had a physician order for a podiatry consult and ongoing wound care for a pressure injury, was observed during a dressing change with similarly neglected toenails. The Director of Nursing confirmed the lack of podiatry care for both residents, indicating a failure to follow facility policy and provide necessary foot care services.
Delayed Access to Resident Funds
Penalty
Summary
The facility failed to provide timely access to personal funds for three residents, as evidenced by grievances and interviews. Resident R2 expressed dissatisfaction with the delay in receiving his Social Security funds, which took 13 days to be resolved. Similarly, Resident R4's family raised concerns about the resident not receiving his personal allowance for December, despite having a sufficient account balance. The Business Office Manager noted that the delay was due to the check arriving late and the bank's opening schedule, which led to frustration and erratic behavior from the resident and family. Resident R1 also experienced issues accessing her funds, as she had been waiting since the beginning of December for her check to be processed. The Business Office Manager confirmed that the check had just arrived, and the delay was attributed to the transition of account management from the previous owner. The Nursing Home Administrator acknowledged the facility's failure to provide timely access to personal funds for these residents, which is a violation of their rights under the applicable state codes.
Neglect Due to Inadequate Assistance Leads to Resident Fall
Penalty
Summary
The facility failed to ensure that a resident was free from neglect by not providing the required two-person assistance for bed mobility, resulting in a fall. The resident, who had diagnoses of high blood pressure, quadriplegia, and Multiple Sclerosis, was assessed as needing two-person assistance for bed mobility. Despite this requirement being documented in the resident's care plan and Kardex, a nurse aide provided incontinence care alone and left the resident unattended on their side to obtain new briefs. During this time, the resident experienced spasms and fell from the bed. The incident was reported by the nurse aide, who heard the resident yell about falling and having spasms before hearing a crash. Upon assessment by a registered nurse, the resident was found on the floor without physical injuries and was assisted back to bed using a hoyer lift. The Nursing Home Administrator confirmed that the facility did not adhere to the care plan requiring two-person assistance, which led to the resident's fall.
Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision for a resident with significant mobility needs, resulting in an avoidable fall. The resident, who was diagnosed with high blood pressure, quadriplegia, and Multiple Sclerosis, required assistance from two staff members for bed mobility. However, during an incident, a nurse aide provided incontinence care alone and left the resident unattended on their side to obtain new briefs. During this time, the resident experienced spasms and fell from the bed onto the floor. The incident was documented in progress notes and verbal statements, confirming that the resident was left without the required assistance, leading to the fall. The Nursing Home Administrator acknowledged that the facility did not adhere to the care plan, which specified the need for two-person assistance for bed mobility. This oversight resulted in a failure to provide adequate supervision, as required by the facility's policies and state regulations.
Failure to Provide Timely Physician Services
Penalty
Summary
The facility failed to provide consistent and timely physician services for a resident with a history of high blood pressure, quadriplegia, and Multiple Sclerosis (MS). The resident expressed feeling unwell and requested emergency care on two consecutive days, but the staff did not act promptly. On the first day, the resident's request to go to the emergency room was ignored by aides and nurses. The following day, the resident's representative intervened, and it was revealed that the resident had not been sent to the hospital because the attending physician did not respond to the nurse's call. The resident was eventually sent to the emergency room after a physician assistant evaluated him and noted his symptoms, which included weakness, tiredness, and pain. The resident was admitted to the ICU with sepsis, indicating a delay in receiving necessary emergency treatment. Interviews with staff revealed that there was confusion about the procedure to follow when a physician could not be reached, contributing to the delay in care. The Nursing Home Administrator confirmed the facility's failure to ensure timely physician services for the resident.
Unauthorized Medication Order and Communication Failure
Penalty
Summary
The facility failed to ensure that physician orders were properly obtained, identify pain or spasms to warrant medication, and notify the family for one resident. The review of the clinical record indicated that the resident was admitted with diagnoses including aphasia, depression, and cerebral infarction. The resident had a physician order for Flexeril, a muscle relaxant, which was discontinued and then reordered without proper authorization. The LPN involved ordered the medication without consulting the physician or nurse practitioner, which was against the facility's policy and the scope of practice for an LPN. Interviews with staff revealed that the RN was aware of the discontinuation of Flexeril and questioned the LPN about the unauthorized reorder. The LPN admitted to ordering the medication without contacting the physician. The nurse practitioner and physician confirmed that they were not contacted for the reorder. The facility's management acknowledged the failure to follow proper procedures, which resulted in the deficiency. The report highlights the lack of adherence to policies regarding medication orders and communication with family members.
Failure to Timely Dispose of Discontinued Medication
Penalty
Summary
The facility failed to dispose and reconcile discontinued medication in a timely manner for a resident, identified as Resident R1. According to the facility's policy on the disposal of medication waste, medications that are discontinued, expired, or contaminated should be disposed of in accordance with federal, state, and local regulations. Resident R1 was admitted to the facility with diagnoses including aphasia, depression, and cerebral infarction. The resident had a physician's order for Flexeril, a muscle relaxant, which was discontinued on a specified date. However, during an observation, it was found that a blister pack of Flexeril was still being stored in the medication room. Interviews with the Director of Nursing (DON) confirmed that the Flexeril should have been sent back to the pharmacy or destroyed when the order to discontinue the medication was obtained. The DON acknowledged that the facility did not dispose of and reconcile the discontinued medication in a timely manner for Resident R1. This oversight was identified during a review of the clinical record and through staff interviews, highlighting a lapse in adhering to the facility's medication disposal policy.
Improper Medication Order Without Physician Authorization
Penalty
Summary
The facility failed to ensure that medication orders were properly obtained by a Physician, Physician Assistant, or Nurse Practitioner (NP) for a resident. The issue arose when an LPN ordered Flexeril, a muscle relaxant, for a resident without consulting a physician or NP, despite the medication having been previously discontinued. The LPN believed the resident needed the medication and signed off on the order without proper authorization. This action was discovered by an RN who noticed the discrepancy upon reviewing the resident's chart. The resident involved had a history of aphasia, depression, and cerebral infarction. The medication order was initially discontinued by an NP, and neither the NP nor the physician was contacted to reorder it. Interviews with the NP and physician confirmed that they were not consulted regarding the reordering of Flexeril. The facility's management acknowledged the failure to adhere to proper procedures for obtaining medication orders, as required by state regulations.
Failure to Ensure Safe and Orderly Discharge
Penalty
Summary
The facility failed to implement a safe and orderly discharge for one resident, identified as CR R2, who was admitted on 9/6/24 and diagnosed with Conversion Disorder and Shortness of Breath. The discharge planning indicated that the resident was to return to North Carolina, with arrangements for home care and a personal provider. However, the facility did not have the resident's home address, personal provider's name, or contact information for the resident or physician. On 9/26/24, progress notes indicated that the resident was set to discharge with a bus ticket confirmed and medication delivered, but the facility could not confirm the resident's destination or care arrangements. Interviews with the Nursing Home Administrator and Director of Nursing on 10/8/24 confirmed the failure to ensure a safe discharge, as required by Pa. Code 201.25 and 201.29 (f)(g).
Deficiencies in Food Handling and Sanitation Practices
Penalty
Summary
The facility failed to adhere to its food handling policy, resulting in several deficiencies related to food storage, labeling, and sanitation in the Main Kitchen. Observations revealed that mixing bowls and pots were not stored inverted, a black cart had a white substance on it, and the kitchen floor was littered with debris. Additionally, a drawer containing prep tools had a visible brown/rusty substance. These conditions were confirmed by Dietary Employee E12, indicating a failure to properly store kitchenware and maintain cleanliness. Further observations in the walk-in cooler and dry goods storage area highlighted issues with food labeling and expiration monitoring. Items such as ham, tomato soup, and chicken noodle soup were either past their use-by dates or lacked proper labeling. Similarly, fruit cups, cottage cheese, and creamer in the small cooler were not labeled with prepared or use-by dates. The dry goods storage area contained bins with dust-like substances and items without proper labeling or expiration dates. Additionally, the facility failed to consistently monitor food temperatures, as evidenced by Dietary Employee E12's inability to produce temperature records for breakfast items. These deficiencies were confirmed by Food Service Director Employee E10, who acknowledged inconsistent temperature monitoring practices.
Inadequate Linen Supply on Two Units
Penalty
Summary
The facility failed to maintain an ample linen supply for staff's immediate use on two of three units, specifically the second and third floors. This deficiency was identified through a review of the facility's Accommodation of Needs policy, observations, and interviews with residents and staff. The policy mandates a safe, clean, and comfortable environment, including the provision of clean bed and bath linens. However, residents reported a lack of washcloths and towels, with one resident stating that paper towels were used for personal care due to the shortage. Staff interviews corroborated these claims, with registered nurses and nurse aides acknowledging the frequent shortage of linens, which sometimes required them to search other floors or use alternative materials for resident care. Observations confirmed the deficiency, revealing barren linen supplies in the second-floor linen room and insufficient supplies on the third floor. During a Resident Council meeting, multiple residents expressed concerns about the inadequate supply of towels and washcloths, noting that the facility no longer provided wipes and relied on wash towels for various care needs. Staff interviews further highlighted the issue, with reports of new admissions waiting for linens and residents being cleaned with paper towels due to the shortage. The Nursing Home Administrator confirmed the facility's failure to maintain an adequate linen supply on the affected units.
Failure to Communicate Resident Information During Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider during facility-initiated transfers for four out of five residents sampled. The deficiency was identified through a review of facility policy, clinical records, and staff interviews. The facility's policy on Discharge and Transfer, dated 5/7/24, requires that specific information be communicated when a resident is transferred. However, for Residents R29, R39, R75, and R82, there was no documented evidence that the facility had communicated essential information such as care plan goals, advanced directive information, specific instructions for ongoing care, and resident representative information to the receiving health care provider. Each of the residents involved had been transferred to a hospital and later returned to the facility. Resident R29 had diagnoses including high blood pressure, muscle weakness, and acute cholecystitis. Resident R39 had high blood pressure, coronary artery disease, and osteoarthritis. Resident R75 had high blood pressure, atrial fibrillation, and thyroid disease. Resident R82 had high blood pressure, coronary artery disease, and cerebral infarction. Despite these medical conditions, the facility did not provide the necessary information to ensure continuity of care at the receiving facility. The Nursing Home Administrator confirmed the failure to communicate the required information during an interview.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide timely notification to the Office of the Long-Term Care Ombudsman Division regarding the transfer of four residents to the hospital. The facility's policy on Discharge and Transfer, dated 5/7/24, requires that copies of notices for emergency transfers be sent to the Ombudsman, either when practicable or as per state requirements. However, the clinical records for Residents R29, R39, R75, and R82 did not contain documented evidence of such notifications being sent for their respective hospitalizations. Resident R29, diagnosed with high blood pressure, muscle weakness, and acute cholecystitis, was transferred to the hospital on 5/9/24. Resident R39, with high blood pressure, coronary artery disease, and osteoarthritis, was transferred on 10/23/23. Resident R75, suffering from high blood pressure, atrial fibrillation, and thyroid disease, was transferred on 5/7/24. Lastly, Resident R82, diagnosed with high blood pressure, coronary artery disease, and cerebral infarction, was transferred on 11/27/23. The Director of Social Services admitted to being unaware of the requirement to include transfers and bed holds in the Ombudsman notification list, which was confirmed by the Nursing Home Administrator.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify residents or their representatives about the bed-hold policy during hospital transfers, as required by their own policy and regulatory standards. This deficiency was identified through a review of facility policy, clinical records, and staff interviews. The facility's policy, dated 5/7/24, mandates that a Bed Hold Notice of Policy & Authorization form be provided to residents or their representatives. However, for four out of five residents who were transferred to the hospital, there was no documented evidence that this information was provided. Specifically, residents with various medical conditions, including high blood pressure, coronary artery disease, and other ailments, were transferred to hospitals without receiving the necessary bed-hold policy information. Interviews with facility staff revealed a misunderstanding or misapplication of the policy. Admission Employee E19 stated that they only contacted families about the bed-hold policy if the residents were private pay, to determine if they wanted to continue paying for the bed during the hospital stay. This practice was confirmed by the Nursing Home Administrator, who acknowledged the failure to notify residents or their representatives as required. The deficiency was noted under 28 Pa. Code: 201.29(b)(d)(j) concerning resident rights.
Failure to Implement Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for 17 new residents in the past 30 days. The facility's policy, last reviewed on May 7, 2024, mandates the creation of a person-centered care plan within 48 hours of admission or readmission. This care plan should include the necessary instructions to provide effective and person-centered care that meets professional standards. However, a review of the facility's records revealed that no baseline care plans were documented for any of the new admissions during this period. The Nursing Home Administrator confirmed during an interview that the baseline care plans were not being completed as required, acknowledging the facility's failure to initiate these plans for all 17 new admissions.
Inadequate Dialysis Communication in LTC Facility
Penalty
Summary
The facility failed to provide consistent and complete communication with the dialysis center for three residents requiring dialysis services. The facility's policy required licensed nurses to complete a Hemodialysis Communication Record before and after each dialysis session, ensuring communication with the dialysis center. However, for Resident R1, the facility did not complete the required forms for four out of sixteen dialysis days. Similarly, Resident R27's records showed incomplete forms for ten out of sixteen days, and Resident R41's records were missing forms for thirteen out of twenty-two days, with incomplete documentation for eight additional days. Interviews with facility staff, including registered nurses and the Nursing Home Administrator, confirmed the lack of completed dialysis communication forms. The facility's failure to adhere to its policy resulted in inadequate documentation and communication with the dialysis center, as evidenced by the missing and incomplete forms for the residents. This deficiency was identified through a review of clinical records, facility policy, and staff interviews, highlighting a significant lapse in the facility's dialysis care communication process.
Deficiencies in Medication Storage and Labeling
Penalty
Summary
The facility failed to store drugs and biologicals in a safe, secure, and orderly manner in two of its medication rooms, leading to deficiencies in compliance with health regulations. On the third floor, a vial of tuberculin solution was found opened and undated in the medication room refrigerator. Additionally, the refrigerator was observed to have a brown slime on the bottom drawer and a pink sticky substance in the door seal, while the freezer contained a pink sticky substance and a blue frozen water bottle. These observations were confirmed by a Registered Nurse (RN) during an interview. On the fourth floor, several expired supplies were found in the medication room, including five glucose control solutions, a 0.9% normal saline solution, and a universal viral transport swab kit. These expired items were confirmed by a Licensed Practical Nurse (LPN) during an interview. The facility's policies on medication administration and storage were reviewed, indicating that medications should be dated when opened and stored properly to maintain their integrity, but these policies were not adhered to in the observed instances.
Failure to Coordinate Hospice Services for Residents
Penalty
Summary
The facility failed to ensure the coordination of hospice services with facility services to meet the needs of two residents, identified as R31 and R97, for end-of-life care. The facility's policy required a written plan of care that included the hospice plan and a description of services to maintain the resident's wellbeing. However, the facility did not have a hospice communication binder for either resident, which was confirmed by a Registered Nurse (RN) and the Nursing Home Administrator. Resident R31, who had diagnoses including dementia and cerebral atherosclerosis, was admitted to hospice care, but the facility lacked the necessary documentation to coordinate hospice services. Similarly, Resident R97, with diagnoses of dementia and weakness, was also admitted to hospice care, but the facility failed to include hospice coordination in the resident's comprehensive care plan. The care plan did not provide contact information for the hospice agency or instructions on accessing the hospice's 24-hour on-call system. The Director of Nursing confirmed the facility's failure to coordinate hospice services for Resident R97, which was a violation of the facility's policy and state regulations.
Failure to Conduct Quarterly QAA Meetings
Penalty
Summary
The facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all required committee members for three consecutive quarters. The facility's policy, dated May 7, 2024, mandates that the QAA committee, which operates under the authority of the Administrator and the Governing Body, includes the Administrator, Director of Nursing, Medical Director, Infection Preventionist, consultant pharmacist, patient and/or family representatives, and three additional staff representatives. Despite this requirement, the facility was unable to provide any sign-in sheets or attendance records for the periods of October 2023 through December 2023, January 2024 through March 2024, and April 2024 through June 2024. During an interview on July 26, 2024, the Nursing Home Administrator confirmed the absence of these records and acknowledged the failure to hold the required QAA meetings. This deficiency was identified under the regulation 28 Pa Code: 201.18(e)(1)(2)(3)(4) Management.
Failure to Prevent Cross-Contamination and Implement EBP
Penalty
Summary
The facility failed to prevent cross-contamination during a medication pass for two residents. During observations, an LPN was seen removing medication from its package into their hand and placing it into a medication cup without wearing gloves for two residents. This action was confirmed by the LPN during interviews, and the Director of Nursing acknowledged the failure to prevent cross-contamination during the medication pass. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for residents with tube feedings, indwelling urinary catheters, and indwelling dialysis catheters. The Infection Preventionist admitted to not being aware of all items included in EBP and confirmed the oversight. This lack of implementation was noted for several residents with specific medical devices, indicating a failure to adhere to the facility's policy and CDC guidelines.
Failure to Offer Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that influenza and pneumococcal immunizations were offered to four out of five residents, as required by their policies. The facility's policy IC600, dated 5/7/24, mandates that influenza immunization history be obtained and documented upon admission. Similarly, policy OC601 requires that the pneumococcal vaccination history be obtained and documented, and the opportunity to receive the vaccine be provided to all residents. However, upon review, it was found that Residents R53, R94, R106, and R112 were not offered these vaccinations, and there was no documentation in their clinical records indicating that the vaccinations or related education were provided. Resident R53, with diagnoses of seizure disorder and high blood pressure, was not offered the influenza or pneumonia vaccines, and no reason was documented. Resident R94, diagnosed with depression and high blood pressure, was not offered the influenza vaccine, with no documentation of education provided. Resident R106, with Alzheimer's disease, depression, and anxiety, was not offered the pneumonia vaccine, and there was no documentation of education. Resident R112, also with depression and high blood pressure, was not offered the influenza vaccine and was not administered the pneumonia vaccine, with no reason documented. The Infection Preventionist confirmed these deficiencies during an interview.
Deficiency in Staff Training Program
Penalty
Summary
The facility failed to implement and maintain an effective training program for its staff, as evidenced by the review of personnel records and staff interviews. Specifically, three out of five personnel records reviewed did not include documentation of required annual in-service training. Nurse Aide Employee E25, hired on 4/13/05, lacked training in effective communication, resident rights, abuse, QAPI, infection control, compliance and ethics, and behavioral health. Nurse Aide Employee E26, hired on 12/31/18, did not have training in resident rights, abuse, and compliance and ethics. Nurse Aide Employee E27, hired on 3/31/03, was missing training in effective communication and QAPI. This deficiency was confirmed during an interview with Scheduler Employee E18.
Failure to Notify Resident's Representative of Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's representative of a change in condition and transfer to the hospital, as required by their policy. The deficiency was identified through a review of clinical records and staff interviews. The resident, identified as Closed Resident Record CR241, was admitted to the facility with diagnoses including high blood pressure, a history of falling, and muscle weakness. On a specific date, the resident was found unresponsive with low oxygen saturation levels, prompting the staff to administer oxygen and call emergency services. Despite these actions, the facility did not notify the resident's emergency contacts about the change in condition and subsequent hospital transfer. The investigation revealed that the facility's failure to notify the resident's representatives was due to missing contact information in the resident's records. Admission Employee E19 admitted to not entering the emergency contact phone numbers into the system, despite these numbers being available on the hospital paperwork provided prior to the resident's admission. This oversight was confirmed during an interview with the Nursing Home Administrator, who acknowledged the facility's failure to comply with the notification requirements as outlined in their policy.
Failure to Provide Appropriate Diet Texture for Resident
Penalty
Summary
The facility failed to provide food in a form that meets the individual needs of a resident who was ordered an easy-to-chew diet texture. Resident R45, who has diagnoses including high blood pressure, cerebral infarction, and coronary artery disease, was observed eating a meal that did not conform to the prescribed mechanically altered diet. The resident's meal ticket indicated a regular diet with dysphagia advanced modifications, but the tray contained items such as a link Italian sausage on a bun and red skin potatoes, which were not suitable for the resident's dietary needs. Interviews with facility staff, including a registered nurse, a speech-language pathologist, and a cook, confirmed the discrepancy. The RN acknowledged the meat should have been ground, and the speech-language pathologist noted the resident should not have received that tray. The cook admitted that the meal should have included mechanical soft sausage and mashed potatoes, and that there was a failure in the tray line checking process. The Director of Nursing confirmed the facility's failure to provide food in the appropriate form for the resident's needs.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for residents on the 4th Floor Nursing Unit, as observed and confirmed through various interviews and documentation reviews. The facility's policy FNS308, dated 5/7/24, mandates that meals be served accurately, timely, and at the appropriate temperature, using heated bases and dinner plates, with exceptions only for dishwasher malfunctions or residents on suicide precautions. Despite this policy, grievances dated 3/7/24 and 7/11/24, as well as food committee minutes from 7/11/24, indicated ongoing issues with meals being served in Styrofoam containers and with plastic silverware, sometimes lacking a knife. On 7/22/24, an observation at 9:10 a.m. revealed that residents received breakfast in Styrofoam containers. Interviews with Nurse Aide Employee E21 and Dietary Aide Employee E13 confirmed the use of Styrofoam due to a shortage of plates, specifically affecting the 4th floor. These actions were in violation of the facility's policy and failed to uphold the residents' right to a dignified dining experience, as outlined in PA Code: 201.29(j) Resident Rights.
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A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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