Locust Grove Retirement Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Mifflin, Pennsylvania.
- Location
- 69 Cottage Road, Mifflin, Pennsylvania 17058
- CMS Provider Number
- 395350
- Inspections on file
- 25
- Latest survey
- June 27, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Locust Grove Retirement Village during CMS and state inspections, most recent first.
The facility failed to follow physician orders and document care for multiple residents, including administering antihypertensive medication outside of ordered parameters without explanation, not notifying a physician of repeated critically high blood glucose levels, and not documenting wound assessments or treatments as ordered for a resident with an open area.
A resident received PRN acetaminophen for severe pain levels, despite physician orders specifying use only for mild or moderate pain. Staff administered the medication outside the prescribed parameters on multiple occasions, as documented in the MAR and confirmed by facility leadership.
A resident with a history of behavioral issues, including agitation and aggression, did not have a care plan with individualized interventions for staff to manage these behaviors. Despite multiple documented incidents of combative actions such as biting and kicking during care, the care plan lacked specific strategies for staff response.
A resident who was initially not at risk for pressure ulcers was later assessed as at risk, but the care plan was not updated with new preventative interventions. The only measures in place were a standard mattress and repositioning as needed, and the resident subsequently developed a deep tissue injury to the heel.
A resident with limited left-sided motion did not receive a physician-ordered carrot device in her left hand after PROM exercises, as required. Despite documentation that PROM was completed, observations on multiple occasions showed the device was not in place, and the resident reported it had not been used for about a week. The Nursing Home Administrator confirmed the order was not communicated to nurse aides.
A resident with a physician's order for a tab alarm to prevent falls experienced an unwitnessed fall, and staff did not document that the alarm was in place or functioning at the time. Documentation showed a significant delay in checking the alarm after the incident, and there was no evidence of a thorough investigation into the fall or the effectiveness of fall prevention interventions.
A resident with anxiety, major depressive disorder, and dementia who expressed suicidal ideation was placed on physician-ordered suicide precautions, including the use of a cordless call bell. Despite staff awareness of these orders, the resident was repeatedly observed with a corded call bell in her room, contrary to the precautions required.
A resident with dementia did not have an individualized, person-centered care plan addressing cognitive loss, as required. Review of clinical records and staff interviews confirmed that the care plan lacked specific interventions tailored to the resident's dementia diagnosis.
The facility failed to administer physician-ordered medications to five residents and provide adequate incontinence care to a resident. Documentation showed missed medication administrations and toileting refusals without proper follow-up. Staffing shortages on specific days contributed to these deficiencies, impacting the quality of care provided.
A resident with severe intellectual disabilities and dental issues did not receive routine or emergency dental care since admission. Despite physician orders and nursing documentation noting dental concerns, the facility failed to offer or provide necessary services. The resident was only added to the dental appointment list after surveyor intervention, with no prior evidence of services being offered or refused.
A resident sustained a knee fracture after being improperly transferred by a staff member who did not follow the care plan requiring a mechanical lift with two staff assistance. The staff member admitted to transferring the resident alone, leading to the injury.
The facility failed to provide adequate bathing assistance for residents dependent on staff, with multiple residents not receiving scheduled showers and lacking documented bathing preferences. Interviews with the Nursing Home Administrator and DON confirmed these deficiencies.
The facility failed to have sufficient nursing staff, leading to increased call bell response times and missed care activities. Residents reported long waits for assistance and missed showers due to staffing shortages. The facility's nurse staffing levels were below the state minimum requirement, and the issue was acknowledged by the Director of Nursing.
The facility failed to secure medications on the One, Two, Three Hall nursing unit. Medications like Zofran and Celexa were found accessible to non-licensed staff, visitors, and residents. An unlocked treatment cart with various medications, some requiring refrigeration, was also observed. The DON and an LPN confirmed these findings.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with chronic wounds or indwelling devices, as required by CMS guidelines. Observations revealed that a resident with a catheter and two residents with wounds did not have EBP measures in place, while another resident had EBP but improper disposal of PPE was noted. Staff interviews confirmed the lack of EBP implementation for affected residents.
The facility failed to ensure an LPN had the necessary competencies to administer IV medication via a PICC line. The LPN administered Cefazolin Sodium to a resident but lacked documented competencies or specialized training for this procedure, as confirmed by the Director of Nursing and the Nursing Home Administrator.
A facility failed to maintain consistent advance directives for a resident, resulting in a discrepancy between a full code physician's order and a DNR status on the POLST form. This inconsistency was identified by a surveyor and confirmed by the Administrator and DON.
A facility failed to protect a resident's personal property by not completing the Inventory of Personal Effects form upon admission. The resident's husband reported missing jewelry, and a review confirmed the form was incomplete, lacking signatures from staff or the resident's responsible party. Interviews with a nurse aide and an LPN confirmed the oversight.
The facility failed to obtain the necessary attestation of Pennsylvania residency for a newly hired nurse aide, Employee 3, as required by state regulations. The personnel file lacked responses to questions about her residency status in Pennsylvania for the past two years and her citizenship status. The facility's policy did not include procedures for obtaining this attestation, which was confirmed during an interview with the Nursing Home Administrator and the HR coordinator.
The facility failed to provide baseline care plan summaries for two residents. One resident's care plan lacked essential information, including hospice services, and was incomplete. Another resident did not receive a written care plan summary, and the document lacked necessary signatures. These deficiencies were confirmed during interviews with the DON and Nursing Home Administrator.
The facility failed to provide adequate care for a resident with a PICC line by not documenting necessary measurements and medication administration. Another resident with a skin condition did not receive timely antibiotic therapy due to delayed communication with the physician. Additionally, the facility did not follow the bowel protocol for a resident, failing to administer prescribed laxatives after three days without a bowel movement.
A facility failed to assess and document a blister on a resident's left great lateral toe. Initially noted on April 10, 2024, the blister was treated with bacitracin and a Band-Aid, later changed to Vaseline. Despite a maintenance work order for a longer bed and treatment updates, no weekly assessments or updates were documented until May 1, 2024, when the issue was highlighted by a surveyor. The lack of follow-up was confirmed by the Nursing Home Administrator and DON.
A resident was assessed with limited range of motion in the lower extremity, but the facility failed to initiate a restorative nursing program as recommended by occupational therapy. Despite the discharge summary indicating the necessity of such a program to maintain the resident's function, no actions were taken from December 2023 to May 2024.
A resident admitted with a history of necrotizing pancreatitis did not receive prescribed TPN and Vitamin A supplements due to unavailability from the pharmacy. The resident experienced significant weight loss and was assessed as malnourished, yet the facility's nutritional evaluations failed to acknowledge these issues. TPN administration was delayed by more than two days after admission.
A facility failed to provide trauma-informed care for a resident with PTSD, as they did not label the diagnosis or identify triggers in the care plan. Despite recognizing the resident's confusion and potential recall of military memories, strategies to manage trauma-related behaviors were not documented, leaving staff without guidance.
A facility failed to develop and implement a person-centered care plan for a resident diagnosed with dementia. Despite the diagnosis being confirmed in the resident's annual MDS assessment, no care plan was created to address the cognitive loss. A social worker confirmed the absence of documentation for such a plan, highlighting a deficiency in the facility's care provision.
A facility failed to ensure a resident's medication regimen was free from unnecessary medications, specifically regarding PRN Seroquel for agitation. Despite recommendations from the consultant pharmacist to discontinue or add a stop date, the prescribing physician continued the medication indefinitely without documented rationale. The facility confirmed the lack of documentation justifying the extension beyond 14 days.
The facility reported a medication error rate of 6.67%, exceeding the acceptable threshold. An LPN administered medications to two residents without food, despite pharmacy labels instructing otherwise. The facility lacked a policy addressing this requirement.
Failure to Follow Physician Orders and Document Care for Multiple Residents
Penalty
Summary
The facility failed to provide care and treatment in accordance with physician orders and professional standards for multiple residents. For one resident with essential hypertension, Metoprolol was administered on several occasions despite blood pressure and heart rate readings falling below the physician-ordered parameters. There was no documented evidence explaining why the medication was given outside of these parameters, and the care plan required monitoring for side effects and effectiveness, which was not documented. Another resident with diabetes had repeated blood glucose readings significantly above the physician-ordered threshold that required staff to notify the physician if blood sugar exceeded 400 mg/dL. Despite numerous instances of elevated blood sugar, there was no evidence that the physician was notified as required by the orders. Additionally, there were several entries where staff documented 'NA' instead of recording blood sugar values or actions taken, indicating a lack of proper monitoring and documentation. A third resident with an open area on the right buttock had a physician's order for daily wound care using Medihoney and border gauze. However, there was no documented evidence that a skin assessment was completed to determine the status or measurement of the wound, nor was there documentation on the MAR or TAR to confirm that the treatment was administered as ordered. These deficiencies were confirmed during interviews with facility leadership.
Failure to Follow Physician Orders for Pain Management
Penalty
Summary
The facility failed to provide the highest practicable care regarding physician-ordered pain medications for a resident requiring pain management. Clinical record review showed that the resident had physician orders for acetaminophen to be administered as needed (PRN) for mild or moderate pain, with specific instructions for use based on pain levels. Despite these orders, staff administered acetaminophen for pain levels that were documented as severe (pain scores of 7-10), which exceeded the parameters set by the physician's orders. Multiple instances were noted where acetaminophen, ordered for mild pain, was given when the resident reported pain levels of 7, 8, or 9. The medication administration records (MARs) documented several occasions where staff did not adhere to the prescribed pain management protocol, administering medication outside the specified pain level range. This was confirmed during an interview with the Nursing Home Administrator and Director of Nursing. The deficiency was cited under 28 Pa. Code 211.12(c)(d)(1)(3)(5) for nursing services, as the facility did not ensure safe and appropriate pain management in accordance with physician orders.
Failure to Develop and Implement Comprehensive Behavioral Care Plan
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan addressing behavioral issues for one resident. Clinical record review showed that the resident was admitted with behaviors such as refusal of care and agitation, which were identified in the Minimum Data Set Assessment. Although a care plan was initiated, there was no documented evidence of specific interventions for staff to use when the resident exhibited these behaviors. The care plan was later updated to include additional behaviors such as slapping and being combative, but still lacked individualized interventions for staff guidance during care. Nursing documentation revealed multiple incidents where the resident displayed aggressive behaviors, including biting, kicking, spitting, and being combative with staff during care activities. These incidents required significant staff intervention, including the involvement of four staff members to provide incontinence care. Despite these documented behaviors, the care plan did not reflect any individualized strategies or interventions to address or manage the resident's actions. The deficiency was confirmed during an interview with the Administrator and DON.
Failure to Update Pressure Ulcer Prevention Measures After Change in Risk Status
Penalty
Summary
The facility failed to implement appropriate preventative measures to prevent pressure ulcers for a resident identified as at risk. Upon admission, the resident had no open areas on her feet, and her initial Braden scale assessment indicated she was not at risk for pressure ulcer development. However, a subsequent Braden scale assessment showed a decreased score, indicating the resident was at risk for pressure ulcer development. Despite this change, the care plan was not updated to include new preventative interventions, and the only interventions in place were a preventative mattress and turn and reposition as needed. It was also noted that the mattress in use was not a specialty mattress. As a result of the lack of updated preventative measures, the resident developed a deep tissue injury (DTI) to her left heel, which was first noted as bleeding and bruising and later documented as a DTI with eschar. The facility did not initiate additional preventative interventions after the resident's risk status changed, leading to the development of the pressure ulcer. The deficiency was identified through clinical record review, observations, and staff interviews.
Failure to Implement Physician-Ordered Device for Range of Motion
Penalty
Summary
A deficiency was identified when a resident with limited motion on her left side, including her left hand, did not receive a physician-ordered carrot device in her left hand after passive range of motion (PROM) exercises. Clinical record review confirmed an active order for PROM to the resident's left upper extremity and placement of the carrot device following the exercises. Observations on two separate dates showed the resident did not have the carrot device in place, despite documentation indicating PROM was completed. The resident reported that staff had not been placing anything in her left hand for about a week. The Nursing Home Administrator confirmed that the order for the carrot device was not carried through in the clinical record for nurse aides to implement.
Failure to Ensure Fall Prevention Alarm Use and Investigation After Resident Fall
Penalty
Summary
The facility failed to thoroughly investigate an accident involving a resident and did not implement or document interventions to prevent future falls. Clinical records showed that a physician's order required staff to use a tab alarm for the resident when in bed or chair and to check its function and placement every shift. On the day of the incident, the resident was found on his knees beside the bed after an unwitnessed fall. Staff documentation and witness statements did not indicate that the tab alarm was in place or sounding at the time of the fall, and there was no evidence that the alarm was checked for function or placement during the evening shift until several hours after the incident. Further review revealed that the day shift had documented the alarm as placed and functioning shortly before the end of their shift, but the evening shift did not assess the alarm until late in their shift, well after the fall occurred. There was no documentation at the time of the fall to confirm that the alarm was on or functioning, nor was there evidence of a timely investigation into the circumstances of the fall or the effectiveness of the interventions in place. The deficiency was confirmed during an interview with the Director of Nursing.
Failure to Implement Suicide Precautions for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to implement physician-ordered suicide precautions for a resident diagnosed with anxiety, major depressive disorder, and dementia with behavioral disturbances. The resident had expressed suicidal ideations, specifically stating an intent to kill herself by ripping her veins out and was observed pinching at the veins in her arms. In response, a physician ordered suicide precautions, including the removal of sharp objects from the resident's room and the use of a cordless call bell for 48 hours. Despite these orders, observations on two separate occasions revealed that the resident continued to have a corded call bell attached to her bed and sheets while she was in bed. Staff interviews confirmed awareness of the suicide precautions and the requirement for a cordless call bell, yet the corded call bell remained in use. The Nursing Home Administrator and Director of Nursing were informed of these concerns regarding the failure to follow suicide precaution protocols for the resident.
Failure to Develop Individualized Dementia Care Plan
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement an individualized, person-centered care plan for a resident admitted with a diagnosis of dementia. Clinical record review showed that the resident, who was admitted with dementia and associated cognitive loss, did not have a care plan that addressed her specific needs related to her cognitive impairment. The existing care plan for impaired cognitive function did not reflect individualized interventions or strategies tailored to the resident's dementia and cognitive loss. This finding was confirmed through both clinical record review and staff interviews, and was discussed with the Nursing Home Administrator and Director of Nursing.
Medication and Incontinence Care Deficiencies Due to Staffing Issues
Penalty
Summary
The facility failed to provide the highest practicable care regarding physician-ordered medications for five residents. Clinical record reviews revealed that there was no documentation of medication administration for Residents 1, 2, 3, 4, and 5 on September 8, 2024, at various scheduled times. This lack of documentation indicates that the medications may not have been administered as prescribed, which is a critical aspect of resident care. Additionally, the facility failed to provide adequate incontinence care for Resident 1. The resident, who was cognitively intact and frequently incontinent, required substantial assistance with toileting. However, documentation showed multiple refusals of toileting assistance on October 5 and 6, 2024, without any indication that nurse aides notified charge nurses about these refusals. This lack of communication and follow-up could impact the resident's health and comfort. The report also highlights staffing issues, noting insufficient nurse aide coverage on October 5 and 6, 2024, for a census of 64 residents. The facility provided an average of 2.73 and 2.45 hours of direct nursing care per resident on these days, respectively, which may have contributed to the deficiencies in medication administration and incontinence care.
Failure to Provide Dental Care for Resident
Penalty
Summary
The facility failed to provide routine and emergency dental care for a resident with severe intellectual disabilities and a mixed receptive-expressive language disorder. The resident, who was dependent on staff for personal hygiene, was admitted with obvious or likely cavities and broken natural teeth. Despite physician orders for dental care as needed, the facility did not offer or provide dental services since the resident's admission. Nursing documentation consistently noted the resident's dental issues, including missing teeth and cavity-like areas, but no action was taken to address these concerns. An observation conducted with the Director of Nursing (DON) revealed the resident had discolored teeth and erythematous gums, yet there was no evidence that the resident's responsible party was offered dental services. The DON confirmed that the resident was not seen by the dental provider during their last visit in March 2024, and the resident was only added to the upcoming dental appointment list after the surveyor's inquiry. The Nursing Home Administrator (NHA) also confirmed the lack of documentation indicating that dental services were offered or refused by the resident's responsible party.
Failure to Follow Transfer Protocols Resulting in Resident Injury
Penalty
Summary
The facility failed to protect the rights of a resident to be free from neglect by not providing the necessary services to avoid physical harm. Resident 33, who had an active physician's order for a full mechanical lift with two staff assistance for transfers, sustained a fracture after being improperly transferred by a staff member. The resident reported that a staff member attempted to transfer her without using the lift, resulting in pain and a broken knee. Clinical records confirmed the resident's need for a mechanical lift, and an x-ray revealed an acute fracture of the left lateral tibial plateau. An investigation revealed that Employee 16, a nurse aide, admitted to transferring the resident alone using the Hoyer lift, despite knowing that two people were required for the transfer. The resident complained of knee pain following the transfer, and the staff member heard a pop during the process. The facility's investigation confirmed that Employee 16 did not follow the resident's care plan, leading to the injury. The staff member was subsequently terminated, and the facility conducted staff education on proper transfer procedures.
Removal Plan
- Random audits of transfers will be completed by the director of clinical services or their designee.
- Staff education on using the correct transfer status when providing residents with care and transfers.
- Random audits on each shift will continue for another month.
- Staff continue to be educated on proper transfer status at orientation and as needed.
Failure to Provide Adequate Bathing Assistance
Penalty
Summary
The facility failed to provide adequate bathing assistance for residents who were dependent on staff for activities of daily living. Resident 33, who had a leg fracture, was scheduled to receive showers twice a week but only received a shower on two occasions in April 2024. The resident reported not refusing showers and attributed the lack of showers to staff shortages. Similarly, Resident 47, who was assessed as dependent on staff for bathing, had not received a shower since early April 2024, and there was no documentation of her bathing preferences. Resident 52 also reported not receiving her scheduled showers and had not been showered since mid-April 2024. Resident 63 had not received a shower since early April 2024 and only received partial baths thereafter, with no documentation of his bathing preferences. Resident 39, who was unable to be interviewed due to cognitive status, had only received one shower in the last month and there was no documentation of his bathing preferences either. Interviews with the Nursing Home Administrator and Director of Nursing confirmed the lack of adherence to residents' bathing schedules and the absence of documented preferences for bathing. The facility acknowledged these deficiencies, which affected the quality of care provided to the residents. The report highlights the facility's failure to meet the residents' needs for bathing assistance, as evidenced by the lack of showers and incomplete documentation of bathing preferences for multiple residents.
Insufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to have sufficient nursing staff to meet the needs of residents, as evidenced by increased call bell response times and missed care activities. A review of a facility complaint/grievance form dated March 6, 2024, noted a resident concern regarding call bell response times, which was attributed to staffing shortages. The facility's nurse staffing for the week of March 22 - March 28, 2024, was below the state minimum requirement of 2.87 hours per patient day, with only one day meeting the minimum. Interviews with residents revealed that they often had to wait for extended periods for care, such as being taken to the bathroom or receiving showers, due to the lack of staff. For instance, Resident 28 reported waiting 30 to 45 minutes for assistance, and Resident 33 did not receive scheduled showers on multiple occasions, with documentation showing only partial or bed baths instead. Further interviews with residents and a responsible party confirmed the ongoing issue of insufficient staffing. Resident 52 and Resident 64's responsible party both indicated that the lack of staff resulted in long wait times for call bell responses and missed showers. The Director of Nursing acknowledged the staffing issues and admitted that the facility accepted a new admission despite not meeting the minimum staffing requirements for the current census. The deficiency was reviewed with the Nursing Home Administrator and Director of Nursing on May 3, 2024.
Failure to Secure Medications and Biologicals
Penalty
Summary
The facility failed to secure medications and biologicals on the One, Two, Three Hall nursing unit, as observed during a survey. On April 30, 2024, medications including Zofran, Celexa, Buspar, Incruse Ellipta inhaler, and liquid Keppra were found laying on the counter, accessible to non-licensed staff, visitors, and residents. This was confirmed by the Director of Nursing shortly after the observation. Further observations on May 2, 2024, revealed an unlocked room with an unlocked treatment cart containing various medications such as Lidocaine cream, Diclofenac Sodium, Hydrocortisone cream, Nystatin powder, Triamcinolone, Ketoconazole shampoo, and a combination cream with Silvadene, Zinc, and Nystatin. Some of these medications required refrigeration but were not stored accordingly. Employee 8, an LPN, confirmed these findings and acknowledged that the treatment cart should have been locked and medications requiring refrigeration should have been stored in the refrigerator.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement appropriate enhanced barrier transmission-based precautions on two nursing units, affecting residents with chronic wounds or indwelling medical devices. According to the CMS memo, nursing care facilities are required to use Enhanced Barrier Precautions (EBP) for residents with such conditions during high-contact care activities. However, observations revealed that Resident 65, who had a catheter, did not have any EBP signage or additional PPE available in or near the room. Staff interviews confirmed that EBP measures were not implemented for this resident, as the nurse aide was unsure about the necessity of additional PPE without signage. Further observations indicated that Residents 231 and 232, both with wounds, also lacked EBP measures. Resident 231 had a foot wrapped in gauze with possible wound drainage, and Resident 232 had head wounds following brain surgery. Despite these conditions, there was no evidence of EBP implementation in their rooms. An LPN confirmed the presence of wounds in these residents but acknowledged the absence of EBP measures. In contrast, Resident 74 had EBP measures in place, including signage and PPE outside the room. However, during the administration of intravenous medication, the LPN removed the isolation gown outside the resident's room and disposed of it in a soiled utility room, contrary to CDC guidelines that require disposal in the room. This inconsistency in following EBP protocols was discussed with the Nursing Home Administrator and Director of Nursing.
Lack of Competency in IV Medication Administration
Penalty
Summary
The facility failed to ensure that a licensed practical nurse (LPN) had the necessary competencies to administer intravenous medication via a PICC line. The deficiency was identified during an observation on May 1, 2024, when the LPN was seen preparing and administering Cefazolin Sodium to a resident through a PICC line. The LPN flushed the PICC line with normal sterile saline before connecting the medication to an electrical pump for infusion over one hour. However, upon request, the facility could not provide evidence of any competencies or specialized training completed by the LPN for intravenous medication administration via a PICC line. The facility's policy on Peripheral Intravenous Catheter Flushing, last reviewed on March 29, 2024, requires that licensed nurses maintain competence in infusion therapy according to state law and facility policy. The Pennsylvania Code also mandates that LPNs perform only the IV therapy functions for which they are competent. Interviews with the Director of Nursing and the Nursing Home Administrator confirmed the lack of documented competencies or specialized training for the LPN involved in the incident. This failure to ensure proper competencies was cited under multiple Pennsylvania Code regulations related to personnel policies, staff development, and nursing services.
Inconsistent Advance Directives for Resident
Penalty
Summary
The facility failed to establish clear and consistent advance directives for a resident, leading to a discrepancy between the physician's order and the POLST form. The clinical record review revealed that the resident was admitted with a physician's order indicating full code status, which includes CPR. However, the POLST form, signed by the resident's responsible party, indicated a DNR status. This inconsistency persisted until it was identified by a surveyor. The Administrator and Director of Nursing confirmed the findings during an interview.
Failure to Protect Resident's Personal Property
Penalty
Summary
The facility failed to ensure reasonable care for the protection of a resident's property, specifically for one resident among the 18 reviewed. The facility's policy on Personal Items Inventory, which was last reviewed without changes, outlines the procedure for documenting a resident's personal effects upon admission. This includes entering the resident's details, listing and describing personal items, and obtaining signatures from the resident or responsible party and a nurse. However, upon review, it was found that the Inventory of Personal Effects form for the resident in question was not completed at the time of her admission. The deficiency was highlighted when the resident's husband reported that he could not locate her wedding band or diamond ring. He was unsure if she was wearing the jewelry upon her admission to the hospital or the facility. A clinical record review confirmed that the resident was admitted without any property listed on the Inventory of Personal Effects form, and there were no signatures from staff or the resident's responsible party. Interviews with a nurse aide and an LPN confirmed that the inventory form had not been completed since the resident's admission. These findings were reviewed with the Nursing Home Administrator and the Director of Nursing.
Failure to Obtain Required Residency Attestation for Employee
Penalty
Summary
The facility failed to comply with the requirements of Act 13 Elder Abuse Mandatory Reporting and Act 169 Criminal Background Checks by not obtaining the necessary attestation of Pennsylvania residency for one of the five personnel records reviewed. Specifically, the facility did not ensure that Employee 3, a nurse aide hired on January 7, 2024, completed the required documentation to confirm her residency in Pennsylvania for the two years preceding her application. The personnel file for Employee 3 included a document titled 'Statement of Two Year PA State Residency,' which was signed and dated by Employee 3 on the day of her hire. However, this document lacked responses to questions regarding her residency status in Pennsylvania for the past two years and her citizenship status in the United States. The facility's policy on Abuse, Neglect, Exploitation, and Misappropriation, last reviewed on March 29, 2024, mandates screening applicants for a history of abuse, neglect, exploitation, or misappropriation of resident property, including criminal background checks. However, the policy did not specify the procedure for obtaining an employee's attestation of two consecutive years of Pennsylvania residency before employment. This oversight was confirmed during an interview with the Nursing Home Administrator and the human resources coordinator, Employee 9, on May 1, 2024.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility failed to provide a summary of the baseline care plan to two residents, which is a requirement for meeting residents' immediate needs within 48 hours of admission. For Resident 228, the facility did not develop a comprehensive plan of care, including necessary healthcare information such as hospice services. The resident's husband was unaware of the hospice care details, and there was no physician's order for hospice services in the clinical record until after the surveyor's review. The baseline care plan form for Resident 228 was incomplete, lacking essential information beyond the resident's name, date of birth, and physician's name. For Resident 231, the facility did not provide a written summary of the care plan, and the baseline care plan and summary in the clinical record lacked signatures from staff, the resident, or the resident's representative. The section for completion signatures and dates was left blank. The deficiency was confirmed during an interview with the Director of Nursing and the Nursing Home Administrator, and the resident signed the baseline care plan and summary only after the surveyor's inquiry.
Deficiencies in Care for Residents with PICC Line, Skin Conditions, and Bowel Protocol
Penalty
Summary
The facility failed to provide the highest practicable care for Resident 74, who was receiving antibiotic therapy for an endocarditis infection. The care plan included the use of a PICC line, which required careful monitoring and specific interventions such as flushing with normal saline and measuring the upper arm circumference. However, observations revealed that there was no emergency equipment in the resident's room, and staff failed to document the required measurements and administration of medications on several occasions. For Resident 231, the facility did not implement interventions for a skin condition as ordered by the physician. The resident was observed without the prescribed heel lift boot, and there was a delay in referring wound care recommendations to the resident's physician, which postponed the start of necessary antibiotic and probiotic therapy. Additionally, the facility failed to ensure the receipt and availability of documentation from the wound care provider, which contributed to the delay in treatment. Furthermore, the facility did not adhere to the bowel protocol for Resident 231, who had not had a bowel movement for three days. Despite a physician's order to administer Milk of Magnesia if the resident did not have a bowel movement in three days, the medication was not given as required. This oversight was confirmed through a review of the resident's medical records and interviews with facility staff.
Failure to Assess and Document Blister on Resident's Toe
Penalty
Summary
The facility failed to properly assess and document the condition of a blister on a resident's left great lateral toe. Initially, a progress note on April 10, 2024, indicated that the resident had a blister that opened after rubbing it on the footboard, and a longer bed was needed. Bacitracin and a Band-Aid were applied, and later that day, Vaseline and a Band-Aid were used instead. A maintenance work order confirmed that a longer bed was provided on April 11, 2024, and the treatment order was updated to apply Vaseline and a Band-Aid, which was discontinued on April 19, 2024. Despite these initial actions, there was no evidence of a weekly assessment or updated evaluation of the blister from April 10, 2024, until May 1, 2024, when the issue was brought to the attention of the Nursing Home Administrator and Director of Nursing by the surveyor. A nursing note on May 1, 2024, indicated that the area was healed, and an observation on May 2, 2024, revealed a scabbed area. The lack of follow-up assessment was confirmed in an interview with the Nursing Home Administrator and Director of Nursing on May 2, 2024.
Failure to Maintain Resident's Range of Motion
Penalty
Summary
The facility failed to provide necessary services to maintain a resident's range of motion, as evidenced by the case of a resident who was assessed with no upper or lower extremity impairments in a quarterly MDS dated September 6, 2023. However, subsequent assessments indicated a limited range of motion in the resident's lower extremity. Despite the occupational therapy discharge summary recommending a restorative nursing program to maintain the resident's function, the facility did not initiate such a program. The occupational therapy discharge summary, dated December 18, 2023, highlighted the need for skilled occupational therapy services to promote strength, range of motion, and participation in activities of daily living. It also emphasized the importance of establishing a restorative nursing program. However, a review of the resident's clinical records from December 2023 to May 2024 confirmed that no restorative nursing program was initiated, leading to a deficiency in maintaining the resident's range of motion.
Failure to Provide Prescribed Nutritional Interventions
Penalty
Summary
The facility failed to implement necessary interventions to maintain the nutritional status of a resident, identified as Resident 233, who was admitted from the hospital with a history of necrotizing pancreatitis and had been receiving total parenteral nutrition (TPN) since March 8, 2024. Upon admission, the resident was supposed to receive TPN from 6:00 PM to 6:00 AM, but nursing documentation revealed that the TPN was not available from the pharmacy for administration on April 23, 24, and 25, 2024. Additionally, the Vitamin A supplement ordered for the resident was also unavailable, and the facility failed to obtain it from a second pharmacy as instructed by the physician. The resident experienced a weight loss of 4.6 pounds between April 24 and April 25, 2024, and was assessed as malnourished with a severe decrease in food intake. Despite these assessments, the facility's nutritional evaluations did not acknowledge the resident's weight loss or the lack of TPN and Vitamin A administration. The first indication of TPN administration was documented on April 26, 2024, more than two days after the resident's admission. The facility's failure to provide the prescribed nutritional interventions was confirmed during interviews with the Director of Nursing and the Nursing Home Administrator.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for a resident diagnosed with Chronic Post-Traumatic Stress Disorder (PTSD). The resident, identified as a veteran, exhibited behaviors such as increased agitation and yelling, which were documented by a social worker. Despite recognizing the resident's confusion and potential recall of military memories, the facility did not label the PTSD diagnosis in the care plan or identify triggers that could cause re-experiencing of traumatic events. The social worker noted the importance of avoiding overstimulation and using a calm approach when interacting with the resident. However, these strategies were not incorporated into the resident's care plan. The facility acknowledged the PTSD diagnosis in October 2023, but did not identify or document triggers until April 2024, leaving staff without guidance on how to manage the resident's trauma-related behaviors effectively.
Failure to Implement Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement individualized person-centered care plans for a resident diagnosed with dementia. The resident was admitted to the facility on September 17, 2021, and was diagnosed with dementia on November 29, 2022. Despite this diagnosis, a review of the resident's most recent annual Minimum Data Set Assessment dated August 15, 2023, confirmed the presence of dementia, but the facility did not create a care plan to address the resident's cognitive loss. An interview with a social worker on May 3, 2024, confirmed that there was no documentation of an individualized care plan for the resident's dementia and cognitive loss. This lack of a person-centered care plan constitutes a deficiency in providing appropriate treatment and services for the resident's condition.
Failure to Ensure Appropriate Use of PRN Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from potentially unnecessary medications, specifically regarding the use of Seroquel, an antipsychotic medication, prescribed on a PRN basis for agitation. Resident 3 was admitted to the facility on September 17, 2021, and had a PRN order for Seroquel 25 mg every 24 hours as needed, starting September 20, 2023. The consultant pharmacist recommended discontinuing the PRN Seroquel or adding a stop date not exceeding 14 days from initiation. Despite these recommendations, the prescribing physician responded with indefinite continuation of the medication, citing stability in the resident's condition without providing documented rationale or specific conditions being treated. Subsequent reviews by the consultant pharmacist in January and March 2024 reiterated the need for a stop date or discontinuation of the PRN Seroquel, as it had not been administered frequently. However, the prescribing physician maintained the medication regimen, stating the resident was stable. An interview with the Nursing Home Administrator and Director of Nursing confirmed the lack of documentation justifying the extension of the PRN Seroquel beyond 14 days, leading to the deficiency finding.
Medication Administration Errors Due to Lack of Adherence to Pharmacy Instructions
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, with a reported rate of 6.67 percent based on 30 medication opportunities and two errors. The errors involved the administration of medications to two residents without adhering to specific instructions on the pharmacy labels. The facility's policy on oral medication administration, last reviewed without changes, did not address the requirement for staff to follow specific instructions such as administering medications with food. During a medication pass, an LPN administered Metformin HCL to a resident without providing food, despite the label's instruction to give the medication with a meal. The resident had likely finished breakfast hours earlier and did not receive any food during a morning activity. Similarly, the LPN administered Celecoxib to another resident without food, contrary to the label's instructions. Interviews with the LPN and an activities aide confirmed the absence of food during the medication administration. The facility lacked a policy or procedure guiding staff on administering medications with food when required by the pharmacy label.
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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