Midtown Oaks Health & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Altoona, Pennsylvania.
- Location
- 1020 Green Avenue, Altoona, Pennsylvania 16601
- CMS Provider Number
- 395985
- Inspections on file
- 47
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at Midtown Oaks Health & Rehab Center during CMS and state inspections, most recent first.
A resident with cognitive impairment, swallowing difficulties, and dependence on staff for feeding had a care plan requiring that an alternative meal be offered whenever less than 50% of a meal was consumed. Review of meal intake records over multiple days showed repeated instances of the resident eating under 50% of meals, with no documentation that any alternative meals were offered as required. The DON confirmed that there was no indication alternative meals were provided despite the care plan directive.
A resident who was cognitively impaired, dependent on staff for feeding, and at increased nutritional risk had a care plan requiring staff to offer an alternative meal when less than 50% of a meal was consumed and to provide spoon-fed nectar thick liquids. Meal intake records showed repeated instances of the resident consuming less than half of multiple meals over several days, yet there was no documentation that alternative meals or additional fluids were offered as planned. The resident’s family later voiced concern about poor intake and lethargy, and the resident was subsequently found unresponsive and transferred to the hospital, where diagnoses included hyponatremia, UTI, and pneumonia. The DON confirmed that required nutritional interventions were not provided on the days of poor intake.
A resident's private medical information, including guardianship, insurance, and dialysis details, was discussed by a Health Insurance Service Coordinator in a public dining area with other residents, a family member, and staff present. The resident, who was cognitively intact, expressed discomfort with the lack of privacy, and both the coordinator and administrator confirmed the conversation should have occurred in a private setting.
Two residents with ESRD receiving hemodialysis had physician orders allowing medication administration either before or after dialysis, but staff did not clarify with the physicians which medications should be given at each time. The lack of documented clarification was confirmed by the DON after review of clinical records and staff interviews.
The facility failed to administer prescribed medications as ordered before or after dialysis for two residents with ESRD, and did not complete a therapy screening as ordered for one resident following an orthopedic consult. Documentation did not show that medications were given according to physician instructions, and staff did not clarify medication timing with the physician when issues arose.
A resident with end-stage renal disease who required regular dialysis did not have documented pre-dialysis assessments sent to the dialysis center or post-dialysis information received and reviewed by staff, as required by facility policy. The DON confirmed the lack of documentation and communication between the facility and the dialysis provider.
Dietary staff prepared and delivered meal trays, but a test tray showed that several food items, including beef stew and cauliflower, were served at improper temperatures and were not palatable. The Dietary Manager confirmed the issues with food temperature and quality.
A resident with end stage kidney failure and neurogenic bladder did not consistently receive straight catheterization as ordered, particularly on days when the resident was scheduled for dialysis. Documentation showed multiple missed catheterizations, and the DON confirmed the lack of evidence that the procedure was completed as required.
The facility did not provide or document scheduled showers for four residents who required assistance with bathing and hygiene. Despite physician orders and care plans specifying shower frequency and documentation of refusals, there was no evidence that showers were given or refusals recorded, nor that alternative care such as bed baths was offered. The DON confirmed the lack of documentation for these residents.
Hot food items, including taco beef and rice, were served at temperatures below the facility's standard, resulting in food that was cold and not palatable. A test tray confirmed these findings, and the Dietary Manager acknowledged the issue.
The facility failed to ensure dietary staff wore appropriate hair restraints during food preparation and tray line service, as required by their policy. Observations revealed that a staff member was plating meals without a facial hair restraint, and another was pushing carts without a hair restraint. Interviews confirmed the staff's non-compliance with the facility's dress and personal hygiene policy.
A resident's care plan required the application of Triad barrier cream every shift and after each incontinent episode. However, the cream was only applied every shift, not after each episode, as confirmed by the resident, an LPN, and the DON. Clinical records showed multiple instances of missed applications, leading to a deficiency in care.
A facility failed to maintain accurate clinical records for a resident. A nursing note incorrectly documented an attempted straight catheterization, which was later confirmed by the DON to have not occurred. This error was due to the note being placed in the wrong chart, highlighting a deficiency in record-keeping practices.
The facility failed to meet the required NA-to-resident staffing ratios over a six-day period, with significant deficiencies noted in the day and night shifts. The census data showed a need for specific numbers of NAs, but actual staffing levels consistently fell short. Interviews confirmed the facility's failure to meet these requirements, with no additional staff available to compensate.
The facility did not meet the required 3.2 hours of direct resident care per resident on three days, providing only 3.07, 3.15, and 2.87 hours on different days. This was confirmed by the DON through a review of nursing schedules.
A facility failed to provide scheduled showers for a cognitively impaired resident who required extensive assistance for personal hygiene. Despite the resident's care plan indicating a preference for showers on specific days, records showed no showers were given over a three-month period, with no documentation of refusal. The DON confirmed the lack of showers and absence of refusal documentation.
A resident at risk for pressure ulcers developed a new ulcer on the coccyx, which was identified by a nurse. Although the physician and resident representative were notified, there was a delay in obtaining a treatment order, and the treatment did not start until several days later. By the time the wound was assessed by a wound CRNP, it had worsened to a Stage 3 pressure ulcer.
A resident with acute respiratory failure and hypoxia did not receive the prescribed oxygen flow rate of 4 LPM, as it was set at 3 LPM. This led to critically low oxygen saturation levels, requiring an increase in oxygen flow and eventual hospitalization for pneumonia, hypoxia, and NSTEMI.
A resident with COPD and asthma did not receive their prescribed inhaler on multiple occasions due to unavailability in the Omnicell and delayed pharmacy delivery. Despite being aware of the issue, the nursing staff failed to ensure timely administration, and the DON was unaware of the reasons for the delivery problems.
The facility failed to update care plans for two residents with cognitive impairments and fall histories. One resident's care plan did not reflect changes after a fall, including mattress adjustments, while another's did not include the use of a low bed and fall mats. Staff confirmed these omissions.
A resident with cognitive impairment and hemiparesis fell during a transfer due to a nurse aide's failure to follow the care plan, which required assistance from two facility staff members. Instead, the aide used a private caregiver, resulting in the resident sliding off the chair and sustaining injuries.
A facility failed to follow a physician's recommendations for a resident with a Stage IV pressure ulcer, leading to wound deterioration. Additionally, the facility did not document weekly skin checks for another resident or urinary output for a resident with a Foley catheter, as ordered by physicians. These deficiencies were confirmed by nursing staff.
A facility failed to provide necessary treatment for a resident's Stage 4 pressure ulcer, leading to wound deterioration. Despite recommendations for a wound vacuum and follow-up care, the facility only implemented a Dakins wet-dry dressing and did not ensure follow-up appointments or additional referrals. The resident's wound worsened, and she experienced discomfort and pain, particularly during dialysis sessions.
The facility did not ensure that residents and/or their representatives were informed or assisted in developing advance directives, affecting 12 residents. Despite the facility's policy requiring discussions on advance care planning upon admission, there was no documentation of such discussions or information provided to residents, regardless of their cognitive status. This was confirmed by the Social Service Director, highlighting a failure to comply with resident rights regulations.
The facility failed to serve hot foods at the required temperature of 135°F. During a lunch meal observation, the chicken breast served to a resident was found to be 124°F, which was lukewarm and unappetizing. The Dietary Director confirmed the temperature requirement.
The facility failed to maintain food safety and hygiene standards, with unclean kitchen equipment, improperly stored and labeled food, and staff not fully covering their hair with hairnets. Observations revealed opened and undated food items, a lack of a thermometer in the ice cream freezer, and improper thawing of meat. The Dietary Manager confirmed these issues should not have occurred.
The facility failed to maintain an effective pest control program, resulting in flies and gnats in the kitchen's food prep area. Despite a policy requiring treatment to control insects, observations revealed pests, and interviews indicated the pest control company visited every other month. The issue persisted, leading to additional pest control measures being requested.
The facility failed to involve two residents in the development and implementation of their person-centered care plans. Despite policy requirements, there was no evidence of scheduled or completed care plan conferences following MDS assessments for these residents. Interviews with staff confirmed the absence of meetings and notifications, highlighting a lapse in adhering to the facility's care planning schedule.
A facility failed to obtain physician's orders for pacemaker checks for a resident with a cardiac pacemaker, as required by policy. The resident's care plan indicated the need for these checks, but there was no documented evidence of orders or completed checks. Interviews confirmed the oversight, highlighting a lapse in adhering to care protocols.
The facility failed to schedule vision exams for two residents, despite physician orders and resident requests. One resident, who was nearly blind, missed an appointment due to a scheduling error and lack of follow-up. Another resident with diabetes had a physician's order for a vision exam, but there was no evidence it was scheduled.
The facility did not timely address pharmacy recommendations for two residents. A resident on midodrine had a scheduling issue unaddressed, while another had unreviewed medication interactions and a pending lipid panel. These oversights were confirmed by nursing staff.
A facility failed to document non-pharmacological interventions before administering psychotropic medications to a resident with Alzheimer's and anxiety. Despite orders for monitoring and documentation, Ativan and Xanax were given without prior non-pharmacological attempts, as confirmed by the RN Assessment Coordinator.
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper handling of soiled linens and PPE for a COVID-19 positive resident. A nurse aide carried unbagged dirty linens from a droplet isolation room to a hallway linen cart, and incorrect signage for transmission-based precautions was observed. The Director of Nursing confirmed the need for correct signage and appropriate receptacles for soiled PPE.
A facility failed to assess a resident for self-administration of medication, as required by policy. The resident, who was cognitively intact and required supervision, had a medication bottle labeled Bactrim DS from a hospital pharmacy on the over-bed table. The resident stated he took two tablets when the facility's medication system was not working. An LPN confirmed medications should not be at the bedside, and the DON confirmed the resident had not been assessed for self-administration.
A resident, who was cognitively impaired and dependent on staff for mobility, was found with the call bell out of reach, contrary to facility policy. The resident needed assistance, and a nurse aide confirmed the call bell was inaccessible, later providing it to the resident. The Nursing Home Administrator acknowledged the call bell should have been within reach.
A facility failed to protect a resident's health information during medication administration. An LPN left a computer screen displaying a resident's personal health information visible to the hallway and elevator door. Both the LPN and the Assistant DON confirmed that the information should have been covered when unattended.
The facility failed to create comprehensive care plans for two residents, one with left-sided hemiparesis and another with schizophrenia exhibiting self-harm behaviors. Despite therapy and interdisciplinary discussions, there was no documented evidence of care plans addressing these specific needs, as confirmed by staff interviews.
The facility failed to update care plans for three residents, leading to discrepancies in dietary and wound care management. A resident's care plan was not revised to reflect a change from nectar thick to thin liquids, another resident's plan lacked instructions to contact family during care refusals, and a third resident's plan did not reflect healed and new wounds. These oversights were confirmed by facility staff.
A resident admitted with multiple diagnoses, including diabetes and hypertension, left the facility against medical advice. The facility failed to complete a discharge summary with a recapitulation of the resident's stay, as confirmed by the RN Assessment Coordinator.
A resident with cerebral palsy was not provided with the restorative ambulation program as care planned, despite being cognitively intact and requiring supervision. The program aimed to help the resident walk 100 feet with a walker twice daily. However, documentation showed that the program was not completed on numerous occasions over several months. The resident reported not receiving the ambulation as planned, and the Nursing Home Administrator confirmed the lack of documentation.
A resident, dependent on staff for personal care, did not receive scheduled showers or adequate oral care as per her care plan. Documentation from a specific period showed no evidence of showers being offered or refused, and oral care was provided only three times instead of twice daily. The resident's sister expressed concerns about cleanliness, and the ADON confirmed the lack of documentation.
The facility failed to conduct safety assessments for two residents using air mattresses, leading to a fall incident. One resident, with a Stage IV pressure ulcer, was recommended a low air loss mattress but lacked a safety assessment. Another resident, severely cognitively impaired, fell from bed due to the air mattress pushing them to the edge after bed enablers were removed. The DON confirmed the absence of necessary safety assessments.
The facility failed to address a change in urine status for a resident with a history of UTIs, delaying assessment and treatment. Additionally, another resident's catheter tubing and drainage bag were improperly placed on the floor without a dignity bag, contrary to facility policy.
A facility failed to provide a resident with the prescribed 4 liters of fluid per day as recommended by urology for chronic UTIs. Despite physician's orders to document fluid intake every 6 hours, records showed significantly lower intake with no evidence of refusal or receipt of fluids. The Nursing Home Administrator confirmed the lack of documentation.
The facility failed to provide adequate nursing staff, resulting in unmet care needs for two residents. One resident did not receive scheduled showers or oral care, while another experienced delays in incontinence care. Interviews revealed concerns about insufficient staffing, with only five aides for over 55 residents, leading to inadequate care delivery.
A facility failed to ensure accountability for controlled medications for a resident who required assistance for daily care and experienced significant pain. Although staff signed out hydrocodone/Tylenol tablets on several occasions, there was no documentation on the MAR that the medication was administered. The DON confirmed the lack of evidence for administration, despite expectations for nurses to sign the MAR when administering pain medication.
A facility failed to maintain a medication error rate below five percent, with errors involving a resident with severe cognitive impairment. An LPN crushed Depakote tablets, which should not have been crushed, and did not instruct the resident to rinse after using Trelegy Ellipta inhaler. Interviews confirmed these errors, and there was no documentation of physician awareness of the resident's refusal to take whole pills or rinse his mouth.
The facility failed to properly store controlled medications and label insulin pens. A narcotic storage box with Ativan was not permanently affixed in the refrigerator, and an insulin pen for a resident with diabetes was opened and undated. These issues were confirmed by staff and violated facility policy and 28 Pa. Code 211.9(a)(1) Pharmacy Services.
Two residents in an LTC facility did not receive the necessary assistive devices for eating as per their care plans. One resident, who required a two-handled cup due to a straw restriction, was observed using a straw. Another resident, who needed weighted utensils, was given regular flatware, making it difficult for him to eat. These deficiencies were confirmed by staff interviews.
The QAPI committee at the facility was ineffective in addressing recurring deficiencies identified in surveys. Despite plans to conduct audits and report findings, issues persisted in areas such as resident needs, MDS assessments, professional standards, quality of care, and infection control. The committee failed to ensure compliance with regulations, leading to repeated deficiencies under various F-tags.
Failure to Implement Care-Planned Nutritional Interventions
Penalty
Summary
Surveyors identified a deficiency in the implementation of a resident-centered care plan related to nutritional interventions for Resident 2. A comprehensive MDS assessment dated September 4, 2025 documented that the resident was cognitively impaired and dependent on staff for daily care tasks, including feeding, and had increased nutrition risk due to requiring staff assistance and having swallowing difficulties. The resident’s care plan, last updated on the same date, specified that an alternative meal was to be offered whenever the resident consumed less than fifty percent of a meal. Review of the resident’s November 2025 meal intake records showed multiple instances where the resident ate less than fifty percent of meals across breakfasts, lunches, and dinners on numerous dates throughout the month. There was no documented evidence that an alternative meal was offered on any of these occasions, despite the care plan requirement. In an interview on February 12, 2026 at 2:14 p.m., the Director of Nursing confirmed there was no indication that the resident had been offered an alternative meal on those dates and acknowledged that the resident should have been offered one according to the care-planned intervention.
Failure to Implement Nutritional Interventions for Dependent Resident
Penalty
Summary
The facility failed to initiate nutritional interventions and ensure sufficient food and fluid intake for a cognitively impaired resident who was dependent on staff for feeding. A comprehensive MDS assessment dated September 4, 2025, showed that the resident had swallowing difficulties and required staff assistance with all daily care tasks, including feeding. The resident’s care plan, updated the same day, identified increased nutrition risk and directed staff to offer an alternative meal if the resident consumed less than 50% of a meal and to spoon feed nectar thick liquids. Meal intake records for November 2025 documented that the resident ate less than 50% of multiple meals across numerous days, including several breakfasts, lunches, and dinners. Despite these repeated low intakes, there was no documented evidence that staff offered alternative meals or additional fluids for hydration on the identified dates, as required by the care plan. On November 23, 2025, a nursing note recorded that the resident’s sister expressed concern about the resident’s recent poor intake and lethargy. Later that day, another nursing note documented that the resident was found unresponsive and in respiratory distress and was transferred to the hospital. A subsequent nursing note indicated that the resident was admitted with hyponatremia, a urinary tract infection, and pneumonia. In an interview, the DON confirmed there was no indication that the resident had been offered alternative meals or fluids on the dates of poor intake and acknowledged that this should have occurred.
Failure to Maintain Resident Health Information Confidentiality
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's personal health information during a lunch service. The Health Insurance Service Coordinator discussed private medical information, including guardianship, insurance plan, and dialysis details, with the resident at her dining table in the presence of other residents, a family member, and multiple staff members. The conversation took place in a public area where others could overhear, rather than in a private setting as required by facility policy. The resident involved was cognitively intact and able to communicate effectively. She later expressed discomfort with having her personal information discussed openly and stated she would have preferred a private conversation. Both the Health Insurance Service Coordinator and the Nursing Home Administrator acknowledged that the discussion should have been conducted in a private area, in accordance with the facility's policy on protecting resident health information.
Failure to Clarify Physician Orders for Dialysis Medication Administration
Penalty
Summary
The facility failed to ensure that physician's orders regarding medication administration for two residents with end-stage renal disease (ESRD) receiving hemodialysis were properly clarified. Both residents had physician's orders indicating that medications could be administered either prior to dialysis or upon return from dialysis, but there was no documented evidence that the facility contacted the residents' physicians to clarify which specific medications should be given at each time. This lack of clarification was identified through review of clinical records, the Pennsylvania Nurse Practice Act, and staff interviews. One resident was noted to be cognitively intact and required staff assistance for daily care, while the other was able to understand and be understood by others. Both residents had scheduled dialysis sessions multiple times per week. Despite the presence of multiple, potentially conflicting orders regarding medication timing on dialysis days, the facility did not document any communication with the physicians to resolve these ambiguities. The Director of Nursing confirmed that no such clarification was obtained or documented for either resident.
Failure to Follow Physician Orders for Medication and Therapy Evaluation
Penalty
Summary
The facility failed to ensure that residents received care and treatment in accordance with professional standards of practice by not following physician's orders for medication administration and therapy evaluations. For one resident with end-stage renal disease (ESRD) receiving hemodialysis, there was no documented evidence that multiple prescribed medications, including antihypertensives, antidepressants, blood thinners, and dietary supplements, were administered as ordered either prior to or after dialysis sessions on numerous specified dates. The care plan and physician's orders clearly indicated the need for medication administration in relation to dialysis, but the Medication Administration Records did not reflect that these orders were followed. Another resident, also with ESRD and Parkinson's disease, had similar deficiencies in medication administration. The records showed that several doses of prescribed medications, including midodrine, methocarbamol, and carbidopa-levodopa, were not documented as given before or after dialysis on multiple occasions. The care plan for this resident also specified the importance of medication timing in relation to dialysis, but staff failed to document administration as required. The DON confirmed that there was no evidence these medications were given as ordered and acknowledged that the timing of doses was not clarified with the physician when concerns arose. Additionally, the facility did not follow through on a therapy screening ordered for one resident after an orthopedic consult. Although the order for a therapy screen was present in the clinical record, and the resident had previously received therapy services, the required screening was not completed. The Director of Rehabilitation and the DON both confirmed that the therapy screen was not conducted as ordered.
Failure to Follow Hemodialysis Communication and Assessment Policy
Penalty
Summary
The facility failed to follow its own policy regarding the care and monitoring of residents receiving dialysis. According to the facility's Hemodialysis Care policy, staff are required to conduct and document a pre-dialysis assessment using a dialysis communication tool, print it, and send it with the resident to the dialysis center. After dialysis, staff are expected to receive a report from the dialysis provider and/or review the documentation provided, and promptly contact the dialysis center with any questions or concerns. For one resident with end-stage renal disease who was cognitively intact and required assistance with daily care, there was no evidence in the clinical record or at the nursing station that these assessments or communications were being completed or shared as required. An interview with the DON confirmed that there was no documented evidence of pre-dialysis assessments being sent with the resident or of post-dialysis information being received and reviewed by staff, as outlined in the facility's policy. This deficiency was identified through review of policies, clinical records, observations, and staff interviews.
Failure to Serve Palatable and Properly Tempered Food
Penalty
Summary
The facility failed to serve food items that were palatable, as required by its own policy. During observation of the lunch meal tray line, dietary staff prepared and delivered trays to residents on the second floor low hall. A test tray revealed that the milk was 45.4°F and tasted cold, orange juice was 51.4°F, coffee was 142°F, beef stew was 117°F and tasted cold and not palatable, and cauliflower was 129°F, unseasoned, tasted cold, overcooked, and not palatable. The Dietary Manager confirmed that the beef stew was cold and not palatable, and the cauliflower was mushy and lacked seasoning. These findings were based on direct observation, temperature measurements, and staff interviews.
Failure to Provide Ordered Straight Catheterization for Resident with Neurogenic Bladder
Penalty
Summary
A cognitively intact resident with end stage kidney failure and a diagnosis of neurogenic bladder was admitted to the facility and required straight catheterization three times daily, as ordered by a physician. The resident also received dialysis three times per week. The care plan and physician's orders specified the need for straight catheterization every shift, regardless of the resident's dialysis schedule. Review of the medication and treatment administration records for July and August revealed multiple instances where the resident did not receive straight catheterization as ordered, particularly on days when the resident was scheduled for dialysis, despite not leaving for dialysis until later in the morning. Additional documentation indicated missed catheterizations on other dates and shifts, with reasons such as the resident not being available or the procedure being completed on a previous shift. The DON confirmed that there was no documented evidence that the straight catheterization was completed as ordered on the identified dates and shifts.
Failure to Provide and Document Scheduled Showers for Dependent Residents
Penalty
Summary
The facility failed to provide scheduled showers and document bathing care for four residents who required assistance with activities of daily living, specifically bathing and hygiene. Facility policy required that residents be bathed or showered according to their preferences at least twice per week, with refusals to be reported and documented. However, for multiple residents, there was no documented evidence that their bathing preferences were obtained or followed, and no record of showers or refusals as required by policy. One resident, who was cognitively intact and required assistance with bathing and toileting hygiene, reported receiving only one shower during a two-week stay, with no documentation of bathing preferences or scheduled showers in the clinical record. Another resident, also cognitively intact and with frequent incontinence, had physician orders and a care plan specifying showers on certain days, but there was no documentation that these showers were provided or refused, nor that bed baths were offered as an alternative. Two additional residents, one cognitively impaired and the other cognitively intact, both had physician orders and care plans specifying regular showers and documentation of refusals. For both, there was no evidence in the records that showers were provided as ordered, nor that refusals or alternative care were documented. The DON confirmed the lack of documentation for all four residents, indicating a failure to provide and record necessary bathing care as per facility policy and physician orders.
Plan Of Correction
Residents # 4, 5, 6, and 7 have had no adverse effects from not being showered according to preference. Residents 4, 5, 6, and 7 were showered according to preference as care planned. To identify residents who have the potential to be affected, the Director of Nursing/designee will complete an audit of shower preferences and ensure care plans are accurate. To prevent recurrence, the licensed nursing staff and nurse aides will be educated on the facility Resident bathing/showering/scheduling policy by the Director of Nursing/designee. To maintain and monitor compliance, audits of 6 residents to ensure showers are completed according to preference audits will be completed weekly x 4 and monthly x 2.
Failure to Serve Palatable Hot Food Items
Penalty
Summary
The facility failed to serve food items that were palatable, as required by its policy on food temperatures. During observation of the supper meal service, it was noted that there was a significant delay between the preparation of the food cart and the actual serving of the trays to residents. A test tray revealed that while cold items such as milk and salsa salad were served at appropriate cold temperatures, hot food items including taco beef and rice were served at temperatures of 109.3°F and 113.2°F, respectively, and were described as cold and not palatable. The Dietary Manager confirmed that these hot food items were indeed cold and not palatable at the time of service.
Failure to Use Hair Restraints in Food Service
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not ensuring that dietary staff wore appropriate hair restraints during food preparation and tray line service. The facility's policy, dated February 14, 2025, mandates that staff in Food and Nutrition Services must wear clean and appropriate hairnets and hair restraints that cover all hair, including beards and facial hair. However, observations in the main kitchen on April 22, 2025, revealed that Dietary Staff 2 was plating breakfast meals without a facial hair restraint. During an interview, Dietary Staff 2 admitted to removing the restraint because it was hot and he had to answer the phone multiple times. Further observations on the same day at lunchtime showed that Dietary Aide 3 was pushing carts in the main kitchen without a hair restraint. Upon interview, Dietary Aide 3 confirmed that she should have been wearing a hair restraint, but it must have fallen off when she went outside. The Interim Certified Dietary Director confirmed that the dietary department was fully staffed on April 21, 2025, and that staff should have had their hair covered appropriately with hair restraints.
Plan Of Correction
Dietary staff adorned appropriate hair restraints during food preparation and tray line service. Certified Dietary Manager and/or designee will educate dietary staff on Dress and Personal Hygiene and Employee Sanitary Practices Policies. Dietary Manager and/or supervisor will monitor compliance daily with kitchen observation. Administrator and/or designee will perform random audits to verify staff are wearing appropriate hair restraints during food preparation and tray line service. These audits will be completed 3 times weekly for two weeks and 1 time weekly for four weeks. The results of these audits will be reviewed by the Quality Assurance Performance Improvement team for further recommendations.
Failure to Follow Physician's Orders for Barrier Cream Application
Penalty
Summary
The facility failed to adhere to physician's orders for a resident, identified as Resident 2, regarding the application of barrier cream. According to the resident's care plan and physician's orders, the Triad barrier cream was to be applied every shift and after each episode of incontinence. However, interviews and clinical record reviews revealed that the cream was only applied every shift and not after each incontinent episode as required. This was confirmed by both the resident and a Licensed Practical Nurse (LPN), who acknowledged the deviation from the prescribed care plan. Further examination of Resident 2's clinical records showed multiple instances where there was no documented evidence of the cream being applied as ordered. Specific dates were noted where the application was missed on various shifts throughout March 2025. An interview with the Director of Nursing (DON) corroborated the findings that the barrier cream was not applied according to the physician's orders, leading to a deficiency in the quality of care provided to the resident.
Plan Of Correction
Resident #2 has had no adverse effects from moisture barrier not being documented. Current skin preventative creams and treatments will be reviewed with the physician or NP to determine necessary measures, and orders implemented as received. To identify residents who have the potential to be affected, the Director of nursing/ designee will complete a review of residents who are incontinent and receive moisture barrier to determine if any administrations missed. If missed administrations identified, a skin check will be conducted. To prevent recurrence, the licensed nursing staff will be educated on the physician/ provider orders policy including carrying out orders by the Director of nursing/ designee. To maintain and monitor compliance, audits of 5 residents receiving moisture barrier will be conducted by the Director of nursing/ designee to ensure residents receive it as ordered weekly x 4 weeks and monthly x 2.
Inaccurate Clinical Documentation for a Resident
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented for one of the residents reviewed. Specifically, a quarterly Minimum Data Set (MDS) assessment for the resident indicated that the resident was sometimes understood and able to sometimes understand others, and was dependent on staff for personal hygiene care. However, discrepancies were found in the nursing notes related to the resident's care. A nursing note dated April 2, 2025, incorrectly documented that a straight catheterization was attempted three times without success. An interview with the Director of Nursing later revealed that this procedure was not attempted on the resident, and the note was mistakenly placed in the wrong chart. This error highlights a failure in maintaining accurate and complete clinical records for the resident, as required by regulatory standards.
Plan Of Correction
Resident #2 medical recorded updated marked progress note as invalid for incorrect documentation. To identify residents who have the potential to be affected, the Director Nursing/Designee will complete a review of nursing progress notes for the past 30 days to ensure that documentation is correct and accurate. To prevent recurrence, the licensed nursing staff will be educated on accurate and timely documentation of the medical record. To maintain and monitor compliance, the Director of Nursing/ designee will review progress notes of 5 residents weekly x's 4 weeks and monthly x's 2. Step 4: To maintain and monitor compliance, the Director of Nursing/ designee will review progress notes of 5 residents weekly x's 4 weeks and monthly x's 2.
Staffing Deficiencies in Nurse Aide Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident staffing ratios as mandated by the regulation effective July 1, 2024. Specifically, the facility did not provide the necessary number of NAs per residents during various shifts over a six-day period from March 25 to March 30, 2025. On five of these days, the day shift was understaffed, with the number of NAs falling short of the required ratio. Additionally, the evening shift was understaffed on one day, and the night shift was understaffed on four days. The facility's census data and nursing time schedules were reviewed, revealing discrepancies between the required and actual staffing levels. The facility census varied from 93 to 98 residents during the reviewed period, necessitating specific numbers of NAs per shift to comply with the regulation. However, the actual staffing levels consistently fell short, with the most significant deficiencies noted on the day and night shifts. Interviews with the Nursing Home Administrator confirmed the facility's failure to meet the staffing requirements, and there were no additional higher-level staff available to compensate for these deficiencies.
Plan Of Correction
1. Facility unable to correct nurse aide staffing hours for the cited 5 of 6 days on day shift, 1 of 6 days for evening shift, and 4 of 6 days for night shift. 2. To help prevent reoccurrence, the Director of Nursing or Designee will in-service the scheduling staff on the importance of staffing the facility according to the regulation and policy. 3. The Administrator or designee will audit the direct care staffing five times per week to ensure regulatory compliance. Agency personnel are utilized as necessary to assist in staffing regulatory compliance. Facility staff can volunteer to pick up open shifts. When staffing is critical, management staff will consider delaying, limiting new admissions, or placing admissions on hold. 4. The audit outcomes will be presented to the Quality Assurance Committee for review and recommendations.
Deficiency in Meeting Required Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident in a 24-hour period on three out of six days reviewed. Specifically, the facility provided only 3.07 hours on March 25, 3.15 hours on March 29, and 2.87 hours on March 30, 2025. This deficiency was identified through a review of nursing time schedules and confirmed during an interview with the Director of Nursing on April 1, 2025, who acknowledged the shortfall in meeting the required care hours on the specified days.
Plan Of Correction
1. Facility unable to correct the staffing hours on the cited dates; efforts are continuously being made to maintain the staffing hours within regulatory guidelines. 2. To help prevent reoccurrence, the Director of Nursing or Designee will in-service the scheduling staff on the importance of staffing the facility according to the regulation and policy. 3. The Administrator or designee will audit direct care staffing hours five times per week to ensure regulatory compliance. The facility will continue with recruiting efforts, as well as offering employment incentives in order to increase staff availability. When there are staffing challenges, administrative staff can/will assist with mealtime, answering call bells, etc. When there is a call off, the scheduler makes contact with all staff via phone/text to find coverage. We encourage staff to take turns in staying beyond their regularly scheduled shift to cover call offs. Agency personnel are utilized as necessary to assist in staffing regulatory compliance. Facility staff can volunteer to pick up open shifts. When staffing is critical, management staff will consider delaying, limiting new admissions, or placing admissions on hold. 4. The audit outcomes will be presented to the Quality Assurance committee for review and recommendations.
Failure to Provide Scheduled Showers for a Dependent Resident
Penalty
Summary
The facility failed to provide necessary services to maintain personal hygiene for a dependent resident, identified as Resident 2, who was cognitively impaired and required extensive assistance for daily care needs, including bathing. According to the resident's care plan, they preferred showers on Sundays and Wednesdays during the second shift. However, a review of the resident's bathing records for January, February, and March 2025 showed that the resident did not receive any showers during these months. There was no documentation indicating that the resident was offered a shower and refused it during this period. An interview with the Director of Nursing confirmed that the resident was not showered in these months, and there was no evidence of refusal.
Delayed Treatment of Pressure Ulcer
Penalty
Summary
The facility failed to provide timely treatment for a newly identified pressure ulcer in a resident. The resident, who was cognitively intact and required substantial assistance with bed mobility, was at risk for developing pressure ulcers and was incontinent of urine and frequently incontinent of bowel. On December 28, 2024, a registered nurse was notified of a new pressure ulcer on the resident's coccyx, measuring 0.5 x 1.0 x 2.0 cm with tunneling. A foam dressing was applied, and the physician and resident representative were notified. However, there was no documented evidence of a physician's order for treatment until December 31, 2024, and the treatment was scheduled to start on January 1, 2025. By January 3, 2025, the wound had worsened to a Stage 3 pressure ulcer, measuring 1.5 x 1.3 x 1.0 cm with moderate serosanguineous drainage. The Director of Nursing confirmed that the physician was notified of the new pressure ulcer, but a treatment order was not obtained at the time of notification, which should have been done. This delay in obtaining a treatment order and starting the appropriate care contributed to the worsening of the resident's pressure ulcer.
Failure to Administer Correct Oxygen Flow Rate
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, as evidenced by the incorrect administration of oxygen. The resident, who was admitted with acute respiratory failure and hypoxia, had a physician's order for continuous oxygen at a flow rate of 4 liters per minute (LPM) via nasal cannula. However, during a visit by the resident's daughter, it was discovered that the oxygen was set at 3 LPM, which was below the prescribed rate. This discrepancy was confirmed by a nursing note dated January 19, 2025, and an interview with the Director of Nursing. Upon assessment, the resident's oxygen saturation was critically low at 68 percent on the incorrect flow rate. The nurse increased the oxygen flow to 5 LPM, which only marginally improved the saturation to 77 percent. Subsequently, the resident was placed on a non-rebreather mask, which increased the oxygen saturation to 93 percent, but the resident's mental status remained unchanged. The physician was notified, and the resident was sent to the hospital, where he was admitted with pneumonia, hypoxia, and a non-ST-elevation myocardial infarction.
Medication Unavailability Leads to Deficiency
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by the unavailability of a prescribed inhaler for several days. The resident, who was cognitively intact and had chronic obstructive pulmonary disease (COPD) and asthma, was supposed to receive fluticasone propionate inhaler twice daily. However, the medication was not administered on multiple occasions in January 2025 due to it being unavailable in the Omnicell or awaiting delivery from the pharmacy. Interviews and documentation revealed that the nursing staff was aware of the medication's unavailability but failed to ensure timely delivery or administration. The Director of Nursing confirmed the lack of documentation for the medication's administration and was unaware of the reasons for the delivery issues. The resident expressed confusion and concern over the repeated unavailability of her medication, highlighting a significant lapse in the facility's medication management processes.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update and revise the care plans for two residents to reflect their specific care needs. For Resident 2, who was cognitively impaired and had a history of falls, the care plan was not updated after an unwitnessed fall. Although interventions were made, such as discontinuing the air mattress and marking the appropriate mattress height with a decal, these changes were not documented in the care plan. The Director of Nursing confirmed that the care plan did not reflect the intervention for the decal to ensure the mattress was kept at the appropriate level. Similarly, Resident 5, who was also cognitively impaired and had a history of falls, was observed in a low bed with bilateral fall mats, but these interventions were not documented in the care plan. The Assistant Director of Nursing confirmed that the care plan was not revised to include the need for a low bed and fall mats. These omissions indicate a failure to ensure that the care plans were updated to reflect the residents' specific care needs, as required by the facility's policy.
Failure to Follow Transfer Protocols Leads to Resident Fall
Penalty
Summary
The facility failed to ensure safe transfer techniques were used in accordance with the care plan for a resident, resulting in a fall. The resident, who was cognitively impaired and dependent on assistance for transfers, was supposed to be transferred with moderate assistance from two staff members using an orbiturn. However, during a transfer, the resident slid off the chair and fell to the floor, sustaining bruising and discomfort. The incident occurred because a nurse aide transferred the resident with the help of a private caregiver instead of another facility staff member, as required by the care plan. The resident had a history of hemiparesis and required specific support during transfers, as outlined in their care plan. Despite the care plan's clear instructions, the nurse aide did not adhere to the requirement of using two facility staff members for the transfer. The Director of Nursing confirmed that the nurse aide's actions did not align with the care plan, as the aide used a private caregiver instead of another staff member. This deviation from the care plan led to the resident's fall and subsequent injuries.
Failure to Follow Physician's Orders and Document Care
Penalty
Summary
The facility failed to follow a physician's recommendations for a resident with a Stage IV pressure ulcer, resulting in the deterioration of the wound. The resident was admitted with a Stage IV pressure ulcer and was recommended to have a high protein diet, a low air loss mattress, frequent repositioning, and a wound vacuum. However, the facility did not document evidence of ordering or applying the wound vacuum, nor did they schedule a follow-up appointment as recommended. The resident's wound showed stalled healing and increased in size, with no evidence of the recommended treatments being followed. Additionally, the facility did not document weekly skin checks for another resident, as ordered by the physician. The resident required maximum assistance and was cognitively intact, but there was no evidence in the clinical record that skin checks were completed for two months. This lack of documentation was confirmed by the Assistant Director of Nursing. Furthermore, the facility failed to document urinary output for a resident with a Foley catheter, as required by a physician's order. The resident was cognitively intact and required maximum assistance, but there was no documented evidence of urine output being recorded each shift over several months. This deficiency was confirmed by the Director of Nursing.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for a Stage 4 pressure ulcer for Resident 13, resulting in the deterioration of the wound. Upon admission, Resident 13 had a Stage 4 pressure ulcer with exposed bone on the sacral area. A wound healing consult recommended a high protein diet, a low air loss mattress, frequent repositioning, and a wound vacuum, among other treatments. However, the physician's orders only included a Dakins wet-dry dressing, and there was no evidence that a wound vacuum was ordered or applied. Additionally, the resident did not receive the recommended follow-up appointment at the wound clinic due to scheduling conflicts, and the wound was not assessed by a registered nurse or the wound team since July 23, 2024. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed that the facility failed to obtain a wound vacuum, ensure follow-up wound appointments, and make additional referrals to the wound clinic. As a result, Resident 13's wound declined, with measurements indicating an increase in size and depth. The resident expressed discomfort and pain, particularly when sitting in a chair at dialysis, as she was unable to offload pressure or reposition. The facility's inaction and failure to follow through with recommended treatments and assessments contributed to the deterioration of the resident's condition.
Failure to Facilitate Advance Directives for Residents
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were given the opportunity to develop advance directives, as required by their policy. This deficiency was identified for 12 out of 45 residents reviewed. The facility's policy, dated July 1, 2024, mandates that upon admission, residents should meet with a healthcare team member to discuss and document their preferences for advance care planning, including living wills and medical power of attorney. However, the review of clinical records for the affected residents showed no documented evidence that these discussions took place or that residents were informed of their rights to develop advance directives. The residents involved had varying levels of cognitive function, with some being cognitively intact and others impaired. Despite these differences, there was no documentation indicating that any of the residents or their representatives were provided with the necessary information or assistance to formulate advance directives. The Social Service Director confirmed the lack of documentation, indicating a systemic failure to address advance directives with residents and their representatives throughout their stay, as required by the facility's policy and resident rights regulations.
Improper Food Temperature
Penalty
Summary
The facility failed to serve hot foods at the proper and palatable temperatures as required by their policy. The policy, dated June 1, 2024, mandates that hot foods should be served at 135 degrees Fahrenheit or above. During an observation of the lunch meal tray line in the main kitchen on August 21, 2024, it was noted that the food cart for the Second Floor left the kitchen at 12:28 p.m. and arrived at 12:32 p.m. The last resident was served at 12:43 p.m., and at 12:45 p.m., the temperature of the chicken breast was recorded at 124 degrees Fahrenheit, which was lukewarm and not appetizing. An interview with the Dietary Director confirmed that the hot foods should have been served at 135 degrees Fahrenheit. This deficiency was identified under the regulation 28 Pa. Code 211.6(b) Dietary Services.
Deficiencies in Food Safety and Hygiene Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple observations and staff interviews. The kitchen and its equipment were found to be unclean, with a microwave covered in a white, creamy substance, and a meat slicer and mixer with dried food remnants. Additionally, the ice cream freezer lacked a thermometer, and there was general debris under the coffee counter and throughout the kitchen. Food items in the kitchen and pantries were not properly labeled, dated, or secured, with several items found opened and exposed to air. In the walk-in cooler, various food items, including muffins, ham slices, and cheese, were undated and exposed to air. Similarly, in the walk-in freezer and second-floor pantry freezer, several items were found opened, undated, and unlabeled. The facility also failed to ensure proper hygiene practices among staff during food preparation. Observations during the tray line revealed that several dietary staff members wore hairnets that did not fully cover their hair, with hair tendrils exposed on their necks and foreheads. Additionally, a 10-pound ham was observed thawing improperly on the prep area counter, and there was a puddle of water under the ice machine extending onto the kitchen floor. An interview with the Dietary Manager confirmed that these issues should not have occurred and that staff were expected to have their hair completely covered.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of flies and gnats in the kitchen's food prep area. Observations on August 19, 2024, revealed approximately six flies and several gnats around the sink and general kitchen area. The facility's pest control policy, dated July 1, 2024, stated that treatment would be rendered as required to control insects, but the presence of pests indicated a lapse in this policy. Interviews with the Dietary Manager and Maintenance Director revealed that the pest control company was visiting every other month, with the last visit on June 20, 2024. Despite these visits, the pest issue persisted. The Maintenance Director requested an additional visit from the pest control company on August 19, 2024, after being informed of the problem. The pest control company recommended thorough cleaning, eliminating food debris, proper ventilation, and installing fly lights. The Nursing Home Administrator confirmed that flies and gnats should not be present in the kitchen.
Failure to Involve Residents in Care Plan Development
Penalty
Summary
The facility failed to ensure that residents and/or their responsible parties were given the opportunity to participate in the development and implementation of person-centered care plans. This deficiency was identified for two residents during a review of policies, clinical records, and staff interviews. The facility's policy, dated July 1, 2024, mandates that residents and their representatives should be involved in discussing care goals, including preferences for advanced care planning, and that these discussions should be documented. However, for Resident 12, who was cognitively impaired but able to understand and communicate, there was no evidence of a care plan conference being scheduled or completed after the Minimum Data Set (MDS) assessment. An interview with the Registered Social Worker confirmed that a meeting was initially scheduled but was rescheduled and eventually not held, with no subsequent meetings scheduled. Similarly, for Resident 77, who was cognitively intact and required assistance with care needs, there was no documented evidence of a care plan conference following the MDS assessment. An interview with the Registered Nurse Assessment Coordinator confirmed the absence of a scheduled or completed care plan conference and the lack of notifications or invitations to the resident or their representative. The Director of Nursing confirmed that care conferences should occur quarterly, indicating a failure to adhere to this schedule for both residents.
Failure to Obtain Physician's Orders for Pacemaker Checks
Penalty
Summary
The facility failed to obtain physician's orders for pacemaker checks for a resident, as required by both the Pennsylvania Nursing Practice Act and the facility's own policy. The resident, who was cognitively impaired and had a cardiac pacemaker, was admitted to the facility with a care plan indicating the need for pacemaker checks per physician's order. However, there was no documented evidence in the resident's clinical record of any physician's order for these checks, nor any documentation that the checks had been completed since the resident's admission. Interviews with the Nursing Home Administrator and the Registered Nurse Assessment Coordinator confirmed the absence of documented evidence for the pacemaker checks. The RNAC also noted that the resident had missed a scheduled pacer clinic appointment. This oversight indicates a failure to adhere to the facility's policy and the resident's care plan, which required routine pacemaker checks to ensure the device's proper functioning.
Failure to Schedule Vision Exams for Residents
Penalty
Summary
The facility failed to follow physician's orders and residents' requests for ophthalmology appointments for two residents. Resident 69, who was cognitively intact and required supervision with care needs, expressed a desire to see an eye doctor due to severe vision impairment. Despite a scheduled appointment, a miscommunication with Senior Life and transportation issues prevented the visit. The Social Service Director received an email from the local Senior Services office about the need to reschedule the vision exam, but no further attempts were documented to follow up or reschedule the appointment after the initial email. Resident 87, who was cognitively impaired and had a diagnosis of diabetes, was ordered by a physician to have a vision exam with 360 services. An email was sent by a registered nurse to the Social Service Director to schedule this exam, but there was no documented evidence in the resident's clinical record that the appointment was ever scheduled. The Nursing Home Administrator confirmed the lack of documentation for the scheduling of the vision exam for Resident 87.
Failure to Address Pharmacy Recommendations
Penalty
Summary
The facility failed to respond in a timely manner to pharmacy recommendations for two residents, leading to a deficiency in medication regimen review. For Resident 30, who was cognitively impaired and required total care, a pharmacy consultant recommended reassessing the prescription for midodrine to avoid administration after 6:00 p.m. However, the medication was scheduled for 8:00 p.m., and there was no documented evidence that the physician addressed this recommendation by August 22, 2024. This was confirmed by the Director of Nursing during an interview. Similarly, for Resident 89, who was cognitively intact and dependent on staff for daily care, the pharmacist recommended reviewing the concurrent use of Citalopram and Cilostazol and stopping the order for nystatin. Additionally, a lipid panel was recommended. There was no documented evidence that these recommendations were addressed by the physician, as confirmed by the Assistant Director of Nursing. These failures to act on pharmacy recommendations were in violation of the facility's policy and state regulations.
Failure to Document Non-Pharmacological Interventions Before Psychotropic Medication Administration
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications, as evidenced by the lack of documented non-pharmacological interventions prior to administering such medications. The facility's policy required that all residents receiving psychoactive medications have their behaviors and the effectiveness of interventions monitored and documented. However, for one resident, there was no evidence that non-pharmacological interventions were attempted before administering Ativan and Xanax on multiple occasions. The resident in question was cognitively impaired with diagnoses including Alzheimer's disease, dementia with agitation, and anxiety. Despite physician orders for medication monitoring and documentation of non-pharmacological interventions, the Medication Administration Record showed repeated administration of Ativan and Xanax without prior attempts at non-pharmacological interventions. This was confirmed by the Registered Nurse Assessment Coordinator, who acknowledged that such interventions should have been attempted before administering the medications.
Infection Control Deficiencies in Handling PPE and Linens
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies in handling soiled linens and personal protective equipment (PPE) for a COVID-19 positive resident. The facility's policy required soiled linens to be bagged at the point of use and placed in a designated soiled linen bin. However, observations revealed that a nurse aide carried dirty linens from a droplet isolation room to a linen cart in the hallway without bagging them, which was confirmed by the aide and the Nursing Home Administrator. Additionally, Resident 11, who was COVID-19 positive, was on droplet precautions, but the signage incorrectly indicated contact precautions, and there was no appropriate receptacle for disposing of used PPE in the resident's room. The Director of Nursing confirmed that the correct transmission-based precaution signs should have been posted, and appropriate receptacles for soiled PPE should have been available. The facility's failure to provide a dirty linen bin in each isolation room and the incorrect handling of contaminated PPE and linens contributed to the deficiency. The report highlights the facility's non-compliance with infection control protocols, as outlined in the relevant Pennsylvania Code sections.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to determine if a resident was safe to self-administer medications, as required by their policy. The policy, dated July 2024, stated that residents were not allowed to bring medications from outside the facility and that medications should not be left in open view. However, an admission Minimum Data Set (MDS) assessment for the resident, dated July 31, 2024, showed no documented evaluation to determine the resident's capability to self-administer medications. The resident, who was cognitively intact and required supervision for care needs, was taking an antibiotic for cellulitis. Physician's orders indicated the resident was to receive Bactrim DS twice a day until July 27, 2024. On August 19, 2024, an observation and interview with the resident revealed a medication bottle labeled Bactrim DS from a hospital pharmacy on the over-bed table. The resident stated that the medication was from the hospital and that he had taken two tablets when the facility's medication system was not working. An LPN confirmed that medications should not be at the bedside and noted two tablets were missing from the bottle. A nursing note from July 24, 2024, indicated the resident was admitted with cellulitis and was to take Bactrim DS through August 27, 2024. The medication administration record showed the 8:00 p.m. dose on July 25, 2024, was not administered due to unavailability. The DON confirmed the resident had not been assessed for self-administration and the two missing pills could have been taken when the medication was unavailable.
Failure to Ensure Call Bell Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call bell was within reach, which is a deficiency in accommodating the needs and preferences of residents. The facility's policy, dated July 1, 2024, requires that residents have a means of communicating with staff through a call system installed in each room and toilet/bath area. Resident 19, who was cognitively impaired and totally dependent on two staff members for assistance with bed mobility and transfers, was identified as being at risk for falls and required the call bell to be within reach at all times. However, during an observation on August 19, 2024, it was noted that the resident was sitting in a geri-chair with the call bell out of reach, placed on the head of the bed behind her. The resident expressed a need for assistance, and a nurse aide confirmed the call bell was not accessible, subsequently handing it to the resident. The Nursing Home Administrator confirmed that the call bell should have been within reach of the resident.
Breach of Resident Health Information Confidentiality
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's personal health information during medication administration. On August 21, 2024, at 7:50 a.m., a Licensed Practical Nurse (LPN) left the medication cart unattended without securing the computer screen, which displayed Resident 5's personal health information. The screen was visible to the hallway and elevator door, compromising the resident's privacy. The LPN confirmed that she should have covered the information when leaving the cart. The Assistant Director of Nursing also confirmed that the computer screen should have been covered when unattended.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in addressing their specific care needs. For one resident, who was cognitively intact and receiving physical and occupational therapy, there was no documented evidence of a care plan addressing her left-sided hemiparesis, despite her inability to move her left arm and the use of a splint for contractures. Interviews with staff confirmed that this resident should have had a care plan for her condition, but it was not developed. Another resident, who was cognitively impaired and had a diagnosis of schizophrenia, exhibited behaviors such as yelling and self-harm. Despite these behaviors being discussed by the Interdisciplinary Team, there was no documented evidence of a care plan to address these behaviors. The Nursing Home Administrator confirmed the absence of a care plan for this resident's behaviors, acknowledging that it should have been created.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure that care plans were updated or revised to reflect changes in care needs for three residents. For Resident 5, the care plan was not updated to reflect a change in diet from nectar thick liquids to thin liquids, despite recommendations from hospital radiology and confirmation from the Director of Rehabilitation and the Registered Dietician. Resident 12's care plan was not updated to include contacting her sister when the resident refused care, even though the resident had a history of rejecting care and concerns were raised by the resident's sister about the resident not eating, participating in activities, or taking showers. For Resident 77, the care plan was not revised to reflect the healing of a Stage 2 pressure ulcer on the right buttock, nor was it updated to include a new wound on the left malleolus, despite physician's orders for wound care and a nursing note confirming the healing of the buttock wound. The Director of Nursing confirmed that the care plans for these residents should have been updated to reflect the changes in their care needs.
Failure to Complete Discharge Summary for Resident
Penalty
Summary
The facility failed to ensure that a discharge summary, including a recapitulation of the resident's stay, was completed for a resident who was discharged. The resident, identified as Resident 104, was admitted with diagnoses including diabetes mellitus, hypertension, atrial fibrillation, and cellulitis. The resident left the facility against medical advice shortly after admission. As of a later date, there was no documented evidence of a completed discharge summary for this resident. This was confirmed through an interview with the Registered Nurse Assessment Coordinator.
Failure to Implement Restorative Nursing Program
Penalty
Summary
The facility failed to ensure that restorative nursing programs were provided as ordered and care planned for a resident with cerebral palsy. The resident, who was cognitively intact and required supervision for care needs, was on a restorative ambulation program with a goal to walk 100 feet with a front-wheeled walker and non-skid footwear under supervision twice a day. Despite being care planned for this program since July 2023, there was no documented evidence that the program was completed as per therapy recommendations and care plan on numerous dates between June and August 2024. Interviews with the resident revealed that he was not receiving the restorative ambulation as frequently as care planned after being discharged from therapy. The Nursing Home Administrator confirmed the lack of documentation for the restorative ambulation program on the specified dates and times. This deficiency was identified during a review of clinical records and interviews with the resident and staff, indicating a failure to maintain or improve the resident's physical abilities as required.
Failure to Provide Scheduled Showers and Oral Care
Penalty
Summary
The facility failed to provide scheduled showers and oral care for a resident, identified as Resident 12, who was dependent on staff for personal care needs. According to the resident's care plan, she preferred to have showers every Tuesday and Saturday during the second shift and oral care twice a day. However, a review of the bathing documentation from August 13, 2024, through August 22, 2024, showed that the resident did not receive any showers during this period. Additionally, there was no documented evidence that the resident was offered or refused showers as per her care plan. Furthermore, the oral care documentation for the same period revealed that the resident only received oral care three times, contrary to the care plan's requirement of twice daily. An interview with the resident's sister indicated concerns about the resident's cleanliness, as she observed greasy hair, dirty clothes, and unbrushed teeth, prompting her to provide care herself. The Assistant Director of Nursing confirmed the lack of documentation for both showers and oral care, indicating a failure to adhere to the resident's care plan.
Failure to Conduct Safety Assessments for Air Mattress Use
Penalty
Summary
The facility failed to complete safety assessments for two residents who were using air mattresses. Resident 13, who was cognitively intact and had a Stage IV pressure ulcer, was recommended to use a low air loss mattress by a wound healing consult. Despite the physician's order to obtain such a mattress, there was no documented evidence that the facility assessed the air mattress for potential safety hazards before it was placed on the resident's bed. Resident 51, who was severely cognitively impaired and dependent on staff for daily care, also had an air mattress placed on their bed without a safety assessment. This resident experienced a fall from the bed after the removal of bed enablers, as the air mattress forced them to the edge of the bed. The Director of Nursing confirmed that safety assessments should have been conducted prior to the use of air mattresses for both residents.
Failure to Address Urine Status Change and Proper Catheter Care
Penalty
Summary
The facility failed to address a change in urine status for a resident with a history of chronic urinary tract infections (UTIs). The resident, who was cognitively intact and required extensive assistance for daily care tasks, had an indwelling urinary catheter. On a specific date, the resident was noted to have 300 milliliters of blood-tinged urine in her catheter collection bag. Despite this significant change, the resident was not assessed until three days later when her sister reported tea-colored urine, prompting a urinalysis and subsequent antibiotic treatment for a UTI. The Director of Nursing confirmed that the resident should have been assessed when the initial change in urine color was observed. Additionally, the facility did not provide proper care for another resident with an indwelling urinary catheter. This resident, who was severely cognitively impaired and had diagnoses including dementia and urinary retention, was observed with the catheter tubing and drainage bag lying on the floor without a dignity bag, contrary to the facility's policy. Both a nurse aide and the Assistant Director of Nursing/Infection Control confirmed that the catheter tubing and drainage bag should not have been on the floor and should have been placed in a dignity bag.
Failure to Provide Prescribed Hydration
Penalty
Summary
The facility failed to provide the recommended aggressive hydration for a resident with chronic urinary tract infections. The resident, who was cognitively intact and required assistance for daily care, had a urology consult recommending 4 liters of fluid intake per day. Physician's orders were in place to document the resident's water intake every 6 hours. However, a review of the clinical records showed that the resident's daily fluid intake was significantly below the prescribed 4 liters on multiple days, with no documentation of refusal or receipt of the ordered fluids. An interview with the Nursing Home Administrator confirmed the lack of documentation regarding the resident's fluid intake, indicating a failure to adhere to the physician's orders. This deficiency was identified under 28 Pa. Code 211.12(d)(3)(5) Nursing Services.
Insufficient Staffing Leads to Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the care needs of residents, as evidenced by the lack of documented care for two residents. Resident 12, who was cognitively intact and dependent on staff for personal care, did not receive scheduled showers or oral care as per her care plan. From August 13 to August 22, 2024, there was no documentation that Resident 12 was offered or refused showers twice weekly or oral care twice daily. An interview with Resident 12's sister revealed concerns about the resident's cleanliness, indicating that she often had to provide care herself due to insufficient staffing. Resident 19, who was cognitively impaired and dependent on two staff for assistance, experienced delays in receiving incontinence care. On August 19, 2024, Resident 19 activated her call bell twice, requesting to be changed due to wetness from a fluid pill. Nurse Aide 5 responded but only changed the resident's shirt, not providing full incontinence care. The aide reported that there were not enough staff to meet the needs of over 55 residents, with only five aides available. The Nursing Home Administrator confirmed that the call bell wait time was inappropriate and acknowledged staffing challenges.
Failure to Document Administration of Controlled Medications
Penalty
Summary
The facility failed to ensure the accountability of controlled medications for a resident, identified as Resident 86. The resident was cognitively intact, required assistance for all daily care needs, and experienced pain rated as a 6 on a scale of 1 to 10. Physician's orders indicated that the resident was to receive a 10-325 mg tablet of oxycodone/Tylenol as needed between 12:00 a.m. and 4:00 a.m. However, the controlled drug record showed that staff signed out a hydrocodone/Tylenol tablet on several occasions in April and May 2024, but there was no documentation on the Medication Administration Record (MAR) that the medication was administered to the resident on those dates and times. An interview with the Director of Nursing confirmed the lack of documented evidence that the narcotic pain medication was administered to the resident on the specified dates and times. The nurses are expected to sign the MAR when they administer pain medication, which was not done in this case.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, as evidenced by observations during medication administration. During a review of medication administration procedures, it was found that two errors occurred out of 30 opportunities, resulting in a 6.67 percent error rate. The errors involved the administration of medications to a resident with severe cognitive impairment and a history of seizures. The resident was prescribed Depakote-delayed release tablets and Trelegy Ellipta inhalation. However, the Licensed Practical Nurse (LPN) crushed the Depakote tablets, which should not have been crushed, and administered them in applesauce. Additionally, the resident was not instructed to rinse and spit after using the inhaler, contrary to the manufacturer's instructions. Interviews with the LPN, Registered Nurse Supervisor, and Director of Nursing confirmed the errors. The LPN admitted to crushing the Depakote tablets and not instructing the resident to rinse his mouth after inhalation, citing the resident's past refusals. The RN Supervisor and Director of Nursing confirmed that the Depakote should not have been crushed and that the physician was not informed of the resident's refusal to take whole pills or rinse his mouth. There was no documentation indicating the physician's awareness of these issues, contributing to the medication administration errors.
Deficiencies in Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper storage of controlled medications and correct labeling of insulin pens, as observed during a survey. In the second-floor medication room, a narcotic storage box containing liquid Ativan was not permanently affixed inside the refrigerator, contrary to the facility's policy. This was confirmed by the Assistant Director of Nursing during an interview. The policy requires that narcotics be stored in a separately locked, permanently affixed compartment within the medication room refrigerator. Additionally, on the third floor, an insulin pen used for a resident with diabetes mellitus was found to be opened and undated on the medication cart. The resident was cognitively intact and dependent on staff for daily care, receiving insulin injections daily. The lack of a date on the insulin pen was confirmed by an LPN, and the Nursing Home Administrator acknowledged that insulin pens should be dated upon opening. These deficiencies were noted in violation of 28 Pa. Code 211.9(a)(1) Pharmacy Services.
Failure to Provide Assistive Eating Devices
Penalty
Summary
The facility failed to provide necessary assistive devices for eating to two residents as per their care plans. Resident 12, who was cognitively intact and required set-up assistance with eating, was observed during a lunch meal without the prescribed two-handled cup for all liquids, despite having a straw restriction. This was confirmed by both a Licensed Practical Nurse and the Assistant Director of Nursing, who acknowledged that the resident's meal ticket indicated the need for a two-handled cup, which was not provided. Similarly, Resident 28, who was also cognitively intact and required set-up and clean-up assistance for eating, was observed eating lunch with regular flatware instead of the ordered weighted built-up utensils. The resident expressed difficulty eating without the adaptive equipment, and this oversight was confirmed by a Nurse Aide and the Director of Nursing. Both residents' care plans and physician's orders clearly indicated the need for specific adaptive equipment, which was not adhered to during meal times.
Ineffective QAPI Committee Fails to Address Recurring Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee was found to be ineffective in addressing and correcting recurring deficiencies identified in the surveys conducted by the State Survey and Certification (Department of Health). The deficiencies were initially identified in a survey ending September 8, 2023, and included issues related to accommodation of resident needs, accuracy of Minimum Data Set (MDS) assessments, adherence to professional standards, quality of care, maintaining a safe environment free from accident hazards, nutrition and hydration maintenance, accounting of controlled medications, storage and labeling of medications, use of assistive devices for eating and hydration, food preparation and storage, and infection control. The facility had developed plans of correction for these deficiencies, which included conducting audits and reporting the results to the QAPI committee for further monitoring. However, the subsequent survey ending August 22, 2024, revealed that the QAPI committee failed to effectively implement these plans and ensure compliance with the regulations. The repeated deficiencies indicated that the committee did not successfully address the issues related to the accommodation of resident needs, accuracy of MDS assessments, professional standards, quality of care, and other critical areas. The report highlights specific deficiencies under various F-tags, such as F558 for accommodation of resident needs, F641 for MDS assessments, F658 for professional standards, F684 for quality of care, F689 for a safe environment, F692 for nutrition and hydration, F755 for accounting of controlled medications, F761 for storage and labeling of medications, F810 for assistive devices, F812 for food preparation and storage, and F880 for infection control. Despite the facility's plans to conduct audits and involve the QAPI committee, the recurring nature of these deficiencies suggests a lack of effective oversight and corrective action by the committee.
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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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