Lecom At Village Square, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Erie, Pennsylvania.
- Location
- 149 West 22nd Street, Erie, Pennsylvania 16502
- CMS Provider Number
- 395672
- Inspections on file
- 20
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Lecom At Village Square, Llc during CMS and state inspections, most recent first.
Multiple residents reported excessive delays in staff response to call bells, with some waiting an hour or more for assistance and others noting that staff ignored call lights or failed to return as promised. These concerns were also documented in Resident Council meeting minutes, and the facility administrator confirmed awareness of the issue.
Multiple residents reported consistently receiving cold meals, with complaints documented over several months and attributed to delays in tray delivery. The administrator confirmed awareness of the issue, and records showed ongoing resident dissatisfaction with food temperature.
A resident with dementia and other conditions required a mechanical lift with two staff for transfers. However, a nursing assistant attempted a transfer alone, leading to the resident's anterior shoulder dislocation. The facility's investigation confirmed the neglect due to non-compliance with the care plan.
The facility failed to provide a written summary of the baseline care plan and order summary to several residents and/or their representatives, including those with conditions such as dementia and heart failure. Additionally, a baseline care plan for an indwelling foley catheter was not developed for a resident admitted with this device, as confirmed by a charge nurse.
The facility failed to provide two residents or their representatives with written notification of the bed-hold policy within 24 hours of hospital transfer, as required by its policy. The clinical records for these residents lacked documentation of the notification, which was confirmed by the Corporate Nursing Home Administrator.
A facility failed to transcribe a physician's order for Hydroxyzine, an antianxiety medication, for a resident with anxiety, diabetes, and hypertension. The facility's policy mandates that such orders be recorded on the physician's order sheet. A review of the resident's clinical record showed the absence of the transcribed order, which was confirmed by the DON during an interview.
A facility failed to have adequate physician orders for a resident's indwelling urinary catheter, which was present upon admission. The orders should have included details on catheter size, scheduled changes, and hygiene care. This deficiency was confirmed by a charge nurse during an interview.
The facility failed to document a clinical rationale for the continued use of PRN psychotropic medication beyond 14 days and did not attempt non-pharmacological interventions before administering the medication for two residents. Both residents received Vistaril for anxiety without the required stop date or rationale for extended use, and there was no evidence of non-pharmacological interventions being attempted prior to administration. The DON confirmed these deficiencies.
The facility failed to discard outdated medications, including Tubersol vials without open dates, expired Glargine and Aspart Insulin pens, and a bottle of cholestacare tablets. Staff confirmed these items should have been discarded according to policy and guidelines.
Delayed Call Bell Response Times
Penalty
Summary
The facility failed to meet the needs of residents in a timely manner, as evidenced by multiple resident complaints and documentation from a Resident Council meeting. During a facility tour and random resident interviews, nine out of eleven residents reported excessive delays in staff response to call bells, with several residents stating they often waited an hour or longer for assistance. Some residents expressed concerns about staff ignoring call lights, sometimes while using their cell phones, and others reported that after long waits, staff would promise to return but did not follow through. The issue of delayed call bell response was also documented in the Resident Council meeting minutes, and the Nursing Home Administrator acknowledged awareness of the problem and agreed that such delays were inappropriate.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
The facility failed to serve food at a palatable temperature to nine out of eleven residents interviewed, as evidenced by multiple complaints from alert and oriented residents who consistently received cold meals. During a facility tour, residents reported that their food was not palatable due to it being cold upon delivery, attributing this to meal trays sitting in the hallway for extended periods before being served. A review of Resident Council meeting records for three consecutive months also documented repeated complaints about cold food. The Nursing Home Administrator confirmed awareness of the ongoing issue during an interview.
Neglect During Resident Transfer Results in Injury
Penalty
Summary
The facility failed to ensure that a resident was free from neglect during a transfer, resulting in actual harm. The resident, who had a history of dementia, diabetes, and cognitive communication deficit, required dependent assistance for transfers, specifically needing a mechanical lift with the assistance of two staff members. However, during a transfer from a wheelchair to bed, a nursing assistant attempted to perform the transfer alone using a sit-to-stand lift, contrary to the resident's care plan and facility policy. During the transfer, the resident's knees gave way, causing them to start sliding down the lift. The nursing assistant then called for help from a fellow team member, but by that time, the resident had already sustained an injury. The resident complained of pain in the left shoulder, which was later diagnosed as an anterior dislocation at the emergency room. The incident was a result of the nursing assistant's failure to adhere to the care plan that required two staff members for the transfer. The facility's investigation confirmed that the nursing assistant did not have a second staff member present at the start of the transfer, which was a violation of the facility's policy on safe lifting and movement of residents. This neglect led to the resident's injury, highlighting a lapse in following established protocols for resident safety during transfers.
Removal Plan
- The facility initiated education for all nursing staff including Registered Nurse's (RN's), Licensed Practical Nurses (LPN's), and NA's to ensure that resident transfers were performed per facility policy and resident care plans.
- Immediate suspension of NA Employee E10.
- Immediate education regarding resident mechanical lifts and checking transfer status before transferring a resident was provided to nursing staff which included RN's, LPN's, and NA's, and was ongoing.
- Therapy Department conducted competencies of staff included in the education to ensure that they understood the education and could perform the task correctly.
- Interviews with LPN Employees E3 and E4, NA Employees E5, E6 and E7, and RN Employee E8 confirmed the facility initiated education and competencies, which included education on where to find transfer status for the resident and performing a return demonstration to ensure proper knowledge and technique while using mechanical lifts.
- Audits were conducted to ensure safe transfers for residents and remain ongoing.
- These audits will be reviewed by the Quality Assurance Performance Improvement (QAPI) Committee meeting post incident.
- The NHA also identified that review of resident transfers will continue to be reviewed at QAPI meeting and will continue until determined otherwise by the QAPI committee.
- The facility has demonstrated compliance with using correct transfer status for residents.
Failure to Provide Baseline Care Plans and Documentation
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan and order summary to four residents and/or their representatives. These residents included individuals with various diagnoses such as dementia, dysphagia, malignant neoplasm of the lung, muscle wasting, hyperlipidemia, heart failure, hypertension, and hypothyroidism. The clinical records for these residents lacked evidence that the required documentation was provided, which is necessary to ensure effective, person-centered care and meet professional standards of quality care. Additionally, the facility did not develop and implement a baseline care plan for an indwelling foley catheter for one resident who was admitted with this medical device. This oversight was confirmed by a charge nurse during an interview. The absence of a baseline care plan for the foley catheter indicates a failure to address the specific medical needs of the resident upon admission, as required by the facility's policy.
Failure to Provide Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of its bed-hold policy to residents or their representatives within 24 hours of a hospital transfer, as required by its own policy. This deficiency was identified during a review of the facility's policy and clinical records, as well as through staff interviews. Specifically, two residents, identified as R41 and R7, were transferred to the hospital, but their clinical records did not contain documentation that they or their representatives received the bed-hold policy notification. Resident R41, who has diagnoses including intellectual disabilities, dysphagia, and hypertension, was transferred to the hospital on a specific date, but there was no evidence of the required notification. Similarly, Resident R7, with diagnoses of hyperlipidemia, hypertension, and hypothyroidism, was transferred on two separate occasions, yet the clinical records also lacked the necessary documentation. The Corporate Nursing Home Administrator confirmed the absence of this documentation during an interview.
Failure to Transcribe Physician's Order for Anxiety Medication
Penalty
Summary
The facility failed to transcribe a physician's order for an anxiety medication for one resident. The facility's policy requires that drug and biological orders be recorded on the physician's order sheet in the resident's chart. A review of the clinical record for a resident with diagnoses including anxiety, diabetes, and hypertension revealed a physician's progress note indicating the addition of Hydroxyzine 25 mg every six hours as needed for anxiety. However, the physician's orders for this resident lacked evidence that the Hydroxyzine order was transcribed. During an interview, the Director of Nursing confirmed that the order was not transcribed as required.
Lack of Physician Orders for Urinary Catheter Care
Penalty
Summary
The facility failed to ensure adequate physician orders were in place for a resident with an indwelling urinary catheter. The resident, who was admitted with diagnoses including benign prostatic hyperplasia, heart failure, and dysphagia, had a foley catheter upon entry into the facility. However, the clinical record review revealed a lack of physician orders for the urinary catheter, which should have included details such as catheter and balloon size, scheduled changes, changes as needed due to soiling or dislodgement, draining of the collection bag, collection bag changes, and hygiene care. This deficiency was confirmed during an interview with a charge nurse, who acknowledged the absence of necessary physician orders for the resident's catheter care.
Failure to Document Rationale and Non-Pharmacological Interventions for PRN Psychotropic Medication
Penalty
Summary
The facility failed to provide a clinical rationale for the continued use of PRN psychotropic medication beyond 14 days and did not document attempts of non-pharmacological interventions prior to administering the medication for two residents. Resident R12, diagnosed with anxiety, heart failure, and chronic pain, had a physician's order for Vistaril 50 mg as needed for anxiety, but the order lacked a required stop date within 14 days or a clinical rationale for continued use beyond this period. The medication was administered multiple times in October and November 2024 without evidence of non-pharmacological interventions being attempted beforehand. Similarly, Resident R67, with diagnoses of anxiety and dementia, had a physician's order for Vistaril 10 mg as needed for anxiety, also lacking the required stop date or clinical rationale for extended use. The medication was administered numerous times in October and November 2024 without documentation of non-pharmacological interventions being attempted prior to administration. The Director of Nursing confirmed these deficiencies during an interview, acknowledging the lack of required documentation and intervention attempts.
Failure to Discard Outdated Medications
Penalty
Summary
The facility failed to appropriately discard outdated medications, as evidenced by observations and staff interviews. During a review of the first floor medication room, two open multi-dose vials of Tubersol were found without any indication of when they were opened, making it impossible for staff to determine the discard date. This was confirmed by a Registered Nurse, who acknowledged that the vials should have been discarded. Additionally, the facility's policy and manufacturer's guidelines specify that Tubersol should be discarded within 30 days of opening. Further observations of the two east medication cart revealed an opened Glargine Insulin pen and an opened Aspart Insulin pen, both of which were past their expiration dates. An open bottle of cholestacare tablets was also found with a best-by date that had passed. The Director of Nursing confirmed that these items were expired and should have been discarded. The facility's policy and manufacturer's guidelines require that insulin pens be discarded 28 days after opening, even if they still contain insulin.
Latest citations in Pennsylvania
Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
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