Kearsley Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- 2100 North 49th Street, Philadelphia, Pennsylvania 19131
- CMS Provider Number
- 395983
- Inspections on file
- 45
- Latest survey
- May 19, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Kearsley Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident with significant cognitive and physical impairments, requiring two-person assistance for bed mobility, was left with only one CNA during incontinent care. The CNA, unaware of the resident's care requirements, attempted to reposition the resident alone, resulting in the resident falling from the bed and sustaining a compound femur fracture that required hospitalization and surgery.
A resident admitted with a left heel deep tissue injury and multiple diagnoses, including malnutrition and muscle weakness, did not have a baseline care plan developed within 48 hours as required. The care plan addressing the pressure injury was not implemented until several days after admission.
A resident with chronic respiratory failure, stroke, and cognitive impairment had a care plan specifying communication interventions for aphasia, including staff engagement during care. An LPN provided care without speaking to or reassuring the resident, who appeared agitated and expressed fear, contrary to the documented care plan requirements.
Two residents with complex medical histories experienced significant unaddressed weight loss, as staff failed to document reweighs or conduct nutritional assessments despite care plans and physician orders requiring regular monitoring and intervention.
A medication error rate of 40% was observed when an LPN administered multiple scheduled medications to a resident several hours late, citing staffing issues as the cause. All medications were ordered for the morning but were given outside the facility's policy window, and there was no documentation of physician notification prior to the late administration.
A resident with COPD, diabetes, and hypertension did not receive scheduled morning breathing treatments on time, with medications administered several hours late by an LPN who also failed to notify the physician and inaccurately documented administration times. The resident expressed concern about missing these important treatments, and the LPN admitted to not recording medication administration in real time.
Surveyors found that opened medications, including Geri-tussin, Albuterol Sulfate, Budosemide, Vancomycin, and Tuberculin, were not labeled with open dates on two medication carts and in the medication room. LPNs and staff confirmed the absence of required labeling during interviews.
A resident received physician-ordered antibiotics for a UTI and experienced a change in mental status due to the infection. Despite these clinical events, staff did not include any goals or interventions related to the UTI in the resident's care plan, as confirmed by the DON and administrator.
A resident was not provided with toiletries or a basin upon admission. The omission was confirmed through resident interview and facility documentation, with the resident only receiving a roll of toilet paper after requesting tissues.
Three residents reported extended wait times for assistance after activating their call bells. In one case, a resident requested help to use a bed pan, but the staff member left to get help and did not return after turning off the call light. Facility policy requires prompt response to call bells, but this was not consistently followed.
Multiple clogged bathroom sinks with standing water were observed in two nursing units, with maintenance logs and staff interviews confirming this as a recurring issue. A resident reported persistent drainage problems despite recent maintenance efforts, and direct observation verified several sinks remained clogged. The administrator acknowledged the ongoing problem, indicating the facility failed to maintain a comfortable and homelike environment.
A resident with Type 2 diabetes mellitus did not have insulin administration properly documented on two occasions. An LPN was unaware of the prescribed insulin dose and relied on the resident to provide the information before administering the medication. The MAR did not reflect the administration, and the DON confirmed the lack of documentation, which did not meet facility policy or professional standards.
A resident at Kearsley Rehabilitation and Nursing Center was admitted with conditions such as cerebral infarction and severe malnutrition, and was at risk for pressure ulcers. Despite a wound assessment identifying a full-thickness abrasion on the resident's right dorsal foot, the facility failed to include this in the resident's care plan. The facility's policy requires a comprehensive care plan within seven days of the Resident Assessment, but this was not followed, as confirmed by the DON.
A resident requested a grilled cheese sandwich instead of the Thanksgiving meal served, but the dietary department could not accommodate the request due to increased workload and staffing limitations. Consequently, the resident did not receive an alternative meal and was documented as having refused lunch, relying on snacks instead.
The facility failed to maintain an effective pest control program, resulting in a mice infestation on two nursing units. Multiple residents reported sightings of mice in their rooms, with one seeing a mouse on her bed and another observing mice entering through the AC vent. Despite using pest control products and mouse traps, the measures were ineffective. Interviews with the DON and Director of Maintenance confirmed these findings.
A resident with severe cognitive impairment and osteopenia was harmed during a transfer using a mechanical lift when a CNA performed the transfer alone, contrary to facility policy requiring two staff members. The resident sustained multiple fractures due to the improper use of the sling pad, leading to hospital admission. The facility's investigation confirmed the injuries occurred during the transfer, but did not substantiate neglect.
A resident with severe cognitive impairment and multiple medical conditions was improperly transferred using a mechanical lift by a CNA without the required assistance of a second staff member. This resulted in multiple fractures due to the tightening of the sling pad. The CNA admitted to performing such transfers alone, contrary to facility policy.
The facility did not adhere to professional standards for food service safety. Observations revealed a dirty path in the dry storage room, unlabeled food in the refrigerator, improperly covered chicken in the freezer, and water leakage from a hand sink. These issues were confirmed by the Food Service Director.
The facility failed to provide a safe and comfortable environment for residents, as several reported non-functioning phones and inconsistent air conditioning. A resident's phone was not working, and others experienced similar issues. Additionally, a built-in A/C unit was unreliable, prompting the use of a portable unit, which only provided relief when nearby. A window that did not close properly allowed a wasp to enter the area, further compromising the environment.
The facility failed to maintain accurate clinical records for two residents. One resident's enteral feeding volume was incorrectly documented due to a misunderstanding of nutritional information, while another resident was not informed of a change in medication dosage, with no documentation to confirm notification. Staff interviews confirmed these documentation errors.
The facility failed to document that residents were given the opportunity to participate in their care plan meetings. Several residents reported not recalling being invited to such meetings, and clinical records lacked evidence of notification or discussion. A social worker mentioned notifying residents verbally and sending letters, but no documentation was available.
A resident with multiple diagnoses, including chronic pain, did not receive prescribed Oxycodone due to the facility's failure to obtain a timely prescription from the physician. The medication was not administered as ordered on several occasions, leading to unmanaged pain. The DON confirmed the delay in obtaining the necessary script.
A resident with multiple health conditions experienced significant weight loss, which was not addressed in a timely manner by the facility's dietitian. The resident's weight was inaccurately recorded and interventions were delayed, leading to a deficiency in maintaining the resident's nutritional health.
The facility did not complete required performance reviews for nurse aides. The DON could not provide documentation of reviews, and the Administrator confirmed the absence of a process to ensure reviews were conducted. Training was based on facility events rather than staff evaluations.
A facility failed to ensure effective communication with hospice care agencies for a resident receiving hospice services. Despite regular visits from hospice staff, the communication log lacked detailed documentation of the care provided. The resident, with multiple diagnoses including dementia and diabetes, was under hospice care as per physician orders. Interviews confirmed verbal communication occurred, but no written evidence of care details was documented, leading to the deficiency.
The facility failed to administer medications at the correct times as ordered by the physician for a resident. Multiple instances were found where medications were given significantly later than prescribed, despite the facility's policy requiring administration within one hour of the scheduled time. The DON confirmed these findings.
The facility failed to ensure nursing services met professional standards by documenting that medications were administered to a resident who was at dialysis. An LPN signed out medications on the MAR without administering them, leaving medication cups in the resident's room. The DON confirmed this was against protocol.
The facility failed to create a care plan for a resident with cardiogenic shock and dementia, despite multiple reports of disruptive nighttime behaviors. Staff and residents reported the issue, but no formal plan was developed to manage the resident's screaming at night.
A resident reported difficulty breathing to an LPN, who assessed the resident but did not document the complaint or assessment in the medical record. This failure to document violates the facility's policy on Charting and Documentation.
Failure to Provide Required Two-Person Assistance During Bed Mobility Results in Resident Harm
Penalty
Summary
The facility failed to provide adequate supervision and assistance during care for a resident who required extensive help with bed mobility, resulting in actual harm. The resident, who had a history of cerebral infarction, psychomotor deficit, hemiplegia, and hemiparesis affecting the right side, was assessed as needing the assistance of two or more staff members for turning and repositioning in bed. Both the care plan and bedside Kardex clearly indicated this requirement. The resident also had significant cognitive impairment, being rarely understood and unable to recall basic information, making them non-interviewable and highly dependent on staff for care. Despite these documented needs, only one nurse aide was present during the provision of incontinent care when the incident occurred. The nurse aide attempted to turn and reposition the resident alone, during which the resident's legs slipped off the bed and the aide was unable to prevent the resident from sliding to the floor. The bed was positioned high for care, and the resident was rolled onto their weak side, further increasing the risk. The nurse aide and the charge nurse both stated they were unaware at the time that two-person assistance was required for this resident's bed mobility and repositioning. As a result of this lack of adequate supervision and failure to follow the resident's care plan, the resident fell from the bed, sustained a compound fracture of the right femur, and required hospitalization and surgical repair. The incident was witnessed and documented in the facility's incident report, and subsequent interviews with staff confirmed that the required level of assistance was not provided at the time of the fall.
Failure to Develop Timely Baseline Care Plan for Pressure Injury
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident who was admitted with a left medial heel deep tissue injury. Documentation review showed that the resident had diagnoses of muscle weakness, malnutrition, and depression, and was identified as being at risk for pressure ulcers with an unhealed pressure injury present at admission. Despite facility policy requiring a baseline care plan to address immediate health and safety needs within 48 hours, there was no evidence that such a plan was created to address the resident's pressure injury until four days after admission. The care plan for the left heel deep tissue injury was not developed and implemented until after the required timeframe.
Failure to Implement Communication Interventions for Resident with Aphasia
Penalty
Summary
A deficiency was identified when the facility failed to implement a comprehensive care plan addressing the communication needs of a resident with chronic respiratory failure, cerebrovascular accident, and cognitive impairment. The resident's care plan, revised on multiple occasions, documented a communication deficit related to aphasia and outlined interventions such as lip reading, writing, communication board, gestures, sign language, and translator use. Additionally, the care plan required all staff to converse with the resident during care to support cognitive stimulation and social interaction. However, during an observation, an LPN provided care to the resident, who appeared agitated and expressed fear, without speaking to or addressing the resident, and failed to offer reassurance or directions as required by the care plan.
Failure to Monitor and Respond to Significant Weight Loss
Penalty
Summary
The facility failed to ensure that residents' weights were adequately monitored and that appropriate follow-up actions were taken in response to significant weight changes for two residents. One resident, admitted with diagnoses including a thoracic vertebrae fracture, type 2 diabetes, and malnutrition, had a care plan indicating a nutritional problem and an intervention to obtain weights as ordered. Despite a physician's order for monthly weights, the resident experienced a weight loss from 105.4 lbs to 96.0 lbs over two months, representing a 6.61% decrease. There was no documented evidence of a reweigh or a nutritional assessment in response to this significant weight change. Another resident, admitted with conditions such as osteoarthritis, hyperlipidemia, type 2 diabetes, and other complications, also had a care plan for nutritional monitoring and a registered dietician evaluation as needed. This resident's weight dropped from 219 lbs to 203.6 lbs, a 7.6% decrease, without any documented reweigh or nutritional assessment following the significant weight loss. These findings were based on clinical record reviews and staff interviews, indicating a failure to follow established resident care policies and nursing services requirements.
High Medication Error Rate Due to Late Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, during medication administration for one of three residents observed. Specifically, during observation of 25 medication administration opportunities, 10 errors were identified, resulting in a 40% medication error rate. All of the errors involved the late administration of medications, as the medications ordered for 9:00am were instead administered at 12:05pm. The LPN responsible for the medication pass confirmed that all medications were scheduled for 9:00am, and the late administration was attributed to staffing issues. Review of the resident's Medication Administration Records showed multiple medications, including treatments for hypertension, bacterial infection, prophylaxis, supplementation, wheezing, anxiety, hyperlipidemia, nerve pain, and osteoporosis, all scheduled for the same morning time. There was no documentation that the physician was notified prior to the late administration of these medications. The facility's policy requires medications to be administered within one hour of their prescribed time unless otherwise specified, which was not followed in this instance.
Significant Medication Error Due to Late Administration and Inaccurate Documentation
Penalty
Summary
A deficiency occurred when a resident with diagnoses including COPD, diabetes, and hypertension did not receive prescribed morning breathing treatments (Albuterol and Budesonide) at the scheduled time. Facility policy requires medications to be administered within one hour of their prescribed time, but the resident did not receive these medications until after noon, despite being ordered for 9:00am. The resident, who is cognitively intact, expressed concern about not receiving her breathing treatments on time, stating their importance for her ability to breathe. Observation of the medication pass confirmed that the LPN administered the medications late and did not notify the physician prior to the late administration. Additionally, review of the Medication Administration Records (MARs) revealed inaccurate documentation, as the LPN recorded the medications as being administered earlier than they actually were. The LPN admitted to not signing out medications at the time of administration, instead documenting them later from notes. These actions resulted in a significant medication error for the resident.
Failure to Label Opened Medications with Open Dates
Penalty
Summary
Surveyors observed that the facility failed to ensure that opened medications were properly labeled with the date they were opened, as required by professional standards. Specifically, on the Lower-Level South Med Cart, an opened bottle of Geri-tussin solution was found without an open date. On the Lower-Level North Med Cart, two opened packages of nebulizer treatments, Albuterol Sulfate and Budosemide, were also not labeled with open dates. In the Upper Level Med Room, two open bottles, Vancomycin oral solution and Tuberculin injectable, were similarly missing open dates. These findings were confirmed through interviews with licensed nurses and staff present at the time of observation. No information about residents' medical history or condition at the time of the deficiency was provided in the report.
Failure to Develop UTI Care Plan
Penalty
Summary
Facility staff failed to develop a comprehensive care plan addressing a urinary tract infection (UTI) for one resident. The resident had physician orders for Bactrim DS and Ciprofloxacin to treat a UTI, as documented in the electronic medication administration record. An incident report noted a change in the resident's mental status due to a positive UTI, and nursing notes confirmed treatment for the infection. Despite these findings, review of the resident's care plan revealed no documented goals or interventions related to the UTI. This omission was confirmed by both the director of nursing and the administrator.
Failure to Provide Toiletries Upon Admission
Penalty
Summary
The facility failed to provide required toiletries to a resident upon admission. Interview with the resident revealed that she did not receive any toiletries or a basin when she was admitted. During the interview, it was observed that the resident had a roll of toilet paper on her bedside table, which she stated was given to her when she requested tissues. Review of facility documentation confirmed that the resident was admitted without new toiletries, as noted in a grievance report.
Delayed Response to Resident Call Bells
Penalty
Summary
Facility staff failed to respond promptly to resident call bells for three of nine residents reviewed. According to facility policy, staff are required to answer the resident call system as soon as possible, identify themselves, and address the resident by name. One resident reported having to wait an extended period for assistance after using the call bell, and a grievance report documented an incident where a resident requested help to use a bed pan, but the staff member left to get help and did not return after turning off the call light. Two additional residents also reported experiencing extended wait times for assistance after activating their call bells. These findings were based on resident interviews and review of facility documentation, indicating that the facility did not ensure timely response to call bells as required by policy.
Ongoing Clogged Sinks Compromise Resident Comfort and Environment
Penalty
Summary
The facility failed to provide a comfortable and homelike environment for residents due to ongoing issues with clogged bathroom sinks in two of the four nursing units observed, specifically the Upper-Level South and North Nursing Units. Observations and interviews revealed that multiple sinks in resident rooms were clogged, with some containing standing water. The Maintenance Assistant confirmed that sink clogging was a recurring problem, and the maintenance log documented several instances of clogged sinks in various rooms from December 2024 through March 2025. On the day of the survey, several sinks remained clogged despite recent attempts to address the issue. A resident reported that their sink, which had been unclogged the previous day, was still not draining properly. Direct observation with the Maintenance Director confirmed the presence of standing water in several sinks across both nursing units. The facility administrator acknowledged the ongoing nature of the sink clogging problem. These findings indicate that the facility did not maintain plumbing and piping systems in a manner that ensured a safe, clean, and comfortable environment for residents.
Failure to Document Insulin Administration as Ordered
Penalty
Summary
A deficiency occurred when a licensed nurse failed to accurately document the administration of insulin for a resident with Type 2 diabetes mellitus who was prescribed NovoLOG FlexPen insulin before meals. The physician's orders specified that the resident should receive 10 units of insulin subcutaneously at three specific times daily. On two separate occasions, the nurse was not aware of the correct insulin dosage and relied on the resident to provide this information before administering the medication. Review of the Medication Administration Report (MAR) showed that the insulin administration was not documented for the two dates in question. The nurse later confirmed that the medication was given but could not explain why it was not recorded. The Director of Nursing also confirmed the lack of appropriate documentation for those dates. This failure to document medication administration is not in accordance with facility policy and accepted professional standards.
Failure to Develop Comprehensive Care Plan for Wound Care
Penalty
Summary
Kearsley Rehabilitation and Nursing Center was found to be non-compliant with the requirements for developing and implementing a comprehensive care plan as per 42 CFR Part 483, Subpart B. The facility failed to create a care plan addressing wound care for a resident, identified as Resident R1, who was at risk of developing pressure ulcers. The resident was admitted with conditions including cerebral infarction, severe protein-calorie malnutrition, and adult failure to thrive. Despite these conditions, the care plan did not include measures for a full-thickness abrasion on the resident's right dorsal foot. The facility's policy mandates that an interdisciplinary team develop an individualized comprehensive care plan within seven days of completing the Resident Assessment (MDS). However, a review of Resident R1's clinical records revealed that the care plan did not address the abrasion on the right dorsal foot, which was identified during a wound assessment. The wound assessment recommended specific treatments and preventative measures, such as cleansing with normal saline, applying medical-grade honey, and securing with bordered foam, but these were not incorporated into the care plan. Interviews with staff, including the Director of Nursing, confirmed the omission of the abrasion in the care plan. The facility's failure to include this critical aspect of wound care in the resident's care plan was a significant oversight, as it did not align with the facility's policy or federal regulations. This deficiency highlights a lapse in ensuring that the resident's medical and nursing needs were comprehensively addressed in their care plan.
Plan Of Correction
1. R1 no longer resides in the facility. 2. An Initial audit will be completed of all current residents in the facility with wounds to assure the care plans include current skin alterations and appropriate interventions. 3. The Director of Nursing will educate the facility wound nurse on the process and expectations of reviewing and updating care plans to ensure they include all skin alterations and appropriate interventions with new, changed, or resolved skin alterations. 4. NHA or designee will conduct weekly audits for 4 weeks or until compliance is met, to ensure residents who have wounds or skin alterations have a care plan in place that addresses current wounds or skin alterations. Audits will be reviewed by the QAA Committee. The QAA committee will determine continued audits.
Failure to Provide Alternative Meal Options During Holiday Service
Penalty
Summary
The facility failed to provide appealing food options for a resident who requested an alternative meal during a holiday meal service. On Thanksgiving Day, a resident expressed dissatisfaction with the meal served and requested a grilled cheese sandwich instead. The dietary department informed the resident's assigned nurse that they could not provide the requested grilled cheese sandwich due to the increased workload of preparing holiday meals for both residents and staff, and a lack of sufficient dietary staff to prepare hot food items from the 'Always Available' menu. As a result, the resident did not receive an alternative meal and was documented as having refused lunch. The resident reportedly had snacks in her room instead of a proper meal. This incident highlights the facility's failure to ensure that appealing food options were available for residents who requested different meal choices, particularly during holiday meal services.
Plan Of Correction
1. R1's food preferences have been updated and R1 is receiving preferred meals. 2. Facility ensured that food preferences are up to date for current residents. 3. Nursing staff and Dietary staff will be inserviced on always available menu/alternatives. 4. NHA or designee will conduct weekly audits to ensure residents are receiving an alternative meal choice if requested. Results of the audits will be presented to the QAA committee and the QAA committee will determine the need for continued audits.
Ineffective Pest Control Program Leads to Mice Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a mice infestation on two of its nursing units, the LL South Wing and LL North Wing. Multiple residents reported sightings of mice in their rooms, with one resident on the LL South Wing seeing a mouse on her bed and another observing mice entering through the AC vent. Similarly, residents on the LL North Wing reported seeing mice in their rooms on different occasions. A review of the facility's work orders revealed previous reports of mouse sightings, including a dead mouse, dating back to October 1, 2024. Despite the use of pest control products and mouse traps on several occasions, the measures implemented by the facility were ineffective in resolving the rodent infestation. Interviews with the Director of Nursing and the Director of Maintenance confirmed these findings.
Resident Harmed Due to Improper Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure that a resident was free from neglect during a transfer using a mechanical lift, resulting in actual harm. The resident, who had a history of severe cognitive impairment, osteopenia, and other medical conditions, was transferred by a nurse aide using a Hoyer lift without the required assistance of a second staff member. This action was against the facility's policy, which mandates two staff members for such transfers. The resident sustained multiple fractures, including those of the lumbar vertebrae and ribs, due to the improper use of the sling pad during the transfer. The resident's clinical records indicated a diagnosis of osteopenia, which made their bones more susceptible to fractures. The nurse aide admitted to performing the transfer alone because no other staff was available at the time, despite knowing the policy requirement. The aide had previously transferred residents using the mechanical lift by herself, which was a common practice despite the facility's policy. The resident did not show immediate signs of pain, but bruising and tenderness were later discovered, leading to a hospital admission where the fractures were diagnosed. The facility's investigation concluded that the injuries occurred during the transfer due to the tightening of the sling, exacerbated by the resident's osteopenic condition. The investigation did not substantiate neglect, but it was clear that the facility's policy was not followed, leading to the resident's harm. The nurse aide involved was reeducated on the proper procedure for using mechanical lifts, emphasizing the need for two staff members to assist in such transfers.
Removal Plan
- Conduct competencies for using mechanical lifts with nursing staff.
- Interview residents who require full mechanical lifts about feeling safe and confirming 2 staff perform transfer.
- Interview nursing staff to ensure they are comfortable in reporting abuse or neglect and if they have any knowledge of an incident or accident not being reported.
- Educate staff on reporting abuse and neglect and following plan of care.
Improper Mechanical Lift Transfer Causes Resident Harm
Penalty
Summary
The facility failed to ensure the proper transfer of a resident using a mechanical lift, which resulted in actual harm to the resident. The resident, who had a history of osteopenia and other medical conditions, was transferred by a CNA using a Hoyer lift without the assistance of a second staff member, contrary to the facility's policy. This improper transfer led to the tightening of the sling pad, causing multiple fractures, including those of the lumbar vertebrae and ribs. The resident was admitted to the facility with several diagnoses, including osteoarthritis, polyosteoarthritis, and other intervertebral disc degeneration. The resident was unable to participate in mental status assessments due to severe cognitive impairment and had impairments in both upper and lower extremities. Despite these conditions, the CNA performed the transfer alone, which was against the facility's policy that required two staff members for such procedures. The incident was discovered after bruising was noted on the resident's stomach, and subsequent hospital evaluation revealed multiple fractures. The facility's investigation concluded that the injuries were caused by the improper use of the mechanical lift, specifically the tightening of the sling pad during the transfer. The CNA admitted to using the lift alone on multiple occasions, despite knowing the policy requirement for two-person assistance.
Removal Plan
- Conduct competencies for using mechanical lifts with nursing staff.
- Interview residents who require full mechanical lifts about feeling safe and confirming 2 staff perform transfer.
- Interview nursing staff to ensure they are comfortable in reporting abuse or neglect and if they have any knowledge of an incident or accident not being reported.
- Educate staff on reporting abuse and neglect and following plan of care.
Food Storage and Safety Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During an initial tour of the Food Service Department, several deficiencies were observed. In the dry storage room, a dark dirt path was noted on the white tile floor, and multiple ceiling tiles had brown stains. In the walk-in refrigerator, a pan of thick red sauce was found without a label or date. In the walk-in freezer, a pan of chicken was partially covered with torn plastic wrap, exposing the food to circulating air. Additionally, frozen icicles were hanging from the condenser and drainpipe, dripping onto the shelving unit and forming a patch of ice on the floor. Near the three-compartment sink, a hand sink was observed to have water squirting from the drainpipe onto the wall and floor. These findings were confirmed by the Food Service Director during an interview.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for several residents, as evidenced by issues with the phone system and air conditioning units. Multiple residents, including R70, R87, R51, R75, R23, and R45, reported that their phones were not functioning, as they were plugged in but did not have a dial tone or light up. This issue was confirmed by the Maintenance Director, who acknowledged the ongoing problems with the phone system and mentioned that he was working with corporate to get approval for a replacement. Additionally, there were issues with the air conditioning in the facility. Resident R51 reported that the built-in A/C unit was not working consistently, leading to the installation of a portable unit, which only provided relief when sitting near it. Resident R65 also mentioned that the room temperature varied, often feeling warm, while Resident R141, who shared the room, was content with the portable A/C unit near his bed. Furthermore, a window at the end of the Upper Level North long hall was observed to not close properly, with a screen only covering half of it, allowing a wasp to enter the area.
Inaccurate Documentation of Enteral Feeding and Medication Changes
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for two residents, specifically regarding enteral feeding volume documentation. For one resident, the clinical record inaccurately documented the volume of enteral feeding administered. The physician's order incorrectly stated that one carton of Jevity 1.5 contained 355 ml, when it actually contained 237 ml. This error was perpetuated in the medication administration record (MAR) from July 1 to July 15, 2024. Interviews with staff, including an LPN and the Director of Nursing, confirmed the documentation error, which originated from a misinterpretation of the nutritional information by the Registered Dietitian. Another resident's clinical record lacked documentation of notification regarding a change in medication dosage. The cardiologist reduced the resident's Lasix dosage, but there was no evidence in the clinical record that the resident was informed of this change. The Director of Nursing acknowledged the absence of documentation confirming that the resident was notified about the medication adjustment during the cardiologist's visit.
Failure to Document Resident Participation in Care Plan Meetings
Penalty
Summary
The facility failed to ensure that residents were provided with the right to participate in their care plan meetings, as evidenced by the lack of complete and accurate documentation in the clinical records of six residents. During a resident group meeting, several residents reported that they did not recall attending or being invited to a care plan meeting. The clinical records for these residents indicated that care plan meetings had been scheduled, but there was no documentation of the residents being notified or their responses to the invitations. Additionally, there was no evidence of any discussions that took place during these meetings. Employee E14, a social worker, stated that she verbally notified residents about their care plan meetings and contacted family members if the residents were not alert or oriented. She also mentioned sending letters to residents and their families, but no copies of these letters were available. The lack of documentation in the multidisciplinary notes and Care Plan Meeting Review documents further supports the deficiency, as there was no evidence that residents were given the opportunity to participate in their care plan meetings.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to ensure that physician orders were followed for the administration of pain medication for a resident, identified as Resident R5. The resident was admitted with multiple diagnoses, including malnutrition, cerebral infarction, depression, PTSD, cervical disc disorder, spinal stenosis, and chronic pain. The resident had specific physician orders for Oxycodone to be administered every 12 hours and as needed for severe pain. However, the facility did not administer the medication as ordered on multiple occasions due to a delay in obtaining the necessary prescription from the physician. Interviews and record reviews revealed that the nursing staff did not notify the physician in a timely manner to obtain a new prescription, resulting in the resident experiencing unmanaged pain. The resident reported that her medication was often unavailable, and the Director of Nursing confirmed that the medication was not administered as ordered because the script was not obtained promptly. This deficiency was identified through staff interviews, facility policy review, and clinical record examination.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to accurately record and monitor the weight of a resident, identified as R76, who was admitted with multiple health conditions including failure to thrive, dysphagia, and chronic kidney disease. The facility's policy required weights to be taken upon admission and at specified intervals, with any significant weight change of 5% or more to be retaken the next day and reported to the dietitian. However, the resident experienced a significant weight loss of 13 lbs, or 10.4%, from May 22 to June 5, which was not addressed by the dietitian until six days later. The resident's weight continued to decline, reaching 94.2 lbs on June 26, representing a 25% loss since admission. Despite this, the significant weight loss was not addressed by the dietitian until five days later, and the resident and their responsible party were not informed until six days after the weight was recorded. The dietitian's notes indicated that the weight loss was unplanned, yet interventions were delayed, and the resident's nutritional status was not stabilized or improved in a timely manner. Furthermore, the dietitian later identified the June 26 weight as an outlier and invalidated it 20 days after it was recorded, despite having implemented interventions based on that weight. During an interview, the facility dietitian and regional dietitian could not provide a specific timeframe for addressing significant weight loss, and the facility dietitian cited workload as a reason for the delay. This lack of timely intervention and monitoring contributed to the deficiency in maintaining the resident's nutritional health.
Failure to Conduct Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to complete performance reviews of nurse aides as required, as determined by a review of facility documentation and staff interviews. During the survey, it was found that there was no documentation available for performance reviews of facility staff, including nurse aides. The Director of Nursing (DON), who was responsible for conducting annual performance reviews and nursing staff training, was unable to provide any documentation of such reviews. The Administrator confirmed that there was no process in place to ensure that performance reviews were being completed and used to guide training. Instead, training was guided by events at the facility rather than needs identified through staff evaluations.
Deficiency in Hospice Communication for Resident Care
Penalty
Summary
The facility failed to ensure effective communication between the facility and hospice care agencies for a resident receiving hospice care. The facility's Hospice Program policy, revised in July 2017, mandates that the Social Services Director or designee coordinate care between the facility and hospice staff, including communication with hospice representatives and other healthcare providers. However, the hospice communication log, which is intended to document the services provided by hospice staff to the resident, lacked detailed information about the care and services rendered during visits. The log only recorded the presence of hospice staff without specifying the nature of the care provided. Resident R41, who had multiple diagnoses including dementia, anxiety, diabetes, acute kidney failure, and dysphagia, was receiving hospice care from an outside agency as per physician orders. Despite regular visits from hospice staff, including licensed nurses and nurse aides, the communication log did not reflect any detailed documentation of the services provided. Interviews with facility staff, such as Employee E14, confirmed that while verbal communication occurred, there was no written evidence of the hospice care details being documented for facility staff. This lack of documentation and communication led to the deficiency cited in the report.
Failure to Administer Medications on Time
Penalty
Summary
The facility failed to ensure that medications were administered at the correct times as ordered by the physician for one of the residents reviewed. The facility's policy requires medications to be administered within one hour of their prescribed time. However, the review of Resident R1's clinical records revealed multiple instances where medications were administered significantly later than the prescribed times. For example, Carboxymethylcellulose Sodium Ophthalmic Gel 1% was scheduled for administration every four hours but was often given several hours late on multiple occasions in early May 2024. Additionally, Gabapentin Oral Capsule and Medline Active Liquid were also administered late on several dates in May 2024. The Director of Nursing confirmed these findings during an interview. Resident R1 had diagnoses including disorders of the brain, malignant neoplasm of the brain, hemiplegia and hemiparesis, and severe protein-calorie malnutrition. The failure to administer medications on time as per the physician's orders was a clear deviation from the facility's policy and the physician's instructions, leading to a deficiency in the standard of care provided to the resident.
Failure to Administer and Document Medications Properly
Penalty
Summary
The facility failed to ensure that nursing services met professional standards of quality by documenting on the Medication Administration Record (MAR) that medications were administered to a resident who was at dialysis treatment. Specifically, Resident R2, who had multiple diagnoses including protein-calorie malnutrition, hypertension, and dependence on renal dialysis, was not present in their room when medications were documented as given. An observation revealed two medication cups left on the tray table in Resident R2's room, one containing red liquid and the other orange syrup, while the resident was at dialysis treatment. An interview with the licensed nurse, Employee E3, confirmed that the medications were not administered to Resident R2 as the resident was at dialysis. Despite this, Employee E3 had signed out the medications on the MAR. The Director of Nursing, Employee E2, confirmed that no medication should have been left behind and that medications should not have been signed out without being administered to the resident. This failure to follow proper medication administration protocols is a violation of the Pennsylvania Code Title 49, Professional and Vocational Standards, and the facility's own policies on nursing services.
Failure to Develop Comprehensive Care Plan for Disruptive Resident
Penalty
Summary
The facility failed to complete a comprehensive care plan for Resident CL1, who was admitted with diagnoses including cardiogenic shock and dementia. Despite multiple reports from staff and residents about Resident CL1's disruptive nighttime behaviors, no care plan was developed to address these issues. Interviews with several residents revealed that Resident CL1's screaming at night was disturbing their sleep. Staff interviews confirmed that the disruptive behavior was known and reported, but no formal care plan was created to manage it. Resident CL1's clinical records showed a progress note indicating nighttime agitation and yelling, but this was not reflected in the care plan. The charge nurse and nurse supervisors on different shifts acknowledged the issue and confirmed the absence of a care plan for the disruptive behaviors. The lack of a care plan for Resident CL1's nighttime disruptions was a clear deficiency in meeting the resident's needs and ensuring a peaceful environment for other residents.
Failure to Document Resident's Breathing Difficulty and Assessment
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for Resident R1. The resident, who was admitted after undergoing left hip replacement surgery, had a medical history that included hypertension, diabetes, chronic kidney disease, and the presence of a left artificial hip. On November 30, 2023, Resident R1 reported having difficulty breathing to Employee E3 at 5:30 a.m. Employee E3 assessed the resident by taking vital signs and reported that everything was fine. However, there was no documentation in the resident's nursing notes from November 10, 2023, through November 30, 2023, to show evidence of the resident's complaint or the assessment conducted by Employee E3. During an interview on December 6, 2023, Employee E3 and the Director of Nursing confirmed that no documentation could be produced to show evidence that the resident's report of having trouble breathing or the subsequent assessment was recorded in the clinical record. This failure to document the resident's condition and the assessment conducted is a violation of the facility's policy on Charting and Documentation, which requires that all services provided, changes in condition, and assessments be documented in the resident's medical record to facilitate communication between the interdisciplinary team.
Latest citations in Pennsylvania
Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
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