Little Sisters Of The Poor
Inspection history, citations, penalties and survey trends for this long-term care facility in Pittsburgh, Pennsylvania.
- Location
- 1028 Benton Avenue, Pittsburgh, Pennsylvania 15212
- CMS Provider Number
- 396116
- Inspections on file
- 22
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Little Sisters Of The Poor during CMS and state inspections, most recent first.
A resident with dementia, depression, and muscle weakness, care planned as dependent for transfers and requiring a full-body mechanical lift with two-person assistance, was injured during a transfer when a NA attempted to use a Hoyer lift without proper sling attachment and without a second staff member actively assisting. Another NA entered the room and found the resident already suspended in the lift, leaning forward with missing sling attachments, and while attempting to help move the resident to bed, the resident slid out of the improperly secured sling and fell to the floor, sustaining a scalp laceration that required staples. Staff interviews confirmed that facility policy required two staff for mechanical lift use and that the sling should have all required hooks attached, and that the NA involved had previously been reminded not to use the lift alone.
The facility did not provide required training on effective communication to nine out of ten direct care staff, including multiple nurse aides, an LPN, and an RN. This was confirmed through review of training records and staff interviews, resulting in a deficiency related to staff development and management requirements.
A review of education records and staff interviews revealed that three nurse aides did not receive required QAPI training, as confirmed by the Nursing Educator. This failure to provide mandatory training was found to be noncompliant with staff development and management regulations.
The facility did not provide Compliance and Ethics training to three nurse aides, as confirmed by a review of training records and staff interview. This failure was verified by the Nursing Educator and is not in accordance with required staff development regulations.
The facility did not provide required behavioral health training to two nurse aides and an LPN, as shown by missing documentation in their training records and confirmed by the Nursing Educator.
A resident requiring assistance with ADLs and with multiple diagnoses was left unsupervised in a bath chair by an untrained agency NA, resulting in the resident sliding down in the chair with safety mechanisms not in place. The resident was found yelling for help, with water up to the collarbone, and reported feeling terrified during the incident. Facility records and staff interviews confirmed that required supervision and safety procedures were not followed.
A nurse aide did not receive required training on Resident Rights, as confirmed by a review of education records and staff interview. The Nursing Educator acknowledged that this staff member was not provided the mandated education.
A resident with Parkinson's disease, bipolar disorder, and anxiety disorder was injured when a medical driver failed to properly position a van lift during hospital transport, resulting in a fall that required immediate medical attention. Facility documentation and staff interviews confirmed the lift was not in the correct position, leading to the incident.
A resident with Parkinson's disease, bipolar disorder, and anxiety experienced psychological distress after a fall from a van during transport. Despite a psychiatric recommendation for counseling, the facility did not arrange for these services, as no counseling provider had been available since the previous year.
A resident with dementia and moderate impairment eloped from a facility due to inadequate supervision and lack of updated care plans. Despite documented wandering and confusion, the facility failed to conduct regular elopement risk assessments or implement sufficient safety measures, resulting in the resident exiting the building unsupervised.
A resident with dementia and high risk for elopement was involved in multiple wandering incidents at the facility. Despite the facility's policy requiring physician notification within twelve hours of such incidents, the physician was not informed. The Nursing Home Administrator and DON confirmed this failure to comply with regulatory requirements.
The NHA and DON failed to manage the facility effectively, leading to a resident's elopement. Despite their responsibilities to ensure adherence to policies and regulations, the facility did not prevent the incident, placing residents in Immediate Jeopardy.
A facility failed to notify the Department of Health about six out of seven elopement incidents involving a resident with dementia and cerebral infarction. The resident was found in various unauthorized areas of the facility, indicating a high risk for elopement. Despite the facility's policy requiring timely notification of such incidents, the appropriate agency was not informed, compromising patient safety.
The facility did not notify the Department of Health about a reportable event when the fire alarm was activated and the fire company arrived. The DON stated they did not think it was necessary to report the incident, which was a failure to comply with notification requirements.
A visually impaired resident was injured during an activity involving a horse due to inadequate supervision. The resident, who is legally blind, was bitten by a horse, resulting in a finger fracture. The facility's care plan lacked specific safety measures for the resident's visual impairment, contributing to the incident.
The facility failed to date food items upon receipt, risking improper rotation, and stored kitchen items without inverting them, risking cross-contamination. Additionally, an employee did not properly wash hands after handling dirty dishes, potentially leading to foodborne illness.
The facility did not post required information about the Medicaid Fraud Control Unit on the First and Second Floor bulletin boards. This was confirmed by the DON during a survey, violating 28 Pa. Code: 201.14(a) and 201.18e.
The facility failed to make the Department of Health Survey Results readily accessible to residents and visitors. Observations showed no information on bulletin boards about the survey results on the First and Second Floors. During an interview, residents were unaware of the location of the survey results binder. The DON found the binders inside desks, confirming they were not visible or accessible.
The facility failed to provide appropriate respiratory care for four residents by not labeling oxygen tubing with dates, as required by their protocol. Observations revealed that residents with various medical conditions, including respiratory failure and hypertension, were receiving oxygen through undated nasal cannulas. Interviews with RNs confirmed the absence of dates, indicating non-compliance with the facility's policy to routinely change and label oxygen equipment.
The facility failed to conduct ongoing assessments for bedrail use for five residents, despite having policies requiring annual reassessment. Residents with conditions such as blindness, hypertension, and osteoarthritis had physician orders and care plans for side rail use, but no additional assessments were completed. Observations confirmed the presence of side rails, and the DON acknowledged the lack of ongoing assessments.
The facility failed to monitor personal refrigerators for two residents, lacked Enhanced Barrier Precautions for two residents with medical devices, and did not maintain a sanitary medication room. Additionally, infection control practices were not followed during a dressing change for a resident, leading to potential cross-contamination risks.
The facility did not provide communication training to four direct care staff members, as required by its policy and the Pennsylvania Code. Despite the policy mandating verification of educational preparation and competency, including communication skills, the facility's 2023 records lacked evidence of such training for these employees. Interviews with the Human Resources Director and the Director of Nursing confirmed this deficiency.
The facility did not provide required training on resident protection from abuse and neglect for two staff members. Despite policies mandating such training during orientation and ongoing employment, a review of 2023 education documents showed that these employees were not trained. This was confirmed by the DON and HR Director.
The facility did not provide mandatory QAPI training to seven staff members, including RNs and NAs, as required by its policy. Despite the policy mandating ongoing educational preparation and competency verification, a review of 2023 education documents showed no QAPI training for these employees. Interviews with HR and the DON confirmed this deficiency.
The facility failed to provide mandatory infection control training for five staff members, as required by its policies. The training records for an RN and four NAs did not include infection control education, which was confirmed by the HR Director and DON. This deficiency violates specific state codes related to staff development and management.
The facility failed to provide Compliance and Ethics training for two staff members, Employees E11 and E13, as required by their policy on Nursing Education, Mandatory Training, and Competency Evaluation. A review of 2023 education documents showed that these employees did not receive the necessary training, which was confirmed by the DON. The HR Director noted that education is conducted annually.
The facility failed to provide the required 12 hours of annual in-service education for five nurse aides, as mandated by facility policy. A review of 2023 education documents showed that none of the aides met the required training hours, with the highest being 7.75 hours. This deficiency was confirmed by the DON and noted under relevant state regulations.
The facility did not provide required Behavioral Health training for three staff members, including two RNs and one NA, as per its policy on Nursing Education and Competency Evaluation. This deficiency was confirmed by the DON.
A resident was unable to smoke at requested times due to insufficient staff willing to supervise her smoking breaks, as required by facility policy. The resident, who is legally blind and requires assistance, expressed that she often could not go outside to smoke because non-smoking staff were unwilling to accompany her. The ADON confirmed that staffing limitations led to this deficiency in care.
A facility failed to assess a resident's ability to self-administer medications, as required by their policy. The resident's care plan and physician orders did not include provisions for self-administration, and no assessment was documented. An RN was observed leaving medications at the resident's bedside, which was not permitted. The DON confirmed the absence of a self-administration policy and acknowledged the oversight.
A facility failed to maintain a safe and homelike environment in one of its nursing units. An observation revealed a missing door handle in a resident's room, leaving an exposed, sharp piece of metal. The DON confirmed the deficiency, acknowledging the failure to uphold safety and homelike standards as required by Pennsylvania Code.
A resident with high blood pressure, respiratory failure, and shortness of breath filed a grievance that was not addressed by the facility until several months later, contrary to the facility's grievance policy. Interviews with the resident and staff, including the DON and Nursing Home Administrator, confirmed the delay in addressing the grievance.
The facility failed to communicate necessary information to the receiving health care provider for two residents transferred to the hospital. One resident had depression and legal blindness, while the other had high blood pressure and reduced mobility. The lack of documentation of essential information such as care plan goals and advanced directives was confirmed by the ADON.
The facility failed to provide required written notifications for hospital transfers of two residents, including details such as the reason for transfer and contact information for the Ombudsman. The Assistant Director of Nursing confirmed this deficiency.
The facility failed to notify two residents or their representatives of the bed-hold policy during hospital transfers, as required by their policy. Both residents were transferred without receiving written information about the duration of the bed-hold policy, and the Assistant Director of Nursing confirmed this oversight.
A resident with diabetes experienced multiple low blood glucose readings, but the facility failed to implement the hypoglycemia protocol or document interventions. Additionally, the resident refused to be weighed on several occasions, and the facility did not notify the physician as required. The facility also administered Metolazone despite the resident's weight being below the threshold specified in the physician's order.
The facility failed to properly store medical supplies and biologicals in one of two medication rooms. The policy requires medications to be maintained within specific temperature ranges. An observation revealed that the temperature log for the first-floor medication room refrigerator was not completed on three specific dates, as confirmed by an RN.
Neglect During Mechanical Lift Transfer Resulting in Resident Head Injury
Penalty
Summary
The facility failed to protect a resident from neglect during a mechanical lift transfer, resulting in a fall and scalp laceration requiring three staples. Facility policy on abuse, neglect, and misappropriation defined neglect as the failure to provide necessary goods and services to avoid physical harm, and the mechanical lift policy required two staff members for all mechanical lift transfers. The resident involved had non-Alzheimer’s dementia, depression, and muscle weakness, and the care plan and MDS documented that the resident was dependent on staff for transfers and required a full-body lift with assistance of two persons. On the date of the incident, progress notes and hospital records showed that the resident slipped out of the lift pad and onto the floor, was found lying on their back with bleeding from the back of the head, and was transferred to the hospital where a scalp laceration was treated with three staples. Multiple witness statements described that NA E1 had already placed the resident in the air in a whole-body (Hoyer) lift without proper sling attachment and without a second staff member actively assisting. NA E3 entered the room seeking help for another transfer and observed the resident in the lift, leaning forward with upper straps around the neck and shoulders, and noted that not all straps were hooked to the lift, including the absence of the middle hook. Witnesses, including NAs and an RN, consistently reported that facility practice and policy required two staff for mechanical lift transfers and that the sling should have three rings attached. NA E2 reported having previously seen NA E1 coming out of the resident’s room alone with the lift days before the incident and had reminded NA E1 that two people were required for lift use. On the day of the event, NA E3 attempted to assist in moving the resident to the bed, but due to the improper sling application, the resident slid through the lift pad and fell to the floor, striking the back of the head. The DON and RN confirmed that the resident required a mechanical lift with two staff for transfers and that the resident fell from the lift pad during a transfer performed by NA E1, resulting in the scalp laceration.
Failure to Provide Effective Communication Training for Direct Care Staff
Penalty
Summary
The facility failed to provide required training on effective communication for nine out of ten direct care staff members, including nurse aides, an LPN, and an RN. Review of facility education documents and training records showed that these staff members did not receive education on effective communication as mandated. This finding was confirmed during an interview with the Nursing Educator, who acknowledged the lack of such training for the identified staff. The deficiency was cited under relevant Pennsylvania Codes related to licensee responsibility, management, and staff development. No information was provided regarding the involvement or condition of any residents in relation to this deficiency.
Failure to Provide QAPI Training to All Staff
Penalty
Summary
The facility failed to provide mandatory Quality Assurance and Performance Improvement (QAPI) training to three out of ten nurse aide staff members, as evidenced by a review of facility education documents and training records. Specifically, the records for these three nurse aides did not include documentation of QAPI education as required. This deficiency was confirmed during an interview with the Nursing Educator, who acknowledged that the training had not been provided to these staff members. The findings reference noncompliance with state regulations regarding staff development and management responsibilities.
Failure to Provide Compliance and Ethics Training to Staff
Penalty
Summary
The facility failed to provide required Compliance and Ethics training to three out of ten nurse aide staff members, as evidenced by a review of facility education documents and training records. Specifically, the records for these three nurse aides did not include documentation of education on Compliance and Ethics, which is mandated. This deficiency was confirmed during an interview with the Nursing Educator, who acknowledged that the training had not been provided to these staff members. The findings reference specific state regulations regarding the responsibility of the licensee, management, and staff development.
Failure to Provide Behavioral Health Training to Staff
Penalty
Summary
The facility failed to provide required behavioral health training to three out of ten staff members, specifically two nurse aides and one LPN, as evidenced by a review of facility education documents and training records. The records for these staff members did not include documentation of behavioral training as mandated by facility policy and regulatory requirements. This deficiency was confirmed during an interview with the Nursing Educator, who acknowledged that the behavioral training had not been provided to the identified staff members. No information regarding residents, their medical history, or their condition at the time of the deficiency was included in the report.
Failure to Provide Adequate Supervision During Bathing
Penalty
Summary
The facility failed to provide adequate supervision during bathing for one resident, resulting in a deficiency related to accident hazards and supervision. According to facility policy, staff are required to remain with residents at all times during bathing, ensure all safety mechanisms such as seatbelts and locked wheels are in use, and never leave a resident unattended. However, a resident with diagnoses including high blood pressure, arthritis, and schizophrenia, who was cognitively intact and required assistance with activities of daily living, was left alone in a bath chair by an agency nurse aide who was unfamiliar with the equipment and procedures. The incident occurred when the resident was placed in the tub by the agency nurse aide, who then left the room immediately after asking the resident how the machine worked. The resident was found by staff after yelling for help, sliding down in the bath chair with water up to the collarbone/neck, the safety belt unfastened, the handlebar not in place, and the chair wheels unlocked. The resident reported feeling terrified during the incident and estimated being left alone for about ten minutes. The resident denied going under the water and was assessed with stable vital signs and no injuries following the event. Facility documentation and staff interviews confirmed that the agency nurse aide had not been trained on the use of the bathing equipment and that the resident was left unsupervised in violation of facility policy and federal regulations. The deficiency was identified through review of facility records, policies, and interviews, which established that the required supervision and safety measures were not provided during the resident's bath.
Failure to Provide Resident Rights Training to Staff Member
Penalty
Summary
The facility failed to provide required training on Resident Rights to one of ten staff members, specifically a nurse aide identified as Employee E4. This deficiency was identified through a review of facility education documents and training records, which showed that Employee E4 had not received the mandated education on Resident Rights. During an interview, the Nursing Educator confirmed that this staff member had not been trained as required. The deficiency is cited under 28 Pa Code: 201.14 (a) Responsibility of licensee, 28 Pa Code: 201.18 (b)(1) Management, and 28 Pa Code: 201.20 (a)(6)(d) Staff development.
Resident Fall Due to Improper Use of Van Lift
Penalty
Summary
A deficiency occurred when a resident with diagnoses of Parkinson's disease, bipolar disorder, and anxiety disorder was not properly protected from neglect during transportation to a hospital. The facility's medical driver failed to ensure that the van lift was in the correct position before assisting the resident out of the vehicle. As a result, the resident fell from the van, striking the left side of their body, and required immediate evaluation and treatment by hospital staff and paramedics. Facility documentation, including a witness statement from the medical driver and confirmation from the Director of Nursing, indicated that the lift was not properly positioned and that this failure directly led to the resident's fall. The incident was reported to the state survey office, and it was confirmed that the facility did not adhere to its own policy regarding the prevention of neglect, as necessary precautions were not taken to avoid physical harm to the resident.
Failure to Provide Medically-Related Social Services After Traumatic Incident
Penalty
Summary
A deficiency was identified when the facility failed to provide medically-related social services to a resident with a history of Parkinson's disease, bipolar disorder, and anxiety disorder. The resident experienced a traumatic incident when she fell from a van while being transported for a medical appointment, resulting in her being evaluated and treated in the emergency room. Following the incident, the resident exhibited ongoing psychological distress, including preoccupation with the fall, repeated questioning, and a desire to speak with a counselor. Despite a psychiatric evaluation recommending psychological counseling for the resident due to her persistent distress after the fall, the facility did not arrange for such services. An interview with a social service employee confirmed that the facility had not had a counseling service available since the previous year and had not set up a counseling appointment for the resident. This lack of action resulted in the failure to provide necessary medically-related social services as required.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to ensure adequate supervision for a resident, resulting in an elopement incident. The resident, who had a history of dementia and was moderately impaired, was found outside the building on a loading dock, having exited the facility without staff knowledge. The resident's clinical records indicated a moderate risk for elopement, yet the facility did not update care plans or implement sufficient interventions to prevent such incidents. The resident had multiple episodes of wandering and confusion, which were documented in progress notes. Despite these documented behaviors, the facility did not consistently complete elopement risk assessments or notify the resident's family and physician. The facility also failed to update care plans or implement additional safety measures to address the resident's wandering and exit-seeking behaviors. The facility's lack of response to the resident's elopement risk was further evidenced by the absence of wander guard alarms on doors and elevators that did not lock when a wander guard bracelet was detected. This oversight, combined with the failure to conduct regular elopement risk assessments and update care plans, contributed to the resident's ability to leave the facility unsupervised, creating an immediate jeopardy situation.
Plan Of Correction
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? (Resident R1) - Resident R1 now has a Wander Guard and was moved to the first floor where the Wander Guard alarms are located. Resident R1 was assessed for injury and family was notified on 4/16/2025. The physician was notified of the elopement on 4/05/2025 at 16:30. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? - Elopement risk assessments were completed on all residents on 4/16/2025. Any resident identified as at-risk for elopement was reviewed by the interdisciplinary team for appropriate interventions to prevent elopements. Sign-in/Sign-out sheets were initiated on 4/19/2025 to monitor all resident whereabouts on and off the nursing units. 3. What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur? The Elopement - Assessment, Risk & Prevention Policy was revised to include: - Added that the Elopement Risk Assessment will be performed quarterly as part of the resident's care plan review. This is in addition to performing the assessment on admission (or readmission), for changes in the residents' condition or cognition, after an elopement attempt, upon verbalizing their desire to leave the facility, and any time a staff member feels that the resident should be reassessed. - Rounds were added on an hourly basis from 11:00 PM to 7:00 AM every night and every hour for weekend shifts. These rounds will be recorded in logbooks on every nursing unit. - Sign-in/Sign-out logs were added to every unit to update staff when the residents are off the unit for an activity, appointment, or outing. Binders are at every nursing station with at-risk resident photographs and their individualized care plans. Binders are at the front desk with at-risk resident photographs. - In the event of an elopement, a full body assessment will be included. All departments (agency and staff) were educated about elopement risks and procedures, that included recognizing elopement, completing risk assessments, care plans, supervision to prevent elopement, and the Wander Guard system. - Further education will be ongoing and will be included in the new hire curriculum and at least annually with all staff education days. An emergency QAPI meeting was held on April 22, 2025, to review elopement policies and procedures. Another QAPI meeting is scheduled for May 5, 2025, to review elopement policies and procedures and progress with implementation. - CNA meetings were held on April 22, 2025, and a Licensed Nurse meeting was held on April 23, 2025, to educate clinical staff on the changes to the Elopement Policy and to discuss concerns. A Daily Stand-Up Meeting and Policy was developed and will begin on May 1, 2025. These meetings will review the 72-hour nursing report every Monday and will review the 24-hour nursing report every other weekday. The Stand-Up Meeting will address new business and reportables, high-risk review elements, and any events to be reported to the attending physicians and/or the medical director. A binder with the Stand-Up Meeting notes will be maintained by the nurse educator. - Elopement drills will be held on at least a quarterly basis, with every shift evaluated on at least a yearly basis. An elopement drill is scheduled to be conducted on 5/02/2025. A directed In-Service on 42 CFR 483.25 Accidents/Hazard/Supervision F689 will be held on May 7, 2025, by Masters crafted in Healthcare, LLC. This In-Service will include a review of all the federal regulations cited along with a review of the accompanying guidelines and be conducted on all shifts and recorded for any staff unable to attend. All staff will also be educated on new and revised policies at this time. The staff will continue to ensure that the new policies will be followed. This will be monitored at the daily Stand-Up Meetings, and audits of the rounding logbooks. All will be reported quarterly at QAPI. 4. How will the corrective action be monitored to ensure that the deficient practice will not recur; i.e., what quality assurance programs will be established? The Elopement Prevention Audit Tool, which includes physician orders, treatment record documentation, elopement binders, incident reports, hourly logbooks, event reporting, and physician notification is being completed by the DON or designee daily for 2 weeks starting on 4/16/2025, then weekly for 3 weeks, then monthly for 3 months, and then quarterly thereafter with the results reported to the Quality Assurance Committee for further follow-up. 5. Dates of when the corrective action will be completed - May 16, 2025.
Removal Plan
- An elopement assessment will be done on every resident.
- Resident R1 now has a wander guard and is moved to the first floor where the alarms are located.
- Resident R1 has been assessed for injury and family was notified of all the events.
- Elopement care plans, which include resident specific interventions, will be done on every resident.
- Hourly rounds will be added to all night and weekend shifts.
- Wander guard placement will be checked every shift, and wander guard function will be checked daily.
- At risk residents must be supervised when out of bed by a staff member to ensure residents are safe.
- Educate all departments including agency on Elopement Risk and Assessment, Care plans, Supervision, Wander guards, How to activate wander guards and where they are located, Color light indicators.
- Elopement policy revised to add head to toe assessment (full body), elopement risk assessments will be done quarterly with care plan review, elopement binders will be on each nurse's station and front desk, to include picture and room number.
- Emergency Quality Assurance Performance Improvement (QAPI) meeting will be held with all supervisors and committee members.
- All other incidents will be reviewed at regular QAPI meetings.
- Audits will be completed.
- Daily audits will be completed by DON or designee daily for two weeks, then weekly for three weeks, then monthly for three months, and then quarterly.
- Hourly Round tool will be conducted at night and on the weekends.
- Facility called an emergency QAPI meeting, and signature sheet was provided and reviewed.
Failure to Notify Physician of Resident Elopements
Penalty
Summary
The facility failed to comply with the requirement to notify a physician of elopements for a resident, identified as Resident R1, who was involved in multiple incidents of wandering and elopement. The facility's policy mandates that a physician and responsible party must be notified of any accident or incident within twelve hours. However, the facility did not adhere to this policy for Resident R1, who was found in various locations outside of her designated area on several occasions. These incidents included being found on the ground level near the kitchen, in a closet downstairs, and at the reception desk by the front door, among others. Despite these occurrences, the facility did not notify the physician as required. Resident R1, who was admitted to the facility with diagnoses including high blood pressure, dementia, and cerebral infarction, was identified as being at high risk for elopement. The resident's clinical records and interviews with facility staff confirmed the lack of physician notification for these incidents. The facility's failure to notify the physician was acknowledged by the Nursing Home Administrator and Director of Nursing during an interview, confirming the deficiency in meeting the regulatory requirements for quality of care.
Plan Of Correction
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? - Resident R1 now has a Wander Guard and was moved to the first floor where the Wander Guard alarms are located. Resident R1 was assessed for injury and family was notified on 4/16/2025. The physician was notified of the elopement on 4/05/2025 at 16:30. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? - On 5/01/2025 an audit was completed on the nursing notes for all residents over the past 30 days. Only Resident R1 is exit-seeking and verbalizing desire to leave. This occurs almost every day. On the night shift there will always be a staff person to monitor her whereabouts. - All nursing staff were educated on the facility policy including physician notification with elopement events on 4/15/2025 and 4/16/2025. 3. What Measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur? - The facility Elopement Assessment, Risk and Prevention Policy includes notifying the attending physician with any elopement incidents and was reviewed by the Quality Assurance Team on 4/16/2025. - The Change in Condition Policy has been updated to include elopement incidents and attending physician notification. Nursing staff were educated on recognizing elopement and physician notification following any elopement incidents on 4/15/2025 and 4/16/2025. 4. How will the corrective action be monitored to ensure that the deficient practice will not recur; i.e., what quality assurance programs will be established? - An Elopement Prevention Audit Tool, which includes physician notification, is being completed by the DON or designee daily for 2 weeks beginning on 4/16/2025, then weekly for 3 weeks, then monthly for 3 months, and then quarterly thereafter with the results reported to the Quality Assurance Committee for further follow-up. 5. Date of when the Corrective Action will be completed - May 16, 2025.
Failure to Prevent Resident Elopement
Penalty
Summary
The Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility, resulting in the elopement of a resident, identified as Resident R1. The job descriptions for both the NHA and DON emphasize their responsibilities in ensuring adherence to policies and procedures, as well as having a thorough knowledge of federal and state regulations governing long-term care facilities. Despite these outlined duties, the facility did not prevent the elopement, which placed the residents in Immediate Jeopardy. The deficiency was identified through a review of job descriptions, clinical records, and staff interviews. During an interview, the NHA and DON were informed of their failure to manage the facility effectively to prevent the elopement. The report highlights that the NHA and DON did not fulfill their essential job duties to ensure compliance with federal and state guidelines and regulations, as evidenced by the elopement incident involving Resident R1.
Plan Of Correction
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The Nursing Home Administrator and the Director of Nursing reviewed their job descriptions with the Human Resources Director, with a focus on the essential job functions. The Nursing Home Administrator completed her review on 4/30/2025. The Director of Nursing completed her review on 5/01/2025. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The Nursing Home Administrator and the Director of Nursing will attend the directed In-Service on 42 CFR 483.25 Accidents/Hazard/Supervision F689, which will be held on the week of May 5, 2025, by Masters crafted in Healthcare, LLC. This In-Service will include a review of all the federal regulations cited along with a review of the accompanying guidelines. The Elopement Assessment, Risk, and Prevention Policy was updated to include the definition of elopement. New policies were developed and implemented on Investigating and Reporting Accidents and Incidents, for both Administration and Nursing Staff. 3. What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur? The Nursing Home Administrator and Director of Nursing will continue to ensure that the new policies will be followed. This will be monitored at the daily Stand-Up Meetings, through audits of the electronic medical records. All will be reported quarterly at QAPI. 4. How will the corrective action be monitored to ensure that the deficient practice will not recur; i.e., what quality assurance programs will be established? The Nursing Home Administrator and Director of Nursing are in attendance at each morning Stand-Up Meeting where resident specific issues and outcomes are reviewed. The Elopement Prevention Audit Tool, which includes physician orders, treatment record documentation, elopement binders, incident reports, hourly logbooks, event reporting, and physician notification is being completed by the DON or designee daily for 2 weeks starting on 4/16/2025, then weekly for 3 weeks, then monthly for 3 months, and then quarterly thereafter with the results reported to the Quality Assurance Committee for further follow-up. 5. Dates of when the corrective action will be completed - May 16, 2025.
Failure to Report Elopement Incidents
Penalty
Summary
The facility failed to notify the Department of Health of six out of seven reportable elopement events involving a resident. The resident, who was admitted with diagnoses including high blood pressure, dementia, and cerebral infarction, was involved in multiple incidents where they were found outside their designated area. These incidents occurred over a period of time and included the resident being found on different floors and areas of the facility, such as near the kitchen and at the reception desk. Despite these occurrences, the facility did not report these elopements to the appropriate agency as required by regulation. The resident was assessed as being at high risk for elopement, as indicated by an Elopement Evaluation score. The facility's policy required that any accidents or incidents involving residents be reported to the physician and responsible party within twelve hours, but this protocol was not followed in terms of notifying the Department of Health. The Nursing Home Administrator and Director of Nursing confirmed the failure to report these events, which seriously compromised quality assurance and patient safety as outlined in the regulatory requirements.
Plan Of Correction
The facility reported the elopement to the DOH on 4/5/25. The facility developed an Event Reporting Policy that includes an outline of the incidents and events that are required to be reported per Chapter 51.3. The facility updated its Change in Condition Policy to include elopement incidents and the required reporting and follow-up. All departments (Agency and staff) were educated about elopement risks and procedures, that included recognizing elopement and reporting of elopement incidents immediately to their immediate supervisor and then the Nursing Home Administrator and Director of Nursing. This education will also be included in the new hire curriculum and at least annually with all staff education days. The Elopement Prevention Audit Tool, which includes physician orders, treatment record documentation, elopement binders, incident reports, hourly logbooks, event reporting, and physician notification is being completed by the DON or designee daily for 2 weeks starting on 4/16/2025, then weekly for 3 weeks, then monthly for 3 months, and then quarterly thereafter with the results reported to the Quality Assurance Committee for further follow-up. Completion date - May 16, 2025.
Failure to Notify Department of Health of Reportable Event
Penalty
Summary
The facility failed to notify the Department of Health of a reportable event, as required by regulation 51.3 (g)(1-14). The deficiency was identified based on facility reports and staff interviews. On February 3rd, the fire alarm was activated, and the fire company arrived at the facility. During an interview, the Director of Nursing (DON) stated that they did not think it was necessary to report the incident. This oversight was confirmed by the DON, indicating a failure to comply with the notification requirements for events that seriously compromise quality assurance and patient safety.
Plan Of Correction
Immediate Action: The fire alarm event was reported to the Department of Health and accepted. No substantial disruption of services occurred. All supervisors were instructed on reportable events and event reporting will be part of our yearly training sessions. Event reporting will be discussed at safety meetings and quarterly at QAPI meetings. Reportable incidents will be monitored by the Safety Officer and reported monthly at the Safety Committee. All reports will be submitted quarterly at QAPI. Staff in-services will instruct staff on notification of residents as to the status of the event (false alarm, partial evacuation, etc.). An event report was created for the Incident Commander or designee to complete the details of the event, what actions were taken, and who was notified of the event. Subsequently, the Department of Health will be notified according to PA Code 51.3. The Fire Policy was updated to include event reporting to the Department of Health. The corrective action will be completed by February 10, 2025.
Inadequate Supervision Leads to Resident Injury During Activity
Penalty
Summary
The facility failed to provide adequate supervision for a visually impaired resident during an activity involving a horse, resulting in the resident being bitten and sustaining a fracture. The resident, identified as R17, is legally blind and has a history of depression and anxiety. During the activity, the resident was in a wheelchair and unaware that other residents were feeding carrots to the horse. The resident's hand movements were mistaken by the horse for a carrot, leading to the bite. The incident occurred when the resident was participating in an activity where horses were present, and other residents were feeding them treats. The facility's care plan for the resident did not include specific interventions or safety precautions related to the resident's visual impairment during such activities. The lack of supervision and failure to implement safety measures contributed to the incident, as the resident was unable to perceive the danger due to her blindness. Interviews with staff and the resident revealed that there were several staff and volunteers present during the activity, but none witnessed the actual bite. The resident did not feel the bite due to a lack of sensation in her fingers and only became aware of the injury when others noticed the bleeding. The facility's failure to provide adequate supervision and safety measures for the visually impaired resident during the activity led to the resident sustaining a fracture in her finger.
Food Safety and Hygiene Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to proper food safety protocols, as evidenced by several observations and staff interviews. During a review of the facility's food safety policy, it was noted that food items in the Dry Foods Storage Area, Walk-In Refrigerator, and Walk-In Freezer were not dated upon receipt, which is necessary for ensuring proper food rotation. This was confirmed by the Dietary Supervisor, who acknowledged the oversight. Additionally, in the Dish Room, various kitchen items such as casserole dishes, bowls, serving platters, saucepans, and frying pans were stored without being inverted, increasing the risk of cross-contamination. Furthermore, a significant lapse in hand hygiene was observed in the Dish Room. An employee, identified as KP Employee E8, was seen wearing gloves while handling dirty dishes and failed to properly wash hands with soap and water before handling clean dishes. The employee only rinsed gloved hands under water for about two seconds, which was insufficient for maintaining hygiene standards. This was confirmed by both the employee and the Dietary Supervisor, highlighting a failure in proper handwashing practices, which could potentially lead to foodborne illness.
Failure to Post Medicaid Fraud Control Unit Information
Penalty
Summary
The facility failed to comply with regulatory requirements by not posting necessary information about the Medicaid Fraud Control Unit on the bulletin boards located on the First and Second Floor nursing care units. This deficiency was observed during a survey conducted from November 25, 2024, through November 27, 2024. The absence of this information was confirmed during an observation and interview with the Director of Nursing on November 27, 2024, at 11:10 a.m. The failure to post this information is a violation of 28 Pa. Code: 201.14(a) and 28 Pa. Code: 201.18e, which outline the responsibilities of the licensee and management, respectively.
Survey Results Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the Department of Health Survey Results were readily accessible to residents and visitors, as required. Observations on the First and Second Floor bulletin boards revealed that there was no information posted regarding the availability of the survey results. During a group interview, ten out of ten residents were unaware of where the survey results binder was located. Additionally, the Director of Nursing found the survey results binders inside desks on both floors, confirming that they were not visible or accessible to residents and visitors. This deficiency was observed during the survey conducted from November 25, 2024, through November 27, 2024.
Failure to Label Oxygen Tubing in Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for four residents, as evidenced by the lack of proper labeling on oxygen tubing. The facility's policy requires that nasal cannulas, face masks, and nebulizer setups be changed routinely to decrease the chance of infections, with the date written on tape and applied to the tubing. However, during observations, it was noted that the nasal cannula tubing for Residents R15, R25, R27, and R29 did not have dates, indicating a failure to adhere to the facility's protocol for changing and labeling oxygen equipment. Resident R15, who has diagnoses of high blood pressure, respiratory failure, and shortness of breath, was observed receiving oxygen without a date on the nasal cannula tubing. Similarly, Resident R25, with peripheral vascular disease, diabetes, and hypothyroidism, was also observed with undated tubing. Resident R27, diagnosed with hypertension, diabetes, and hyperlipidemia, and Resident R29, with hypertension, diabetes, and hyperlipidemia, were both found to have undated oxygen tubing. Interviews with registered nurses confirmed the absence of dates on the tubing, highlighting the facility's failure to provide appropriate respiratory care as per their established protocols.
Failure to Conduct Ongoing Bedrail Assessments
Penalty
Summary
The facility failed to conduct ongoing accurate assessments to ensure that bedrails were used to meet resident needs and the risks associated with bedrail usage for five residents. The facility's policy on bed rail use, dated 11/6/23, required that a resident's condition be reassessed at least annually or upon a change in condition by Physical Therapy to determine the need for continuing use of half-length rails. However, the clinical records for Residents R17, R21, R27, R29, and R30 revealed that no additional siderail assessments were completed after the initial PCE - Siderails assessment. Resident R17, who was legally blind and required assistance with personal care, had a physician order and care plan indicating the use of top two side rails for mobility. Despite this, there were no additional siderail assessments completed after the initial assessment. Similarly, Resident R21, with diagnoses including high blood pressure and hyperlipidemia, had orders and a care plan for side rail use, but no further assessments were conducted. Observations confirmed the presence of side rails on their beds. Residents R27, R29, and R30 also had physician orders and care plans for the use of side rails to aid in mobility and transfer. However, their clinical records lacked any additional completed siderail assessments beyond the initial one. Observations showed that the side rails were present on their beds, either in the up or down position. The Director of Nursing confirmed the absence of ongoing assessments for all five residents, indicating a failure to adhere to the facility's policy and regulatory requirements.
Infection Control and Monitoring Deficiencies in LTC Facility
Penalty
Summary
The facility failed to properly monitor the personal refrigerators of two residents, R17 and R29, to ensure that food was stored and maintained correctly. Observations revealed that both residents had thermometers in their refrigerators, but there were no temperature logs present. Interviews with staff confirmed that the household aides were responsible for monitoring these refrigerators, yet multiple dates in October and November were missing temperature documentation. The facility also failed to implement Enhanced Barrier Precautions (EBP) for two residents, R1 and R3, who were at increased risk of multidrug-resistant organism (MDRO) acquisition due to their medical conditions. Resident R1, with a feeding tube, and Resident R3, with a suprapubic catheter, did not have orders or care plans for EBP, as confirmed by the Director of Nursing. This lack of precautionary measures was a significant oversight in infection control practices. Additionally, the facility did not maintain a safe and sanitary environment in one of the medication rooms, where personal items such as a lunch bag, water bottle, and purse were found on the counter. The medication room freezer also contained ice packs and ice buildup. Furthermore, during a dressing change for Resident R29, infection control practices were not followed. The RN failed to use a clean barrier field, did not perform hand hygiene after cleansing the wound, and completed the wound care without gloves, leading to potential cross-contamination risks.
Failure to Provide Communication Training to Direct Care Staff
Penalty
Summary
The facility failed to provide communication training to four out of seven direct care staff members reviewed, specifically Employees E1, E10, E12, and E14. The facility's policy on Nursing Education, Mandatory Training, and Competency Evaluation, dated 11/4/24 and previously dated 11/6/23, mandates the establishment, implementation, and maintenance of written policies and procedures for verifying educational preparation and competency, including communication skills. However, upon review of the facility's education documents for 2023, it was found that these employees did not receive training on effective communication. Interviews with facility staff, including the Human Resources Director and the Director of Nursing, confirmed the lack of communication training for these employees. The Human Resources Director noted that education is conducted on a calendar year basis, from January through December. Despite this, the facility's records did not show evidence of communication training for the specified employees, which is a requirement under the facility's policy and the Pennsylvania Code sections 201.14(a) and 201.20(c) regarding staff development.
Failure to Provide Mandatory Abuse and Neglect Training
Penalty
Summary
The facility failed to provide mandatory training on resident protection from abuse and neglect for two of its staff members, identified as Employees E11 and E13. According to the facility's policies on Nursing Education and Abuse, all staff are required to receive training during orientation and on an ongoing basis. However, a review of the facility's education documents for the year 2023 revealed that these two employees did not receive the necessary training. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the oversight. The Human Resources Director also stated that education is conducted on a calendar year basis, from January through December.
Failure to Provide QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training on Quality Assurance and Performance Improvement (QAPI) for seven staff members, including Registered Nurses and Nurse Aides. The facility's policy on Nursing Education, Mandatory Training, and Competency Evaluation, dated 11/4/24 and previously dated 11/6/23, requires the establishment, implementation, and maintenance of written policies and procedures for verifying educational preparation and competency. This includes certification and/or licensure in good standing upon hire and on an ongoing basis while employed. However, a review of facility education documents for the year 2023 revealed that none of the seven staff members received training on QAPI education. Interviews with the Human Resources Director and the Director of Nursing confirmed the lack of QAPI training for these staff members. The Human Resources Director stated that education is conducted by calendar year, running from January through December. Despite this, the facility's records did not include QAPI training for the identified employees. This deficiency was confirmed by the Director of Nursing, who acknowledged the facility's failure to provide the required training. The report cites violations of specific Pennsylvania Code regulations related to the responsibility of the licensee, management, and staff development.
Infection Control Training Deficiency
Penalty
Summary
The facility failed to provide mandatory training on infection control for five out of seven staff members, specifically Employees E1, E9, E10, E12, and E14. The facility's policy on Nursing Education, Mandatory Training, and Competency Evaluation, dated 11/4/24 and previously dated 11/6/23, requires the establishment, implementation, and maintenance of written policies and procedures for verifying educational preparation and competency, including certification and/or licensure in good standing, upon hire and on an ongoing basis. The Infection Control policy, also dated 11/4/24 and previously dated 11/6/23, states that initial orientation for new employees should cover infection control, universal precautions, and hand washing, with this information reviewed annually. Upon reviewing the facility's education documents for 2023, it was found that the training records for RN Employee E1, NA Employees E9, E10, and E12, and RN Employee E14 did not include infection control education. During interviews, the Human Resources Director confirmed that education is conducted by calendar year, and the Director of Nursing confirmed the lack of infection control training for these staff members. This deficiency is a violation of 28 Pa Code: 201.14 (a) Responsibility of licensee, 28 Pa Code: 201.18 (b)(1) Management, and 28 Pa Code: 201.20 (a)(c) Staff development.
Failure to Provide Compliance and Ethics Training
Penalty
Summary
The facility failed to provide training on Compliance and Ethics for two out of seven staff members, specifically Employees E11 and E13. The facility's policy on Nursing Education, Mandatory Training, and Competency Evaluation, dated 11/4/24 and previously dated 11/6/23, requires the establishment, implementation, and maintenance of written policies and procedures for verifying educational preparation and competency, including certification and/or licensure in good standing, upon hire and on an ongoing basis. However, a review of the facility's education documents for the year 2023 revealed that Nurse Aide (NA) Employees E11 and E13 did not receive the required training on Compliance and Ethics. This was confirmed during an interview with the Director of Nursing on 11/27/24. The Human Resources Director, Employee E15, stated that education is conducted by calendar year, running from January through December.
Failure to Provide Required In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that all nurse aide staff received the mandated minimum of twelve hours of in-service education training annually. This deficiency was identified for five nurse aide employees (E9, E10, E11, E12, and E13) based on a review of facility documents and staff interviews. The facility's policy on Nursing Education, Mandatory Training, and Competency Evaluation, dated 11/4/24, requires the establishment and maintenance of written policies and procedures for verifying educational preparation and competency, including certification and licensure. However, the review of the facility's education documents for the year 2023 revealed that none of the five nurse aides met the required 12 hours of in-service training. Specifically, the records showed that Employee E9 received 7.75 hours, Employee E10 received 2.5 hours, Employee E11 received 5.75 hours, Employee E12 received 4.0 hours, and Employee E13 received 7.75 hours of in-service training. These findings were confirmed during an interview with the Director of Nursing, who acknowledged the facility's failure to provide the required annual in-service education. The deficiency was noted under the regulations 28 Pa. Code 201.19(7) Personnel policies and procedures and 28 Pa. Code 201.20(a)(d) Staff development.
Failure to Provide Behavioral Health Training
Penalty
Summary
The facility failed to provide required Behavioral Health training for three out of seven staff members, specifically Employees E1, E10, and E14. The facility's policy on Nursing Education, Mandatory Training, and Competency Evaluation, dated 11/4/24 and previously 11/6/23, mandates the establishment, implementation, and maintenance of written policies and procedures for verifying educational preparation and competency, including certification and/or licensure in good standing, upon hire and on an ongoing basis. However, a review of the facility's education documents for 2023 revealed that Registered Nurse (RN) Employee E1, Nurse Aide (NA) Employee E10, and RN Employee E14 did not receive training on Behavioral Health education. This deficiency was confirmed during an interview with the Director of Nursing on 11/27/24.
Failure to Provide Supervised Smoking Breaks for Resident
Penalty
Summary
The facility failed to honor a resident's right to a dignified existence and self-determination by not allowing Resident R17 to smoke at requested times. The facility's policy on residents' rights emphasizes maintaining a supportive environment that promotes self-esteem and personal dignity. Additionally, the facility's smoking policy requires that residents needing supervision while smoking be provided with supervised smoking breaks in designated areas. Resident R17, who is legally blind and requires assistance with personal care, expressed a desire to smoke outside but was unable to do so due to a lack of available staff or volunteers to assist her. Interviews with Resident R17 revealed that she was often unable to go outside to smoke because there were not enough staff members willing to accompany her, particularly those who do not smoke and wish to avoid secondhand smoke. The Assistant Director of Nursing confirmed that the facility's staffing limitations and the preferences of non-smoking staff members contributed to the resident's inability to smoke at her requested times. This failure to accommodate Resident R17's requests for smoking breaks was acknowledged as a deficiency in providing care that promotes and maintains quality of life.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to determine the ability of a resident, identified as Resident R24, to self-administer medications. The facility's policy on medication administration, dated November 6, 2023, requires staff to remain with residents to ensure medications are swallowed. However, there was no documentation in Resident R24's physician orders or care plan regarding medication self-administration, nor was there a Self-Administration of Medication Assessment present in the clinical record. During an observation, a registered nurse (RN) was seen leaving a medication cup with assorted pills on Resident R24's overbed table, which the RN later confirmed was not in accordance with any order allowing the resident to keep medications in her room. Interviews with staff, including the Director of Nursing, revealed that the facility lacked a policy on medication self-administration and confirmed that medications should not be left at the bedside. The Director of Nursing acknowledged that the facility failed to assess the resident's ability to self-administer medications. This deficiency was identified for one of three residents reviewed, highlighting a lapse in the facility's adherence to its own medication administration policies and state regulations.
Facility Fails to Maintain Safe Environment Due to Missing Door Handle
Penalty
Summary
The facility failed to maintain a safe and homelike environment in one of its four nursing units, specifically in the St. [NAME] unit. During an observation of a resident's room on November 25, 2024, it was noted that the door handle was missing, leaving an exposed, sharp piece of metal protruding from the mount where the handle should have been. This deficiency was confirmed during an interview with the Director of Nursing (DON) on November 27, 2024, who acknowledged the missing handle and the exposed metal piece. The failure to address this issue compromised the safety and homelike environment expected in the facility, as outlined in the relevant Pennsylvania Code sections regarding management, resident rights, and the administrator's responsibility.
Delayed Response to Resident Grievance
Penalty
Summary
The facility failed to address a resident's grievance in a timely manner, as required by their grievance policy. The policy, last reviewed on 11/4/24, mandates prompt resolution of grievances and keeping the resident informed throughout the process. Resident R15, who has diagnoses of high blood pressure, respiratory failure, and shortness of breath, filed a grievance on 7/8/24. However, there was no documentation of the facility investigating or addressing the grievance until 11/8/24. During interviews, both Resident R15 and facility staff, including the Director of Nursing and the Nursing Home Administrator, confirmed the delay in addressing the grievance.
Failure to Communicate Necessary Information During Resident Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider for two residents who were transferred to the hospital. Resident R17, who was admitted to the facility with diagnoses including depression, need for assistance with personal care, and legal blindness, was transferred to the hospital. However, there was no documented evidence that the facility communicated essential information such as care plan goals, advanced directive information, specific instructions for ongoing care, and resident representative information to the receiving health care provider. Similarly, Resident R35, who had diagnoses of high blood pressure, reduced mobility, and weakness, was also transferred to the hospital. The facility again failed to document the communication of necessary information to the receiving health care provider. This lack of documentation was confirmed by the Assistant Director of Nursing during an interview, indicating a deficiency in the facility's process for handling facility-initiated transfers.
Failure to Notify of Resident Transfers
Penalty
Summary
The facility failed to provide timely written notification of resident transfers to the hospital, as required by regulations. Specifically, the facility did not notify the resident, their representative, or the Office of the State Long-Term Care Ombudsman about the transfers of two residents, identified as R17 and R35, in writing. This notification should have included the reason for the transfer, the date and location of the transfer, the resident's appeal rights, and the contact information for the Ombudsman. Resident R17, who had diagnoses of depression, required assistance with personal care, and was legally blind, was transferred to the hospital without the required notification being documented. Similarly, Resident R35, who had high blood pressure, reduced mobility, and weakness, was also transferred to the hospital without the necessary written notification. The Assistant Director of Nursing confirmed the facility's failure to provide these notifications during an interview.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify residents or their representatives of the bed-hold policy during hospital transfers, as required by their own policy. This deficiency was identified for two residents, who were transferred to the hospital without receiving written information about the duration of the bed-hold policy. The facility's policy, dated 11/4/24, mandates that such notification be provided at the time of transfer for hospitalization or therapeutic leave. Resident R17, who was admitted to the facility with diagnoses including depression, need for assistance with personal care, and legal blindness, was transferred to the hospital on 11/16/24. Similarly, Resident R35, with diagnoses of high blood pressure, reduced mobility, and weakness, was transferred on 11/22/24. In both cases, the clinical records lacked documented evidence of the required notification. The Assistant Director of Nursing confirmed the oversight during an interview.
Failure to Implement Hypoglycemia Protocol and Notify Physician of Weight Refusals
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident, identified as R21, by not implementing the hypoglycemia protocol as per the facility's policy. The resident, who has a history of diabetes, hyperlipidemia, and heart failure, experienced multiple instances of low blood glucose levels, as recorded in their vitals records. Despite these abnormal readings, the facility's progress notes did not document the implementation of the hypoglycemia protocol. Interviews with the Director of Nursing confirmed this oversight. Additionally, the facility did not notify the physician of the resident's refusal to be weighed on several occasions, as required by a physician's order. The resident's Medication Administration Record (MAR) indicated multiple refusals to be weighed, but there was no documentation in the progress notes that the physician was informed of these refusals. This lack of communication with the physician was acknowledged by the Director of Nursing during an interview. Furthermore, the facility failed to adhere to a physician's order regarding the administration of Metolazone, a medication prescribed for weight gain above 240 pounds. The resident's weight records showed that their weight was consistently below this threshold, yet the medication was administered on two occasions. This discrepancy between the physician's order and the actual administration of medication was confirmed by the Director of Nursing.
Improper Storage of Medical Supplies and Biologicals
Penalty
Summary
The facility failed to properly store medical supplies and biologicals in one of two medication rooms. The facility's policy on Medication Storage, last reviewed on 11/4/24, requires that all medications be maintained within specific temperature ranges as noted by the United States Pharmacopeia and the Centers for Disease Control. During an observation on 11/26/24, it was found that the temperature log for the first-floor medication room refrigerator was not completed on three specific dates: 11/11/24, 11/19/24, and 11/21/24. This was confirmed by Registered Nurse Employee E6 during an interview, indicating a failure to adhere to the facility's medication storage policy.
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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