Kittanning Health & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Kittanning, Pennsylvania.
- Location
- 120 Kittanning Care Drive, Kittanning, Pennsylvania 16201
- CMS Provider Number
- 395986
- Inspections on file
- 30
- Latest survey
- January 9, 2026
- Citations (last 12 mo.)
- 41
Citation history
Health deficiencies cited at Kittanning Health & Rehab Center during CMS and state inspections, most recent first.
The facility did not consistently follow procedures for counting and documenting controlled medications during shift changes, as required by policy. This led to a medication error where a resident with anxiety and depression received two doses of lorazepam in one morning due to poor communication and incomplete documentation between LPNs. Staff interviews confirmed that agency and night shift staff often failed to complete the required counts.
Two residents experienced significant medication errors when one received duplicate doses of lorazepam in the morning due to miscommunication and poor documentation among LPNs, and another was given an incorrect dose of chlordiazepoxide at bedtime on two occasions. Both incidents were identified through record review and staff interviews, with no adverse effects reported for the residents involved.
A resident with prostate cancer did not receive multiple scheduled doses of a prescribed cancer medication due to unavailability, and the physician was not notified of these missed doses as required by facility policy. The DON confirmed there was no documentation of physician notification, despite ongoing issues with medication supply and the resident's refusal to allow family involvement.
A resident with prostate cancer did not receive prescribed Nubeqa for multiple days because the medication was unavailable and the facility was unable to obtain it from the family or pharmacy. The resident, acting as his own responsible party, refused to authorize communication with family members who could supply the medication and did not provide clear instructions to staff, resulting in missed doses.
A resident with a history of prostate cancer did not receive multiple scheduled doses of a prescribed cancer medication because the drug was unavailable. The medication had previously been supplied by a family member, but when this was no longer possible, the resident refused to authorize the facility to coordinate with another family member or to provide direction for obtaining the medication through the facility pharmacy. This resulted in repeated missed doses, as confirmed by the DON.
Kittanning Health and Rehab Center was found deficient in maintaining documentation for annual emergency preparedness training and testing for staff, as required by 42 CFR 483.73. The deficiency was confirmed through a document review and an interview with the maintenance supervisor, revealing a lapse in compliance with regulatory requirements.
The facility did not maintain documentation for the cleaning and testing of carbon monoxide detectors for eight of the past twelve months, as required by PA Act #45. The facility attributed the lack of documentation to destruction caused by a water leak, a fact confirmed by the maintenance supervisor.
The facility did not maintain proper documentation for emergency lighting tests as required by NFPA 101, affecting the entire facility. Missing records included monthly 30-second and annual 90-minute tests, confirmed by the maintenance supervisor.
The facility failed to maintain exit and directional signage as required by NFPA 101 standards. Blinds covered 'NOT AN EXIT' signs on the MIU unit courtyard doors, and the facility lacked documentation for monthly exit sign inspections over the past year. These issues were confirmed by the maintenance supervisor.
The facility did not maintain the fire alarm system as required by NFPA standards. Observations during a survey revealed the fire alarm panel was in 'Service mode' with a 'TROUBLE' message, and the facility lacked documentation for the two-year smoke detector sensitivity testing. These issues were confirmed by the maintenance supervisor.
The facility was found non-compliant with sprinkler system regulations due to dust-covered, dirty, and corroded sprinkler heads in the kitchen dishwashing area. Additionally, the third quarter inspection documentation was unavailable during the survey. The maintenance supervisor confirmed these deficiencies.
The facility did not meet fire drill requirements, lacking documentation for 11 of 12 required drills. A review showed missing records for various shifts across all quarters, attributed to document destruction from a water leak. This was confirmed by the maintenance supervisor.
The facility did not conduct the required annual testing and inspection of non-hospital grade electrical receptacles in resident sleeping rooms. The deficiency was identified during a document review and confirmed by the maintenance supervisor, who acknowledged the absence of documentation for these tests.
The facility failed to maintain documentation for essential generator tests for 10 out of 12 months, affecting the entire facility. Missing records included weekly inspections and monthly tests. The maintenance supervisor confirmed the unavailability of documents, which were reportedly destroyed due to a water leak.
The facility failed to maintain proper emergency preparedness documentation, lacking records of an annual full-scale exercise and a tabletop exercise. This deficiency was confirmed by the maintenance supervisor, indicating a significant gap in the facility's emergency readiness.
The facility failed to maintain two exit discharges. One exit discharge near the time clock room had a snow-covered egress path, and another near the employee lounge lacked panic or fire exit hardware. These issues were confirmed by the maintenance supervisor.
The facility failed to maintain self-closing doors, with seven out of over ten doors not functioning properly. Issues included doors not latching, being propped open, or dragging on the floor. These deficiencies were confirmed by the maintenance supervisor.
The facility failed to maintain its kitchen suppression system, with staff unsure of the hood fire suppression system's manual activation and lacking documentation of required inspections. These deficiencies were confirmed by the maintenance supervisor.
The facility failed to maintain smoke barriers in over thirty rooms due to issues with ceiling tiles. Observations revealed loose, misaligned, damaged, and missing tiles on the main floor, and water damage in the basement from a ruptured pipe. The missing tiles could delay fire system activation and allow smoke passage. The maintenance supervisor confirmed these deficiencies.
The facility was found to be non-compliant with NFPA standards for electrical power cords. A refrigerator in the administrator's office was plugged into a power strip, and another in the soiled utility room was connected to an extension cord. These issues were confirmed by the maintenance specialist.
A facility failed to meet corridor door requirements when a door to a resident's room did not positively latch, as observed by surveyors. The maintenance supervisor confirmed the deficiency, which is crucial for fire safety and smoke containment.
The facility failed to implement proper COVID-19 and Influenza monitoring and testing, affecting numerous residents. Several residents with symptoms were not tested, and staff return-to-work guidelines were not followed. These failures placed all residents in Immediate Jeopardy.
The facility failed to properly store, label, and date food products in the Main Kitchen, creating a potential for foodborne illness. Observations revealed opened bottles of soda, mixed vegetables, sausage patties, and corn flake cereal without proper labeling or dating. The Food Service Director confirmed these deficiencies, highlighting a lapse in adherence to food safety standards.
The facility failed to communicate necessary resident information to receiving health care providers during transfers for three residents with conditions such as Alzheimer's and malnutrition. The lack of documentation for care plan goals, advanced directives, and ongoing care instructions was confirmed by the DON.
The facility failed to notify residents or their representatives of the bed-hold policy during hospital transfers, as required by regulations. Three residents were transferred to the hospital and returned without documented evidence of receiving the necessary notifications. The Director of Nursing confirmed this oversight.
The facility failed to document medication regimen reviews for three residents, as required by policy. Despite pharmacist notes indicating irregularities, the facility could not provide the necessary reports for residents with various diagnoses, including dementia and bipolar disorder. The Director of Nursing confirmed the lack of documentation.
The facility failed to properly store medications, with insulin pens not bagged on a medication cart, an unlocked cart with aspirin and Vitamin D3 left unattended, and expired items in a medication room. These issues were confirmed by staff, including an LPN and the DON.
A facility failed to ensure complete and accurate medical records for three residents. One resident had a physician's order for nifedipine without a diagnosis, another for gabapentin, and a third for cefazolin, all lacking corresponding diagnoses. The RNAC confirmed the facility's frequent failure to select appropriate diagnoses, leading to confusion due to the multiple uses of some drugs.
A facility failed to ensure a call bell was within reach for a resident, who was at risk for falls and had poor safety awareness. The resident, admitted with conditions including hypertension and polyneuropathy, was found in distress without access to the call bell, contrary to the care plan and facility policy.
A facility failed to provide a resident with the opportunity to formulate an advance directive, as required by policy. Despite the resident's admission and existing health conditions, there was no documentation in the clinical record to show that this opportunity was provided, which was confirmed by the Social Services Director.
A facility failed to maintain a safe, clean, and homelike environment for a resident, as observed by a red substance on the resident's bed and floor. An LPN confirmed the deficiency, highlighting a lapse in meeting the required standards.
A resident with dementia and depression was involved in a resident-to-resident abuse incident where they were hit by another resident. Despite the facility's policy requiring immediate reporting of such incidents, the event was not reported to the State Agency until over two weeks later. The Nursing Home Administrator confirmed the failure to report the incident in the required timeframe.
A facility failed to ensure the accuracy of MDS assessments for a resident who was ordered to receive hospice services. Despite a physician's order for hospice care, the resident's MDS assessment inaccurately indicated that they were not receiving such care. This discrepancy was confirmed by the RN Assessment Coordinator.
A resident with high blood pressure, Bipolar Disorder, and dementia exhibited significant behavioral issues, including inappropriate language and aggression, which were not addressed in their care plan until much later. Despite documented incidents of exit-seeking behavior, inappropriate requests, and aggression, the care plan lacked specific goals and interventions until January 2025. The Nursing Home Administrator confirmed the facility's failure to update the care plan in a timely manner.
The facility failed to provide an ongoing program of activities to support residents' well-being for four out of five weeks due to a COVID-19 outbreak. Residents reported a lack of activities and confinement to their rooms, leading to boredom. Staff confirmed that group activities were suspended without modifications for social distancing, failing to meet regulatory requirements.
The facility failed to monitor and document wound care for two residents. One resident's abdominal wound was not consistently documented, leading to a lack of proper monitoring. Another resident had unclear physician orders for wound care, resulting in confusion about treatment application. These deficiencies were confirmed by facility staff.
Two residents in the facility did not receive proper treatment and monitoring for pressure ulcers. One resident did not have required weekly wound assessments documented for two weeks, despite having a care plan in place. Another resident had physician orders for wound care that lacked specificity regarding which wound or body area the treatments were for, leading to potential confusion. These deficiencies were confirmed by facility staff.
A facility failed to assess a resident for smoking safety, as required by policy. The resident, who was documented as a non-smoker, was found to be a smoker with nicotine dependence. Interviews confirmed the resident smokes three times daily, highlighting the facility's failure to accurately assess and document the resident's smoking status, which is crucial for ensuring safety measures are in place.
A resident with end-stage renal disease experienced a significant weight gain, and the facility failed to notify the physician as required by policy. Additionally, the resident's medication order for cinacalcet was not entered correctly, leading to a lapse in ensuring proper dialysis care and medication management.
The facility failed to conduct timely physician visits for two residents. One resident did not receive a physician visit for 232 days, violating the required frequency of visits. Another resident's initial visit was conducted by a CRNP instead of a physician, as required.
A facility failed to properly reconcile controlled drugs for a resident who had ceased to breathe. Despite the facility's policy requiring immediate documentation and removal of discontinued medications, the morphine solution prescribed to the resident was not documented as disposed of until three days after the resident's death. This failure was confirmed by the Regional Director of Clinical Services.
The facility failed to ensure that residents' medication regimens were free from unnecessary psychotropic medications. Two residents were affected, with one lacking documentation of the consultant pharmacist's reports and the other having unspecified conditions for prescribed medications. Interviews confirmed the facility's failure to maintain necessary documentation and identify specific treatment conditions.
The facility exceeded the acceptable medication error rate, reaching 6.67% due to two errors. An LPN administered Potassium phosphate late to a resident, and another LPN failed to provide a multivitamin to a different resident due to it being out of stock. The Nursing Home Administrator confirmed these deficiencies.
A facility failed to obtain a diagnosis and order for hospice services and to coordinate hospice services with facility services for a resident requiring end-of-life care. The resident's care plan lacked necessary hospice contact information and instructions, and a hospice admission order form was unsigned by a physician. This was confirmed by facility staff, highlighting a deficiency in meeting the resident's end-of-life care needs.
The facility did not conduct Quality Assessment and Assurance (QAA) meetings quarterly with all required members from January to March 2024. The Nursing Home Administrator was absent from the QAPI Committee meetings, violating the facility's policy and regulatory requirements.
A resident with Parkinson's disease and other conditions fell and pulled out his G-tube, leading to hospitalization. The facility did not notify the State Agency of this incident, as required by regulations. The DON confirmed the failure to report.
The facility failed to include a community member in its Infection Control Meetings for one quarter, as required by the MCARE Act. This omission was confirmed by the Nursing Home Administrator, indicating non-compliance with the mandated multidisciplinary committee composition.
The facility failed to meet the required nurse aide staffing levels, with shortages during day, evening, and night shifts over a 21-day period. The Nursing Home Administrator confirmed the deficiency, noting the absence of additional higher-level staff to compensate for the shortfall.
The facility failed to meet the required LPN staffing levels as per the regulation effective July 1, 2023. On one day, the day shift was understaffed with 3.19 LPN FTE present instead of the required 3.88 for 97 residents. The evening shift on the same day had 8.00 LPN FTE present instead of the required 8.82. The night shift was particularly affected, with staffing shortages on 13 out of 21 days, where the number of LPN FTE present consistently fell short of the required numbers for the census on those days.
The facility failed to provide the required number of LPNs per resident during various shifts and did not meet the minimum 3.2 hours of direct resident care per resident in a 24-hour period on multiple days. This was confirmed through a review of nursing schedules and census data, revealing consistent shortfalls in nursing care hours.
Failure to Accurately Account for and Administer Controlled Medications
Penalty
Summary
The facility failed to implement and follow procedures for the accurate accounting of controlled medications on two medication carts, as required by facility policy. Review of controlled substance count logs revealed that on multiple occasions, both oncoming and outgoing nurses did not sign the verification sheets during shift changes to confirm the counts of controlled drugs. This lapse was confirmed by staff interviews, with LPNs noting that agency and night shift staff often neglected to complete the required counts and documentation. Additionally, the facility failed to ensure the accurate administration of medications, resulting in a medication error for one resident. The resident, who had diagnoses of anxiety, depression, and a history of falls, was prescribed lorazepam 0.5 mg three times daily. On one occasion, the resident received two doses of lorazepam in the morning—once at 7:00 a.m. and again at 10:00 a.m.—due to a lack of communication and documentation between shifts. The error was discovered when staff realized the medication had been signed out and administered twice, with no clear record of the first administration or proper handoff between nurses. Staff interviews and witness statements indicated confusion and lack of clarity during shift changes, with one LPN admitting uncertainty about whether the medication was actually given. The incident was documented in the resident's clinical record, and the nursing home administrator confirmed the facility's failure to follow procedures for controlled medication accounting and administration, resulting in the identified medication error.
Failure to Prevent Significant Medication Errors for Two Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by incidents involving two residents. For one resident with diagnoses of anxiety, depression, and a history of falls, a physician order required lorazepam 0.5 mg to be administered three times daily. On one occasion, the resident received lorazepam twice in the morning—once at 7:00 a.m. and again at 10:00 a.m.—due to miscommunication and lack of proper documentation between LPNs on different shifts. The narcotic log and witness statements revealed confusion regarding whether the medication had been administered, with one nurse unsure if she had given the dose and another not noticing the duplication until the end of her shift. There was also a lack of documentation in the electronic medical record and no report from the midnight shift nurse regarding unscheduled or PRN medication administration. Another resident with depression, anxiety, and chronic pain had physician orders for chlordiazepoxide 10 mg in the morning and 5 mg at bedtime. On two consecutive days, the resident was given 10 mg at bedtime instead of the prescribed 5 mg. This error was identified after a review of the medication administration records, and both the CRNP and the resident's representative were notified. In both cases, the residents did not exhibit adverse effects from the medication errors. The Nursing Home Administrator confirmed that the facility did not ensure residents were free from significant medication errors for these two residents.
Failure to Notify Physician of Missed Cancer Medication Doses
Penalty
Summary
The facility failed to ensure that a physician was appropriately notified of multiple missed medication doses for a resident with a history of prostate cancer, high blood pressure, and depression. The resident had a physician order for Nubeqa, a medication used to decrease the growth and spread of prostate cancer, to be administered twice daily. Review of the Medication Administration Record showed that the medication was not administered over several consecutive days due to it being unavailable, with documentation indicating reasons such as the medication being reordered but not yet arrived, family to provide, or simply unavailable. On one occasion, the medication was not administered due to resident refusal. Despite the ongoing unavailability of the medication, there was no documentation that the physician was notified of the missed doses, as confirmed by the Director of Nursing. Facility policy required immediate action to obtain unavailable medications and to notify the physician and resident/family when there was a need to alter medical treatment, including changes in provider orders. The resident was his own responsible party and had declined to allow the facility to communicate with his brother regarding the medication, further complicating the situation. However, the lack of physician notification regarding the missed doses constituted a failure to follow facility policy and regulatory requirements.
Failure to Provide Physician-Ordered Medication Due to Supply and Communication Issues
Penalty
Summary
The facility failed to provide a prescribed cancer medication, Nubeqa, as ordered by the physician for a resident with a history of prostate cancer, high blood pressure, and depression. According to the Medication Administration Record, the medication was not administered on multiple occasions over several days due to it being unavailable. Documentation indicated that the medication was to be supplied by the resident's family, but there were repeated notations that it had not arrived or was unavailable. The facility's policy requires staff to take immediate action to obtain medications from the pharmacy or seek alternate physician orders if the medication cannot be obtained, but this was not documented as having occurred. Interviews with the DON revealed that the resident's brother had previously supplied the medication out-of-pocket, but was no longer able to do so. Another family member was willing to assist, but the resident, who is his own responsible party, refused to allow the facility to communicate with his brother regarding his care. The resident also did not provide clear direction to the facility on how to proceed with obtaining the medication, and at times refused to discuss the matter. As a result, the facility did not provide the medication as ordered for an extended period.
Failure to Prevent Significant Medication Error Due to Unavailable Cancer Medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of Nubeqa, a medication prescribed to decrease the growth and spread of prostate cancer. The resident, who had diagnoses including high blood pressure, depression, and a history of prostate cancer, had a physician's order for Nubeqa 600 mg by mouth twice daily. Review of the Medication Administration Record for April showed that the medication was not administered on multiple occasions due to it being unavailable, with documentation indicating issues such as the medication not arriving, the family being responsible for supply, and ongoing unavailability. Interviews with the Director of Nursing revealed that the resident's brother had previously provided the medication out-of-pocket, but was no longer able to do so. Although another family member was willing to assist, the resident, who is his own responsible party, refused to allow the facility to communicate with his brother or provide direction on how to obtain the medication through the facility's pharmacy. As a result, the resident missed numerous doses of the prescribed cancer medication over several days, constituting a significant medication error as required by facility policy and state regulations.
Deficiency in Emergency Preparedness Training Documentation
Penalty
Summary
Kittanning Health and Rehab Center was found to have a deficiency related to emergency preparedness training and testing as per the requirements of 42 CFR 483.73. During an emergency preparedness survey conducted on January 22, 2025, it was discovered that the facility failed to provide documentation proving that all staff had received the required annual emergency preparedness training and testing within the previous twelve months. This lack of documentation was confirmed during an interview with the maintenance supervisor. The deficiency was identified through a document review and an interview conducted on the same day. The absence of documentation indicates that the facility did not adhere to the regulatory requirement to maintain an updated emergency preparedness training and testing program. This oversight suggests a lapse in ensuring that staff are adequately prepared for emergency situations, although the report does not specify any immediate consequences or risks resulting from this deficiency.
Plan Of Correction
The Emergency Preparedness Plan (EPP) was reviewed and updated as necessary. The Emergency Preparedness Plan is to be reviewed and updated at least annually based on the most recent documented, facility-based and community-based risk assessment using an all-hazards approach. NHA/designee to complete annual full-scale exercise/table-top exercise by 21MAR2025. NHA/designee to educate all staff by 21MAR2025 on the Emergency Preparedness Plan and annual testing requirements to ensure a comprehensive understanding of policies and procedures and staff readiness. RVPO/designee to educate NHA by 21MAR2025 on the requirements of Emergency Preparedness Plan Guidelines and staff annual EPP training requirements. To prevent this from recurring, RVPO will complete annual audits on facility EPP to ensure current updated version. Negative findings will be addressed. Ad Hoc education will be provided. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendation.
Failure to Maintain Carbon Monoxide Detector Records
Penalty
Summary
The facility failed to comply with the requirements for testing and cleaning carbon monoxide detectors as mandated by PA Act #45. During a document review on January 22, 2025, it was discovered that the facility did not have documentation to confirm that the carbon monoxide detectors had been cleaned or tested for eight of the previous twelve months. The facility claimed that the documents were destroyed due to a water leak. This deficiency was confirmed during an interview with the maintenance supervisor on the same day.
Plan Of Correction
Maintenance immediately cleaned and tested carbon monoxide detectors throughout the building and documented the results. Maintenance completed an audit of carbon monoxide detectors throughout the facility to ensure function and documented with no negative findings. NHA/Designee to educate Maintenance department by 21MAR2025 on the importance of maintaining proper service records for cleaning/testing of carbon monoxide detectors. To prevent this from recurring, Maintenance will perform weekly x4 audits on carbon monoxide detectors for cleanliness and function. Negative findings will be addressed. Ad Hoc education will be provided. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Failure to Maintain Emergency Lighting Documentation
Penalty
Summary
The facility failed to maintain emergency lighting in compliance with NFPA 101 regulations, affecting the entire facility. During a document review, it was found that the facility could not provide documentation for the required emergency lighting tests over the previous 12 months. Specifically, the facility lacked records for monthly 30-second testing and annual 90-minute testing. This deficiency was confirmed through an interview with the maintenance supervisor.
Plan Of Correction
A. Monthly 30-second testing Maintenance performed emergency 30-second lighting test and documented testing results. Maintenance will maintain monthly audit of 30-second lighting testing and documentation. NHA/Designee to educate Maintenance staff by 21MAR2025 on emergency lighting 30-second testing and maintaining documentation. Maintenance Director/Designee to complete monthly x3 audit of emergency lighting test documentation. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. B. Annual 90-min testing Maintenance will complete 90 minute annual testing by 3/21/25 and document. Maintenance will complete annual testing thereafter. NHA/Designee will educate maintenance staff by 21MAR2025 on emergency lighting 90-min testing and documenting annually to remain in compliance. NHA/Designee to complete routine audits of maintenance documentation records. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Deficiency in Exit Signage Maintenance
Penalty
Summary
The facility failed to maintain proper exit and directional signage throughout the building, as required by NFPA 101 standards. During a survey conducted on January 22, 2025, it was observed that the MIU unit courtyard doors had blinds covering the 'NOT AN EXIT' signs, obstructing visibility. Additionally, the facility was unable to provide documentation for monthly exit sign inspections for the previous 12 months. These deficiencies were confirmed during an interview with the maintenance supervisor on the same day.
Plan Of Correction
A. MIU Courtyard Door: Maintenance immediately removed all blinds that were covering courtyard "NOT AN EXIT" sign. Maintenance completed exit sign inspection and documented findings. No additional negative findings. NHA/Designee to educate maintenance staff by 21MAR2025 on exit signage visibility. Maintenance/designee will complete weekly x 4 audits of exit signage to ensure proper display. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. B. Facility couldn't provide documentation for monthly 12 month exit sign inspection: Maintenance performed immediate exit sign inspection and documented findings. Maintenance will keep proper documentation for monthly exit sign inspection. NHA/Designee will educate Maintenance staff by 21MAR2025 on exit sign inspection and documentation. NHA/Designee will complete exit sign inspection documentation audits monthly x 3 audits to ensure proper inspection and documentation. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Fire Alarm System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain and test the fire alarm system in compliance with NFPA 70 and NFPA 72 standards. During a survey conducted on January 22, 2025, it was observed that the fire alarm panel displayed a message indicating 'Service mode, System being service, TROUBLE,' suggesting an issue with the system's operational status. Additionally, the facility was unable to provide documentation of the required two-year smoke detector sensitivity testing. These deficiencies were confirmed through an interview with the maintenance supervisor on the same day.
Plan Of Correction
A. Fire Alarm Panel "Trouble": Maintenance director immediately contacted Alti Protection to perform service on fire alarm panel and clear service mode. NHA/Designee to educate maintenance staff by 21MAR2025 on the fire control panel and service documentation. Maintenance Director/designee will audit monthly x 3. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. B. Sensitivity Test: Maintenance director obtained the 2 year sensitivity smoke detectors test from 3/25/2024.
Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to comply with sprinkler system regulations as evidenced by observations and document reviews. During a survey, it was noted that the sprinkler heads in the kitchen dishwashing area were dust-covered, dirty, and corroded. Additionally, the documentation for the third quarter sprinkler system inspection was not available at the time of the survey. An interview with the maintenance supervisor confirmed these deficiencies, indicating a lapse in the maintenance and testing of the facility's sprinkler system.
Plan Of Correction
A. Kitchen Sprinkler Heads Dust-covered maintenance cleaned kitchen sprinkler heads identified. Maintenance completed audit of whole house sprinkler heads, cleaned the sprinkler heads of dust and changed escutcheons as needed. NHA/Designee to educate maintenance staff by 21MAR2025 on importance of dust free, corrosion free sprinkler heads/escutcheons. Maintenance to complete weekly x4 audits of kitchen sprinklers. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. B. 3rd Quarter Sprinkler Documentation Maintenance immediately completed sprinkler head audit. Maintenance will maintain documentation of inspections. NHA/Designee to educate maintenance staff by 21MAR2025 on the importance of completing sprinkler maintenance and maintaining inspection documentation. NHA/designee will complete quarterly x3 documentation audit to ensure sprinkler system maintenance documentation is complete. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the quarterly audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Fire Drill Documentation Deficiency
Penalty
Summary
The facility failed to meet the fire drill requirements as evidenced by the lack of documentation for 11 out of the 12 required fire drills. The document review conducted on January 22, 2025, revealed that the facility did not have records for the first shift during the second, third, and fourth quarters, and for the second and third shifts for all four quarters. The facility explained that the documents were destroyed due to a water leak. This deficiency was confirmed during an interview with the maintenance supervisor on the same day.
Plan Of Correction
Fire Drill conducted immediately following the safety survey. No negative findings identified. NHA/designee to educate maintenance staff by 21MAR2025 on the fire drill schedule to ensure fire drills are conducted on each shift quarterly. NHA/designee will monitor the fire drills and fire drill documentation quarterly x 3 to ensure they are being done on varying shifts. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Failure to Test Electrical Receptacles Annually
Penalty
Summary
The facility failed to perform an annual test and inspection on non-hospital grade electrical receptacles in resident sleeping rooms throughout the entire facility. This deficiency was identified during a document review and interview conducted on January 22, 2025. The review revealed that electrical receptacles in resident care rooms were not tested at intervals not exceeding 12 months, as required. The testing should have included a visual inspection of physical integrity, verification of correct polarity of the hot and neutral connections, and ensuring the retention force of the grounding blade was not less than 115g (4 oz). An interview with the maintenance supervisor confirmed the lack of documentation for these tests.
Plan Of Correction
Maintenance immediately tested electrical receptacles. Maintenance to monthly testing of electrical receptacles and maintain documentation according to compliance. NHA/Designee to educate maintenance staff by 21MAR2025 about annual receptacle testing and maintaining proper documentation. NHA/designee to audit monthly x3 for electrical receptacle testing and documentation. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Failure to Maintain Emergency Generator Documentation
Penalty
Summary
The facility failed to maintain the emergency generator, which affects the entire facility. During a document review on January 22, 2025, it was revealed that the facility did not provide documentation for essential generator tests for 10 out of 12 months, specifically from March to December. The missing documentation included records of weekly visual inspections and battery voltage or electrolyte levels, as well as monthly specific gravity or conductance tests, 30-minute load runs, and transfer switch tests. The maintenance supervisor confirmed during an interview on the same day that the test documentation was unavailable at the time of the survey. The facility stated that the documents were destroyed due to a water leak, which contributed to the lack of available records. This deficiency indicates a failure to adhere to the required maintenance and testing protocols for the emergency generator, as outlined by NFPA standards.
Plan Of Correction
A. Weekly visual/inspection and battery: Maintenance initiated immediate inspection of battery and voltage test, documenting findings. Maintenance will continue to document weekly inspections. NHA/Designee will educate maintenance staff by 21MAR2025 on importance of maintaining proper documentation and electric system maintenance and testing. Maintenance director/designee will conduct weekly x4 inspections of battery and voltage test and documentation. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. B. Monthly Specific gravity or conductance 30-min load run and transfer switch. Maintenance completed 30-minute load run specific conductance test and documented results. Maintenance to conduct monthly 30-min load run tests, results to be documented and kept on file. NHA/Designee will educate maintenance staff by 21MAR2025 on requirements to do 30-min load run and transfer switch testing monthly and document results to ensure proper function and compliance. Maintenance will complete monthly x 3 audit to remain in compliance. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Failure to Maintain Emergency Preparedness Documentation
Penalty
Summary
The facility failed to maintain proper emergency preparedness guidelines as required by regulatory standards. During a document review conducted on January 22, 2025, it was discovered that the facility did not have records of conducting an annual full-scale exercise, testing, evaluating, and performing a tabletop exercise for their emergency preparedness plan. This lack of documentation indicates that the facility did not adhere to the necessary protocols to ensure readiness in the event of an emergency. The deficiency was confirmed through an interview with the maintenance supervisor on the same day. The supervisor acknowledged the absence of documentation, which further substantiates the facility's failure to comply with the emergency preparedness requirements. This oversight suggests a significant gap in the facility's ability to effectively respond to potential emergencies, as they have not demonstrated the necessary preparedness through documented exercises and evaluations. The lack of a tabletop exercise, in particular, highlights a critical area where the facility did not meet the expected standards. Tabletop exercises are essential for facilitating group discussions and problem-solving in a simulated emergency scenario, which helps in identifying potential weaknesses in the emergency plan. The absence of such exercises means that the facility has not fully tested its emergency procedures, potentially compromising the safety and well-being of its residents and staff.
Plan Of Correction
The Emergency Preparedness Plan (EPP) was reviewed and updated as necessary. The Emergency Preparedness Plan is to be reviewed and updated at least annually based on the most recent documented, facility-based and community-based risk assessment using an all-hazards approach. NHA/designee to complete annual full-scale exercise/table-top exercise by 21MAR2025. NHA/designee to educate all staff by 21MAR2025 on the EPP to ensure a comprehensive understanding of policies and procedures to ensure staff readiness. RVPO/designee to educate NHA by 21MAR2025 on the requirements of Emergency Preparedness Plan Guidelines. To prevent this from recurring, RVPO will complete annual audits on facility EPP to ensure current updated version. Negative findings will be addressed. Ad Hoc education will be provided. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendation.
Egress Discharge Deficiencies
Penalty
Summary
The facility failed to maintain the egress discharges at two of six exit discharges, as observed and confirmed during a survey. At 8:49 a.m., the exit discharge door near the time clock room was found with an exterior egress path that was not maintained and was snow-covered. Additionally, at 8:56 a.m., the exit discharge door near the employee lounge was found lacking panic or fire exit hardware. These deficiencies were confirmed through an interview with the maintenance supervisor.
Plan Of Correction
A. Discharge door not maintained: Maintenance immediately removed snow from the sidewalk from the exit discharge door near the time clock area. Maintenance completed an audit of all exit discharge doors to ensure clear egress. NHA/designee educated maintenance staff by 21MAR2025 on snow removal policy. Maintenance will complete snow removal of discharge exit doors as per policy whenever weather occurs. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. B. Discharge door failed to be equipped with panic or fire exit hardware: Maintenance replaced panic bar hardware on the exit door near the employee lounge. Maintenance completed an audit of all exit doors to ensure proper function. NHA/designee educated maintenance staff by 21MAR2025 on proper exit door function and maintenance. To prevent this from recurring, maintenance will perform weekly audits on exit door hardware/function and document. Negative findings will be addressed. Ad Hoc education will be provided. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Failure to Maintain Self-Closing Doors
Penalty
Summary
The facility failed to maintain doors with self-closing devices, as observed during a survey on January 22, 2025. Seven out of over ten doors were found to have deficiencies. Specifically, the laundry wet/dry room door did not positively latch in the frame, and the laundry wet room door was propped open. The laundry soiled utility room door failed to close and was dragging on the floor. Additionally, the kitchen door to the exterior and the kitchen dishwashing door both failed to close and latch in the frame. Furthermore, the Unit 1 fire door near resident room #127 and the Unit 2 corridor fire door also failed to latch in the frame. These deficiencies were confirmed in an interview with the maintenance supervisor.
Plan Of Correction
A. Laundry wet/dry room failed to latch: Maintenance replaced door handle to properly latch in laundry wet/dry room. Maintenance did audit of all self-closing device doors to ensure proper door latch function. NHA/designee to educate maintenance department by 21MAR2025 on the importance of ensuring door handles are operating properly. To prevent this from recurring, Maintenance will perform weekly x 4 audits on door latch function. Negative findings will be addressed. Ad Hoc education will be provided. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. B. Laundry wet room door propped open: Maintenance immediately removed the cart from the open laundry/wet room door. Maintenance did a whole house audit making sure no doors being propped open. Maintenance/designee to educate staff by 21MAR2025 on importance of not using items to hold doors open and having doors remain securely closed. To prevent this from recurring, Maintenance will perform weekly x 4 audits to ensure doors are not being propped open. Negative findings will be addressed. Ad Hoc education will be provided. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. C. Laundry soiled utility room failed to close/dragging: Maintenance adjusted laundry soiled utility room door to not drag on the floor and ensured properly closing. Maintenance completed an audit on all doors to ensure laundry soiled doors are closing properly. NHA/designee to educate maintenance staff by 21MAR2025 on importance of proper closure of all doors. To prevent this from recurring, Maintenance will perform weekly audits to ensure all doors are closing properly. Negative findings will be addressed. Ad Hoc education will be provided. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. D. Kitchen door to exterior failed to close and latch: Maintenance installed a magna lock with keypad to secure exterior kitchen door. Maintenance completed audit on all doors to ensure exterior kitchen door closed and latched properly. NHA/designee to educate maintenance staff by 21MAR2025 on importance of proper closure and latch of all exit doors. To prevent this from recurring, Maintenance will perform weekly audits to ensure proper closure and latching of doors. Negative findings will be addressed. Ad Hoc education will be provided. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. E. Kitchen dishwashing door failed to close and latch in frame: Maintenance adjusted kitchen dishwashing room door to close and latch properly. Maintenance completed audit on all doors to ensure closing and latch properly. Maintenance/designee will educate kitchen staff by 21MAR2025 on importance of ensuring proper closure and latching of all doors. To prevent this from recurring, Maintenance will perform weekly x4 audits to ensure entry and exit doors are closing and latching. Negative findings will be addressed. Ad Hoc education will be provided. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. F. Unit 1 Fire Door near #127 failed to latch in frame: Maintenance adjusted Unit 1 fire door to ensure door closed and latched properly. Maintenance completed audit on all fire doors to ensure closing and latching properly. NHA/Designee to educate maintenance staff by 21MAR2025 on importance of doors closing properly. Maintenance will do weekly x4 audit on all fire doors to ensure closing and latching properly. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. G. Unit 2 Fire Door failed to latch in frame: Maintenance adjusted Unit 2 fire door to ensure closed and latched properly. Maintenance completed audit on all fire corridor doors to ensure closing and latching properly. NHA/Designee to educate maintenance staff by 21MAR2025 on importance of doors closing properly. Maintenance will do weekly x 4 audits on all unit entry and exit fire doors to ensure closing and latching properly. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Deficiencies in Kitchen Suppression System Maintenance
Penalty
Summary
The facility failed to maintain cooking equipment in its kitchen, as evidenced by deficiencies in the kitchen suppression system. During an observation, document review, and interview, it was found that kitchen staff were uncertain about the location and operation of the hood fire suppression system's manual activation. Additionally, the facility could not provide documentation that the kitchen suppression system had been inspected twice in the previous year, as required. These deficiencies were confirmed during an interview with the maintenance supervisor.
Plan Of Correction
A. Kitchen staff uncertain of hood fire suppression Dietary Director immediately educated dietary staff on the location and proper operation of hood fire suppression system. Dietary Director/Designee to complete education to kitchen/dietary staff by 21MAR2025 to ensure certainty of location and operation of the hood fire suppression systems manual activation. Dietary Manager/Designee to complete annual educations ensuring dietary staff are aware of kitchen equipment and safety. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. B. Hood Suppression Inspection 2x in prior year. Maintenance to schedule and complete hood suppression inspection and document per maintenance schedule. Maintenance to obtain and maintain documentation and have it readily available by 21MAR2025. NHA/Designee to educate staff by 21MAR2025 on importance of completing hood suppression 2x per year and obtaining proper documentation. NHA/Designee to audit hood suppression inspection documentation monthly every 6 months. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Smoke Barrier Deficiencies Due to Ceiling Tile Issues
Penalty
Summary
The facility failed to maintain smoke barriers in over thirty rooms, affecting the entire component. During an observation conducted on January 22, 2025, between 8:45 a.m. and 10:15 a.m., it was noted that multiple ceiling tiles on the main floor were not properly maintained. These tiles were found to be loose, misaligned, damaged, or missing in various locations. Additionally, five rooms in the basement area were impacted by a recently frozen and ruptured pipe, which caused water damage to numerous ceiling tiles. The damaged tiles were removed to address the water damage and to facilitate repairs to the piping. The absence of these ceiling tiles could potentially delay the activation of fire system components and allow smoke to pass through. The maintenance supervisor confirmed these deficiencies during an interview at the time of the survey.
Plan Of Correction
Maintenance replaced damaged and deficient ceiling tiles. Maintenance completed a whole house audit to identify deficient ceiling tiles. NHA/Designee to educate maintenance staff by 21MAR2025 on the importance of ceiling tiles to ensure proper function for smoke barrier. Maintenance/designee to complete audits weekly x 4 of ceiling tiles. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. Fire Drill conducted immediately following the safety survey. No negative findings identified.
Improper Use of Electrical Power Cords
Penalty
Summary
The facility failed to maintain proper use of electrical power cords, as observed during a survey on January 22, 2025. Two specific deficiencies were noted: first, a refrigerator in the administrator's office was plugged into a power strip, which was subsequently removed during the survey. Second, a refrigerator in the soiled utility room on Unit 1 was found to be plugged into an extension cord. These observations were confirmed through an interview with the maintenance specialist, indicating non-compliance with the relevant NFPA standards regarding the use of power strips and extension cords.
Plan Of Correction
A. Refrigerator plugged into power strip in ADMIN office: Refrigerator immediately unplugged from power strip and plugged into wall; power strip removed from administrator's office. Maintenance completed whole house audit for power strip, no additional findings. NHA/Designee will be educating maintenance staff by 21MAR2025 on regulations regarding power strips. Maintenance will complete audits weekly x 4 the building for power strips, addressing negative findings immediately. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. B. Unit 1 Soiled Rm. Refrigerator plugged into extension cord: Refrigerator immediately unplugged from extension cord and plugged into wall; extension cord removed from Unit 1 soiled utility room. Maintenance completed whole house audit for extension cords, no additional findings. NHA/Designee will be educating maintenance staff by 21MAR2025 on regulations regarding extension cords. Maintenance will complete audits weekly x 4 throughout the building for extension cords, addressing negative findings immediately. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Corridor Door Latching Deficiency
Penalty
Summary
The facility failed to meet the corridor door requirements as outlined by NFPA 101 and CMS regulations. During an observation on January 22, 2025, it was noted that the door to resident room #129 did not positively latch in the frame. This deficiency was identified as a failure to comply with the requirement that corridor doors must resist the passage of smoke and have positive latching hardware, especially in fully sprinklered smoke compartments. The maintenance supervisor confirmed the deficiency during an interview conducted at the same time as the observation. The report does not provide additional details about the resident in room #129 or any specific medical history or condition. The focus of the deficiency is on the physical infrastructure of the facility, specifically the corridor door's inability to latch properly, which is a critical component of fire safety and smoke containment in the facility.
Plan Of Correction
Maintenance immediately adjusted room 129 door to ensure closure and latch properly. Maintenance audited all resident doors to ensure doors were operating correctly. Maintenance director/designee to educate maintenance staff by 21MAR2025 on importance of proper door closure. Maintenance Director/designee will do weekly x4 audit of all resident room doors to make sure that doors are closing and latching correctly. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Failure in Infection Control Protocols
Penalty
Summary
The facility failed to implement adequate COVID-19 and Influenza monitoring, tracking, and testing in accordance with state and federal guidance, affecting 95-101 residents over a period from late November to mid-January. The facility did not adhere to the required protocols for identifying and managing outbreaks, which included failing to conduct timely testing and monitoring of residents and staff for symptoms of these illnesses. This oversight placed all residents in an Immediate Jeopardy situation. Several residents with symptoms consistent with COVID-19 and Influenza were not properly monitored or tested. For instance, a resident who tested positive for COVID-19 at the hospital was not accurately tracked by the facility, and another resident with a cough was not tested for Influenza despite exhibiting symptoms. Additionally, the facility's COVID tracking log was inaccurate, and there was a failure to test residents on the required days following exposure. The facility also failed to follow return-to-work guidelines for staff who tested positive for COVID-19. An Infection Preventionist returned to work before the recommended period had elapsed, contrary to the guidelines. Furthermore, the facility did not update signage to reflect the ongoing Influenza outbreak, which was confirmed by multiple positive cases among residents and staff. These lapses in protocol and communication contributed to the Immediate Jeopardy situation.
Plan Of Correction
1. Infection Control Policies and Procedures were updated and are current as of 16JAN2025 to include guidance related to COVID-19 and Flu from CMS, the Center for Disease Control and PA DOH. 2. To prevent reoccurrence, Infection Preventionist, DON/Designee will conduct routine walking rounds to monitor proper use of personal protective equipment and to ensure infection control procedures are followed in accordance with PA DOH COVID 19 Infection Control and Outbreak Response Toolkit for Long Term Care. 3. The DON/designee will complete education by 11FEB2025 with all staff to include use of personal protective equipment (PPE), prevention, identification, and monitoring of signs and symptoms of COVID-19 and Flu in accordance with PA DOH COVID 19 Infection Control and Outbreak Response Toolkit for Long Term Care. 4. The DON/designee will complete education by 11FEB2025 with all staff to include proper co-horting protocol, proper social distancing and how to communicate with residents to encourage compliance with guidance related to COVID-19 and Flu PA DOH Infection Control and Outbreak Response Toolkit for Long Term Care. 5. The DON/designee will complete education by 11FEB2025 with all clinical staff on storage and transportation of soiled linens, sharps containers, and biohazard material per facility policy. 6. The DON/Designee will complete education by 11FEB2025 with all clinical staff on proper handwashing procedure, including the use of alcohol-based sanitizers. 7. The DON/Designee will ensure education by 11FEB2025 with all staff on return-to-work guidelines related to COVID-19 and Flu PA DOH Infection Control and Outbreak Response Toolkit for Long Term Care. 8. DON/Designee will conduct audits to monitor for completion of Day 1 testing for positive COVID results, daily x 5 days for 14 days, then weekly for 4 weeks then monthly x2. 9. To prevent reoccurrence, DON/Designee will conduct ongoing monitoring for COVID positive staff and monitor return to work status, once a week x2 weeks, monthly x 2 with outbreak occurrence in accordance with PA DOH COVID 19 Infection Control and Outbreak Response Toolkit for Long Term Care by 1/16/25. 10. To prevent reoccurrence, DON/Designee will conduct ongoing monitoring for Influenza signs and symptoms and testing, weekly with occurrence in accordance with the PA DOH Influenza Outbreak Response Toolkit for Long Term Care by 1/16/25. 11. The Infection Preventionist will be assigned CDC Infection Preventionist training in CDC-Train to be completed by 11FEB2025 to enhance awareness and compliance with infection control and prevention protocols. Root Cause(s): 1. Knowledge deficit for Infection Prevention Nurse and DON. 2. Performance concerns regarding adhering to guidelines after Education. 3. Facility need for evaluation of new Director of Nursing and Assistant Director of Nursing /Infection Prevention nurse. Facility removed the Director of Nursing and Infection Prevention Nurse from roles, terminated, and replaced with Interim DON and Interim ADON. The Interim ADON will absorb the role of the Infection Prevention Nurse and complete the CDC Infection Preventionist Training in CDC-Train. The facility immediately implemented monitoring, testing and tracking for signs and symptoms of influenza and COVID-19 like symptoms among residents and staff in accordance with the PA DOH COVID-19 Infection Control and Outbreak Response Tool-Kit for Long-Term Care. Effective 1/15/25, facility will ensure that COVID testing occurs on Day 1 following a positive result in accordance with PA DOH COVID 19 Infection Control Outbreak Response Toolkit for Long Term Care. -IP/Designees will conduct house audit of all COVID testing to ensure Day 1 testing complete upon positive result by EOD 1/16/25. -Regional Director of Clinical Services will conduct in-service regarding Infection Control and Outbreak Response testing procedures to facility Infection Preventionist and Director of Nursing by 1/16/25. -IP/Designee will conduct education to all staff regarding Infection Control and Outbreak Response testing procedures at their start of beginning 1/15/2025 and before next shift by EOD 1/16/25. -To prevent reoccurrence, DON/Designee will conduct audits to monitor for completion of Day 1 testing for positive COVID results, daily x5 days for 14 days, then weekly for 4 weeks then monthly x2. Negative findings will be addressed. Policies and Procedures to be reviewed and updated as needed. PA DOH Influenza Outbreak Response Toolkit for Long Term Care beginning 1/15/25 and before next shift by EOD 1/16/25. -To prevent reoccurrence, DON/Designee will conduct ongoing monitoring for Influenza signs and symptoms, weekly with occurrence in accordance with the PA DOH Influenza Outbreak Response Toolkit for Long Term Care by 1/16/2025. Negative findings will be addressed. Policies and Procedures to be reviewed and updated as needed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Removal Plan
- Facility initiated monitoring signs and symptoms for residents with COVID.
- IP/Designee will conduct house audit of residents with signs and symptoms of COVID.
- Regional Director of Clinical Services will conduct in-service regarding Infection Control and Outbreak Response to facility Infection Preventionist and Director of Nursing.
- IP/Designee will conduct education to all staff regarding infection control measures and monitoring at their start of shift.
- DON/Designee will conduct audits to monitor for resident's signs and symptoms for COVID, daily for 14 days, then weekly for 4 weeks then monthly.
- Negative findings will be addressed. Policies and Procedures to be reviewed and updated as needed. Ad hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
- Facility will ensure that COVID testing occurs following a positive result in accordance with PA DOH COVID 19 Infection Control Outbreak Response Toolkit for Long Term Care.
- IP/Designees will conduct house audit of all COVID testing to ensure testing complete upon positive result.
- Regional Director of Clinical Services will conduct in-service regarding Infection Control and Outbreak Response testing procedures to facility Infection Preventionist and Director of Nursing.
- IP/Designee will conduct education to all staff regarding Infection Control and Outbreak Response testing procedures at their start of shift.
- DON/Designee will conduct audits to monitor for completion of testing for positive COVID results, daily for 14 days, then weekly for 4 weeks then monthly.
- Facility will ensure that return to work guidance for a staff member who tested positive for COVID is followed in accordance with PA DOH COVID 19 Infection Control and Outbreak Response Toolkit for Long Term Care.
- IP/Designee will monitor for any COVID positive staff weekly, monthly, and ongoing with occurrence, to ensure that return to work guidance for a staff member who tested positive for COVID is followed.
- IP/Designee will conduct education regarding return to work guidance for a staff member who tested positive for COVID is followed in accordance with PA DOH COVID 19 Infection Control and Outbreak Response Toolkit for Long Term Care.
- DON/Designee will conduct ongoing monitoring for COVID positive staff and monitor return to work status, weekly with outbreak occurrence in accordance with PA DOH COVID 19 Infection Control and Outbreak Response Toolkit for Long Term Care.
- IP/Designee to ensure that residents exhibiting signs and symptoms of Influenza are monitored in accordance with the PA DOH Influenza Outbreak Response Toolkit for Long Term Care.
- IP/Designee will monitor all residents weekly, monthly and ongoing with occurrence for any sign and symptoms of Influenza in accordance with the PA DOH Influenza Outbreak Response Toolkit for Long Term Care.
- Regional Director of Clinical Services will conduct Inservice regarding identification of Influenza signs and symptoms and testing in accordance with the PA DOH Influenza Outbreak Response Toolkit for Long Term Care.
- IP/Designee will conduct education to all staff regarding identification of Influenza signs and symptoms and testing in accordance with the PA DOH Influenza Outbreak Response Toolkit for Long Term Care.
- DON/Designee will conduct ongoing monitoring for Influenza signs and symptoms and testing, weekly with occurrence in accordance with the PA DOH Influenza Outbreak Response Toolkit for Long Term Care.
- IP/Designee will conduct an initial audit of all residents' temperatures to ensure that residents exhibiting signs and symptoms of Influenza are monitored in accordance with the PA DOH Influenza Outbreak Response Toolkit for Long Term Care.
- IP/Designee will monitor all residents' temperatures weekly, monthly and ongoing with occurrence for any sign and symptoms of Influenza in accordance with the PA DOH Influenza Outbreak Response Toolkit for Long Term Care.
- Regional Director of Clinical Services will conduct Inservice regarding identification of Influenza signs and symptoms and monitoring in accordance with the PA DOH Influenza Outbreak Response Toolkit for Long Term Care.
- IP/Designee will conduct education to all staff regarding identification of Influenza signs and symptoms and monitoring in accordance with the PA DOH Influenza Outbreak Response Toolkit for Long Term Care.
- DON/Designee will conduct ongoing monitoring for Influenza signs and symptoms, weekly with occurrence in accordance with the PA DOH Influenza Outbreak Response Toolkit for Long Term Care.
Improper Food Storage and Labeling in Main Kitchen
Penalty
Summary
The facility failed to adhere to food safety requirements as evidenced by improper storage, labeling, and dating of food products in the Main Kitchen. During a review of the facility's policy on 'Storage of Refrigerated Foods,' it was noted that employee lunches should not be stored in dietary refrigerators. However, during an observation in the Main Kitchen Back Reach-in Cooler, an opened bottle of Pepsi and an opened bottle of Dr. Pepper were found without any name or date. Additionally, in the Main Kitchen Walk-in Freezer, an opened bag of mixed vegetables and an opened package of sausage patties were observed without any date or label. Further observations in the Main Kitchen Dry Storage revealed an opened bag of corn flake cereal without a label or date. These findings were confirmed during an interview with the Food Service Director, Employee E10, who acknowledged the facility's failure to properly store, label, and date food, which created the potential for foodborne illness. The lack of adherence to professional standards for food service safety was evident in these observations, indicating a deficiency in the facility's food safety practices.
Plan Of Correction
Dietary concerns were addressed immediately during the survey. The DM/designee completed a kitchen audit to address any additional findings. To prevent this from recurring, the Dietary Manager/designee will educate the dietary staff on requirements of F812 and ensuring that the food is stored, labelled, and dated in kitchen pantries, reach-in coolers, and freezers. To monitor and maintain ongoing compliance, the Dietary Manager (DM) will audit the kitchen 3 times weekly for 4 weeks, then monthly for 2 months to ensure food is stored, labelled, and dated in kitchen pantries, reach-in coolers, and freezers. Negative findings will be addressed. Ad hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
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 for three residents who were transferred from the facility. This deficiency was identified through a review of clinical records and staff interviews. The residents involved in the transfers were identified as having various medical conditions, including high blood pressure, hip fracture, malnutrition, Alzheimer's Disease, and dementia. For Resident R21, who was admitted to the facility in September 2022 and transferred to the hospital in October 2024, there was no documented evidence that the facility communicated essential information such as care plan goals, advanced directive information, and specific instructions for ongoing care to the receiving health care provider. Similarly, Resident R30, admitted in January 2021 and transferred in February 2024, also lacked documentation of communicated information necessary for their care at the receiving facility. Resident R78, admitted in October 2023 and transferred in December 2024, was also affected by this deficiency. The clinical record review revealed that the facility did not document the communication of critical information, including care plan goals and resident representative information, to the receiving health care provider. The Director of Nursing confirmed the absence of this documentation during an interview, highlighting the facility's failure to meet regulatory requirements for resident transfers.
Plan Of Correction
Facility is unable to retroactively make corrections for Residents #21, #30 and #78. Moving forward the facility will make certain the necessary resident information is communicated to the receiving health care provider. To identify other residents, the DON/designee performed a house audit on transfer and discharge from 1/16/2025 to present to ensure the necessary resident information is communicated to the receiving health care provider. There were no negative findings. To prevent this from recurring, the RDCS provided education to the nursing staff on the regulatory requirements of F0622, for transfer and discharge documentation ensuring necessary resident information is communicated to the receiving health care provider, which includes resident care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and resident specific needs. To monitor and maintain ongoing compliance, the DON/designee will audit resident transfers 5 days weekly for 4 weeks, then monthly for 2 months to ensure necessary resident information is communicated to the receiving health care provider. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Failure to Notify Residents of Bed-Hold Policy
Penalty
Summary
The facility failed to comply with the regulatory requirement to notify residents or their representatives of the bed-hold policy during hospital transfers or therapeutic leaves. This deficiency was identified for three residents who were transferred to the hospital and subsequently returned to the facility. The facility's policy, dated 1/12/25, mandates that the bed-hold policy be provided at the time of transfer, or within 24 hours in emergencies. However, the clinical records for these residents did not contain documented evidence that such notifications were provided. Resident R21, admitted on 9/14/22, was transferred to the hospital on 10/19/24 and returned on 10/31/24, without receiving the required bed-hold policy notice. Similarly, Resident R30, admitted on 1/24/21, was transferred on 2/21/24 and returned on 2/27/24, and Resident R78, admitted on 10/20/23, was transferred on 12/1/24 and returned on 12/5/24, both without documented notification of the bed-hold policy. The Director of Nursing confirmed the facility's failure to provide the necessary notifications for these residents.
Plan Of Correction
Facility is unable to retroactively send a bed hold policy to Residents #21, #30 and #78 or their RP. Moving forward, the facility will make certain residents/responsible parties will be provided a bed hold policy when a resident is transferred to the hospital. To identify other residents, the DON/designee performed a house audit of current residents in the hospital to ensure Resident/RP were provided a bed-hold policy. There were no negative findings. To prevent this from recurring, the NHA/designee will educate licensed nursing staff and SS on the regulatory requirements of F625 and facility bed-hold policy. To monitor and maintain ongoing compliance, the DON/designee will audit resident transfers 5 days weekly for 4 weeks, then monthly for 2 months to ensure resident or residents' representative are notified of the facility bed-hold policy. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Failure to Document Medication Regimen Reviews
Penalty
Summary
The facility failed to provide documentation that medication regimen reviews (MRR) were completed for three residents. The facility's policy requires that the consultant pharmacist provide MRRs to designated personnel, who must ensure that the attending physician, medical director, director of nursing, and other necessary staff receive the recommendations. The attending physician is required to document in the resident's health record that any identified irregularity has been reviewed and what action, if any, has been taken. However, the facility did not maintain readily available copies of the consultant pharmacist's reports as part of the residents' permanent health records. Resident R4, admitted to the facility with diagnoses including high blood pressure, bipolar disorder, and dementia, was prescribed medications such as Trazodone and Ziprasidone. Despite pharmacist progress notes indicating irregularities and recommendations on two occasions, the facility failed to provide the consultant pharmacist reports for these dates. Similarly, Resident R26, with diagnoses of difficulty swallowing, dementia, and malnutrition, was prescribed Quetiapine. A pharmacist progress note indicated irregularities, but the corresponding report was not found in the resident's clinical record. Resident R78, diagnosed with Alzheimer's disease, dementia, and malnutrition, was prescribed several medications, including Escitalopram and Divalproex. A pharmacist progress note also indicated irregularities, yet the facility could not provide the consultant pharmacist report. During an interview, the Director of Nursing confirmed the inability to locate and provide the required documentation for the medication regimen reviews for these residents.
Plan Of Correction
Pharmacy recommendations were reviewed by physician and addressed for Residents #4, #26, and #78. Residents #4, #26 and #78 had no negative outcome. To identify other residents that have the potential to be affected, the DON/designee reviewed pharmacy recommendations from 9/2024 to current (date) to ensure they are reviewed by the physician and addressed timely. Corrections will be made as needed. To prevent this from recurring, the RDCS/designee educated DON/ADON/supervisors on ensuring pharmacy medication regimen reviews and recommendations are reviewed by the physician, addressed and documented timely. To monitor and maintain ongoing compliance, the DON/designee will audit pharmacy recommendations weekly x4 then monthly x2 to ensure pharmacy medication regimen reviews and recommendations are reviewed by the physician, addressed and documented timely. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to properly store medications in two medication carts and one medication room, as observed during a survey. On the 2B Medication Cart, insulin pens for three residents were not stored in bags as required. Additionally, the Unit 1 Medication Cart was found unlocked and unattended, with a bottle of aspirin and a bottle of Vitamin D3 left on top of the cart. These observations were confirmed by an LPN, indicating a lapse in the facility's medication storage protocols. Further deficiencies were noted in the Unit 2 Medication Room, where several medications and supplies were found to be expired. These included Hemoccult Single Slides, COVID-19 Antigen Home Tests, Heparin Lock Flushes, and an Ace connector with Legacy Connection. The expiration of these items was confirmed by a registered nurse, and the overall failure to properly store medications was acknowledged by the Director of Nursing and the Nursing Home Administrator.
Plan Of Correction
The identified items from 2B and Unit 1 Medication Carts, Unit 2 Medication Room items were immediately addressed. R1, R54, and R81s insulin pens were immediately discarded. The DON/designee completed an audit of all medication carts and medications rooms to ensure medications are stored and labelled appropriately. There were no negative findings. To prevent this from recurring, the RDCS/designee educated licensed nursing staff on requirements of F761 and proper storage and labelling. To monitor and maintain ongoing compliance, the DON/designee will audit medication carts and medication room/refrigerators weekly x4 then monthly x2 to ensure medications are stored and labelled appropriately. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Incomplete and Inaccurate Medical Records
Penalty
Summary
The facility failed to ensure that medical records for three residents were complete and accurately documented. Resident R21, who was admitted with diagnoses including high blood pressure, hip fracture, and malnutrition, had a physician's order for nifedipine without a corresponding diagnosis for its use. Similarly, Resident R87, admitted with high blood pressure, diabetes, and morbid obesity, had a physician's order for gabapentin without a diagnosis for its use. Resident R199, admitted with high blood pressure, malnutrition, and a stage 2 pressure ulcer, had a physician's order for cefazolin without a diagnosis for its use. During an interview, the Registered Nurse Assessment Coordinator (RNAC) confirmed that the facility often fails to select appropriate diagnoses when entering medication and treatment orders, which can lead to confusion due to the multiple uses of some drugs. This deficiency was confirmed for the three residents mentioned, indicating a pattern of incomplete and inaccurately documented medical records.
Plan Of Correction
Medications were reviewed for Residents #21, #87, and #199 to ensure medical records were complete and accurately documented to include diagnosis for indication of use for medication. To identify other residents that have the potential to be affected, a house audit was completed by DON/designee to ensure medical records were complete and accurately documented to include diagnosis for indication of use for medication. Corrections will be made as needed. To prevent this from happening again, DON/designee educated licensed nurses on the appropriate documentation of resident diagnosis. To monitor and maintain ongoing compliance, the DON/designee will audit new orders weekly x4 then monthly x2 to ensure diagnosis for indication of use are documented in the medical record. Negative findings will be corrected. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Failure to Ensure Call Bell Accessibility for Resident
Penalty
Summary
The facility failed to ensure that call bells were within reach for one of six residents, specifically Resident R4. According to the facility's policy on call lights, it is required that residents have a means of communicating with staff, and a call system is installed in each resident room. Resident R4, who was admitted to the facility on December 15, 2023, had a care plan indicating a risk for falls due to poor safety awareness, with a specific instruction to keep the call light within reach at all times. On January 12, 2025, Resident R4 was observed in her wheelchair, slouched and in distress, crying out due to back pain. During this observation, it was confirmed by Nurse Aide, Employee E11, that the call bell was not within reach of Resident R4. The Nursing Home Administrator also confirmed the facility's failure to ensure the call bell was accessible for Resident R4, which is a violation of the resident's rights and the facility's policies.
Plan Of Correction
Resident #4 was immediately provided call bell. To identify other residents that have the potential to be affected, the Director of Nursing (DON)/designee completed a whole house sweep to ensure residents call bells were within reach. There were no negative findings. To prevent this from recurring, the Regional Director of Clinical Services (RDCS)/designee educated staff on ensuring that a resident's call bell is within reach. To monitor and maintain ongoing compliance, the DON/designee will audit 3 residents weekly x4 then monthly x 2 to ensure that call bell is within reach. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Failure to Provide Opportunity for Advance Directive
Penalty
Summary
The facility failed to provide Resident R87 with the opportunity to formulate an advance directive, which is a written instruction such as a living will or durable power of attorney for health care. This deficiency was identified through a review of the facility's policy on 'Resident Rights Regarding Treatment and Advance Directives' and the clinical records of Resident R87. The policy, dated 1/12/25, indicated that advance directives should be discussed with residents or their representatives to determine if any have been chosen or if there are any questions. However, there was no documentation in Resident R87's clinical record to show that this opportunity was provided. Resident R87 was admitted to the facility on 11/15/24, and their Minimum Data Set (MDS) dated 11/21/24 included diagnoses of high blood pressure, diabetes, and morbid obesity due to excess calories. Despite these health conditions, the clinical record lacked evidence of an advance directive or any documentation that the resident was given the chance to formulate one. This was confirmed during an interview with the Social Services Director, Employee E6, who acknowledged the absence of such documentation in the resident's record.
Plan Of Correction
The resident and/or resident representative for Resident # 87 were immediately provided an opportunity to develop an advance directive. To identify other residents that have the potential to be affected, the DON/designee completed a house audit to ensure residents and/or resident representatives have been provided an opportunity to develop an advance directive. Corrections will be made as needed. To prevent this from recurring, the RDCS/designee educated licensed nursing and Social Services on the regulatory requirements of F578 regarding ensuring residents and/or resident representatives are provided an opportunity to develop an advance directive. To monitor and maintain ongoing compliance, the DON/designee will audit 3 residents weekly x4 then monthly x 2 to ensure residents and/or families are provided an opportunity to develop advance directives. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Failure to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for Resident R47. During an observation, it was noted that Resident R47's bed had a red substance on the sheets, and there was a similar red substance on the floor next to the bed. This observation was made on January 14, 2025, at 9:54 a.m. An interview conducted shortly after the observation with LPN Employee E4 confirmed the facility's failure to provide the required environment for Resident R47. The deficiency was identified based on the facility's policy review, observations, and interviews with residents and staff, indicating a lapse in maintaining the standards set forth in §483.10(i) for a safe, clean, and homelike environment.
Plan Of Correction
During the survey, the sheets were changed for Resident #47 and housekeeping cleaned the floor. To identify other areas of concern, the housekeeping director/ designee completed environmental rounds, cleaned debris, mopped/swept floors as needed, and ensured bed sheets were clean. To prevent this from recurring, The Nursing Home Administrator (NHA)/ designee educated facility staff on the regulatory requirements of F584 and ensuring a safe, clean and home-like environment. To monitor and maintain ongoing compliance, the NHA/designee will audit 10 resident rooms weekly x4 then monthly x 2 to ensure residents have a safe, clean and home-like environment (sheets and floor do not have any substance on them). Negative findings will be placed on a concern form and addressed. Ad hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of abuse within the required timeframe for one of the residents. According to the facility's policy, all allegations of abuse, neglect, involuntary seclusion, injuries of unknown source, and misappropriation of resident property must be reported immediately to the Administrator, Director of Nursing, and the applicable State Agency. However, an incident involving resident-to-resident abuse occurred on 12/31/24, where one resident was hit by another resident. Despite the incident being documented in a progress note, it was not reported to the State Agency until 1/16/25, which is beyond the required reporting timeframe. The resident involved in the incident, identified as Resident R80, was admitted to the facility with diagnoses of anemia, dementia, and depression. The progress note indicated that Resident R80 was hit in the face and on the left side with a cane by another resident, Resident R66, while walking in the hallway. Although there were no obvious signs of trauma, the resident expressed fear of the incident recurring. The failure to report this incident in a timely manner was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the Director of Nursing did not report the abuse allegation as required.
Plan Of Correction
The facility cannot retroactively go back and make corrections. Moving forward, the facility will report allegations of resident to resident abuse in the required timeframe. To identify other residents that have the potential to be affected, the DON/designee completed an audit of current resident events from date of exit (1/16/2025 to current) to ensure timely reporting if needed. Corrections will be made as needed. To prevent this from recurring, the RDCS provided education to the NHA and DON on the regulatory requirements of F609 and timely reporting of resident to resident abuse. To monitor and maintain ongoing compliance, the NHA/designee will audit resident events weekly x4 then monthly x 2 to ensure those occurrences that meet the requirement are reported timely. Negative findings will be addressed. Ad Hoc education will be provided as needed. Facility submitted event to ERS-event #1070939.
Inaccurate MDS Assessment for Hospice Care
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for a resident, identified as Resident R30. The deficiency was identified through a review of the Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews. Resident R30, who was admitted to the facility in January 2021, had a physician order dated March 2024 to be admitted to hospice services. However, the Significant Change MDS assessment dated April 2024 incorrectly indicated that the resident was not receiving hospice care during the assessment period. This inaccuracy was confirmed by the Registered Nurse Assessment Coordinator during an interview in January 2025.
Plan Of Correction
Resident # 30 MDS was immediately corrected to accurately reflect resident status. To identify other residents that have the potential to be affected, the MDS/designee completed an audit of current residents to ensure MDS assessments accurately reflect the resident status. Correction will be made as needed. To prevent this from recurring, the RDCS/designee educated MDS/nursing leadership on requirements of F641 and ensuring that resident MDS are updated and accurately reflect resident status. To monitor and maintain ongoing compliance, the DON/designee will audit 3 residents weekly x4 then monthly x 2 to ensure resident MDS accurately reflect resident status. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Failure to Update Resident Care Plan for Behavioral Issues
Penalty
Summary
The facility failed to update and revise a resident's care plan to reflect specific care needs, as required by regulations. The resident, identified as Resident R4, was admitted with diagnoses including high blood pressure, Bipolar Disorder, and dementia. Despite exhibiting significant behavioral issues, such as exit-seeking behavior and inappropriate language, the care plan was not updated to address these needs until much later. Resident R4 displayed a series of concerning behaviors over several months, including requesting sexual favors from another resident, masturbating in the presence of a female resident, and being verbally abusive and physically aggressive towards staff and other residents. These incidents were documented in progress notes, yet the care plan did not include specific goals and interventions to manage these behaviors until January 12, 2025. The Nursing Home Administrator confirmed that the facility did not ensure the resident's care plan was updated and revised in a timely manner. This oversight was identified during a review of facility documents, clinical records, and staff interviews, highlighting a failure to comply with the requirement for comprehensive care planning and revision after each assessment.
Plan Of Correction
Resident # 4 Care plan was updated to reflect hospice services. Resident # 4 Care plan was updated to reflect behaviors. To identify other residents that have the potential to be affected, the MDS/designee completed an audit of current residents to ensure care plans are updated/revised to reflect current status regarding behaviors and hospice services. To prevent this from recurring, the RDCS/designee educated MDS/nursing leadership on requirements of F657 and ensuring that care plans are updated/revised to reflect the resident's specific care needs. To monitor and maintain ongoing compliance, the MDS/designee will audit 5 residents weekly x4 then monthly x 2 to ensure care plans are updated/revised to reflect current status for behaviors and hospice service. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Failure to Provide Resident Activities During COVID-19 Outbreak
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 for four out of five weeks. This deficiency was identified through a review of facility policy and documents, as well as interviews with residents and staff. The facility's policy on activities, dated January 12, 2025, indicated that a resident-centered Life Enrichment Program should be provided based on comprehensive assessments and care plans. However, during the period from December 10, 2024, through January 16, 2025, the facility did not adhere to this policy. Interviews with residents revealed that there were no activities available, and they were confined to their rooms, leading to feelings of boredom. The deficiency was further corroborated by staff interviews, which revealed that the facility had a COVID-19 outbreak beginning on November 29, 2024, and group activities were suspended as a result. The Activities Director confirmed that all group activities were canceled, and no modifications were made to adapt activities with social distancing or limited group sizes. The Director of Nursing and the Infection Preventionist instructed the suspension of group activities, and the facility did not provide alternative means to engage residents during this period, failing to meet the regulatory requirement for an ongoing program of activities.
Plan Of Correction
The facility cannot retroactively go back and make corrections for Residents #5 and #52 regarding activities. Moving forward, the facility will provide activities to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. To identify residents that have the potential to be affected, the Activities Director/designee completed an audit of current resident scheduled events to ensure residents are provided the opportunity to engage in group activities. Corrections will be made as needed. To prevent this from recurring, the NHA educated the Activity Director on the Regulatory Requirement of F679 and ensuring activities are provided to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. To prevent this from recurring, the Activity Director is to provide the NHA with an updated monthly calendar of scheduled events for the next 30 days. To monitor and maintain ongoing compliance, the NHA/designee will audit resident events weekly for 4 weeks, then monthly for 2 months to ensure activities meet the interests of and support the physical, mental, and psychosocial well-being of each resident. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Failure to Monitor and Document Wound Care
Penalty
Summary
The facility failed to monitor and ensure proper treatment of wounds and complete weekly skin assessments for two residents. Resident R4, who was admitted with a chronic abdominal wound, did not have documentation of the wound for specific weeks, and the wound, initially marked as healed, reopened. Despite the reopening, there was a lack of consistent documentation and monitoring as required by the facility's policy. The Nursing Home Administrator confirmed the failure to adhere to the required monitoring and assessment protocols. Resident R199, admitted with a pressure ulcer and a surgical wound, had physician orders for wound care that did not specify which treatment was for which wound. This lack of clarity in treatment orders led to confusion in the application of wound care, as confirmed by the Registered Nurse Assessment Coordinator. The facility's failure to specify treatment for each wound compromised the proper care and management of Resident R199's conditions.
Plan Of Correction
Resident #199 wound treatment order was immediately clarified and discontinued per physician. Resident #4 wound treatment order was clarified, skin assessment performed, measurements were documented, and physician notified of findings. To identify other residents that have the potential to be affected, the DON/designee conducted a house audit on all resident wound orders to ensure proper treatment of resident wounds and weekly skin assessments. Any negative findings were addressed. To prevent this from reoccurring, the DON/designee educated licensed nursing clinical staff on observation of skin and wound best practices and wound management. To monitor and maintain ongoing compliance, the DON/designee will review wound documentation and new wound treatment orders 5x weekly for 4 weeks, then monthly for 2 months to ensure appropriate monitoring, documentation, and reporting of resident wounds and weekly skin assessments. Negative findings will be addressed. Ad hoc education will be completed as needed. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
Deficient Pressure Ulcer Care and Monitoring
Penalty
Summary
The facility failed to ensure proper treatment and monitoring for pressure ulcers for two residents. Resident R1, who was admitted with conditions including peripheral vascular disease, diabetes, and a pressure ulcer, did not receive the required weekly wound assessments for two consecutive weeks. Despite having a care plan that mandated weekly assessments of the pressure ulcer's stage, size, and surrounding skin condition, there were no documented assessments for the weeks of December 25, 2024, and January 1, 2025. This lapse was confirmed by a registered nurse during an interview. Resident R199, admitted with high blood pressure, an infection due to cardiac and vascular device implants, and a stage 2 pressure ulcer, also experienced deficiencies in care. The resident had physician orders for wound care treatments, including the application of MediHoney alginate and a Wound VAC dressing. However, these orders did not specify which wound or body area the treatments were intended for, leading to potential confusion in care. This oversight was confirmed by the Registered Nurse Assessment Coordinator, who acknowledged the facility's failure to specify treatment applications for the resident's pressure ulcer.
Plan Of Correction
Resident #199 wound treatment order was immediately clarified and discontinued per physician. Resident #1 wound treatment order was clarified, skin assessment performed, measurements were documented, and physician notified of findings. To identify other residents that have the potential to be affected, the DON/designee conducted a house audit on all resident wound orders to ensure proper treatment of resident wounds and weekly skin assessments. Any negative findings were addressed. To prevent this from reoccurring, the DON/designee educated licensed nursing clinical staff on observation of skin and wound best practices and wound management. To monitor and maintain ongoing compliance, the DON/designee will review wound documentation and new wound treatment orders 5x weekly for 4 weeks, then monthly for 2 months to ensure appropriate monitoring, documentation, and reporting of resident wounds and weekly skin assessments. Negative findings will be addressed. Ad hoc education will be completed as needed. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
Failure to Assess Resident for Smoking Safety
Penalty
Summary
The facility failed to properly assess a resident, identified as Resident R52, for smoking safety, which is a requirement under §483.25(d) to ensure the resident environment remains as free of accident hazards as possible. The facility's policy mandates that during the admission process, residents are asked about their smoking habits and intentions, and those who affirmatively respond are further assessed for smoking safety awareness. This assessment is also required on readmission, quarterly, and with any significant change in the resident's condition. However, the Smoking Risk form completed on 10/8/24 incorrectly stated that Resident R52 does not smoke and intends to remain non-smoking, despite the resident's clinical record indicating nicotine dependence and current tobacco use. Interviews with Resident R52 and the Registered Nurse Assessment Coordinator (RNAC) confirmed that the resident is indeed a smoker, who smokes three times a day. This discrepancy highlights the facility's failure to accurately assess and document the resident's smoking status, which is crucial for ensuring adequate supervision and safety measures are in place to prevent accidents. The oversight was acknowledged by the RNAC, who confirmed the facility's failure to properly assess the resident's smoking risk on the specified date.
Plan Of Correction
Resident #52 was assessed for smoking safety awareness and safety accommodations are implemented. To identify other residents that have the potential to be affected, the DON/designee completed an audit of current residents to ensure residents have smoking assessments that reflect current status and reasonable safety accommodations are implemented as needed. Corrections will be made as needed. To prevent this from recurring, the RDCS provided education to licensed nursing on the requirements of completing smoking assessments on the need to implement safety accommodations. To monitor and maintain ongoing compliance, the NHA/designee will audit 3 residents weekly x4, then monthly x2 to ensure smoking assessments are completed per policy to reflect resident current status and that safety accommodations are implemented as indicated. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Failure to Ensure Proper Dialysis Care and Medication Management
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received services consistent with professional standards of practice and the comprehensive person-centered care plan. The resident, who was diagnosed with hypertension, end-stage renal disease, and diabetes, experienced a significant weight gain of 17.1 pounds over a short period. Despite the facility's policy requiring physician notification for weight gains greater than five pounds, there was no evidence that the physician was informed of this change in the resident's condition. Interviews with staff revealed that the responsibility for notifying the physician was not fulfilled, as the dietician did not alert the RN, and consequently, the RN did not contact the doctor. Additionally, there was a failure in medication management for the resident. The facility did not correctly enter the resident's medication order for cinacalcet, which was to be administered on specific days in relation to dialysis sessions. The Director of Nursing confirmed that the medication order was not entered correctly, which further indicates a lapse in ensuring that the resident received dialysis services in accordance with professional standards and the care plan.
Plan Of Correction
Resident #45 was immediately re-weighed, and findings were communicated to the physician. The medication order was reviewed for accuracy and updated as necessary. To identify other residents that have the potential to be affected, the DON/designee reviewed all residents receiving dialysis services to ensure orders are followed, notifications made to physician for weight change and change in condition. Corrections will be made as needed. To prevent this from recurring, the DON/designee educated licensed nurses on regulatory requirements of F698 ensuring residents receiving dialysis services that orders are followed, and notifications made to physician for weight change and change in condition. To monitor and maintain ongoing compliance, the DON/designee will audit current residents on dialysis communication binder upon return from dialysis for any new order recommendations weekly x4 weeks then monthly x2 to ensure orders are followed, and that physician is notified of weight change and changes in condition. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Failure to Conduct Timely Physician Visits
Penalty
Summary
The facility failed to ensure that physician visits were conducted at least every 60 days after the first 90 days of admission for one resident. Specifically, Resident R86 was admitted to the facility on February 7, 2024, and had diagnoses including stroke, hypertension, and dysphagia. However, there was no documented evidence of a physician or physician delegate visit for 232 days between February 7, 2024, and September 25, 2024, which is a violation of the required frequency of physician visits. Additionally, the facility did not ensure that a physician completed the initial visit for another resident, Resident R201. This resident was admitted on December 17, 2024, with diagnoses of anxiety, depression, and bipolar disorder. The initial visit was conducted by a Certified Registered Nurse Practitioner, Employee E14, instead of a physician, as required. The Nursing Home Administrator confirmed these deficiencies during an interview on January 16, 2025.
Plan Of Correction
Facility cannot retroactively correct and will ensure moving forward that physician visits are conducted at least every 30 days for the first 90 days and then at least every 60 days thereafter. Residents #86 and #201 were immediately evaluated by a physician to ensure facility alleges compliance with regulatory requirement of F712 (Physician Visits - Frequency/Timelines/Alt NPP). To identify other residents that have the potential to be affected, the DON/designee will audit current resident admission assessments to ensure initial admission assessment is completed by a physician within required timeframe and all subsequent physician visits are completed per requirement. Negative findings will be addressed. To prevent this from recurring, the NHA/designee educated Medical Director on initial admission assessment to be completed by a physician within required timeframe and all subsequent physician visits to be completed per requirement. To monitor and maintain ongoing compliance, the DON/designee will audit physician visit assessments weekly x4 then monthly x2. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Failure in Controlled Drug Reconciliation
Penalty
Summary
The facility failed to implement proper pharmacy procedures for the reconciliation of controlled drugs, specifically concerning a resident who had ceased to breathe. The facility's policy on the disposal and destruction of expired or discontinued medications requires that such actions be documented on the controlled medication count sheet and signed by a registered nurse and a witnessing licensed professional. Additionally, discontinued and unused medications of discharged or deceased residents should be immediately removed from the medication cart and brought to nursing supervisory staff. However, in the case of a resident who was admitted on June 21, 2010, and had a physician order for morphine solution to be administered as needed, the facility did not adhere to these procedures. The resident, who had diagnoses of Alzheimer's Disease, dementia, and depression, ceased to breathe on December 19, 2024. Despite this, the Controlled Medication Utilization Record indicated that the morphine's "Date of Disposition" was recorded as December 22, 2024, three days after the resident's death. This discrepancy was confirmed during an interview with the Regional Director of Clinical Services, who acknowledged the facility's failure to implement the required pharmacy procedures for the reconciliation of controlled drugs.
Plan Of Correction
Resident #96 closed record reviewed, and the facility cannot retroactively correct reconciliation of controlled drugs. There were no other concerns identified regarding reconciliation of controlled medications during survey. To identify other residents that have the potential to be affected, the DON/designee completed an audit of medication destruction logs for closed records of all residents that discharged at time of exit (1/16/2025 to current) with no negative findings. To prevent this from recurring, the DON/designee educated licensed nursing on medication destruction in compliance with Disposal/Destruction of Expired or Discontinued Medication. To monitor and maintain ongoing compliance, the DON/designee will complete medication destruction audit weekly x4 then monthly x2 to ensure medication disposal/destruction and reconciliation is completed appropriately. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Failure to Ensure Appropriate Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents' medication regimens were free from potentially unnecessary psychotropic medications. Specifically, two residents were affected by this deficiency. One resident, admitted to the facility with diagnoses including high blood pressure, Bipolar Disorder, and dementia, was prescribed Trazodone and Ziprasidone. However, the facility did not maintain documentation of the consultant pharmacist's reports, which noted irregularities and recommendations regarding these medications. Another resident, admitted with Alzheimer's Disease, dementia, and malnutrition, was prescribed several psychotropic medications, including Escitalopram, Divalproex, Mirtazapine, and Trazodone. The physician orders for these medications did not specify the conditions they were intended to treat, as required. Additionally, the facility failed to provide documentation of the consultant pharmacist's report, which also noted irregularities and recommendations. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed the facility's failure to identify specific conditions for treatment with psychotropic medications and to maintain necessary documentation. This lack of documentation and failure to ensure medication regimens were free from unnecessary medications contributed to the deficiency.
Plan Of Correction
Residents #4 and #78 had no negative outcome. Diagnosis was clarified by physician and entered into medical record for treatment. To identify other residents that have the potential to be affected, the DON/designee reviewed current residents on psychotropic medications to ensure resident medication regimens are free from unnecessary medications and that there is a diagnosed specific condition for treatment. Corrections will be made as needed. To prevent this from recurring, the RDCS/designee educated licensed nursing on the regulatory requirements of F758 on ensuring resident medication regimens are free from unnecessary medications, that the consult pharmacist report is in the medical record (and addressed) and that there is a diagnosed specific condition for treatment. To monitor and maintain ongoing compliance the DON/designee will review the medical record of 3 residents on psychotropic medications weekly x4 then monthly x2 to ensure resident medication regimens are free from unnecessary medications, that the consult pharmacist report is in the medical record (and addressed) and that there is a diagnosed specific condition for treatment. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 6.67% based on 30 medication opportunities with two errors. One incident involved a Registered Nurse (LPN), Employee E4, who did not administer a 305-700mg dose of Potassium phosphate to a resident at the scheduled time of 8:00 a.m., instead administering it late during a medication pass at 9:40 a.m. Another incident involved LPN, Employee E1, who failed to administer an Adult 50 Plus multivitamin to a different resident because the medication was not in stock. Both incidents were confirmed by the respective LPNs and the Nursing Home Administrator acknowledged the facility's failure to maintain the required medication error rate.
Plan Of Correction
Residents #47 and #24 had no negative outcome. Education was provided to Licensed Nurse Employee #4 and #1. There were no other medication administration concerns identified during survey. To prevent this from recurring, the DON/designee educated licensed nursing on the 5 rights of medication administration and medication availability. To monitor and maintain ongoing compliance, the DON/designee will complete medication administration observations with 3 licensed nurses weekly x 4, then monthly x 2 to ensure medication administration is completed appropriately. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Failure to Coordinate Hospice Services
Penalty
Summary
The facility failed to obtain a diagnosis and order for hospice services and to ensure the coordination of hospice services with facility services for a resident requiring end-of-life care. The facility's policy indicated that hospice services should be provided through collaboration with a Medicare-certified hospice agency when ordered by the resident's physician. However, the clinical record of a resident admitted to the facility showed a physician order to admit to hospice but lacked a diagnosis related to the need for hospice services or an order to admit the resident to hospice services. The resident's comprehensive care plan did not display the coordination of hospice services, as it failed to include contact information for the hospice agency and instructions on accessing the hospice's 24-hour on-call system. This lack of coordination was confirmed during an interview with the Registered Nurse Assessment Coordinator, who acknowledged the facility's failure to ensure the coordination of hospice services with facility services to meet the resident's end-of-life care needs. Additionally, a review of the resident's hospice communication binder revealed a hospice admission order form that was not signed by a physician, which is a requirement under Medicare regulations. The Nursing Home Administrator and Director of Nursing confirmed the facility's failure to obtain a diagnosis and order for hospice services and to ensure the coordination of hospice services with facility services for the resident.
Plan Of Correction
Resident #46 orders were updated immediately upon discovery during survey. Hospice contact information was obtained and updated in the hospice communication binder located at the central nurse's station. Moving forward, the facility will ensure that diagnosis and order for hospice services are obtained and signed by an ordering physician in accordance with Hospice Care Policy and coordination of hospice services. To identify other like residents, the DON/designee will audit current residents on hospice care services to ensure signed physician orders in accordance with Hospice Care Policy and contact information for hospice services. To prevent this from happening again, the DON/designee educated licensed nurses and MDS on the appropriate documentation of resident order diagnosis, order for hospice services are obtained and signed by an ordering physician in accordance with Hospice Care Policy and ensuring coordination of hospice services with facility services to meet the needs of the resident. To monitor and maintain ongoing compliance, the DON/designee will audit residents on hospice services weekly x4 then monthly x2 to ensure diagnosis order for hospice services, signed physician order, and contact information for hospice services documented in the medical record. Negative findings will be corrected. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Failure to Conduct Quarterly QAA Meetings with Required Members
Penalty
Summary
The facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all the required committee members for one of the four quarters, specifically from January 2024 through March 2024. The facility's policy on Quality Assurance and Performance Improvement (QAPI) requires the QAA committee to include the Administrator, Director of Nursing Services, Medical Director or designee, Infection Preventionist, direct care staff on a rotating basis, staff from ancillary departments on a rotating basis, and at least two other members of the facility staff. However, a review of the QAPI Committee meeting sign-in sheets for the specified period revealed that the Nursing Home Administrator was not in attendance. During an interview, the Nursing Home Administrator confirmed the facility's failure to conduct QAA meetings with all required committee members as mandated. This deficiency was identified based on the review of facility policy, Quality Assurance attendance records, and staff interviews, indicating non-compliance with the regulatory requirements for maintaining a comprehensive QAA committee.
Plan Of Correction
All required attendees failed to attend the Quality Assurance Performance Improvement committee meeting. Facility is unable to retroactively correct this citation. Moving forward the facility will maintain Quality Assurance Performance Improvement (QAPI) committee according to the regulation. To prevent this from happening again the RVPO/designee educated the Interdisciplinary Team and Quality Assurance Performance Improvement (QAPI) Committee to ensure the facility's QAPI meeting is occurring quarterly per the regulation and that attendance records are maintained. To monitor and maintain ongoing compliance the RVPO/designee will audit Quarterly x3 to ensure the facility's QAPI meeting is occurring quarterly per the regulation and that attendance records are maintained.
Failure to Notify State Agency of Resident Hospitalization
Penalty
Summary
The facility failed to notify the local State Agency of an incident involving a fall and subsequent hospitalization of a resident, identified as Resident R48. The resident, who had a medical history including Parkinson's disease, anxiety disorder, seizure disorder, and lack of coordination, experienced an incident where he pulled out his G-tube after throwing himself out of his wheelchair. This incident occurred after the resident was unable to be soothed by staff and was taken to the nurse's station for monitoring due to screaming. The resident was then sent to the Emergency Room for re-insertion of the G-tube following the incident. Despite the severity of the incident, which involved a fall and required hospitalization, the facility did not report this event to the local State Agency as required by regulation 51.3 (g)(1-14). The Director of Nursing confirmed during an interview that the notification was not made. This oversight represents a failure to comply with the notification requirements for events that seriously compromise quality assurance and patient safety.
Plan Of Correction
The facility cannot retroactively go back and make corrections. Moving forward, the facility will report allegations of resident-to-resident abuse in the required timeframe. To identify other residents that have the potential to be affected, the DON/designee reviewed progress notes from date of exit (1/16/2025 to current) to ensure those occurrences that meet the requirement are reported timely. Corrections will be made as needed. To prevent this from recurring, the RDCS provided education to the NHA and DON on the regulatory requirements of F609 and timely reporting of resident-to-resident abuse. To monitor and maintain ongoing compliance, the NHA/designee will audit resident events weekly x4 then monthly x 2 to ensure those occurrences that meet the requirement are reported timely. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. The ERS event was submitted-#1070952.
Infection Control Meeting Deficiency
Penalty
Summary
The facility was found to be non-compliant with the requirements set forth by the Medical Care Availability and Reduction of Error (MCARE) Act, specifically regarding the composition of its Infection Control Meetings. The regulation mandates that a multidisciplinary committee, including a community member, must be present at these meetings. However, during the review of the facility's Infection Control Meeting attendance records for the fourth quarter, it was discovered that a community member was not present, thus failing to meet the required composition of the committee. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the absence of a community member in the Infection Control Meetings for one of the four quarters. The absence of this required member indicates a lapse in adhering to the infection control plan as stipulated by the MCARE Act, which necessitates the inclusion of various representatives to ensure comprehensive infection control oversight.
Plan Of Correction
All required attendees failed to attend the Infection Control Committee meetings. Facility is unable to retroactively correct this citation. From the date of exit (1/16/2025) forward the facility will maintain Infection Control Committee attendance requirements according to the regulation. To prevent this from happening again the RVPO/designee educated the Interdisciplinary Team and Quality Assurance Performance Improvement (QAPI) Committee to ensure the facility's QAPI meeting is occurring quarterly per the regulation and that attendance records are maintained. To monitor and maintain ongoing compliance the RVPO/designee will audit Quarterly x3 to ensure the facility's QAPI meeting is occurring quarterly per the regulation and that attendance records are maintained.
Nurse Aide Staffing Deficiency
Penalty
Summary
The facility failed to meet the required nurse aide staffing levels as per the regulation effective July 1, 2024. Specifically, the facility did not provide the minimum required number of nurse aides per resident during various shifts over a 21-day period. During the day shift, the facility was short of the required one nurse aide per 10 residents on 13 days. The evening shift was understaffed with one nurse aide per 11 residents on 17 days, and the night shift was short of the required one nurse aide per 15 residents on four days. This deficiency was confirmed through a review of nursing time schedules and staff interviews. The Nursing Home Administrator acknowledged the staffing shortages during an interview on January 16, 2025. The facility did not have additional higher-level staff to compensate for the deficiency in nurse aide staffing. The specific dates of non-compliance were documented, highlighting the facility's failure to adhere to the staffing requirements set forth in the regulation. No additional information about the impact on residents or specific incidents resulting from the staffing shortages was provided in the report.
Plan Of Correction
The facility will continue to maintain the required nurse aide ratio of 1-10; 1-11; and 1-15. To increase staffing, the facility will call in off-duty staff, call sister facilities, or utilize agency staff as needed. Additionally, the facility will acquire new agency partnerships and offer bonuses to current staff to ensure sufficient nursing staffing. The RDCS educated the NHA/DON/scheduler on the required 1-10; 1-11; and 1-15 nurse aide ratio requirements, ensuring sufficient nursing staff. To monitor and maintain ongoing compliance, the NHA/DON/scheduler will complete staffing meetings 2x daily for 5x weekly for 4 weeks, then 1x daily for 5x weekly ongoing thereafter to ensure sufficient nursing staff. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
LPN Staffing Shortages in Facility
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) as per the regulation effective July 1, 2023. The regulation mandates a minimum of one LPN per 25 residents during the day, one LPN per 30 residents during the evening, and one LPN per 40 residents overnight. However, the facility did not meet these staffing requirements on several occasions. Specifically, on one day, the day shift was understaffed with 3.19 LPN Full Time Equivalents (FTE) present instead of the required 3.88 for 97 residents. Similarly, the evening shift on the same day had 8.00 LPN FTE present instead of the required 8.82. The night shift was particularly affected, with staffing shortages on 13 out of 21 days, where the number of LPN FTE present consistently fell short of the required numbers for the census on those days.
Plan Of Correction
The facility will continue to maintain the required LPN ratios (1-25, 1-30, 1-40). To increase staffing, the facility will call in off-duty staff, call sister facilities, or utilize agency staff as needed. Additionally, the facility will acquire new agency partnerships and offer bonuses to current staff to ensure sufficient nursing staffing. The RDCS educated NHA/DON/scheduler on the LPN ratio requirements, ensuring sufficient nursing staff (1-25, 1-30, 1-40). To monitor and maintain ongoing compliance, the NHA/DON/scheduler will complete staffing meetings 2x daily x 5x weekly x 4 weeks, then 1x daily x 5x weekly ongoing thereafter to ensure sufficient nursing staff. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Staffing and Nursing Care Hour Deficiencies
Penalty
Summary
The facility failed to meet the required staffing levels and minimum nursing care hours as mandated by regulations. Specifically, the facility did not provide the necessary number of Licensed Practical Nurses (LPNs) per resident during various shifts, with no additional higher-level staff to compensate for this deficiency. Additionally, the facility did not meet the minimum requirement of 3.2 hours of direct resident care per resident in a 24-hour period on 11 out of 21 days. This was confirmed through a review of nursing time schedules and staff interviews, as well as census data, which showed that the facility consistently fell short of the required nursing care hours on specific dates.
Plan Of Correction
The facility will continue to maintain the required 3.2 nursing ratios in a 24-hour period and implement a contingency plan if needed by calling in off duty staff, calling sister facilities or utilizing agency as needed to ensure sufficient nursing staff. The RDCS educated NHA/DON/scheduler on ensuring sufficient nursing staff. To monitor and maintain ongoing compliance, the NHA/DON/scheduler will complete staffing meetings 2x daily x 5x weekly x 4 weeks, then 1x daily x 5x weekly ongoing thereafter to ensure sufficient nursing staff. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Latest citations in Pennsylvania
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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