Paramount Nursing And Rehab At Fayetteville, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Fayetteville, Pennsylvania.
- Location
- 6375 Chambersburg Road, Fayetteville, Pennsylvania 17222
- CMS Provider Number
- 395721
- Inspections on file
- 20
- Latest survey
- October 6, 2025
- Citations (last 12 mo.)
- 2 (2 serious)
Citation history
Health deficiencies cited at Paramount Nursing And Rehab At Fayetteville, Llc during CMS and state inspections, most recent first.
A resident with cognitive impairment and a mechanical soft diet began choking during a meal. Instead of immediately performing the Heimlich maneuver, staff moved the resident to his room and bed, delaying emergency intervention by about ten minutes. Multiple staff were present but did not initiate abdominal thrusts until the resident's condition had deteriorated, resulting in the resident's death.
A resident with a mechanical soft diet and specific speech therapy recommendations for bite-size food was given a large portion of food that was not cut as required. Despite staff cues, the resident consumed the entire piece, resulting in choking and death. The lack of communication and adherence to dietary instructions placed other residents with similar needs at high risk.
Three residents with mental health diagnoses were prescribed multiple psychotropic medications without adequate documentation of side effect monitoring or ongoing assessment of medication necessity. In one case, PRN psychotropic medications were ordered without required stop dates, despite pharmacy and physician agreement to add them. Staff and DON interviews confirmed that side effect monitoring was only documented if adverse effects were observed, rather than as an ongoing process.
Three residents with complex medical conditions had inaccuracies in their MDS assessments regarding medication administration. In each case, the MDS coding did not match the Medication Administration Record or physician orders, resulting in incorrect documentation of anticoagulant, antianxiety, or anticonvulsant medication use. Staff confirmed these discrepancies during interviews.
Three residents with mental health diagnoses and active psychotropic medication orders did not have their medication use addressed in their comprehensive care plans, despite assessments indicating this was necessary. Staff confirmed that care plans should have included this information, but it was not documented.
Three residents with indwelling urinary catheters, each with physician orders and care plans requiring catheter care every shift, did not have evidence in their records that this care was completed or documented as required by facility policy. The DON confirmed the absence of documentation for all affected residents.
A resident with paraplegia and depression, resulting from surviving a plane crash, did not receive trauma-informed or culturally competent care as required. The facility had not conducted trauma screenings or documented trauma history for this resident, and staff confirmed that such screenings were not being completed prior to the deficiency being identified.
Surveyors identified multiple deficiencies in food storage and sanitation, including food items stored directly on the floor, unlabeled and undated foods in refrigerators and dry storage, improper maintenance of the ice machine, and lack of test strips for verifying sanitation solution strength. There was also confusion among staff regarding responsibility for labeling, dating, and cleaning of nourishment refrigerators, and some food items were found past their discard date or in damaged containers.
The facility did not properly review and revise care plans for two residents, resulting in outdated or conflicting interventions. One resident's care plan contained inconsistent fluid restriction orders that did not match the current physician order, while another resident's care plan failed to include a new lumbar fracture after a fall and continued to list a resolved UTI. These deficiencies were confirmed by facility leadership.
A resident with atrial fibrillation and congestive heart failure had a care plan that addressed ADLs and falls but did not specify the required level of assistance for ADL care. The DON confirmed that this information should have been included in the care plan.
The facility did not meet the required nurse aide staffing ratios from November 29 to December 5, 2024, across day, evening, and night shifts. Staffing documents and interviews revealed consistent shortfalls in the number of NAs per resident, failing to comply with regulations effective July 1, 2024.
The facility did not meet Pennsylvania State minimum LPN staffing regulations from November 29 to December 5, 2024. The required LPN-to-resident ratios were not maintained across multiple shifts, including day, evening, and night shifts. This was confirmed during an interview with the Nursing Home Administrator and DON.
The facility did not meet the required minimum of 3.2 hours of direct resident care per resident in a 24-hour period for six out of seven days. Staffing documents showed insufficient hours on multiple days, and the Nursing Home Administrator and DON confirmed the shortfall.
The facility failed to maintain a clean environment for two residents, as observed with fans in their rooms having gray fuzzy debris on the blades. The NHA confirmed the absence of a cleaning policy for fans, with housekeeping only wiping the outside without disassembling them for thorough cleaning.
A facility failed to implement necessary interventions for a resident with a stage 4 pressure ulcer, despite physician orders and wound care recommendations. Observations showed the resident's feet were not properly elevated, and required equipment like an offloading boot and bed cradle were not used. Interviews with the DON and Nursing Home Administrator revealed a lack of documentation for any disagreement with the care plan or resident refusal.
A facility failed to ensure a resident with limited mobility received appropriate care to maintain or improve mobility. The resident, diagnosed with dementia and muscle weakness, was observed without the prescribed palm protector on several occasions. The facility lacked documentation of the palm protector's application since it was ordered, and the NHA confirmed that staff should have documented its use or any refusal.
A resident with congestive heart failure and a fluid restriction order was not properly monitored, leading to excessive fluid intake. The care plan lacked details on the restriction, and staff were unaware of the resident's needs. Discrepancies in fluid documentation were noted, and the DON admitted new staff might not be informed about specific restrictions.
The facility failed to properly administer IV therapy for two residents, leading to medication management deficiencies. One resident had an empty Meropenem IV bag with undated and uncapped tubing, while another had an IV bag labeled for a different resident, indicating a medication error. Staff interviews confirmed these lapses, and the DON acknowledged the expectation for proper medication administration.
A facility failed to maintain oxygen equipment in a sanitary manner for a resident with Covid-19 and respiratory issues. The oxygen tubing, required to be changed bi-weekly, was not updated from June 2 until July 2, despite the resident's positive Covid-19 test on June 20. The DON cited the resident's refusal as the reason for the delay and noted that staff did not reapproach or document refusals. The tubing was eventually changed but was incorrectly dated.
The facility failed to maintain effective infection control measures for two residents. One resident with shingles did not have consistent contact precautions, as the isolation sign was removed, and there was a lack of documentation during treatment. Another resident with bacteremia and a midline IV lacked enhanced barrier precautions, as required by facility policy. These deficiencies highlight lapses in adhering to infection control protocols.
Delayed Emergency Response to Choking Incident
Penalty
Summary
A deficiency occurred when staff failed to provide timely emergency care to a resident experiencing a choking incident. The resident, who had a history of cognitive impairment, decreased safety awareness, and was on a mechanical soft diet with thin liquids, began choking during a meal. Staff observed the resident struggling to breathe and expressing an inability to cough, but instead of immediately initiating emergency measures such as the Heimlich maneuver, they moved the resident from the dining room to his room, a distance of approximately 138 feet, and transferred him to bed before attempting further interventions. During this period, staff encouraged the resident to cough and attempted oral suctioning, but did not perform the Heimlich maneuver until approximately ten minutes after the onset of the choking episode. Multiple staff members, including nursing, therapy, and aide personnel, were present and involved in the response, but there was a delay in recognizing the need for and initiating abdominal thrusts. Witness statements and progress notes confirm that the Heimlich maneuver was not started until the resident was already in his room and in bed, despite clear signs of airway obstruction and the resident's inability to clear the blockage himself. The delay in providing appropriate emergency intervention resulted in the resident losing consciousness and ultimately being pronounced dead. The facility's failure to follow established emergency procedures for choking, as outlined in their own policy and professional standards of practice, directly contributed to the adverse outcome for the resident. The deficiency was identified as an Immediate Jeopardy situation due to the delay in emergency response and the resulting death.
Plan Of Correction
We were unable to correct deficiency F0684 related to Resident 1 as the resident expired in the facility. All nursing staff were educated on the revised choking policy and signs and symptoms to look for when choking. Employee 2 received one-on-one education by Anthony Clark, Director of Nursing, on October 10, 2025, regarding CPR training and emphasis placed on choking resident and employee 2 demonstrated proper technique for the Heimlich maneuver. Employee 2 was placed on a Performance Improvement Plan to demonstrate full knowledge, demonstration of proper Heimlich technique, and adherence to emergency choking protocol. Dysphagia/Choking Procedure in-service was provided to the staff by Anthony Clark, Director of Nursing, and Talayne Gates, SLP, on Tuesday, October 14th at 7am, 1pm, and 3pm, and will be held also on Thursday, October 16th at 7am, 1pm, and 3pm for licensed staff and nursing assistants. DON reviewed the emergency response for a choking resident's times one week. The results of this audit will be reported at the October 23rd QAPI meeting and determined if further staff audits are needed. The facility will begin conducting quarterly mock drills of emergency events, including choking drill, code drill, elopement drill, and active shooter drill, beginning in January 2026. The results will be reviewed at the quarterly QAPI meetings. The QAPI committee will determine if more frequent mock drills for emergency events need to be held.
Removal Plan
- Choking policy was reviewed and updated to American Heart Association Standards.
- All nursing staff will be educated by the Assistant Director of Nursing on the revised choking policy.
- All other nursing staff will be educated by the Registered Nurse Supervisor prior to the start of their shift.
- This will include all full-time, part-time, and prn nursing staff.
- The Assistant Director of Nursing will educate all nursing staff on the signs to look for when someone is choking.
- The Rehab Manager audited all residents on current caseload to ensure current Speech Therapy diet recommendations were being followed.
- The Rehab Manager will audit all residents who have had current Speech Therapy diet recommendations to ensure their current diet order reflects Speech Therapy recommendations.
Failure to Follow Dietary Recommendations Results in Choking Incident
Penalty
Summary
The facility failed to ensure that a resident with specific dietary needs received adequate supervision and assistance to prevent accidents, resulting in a choking incident. The resident had a history of unspecified protein-calorie malnutrition, dehydration, and generalized muscle weakness, and was on a mechanical soft diet with thin consistency. Speech therapy recommendations specified that the resident's food should be cut into bite-size pieces and that small bites or sips should be facilitated during meals. However, these recommendations were not communicated on the resident's meal tray ticket, nor were they consistently followed by staff. On the day of the incident, an occupational therapist handed the resident half of a beef enchilada, approximately 2.5 inches in size, which was not cut into bite-size pieces as required. Despite verbal and visual cues to take small bites, the resident placed the entire portion in his mouth, leading to choking and labored breathing. Staff present attempted to assist the resident, but the food size and lack of adherence to the recommended feeding techniques contributed to the choking event. The speech therapist later confirmed that staff should have cut the food into smaller portions and that such instructions should have been clearly communicated and followed. Further review revealed that other residents with similar dietary needs had varying instructions on their meal tray tickets, such as "cut up meats" or "cut food into bite size pieces," but the process for ensuring these directions were consistently applied was lacking. The nursing home administrator acknowledged that speech therapy recommendations should be properly communicated and documented on meal tray tickets, and that staff should follow these recommendations. The failure to communicate and implement individualized dietary precautions resulted in a choking incident and subsequent death, placing additional residents at high risk for similar events.
Plan Of Correction
We were unable to correct deficiency F0689 related to Resident 1 as resident expired in the facility. Residents 6-14 were screened by Speech Therapy for appropriate diet and checked to see if at risk for choking or require any new safety measures. Director of Rehab audited all current residents that have had a speech therapy diet recommendation to ensure their current diet order reflects speech therapy recommendations. Director of Rehab educated all therapy staff on the new procedure of diet recommendations to be written on the speech therapy recommendation form and physician order as well as provided to nursing. Speech Therapy was also educated to give the speech therapy recommendation form to Dietary. Speech Therapists were instructed if trialing any changes to the diet, the therapist must stay with the resident until the trial item is completed. The Director of Rehab is conducting an ongoing audit for any new speech therapy recommendations to ensure they match the diet order. All nursing staff was educated prior to the start of their shift on the new choking policy and signs and symptoms to look for with a choking resident. Education was given to all nursing staff prior to the start of their shift on diet and diet textures. Dietary Manager educated all dietary staff prior to the start of their shift on diet and diet textures and cutting up food as indicated on the meal ticket. Dysphagia/Choking Procedure in-service was provided to the staff by Anthony Clark, Director of Nursing, and Talayne Gates, SLP, on Tuesday, October 14th at 7am, 1pm, and 3pm, and will be provided on Thursday, October 16th at 7am, 1pm, and 3pm to licensed staff and nursing assistants. The Director of Nursing and Assistant Dietary Manager are conducting audits of all new dietary orders or changes and recommendations for meal ticket accuracy through October 31, 2025. The Dietary Manager audited all meals during tray line service to ensure meal ticket matches diet order and visually observe meal served is accurate through 10/10/25. Beginning 10/13/25, the Dietary Manager will audit 3 meals per week during tray line to ensure meal ticket matches diet order and visually observe meal served is accurate through October 31, 2025. Direct in-service training on F0689, Accidents and Incidents, for all licensed staff and nursing assistants will be provided by Sophie Campbell, MSN, RN, CRRN, RAC-CT, CNDLTC. Sophie Campbell is the Executive Director of the Pennsylvania Association of Directors of Nursing Administration and is an approved directed in-service provider on the list from the Department of Health. The in-service will be held on Wednesday, October 29th at 7am, 1pm, and 3pm. This in-service will be recorded for staff that is unable to attend. Licensed staff unable to attend the in-service will be required to watch the recorded in-service prior to the start of their next shift. All ongoing audits will be reviewed at the monthly QAPI to determine if further auditing is needed. <End of formatted text>
Removal Plan
- Choking policy was reviewed and updated to American Heart Association Standards.
- All nursing staff currently working in the building will be educated by Employee 6 (Assistant DON) on the revised choking policy.
- All other nursing staff will be educated by the Registered Nurse (RN) Supervisor prior to the start of their shift. This will include all full time, part-time and nursing staff.
- Employee 6 will educate all nursing staff currently working on the signs to look for when someone is choking.
- All other nursing staff will be educated by the RN Supervisor prior to the start of their shift. This will include all full time, part-time and nursing staff.
- Employee 7 audited all residents on current caseload to ensure current speech therapy diet recommendations were being followed.
- Employee 7 will audit all residents who have had current speech therapy diet recommendations to ensure their current diet order reflects speech therapy recommendations.
- Employee 7 will educate speech therapists on new procedure to write recommendations on speech therapy recommendation form and physician orders.
- Employee 7 will educate Employee 1 on following dietary orders.
- Employee 12 (Dietary Manager) will educate dietary staff currently working on diet and diet textures.
- All other dietary staff members will be educated by Employee 12 prior to the start of their shift. This will include all full time, part-time, and as needed staff.
- All nursing staff currently working in the building will be educated by Employee 6 on diets and diet textures and to read and follow meal tickets.
- RN Supervisor will educate all nursing staff currently working on diets and diet textures and to read and follow meal ticket directions.
- Employee 12 (Dietary Manager) audited evening meal service tray line to ensure meal tickets matched diet order and visually observed meal service was accurate.
- All meals will be audited during tray line to ensure meal ticket matches diet order and visually observe meal served is accurate.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents' medication regimens were free from unnecessary psychotropic medications and did not provide adequate monitoring for these medications for three of five residents reviewed. Facility policy requires that psychoactive medications be prescribed only when medically necessary, with ongoing documentation of medical necessity, regular reassessment, and monitoring for side effects. However, clinical record reviews revealed that for multiple residents receiving psychotropic medications, there was no documentation of side effects to be observed or evidence of ongoing side effect monitoring. One resident with diagnoses of generalized anxiety disorder and depression was prescribed multiple psychotropic medications, including buspirone, sertraline, and trazodone, since admission. The clinical record lacked documentation of side effect monitoring for these medications. Staff interviews confirmed that side effect monitoring was only documented if side effects were observed, rather than as an ongoing process. Another resident with Alzheimer's disease and anxiety disorder had PRN orders for lorazepam and haloperidol without stop dates, despite a pharmacy recommendation and physician agreement to add a 14-day stop date. The order was not updated to include the stop date as required. A third resident with anxiety and depression was prescribed several psychotropic medications, including buspirone, clonazepam, sertraline, and trazodone, but the clinical record did not include identified side effects to monitor or documentation of ongoing monitoring. Staff interviews and email communication from the DON confirmed that adverse effects were only documented when they occurred, and routine monitoring was not consistently performed or documented. These findings demonstrate a failure to comply with facility policy and regulatory requirements regarding the use and monitoring of psychotropic medications.
Inaccurate Coding of Resident Medication Status in MDS Assessments
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' medication status for three residents. For one resident with cerebral infarction and paraplegia, the quarterly MDS assessment was coded as if the resident was receiving anticoagulant medication, but a review of physician orders showed no such medication had been ordered. For another resident with generalized anxiety disorder and depression, the Significant Change MDS assessment incorrectly documented that the resident was not receiving antianxiety medication, despite the Medication Administration Record showing administration during the assessment period. Additionally, the same resident was documented as receiving anticonvulsant medication on a subsequent MDS, but there was no evidence of administration in the corresponding records. A third resident, diagnosed with Parkinson's Disease and restless leg syndrome, had an admission MDS assessment indicating no anticonvulsant medication was received, while the Medication Administration Record showed that such medication was administered during the assessment period. In each case, staff interviews confirmed that the MDS assessments were coded incorrectly and did not accurately reflect the residents' medication status during the assessment reference periods.
Failure to Develop Comprehensive Care Plans for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans addressing psychotropic medication use for three residents with significant mental health diagnoses. For one resident with major depressive disorder and generalized anxiety disorder, the clinical record showed an active order for olanzapine and documentation in the MDS and Care Area Assessment (CAA) that psychotropic medication use should be care planned. However, the resident's comprehensive care plan did not include any interventions or objectives related to psychotropic medication use. Similarly, another resident with generalized anxiety disorder and depression had ongoing orders for multiple psychotropic medications, with MDS assessments and CAA worksheets indicating the need for care planning in this area. Despite this, the resident's care plan and revision history lacked any documentation of psychotropic medication use. A third resident with Alzheimer's disease and anxiety disorder was also receiving several psychotropic medications, and their assessments triggered the need for care planning, but the comprehensive care plan did not address this. Staff interviews confirmed that it was the facility's expectation to accurately develop care plans, but these were not completed as required.
Failure to Document and Perform Urinary Catheter Care as Ordered
Penalty
Summary
The facility failed to ensure that urinary catheter care was completed and documented for three of four residents with indwelling urinary catheters. Facility policy required daily catheter care to be documented in the electronic health record (EHR), and physician orders for the affected residents specified that catheter care was to be performed every shift. However, clinical record reviews revealed no evidence that catheter care was documented for these residents as required by both policy and physician orders. Specifically, one resident with obstructive uropathy and type 2 diabetes mellitus had an indwelling catheter in place, but there was no documentation of catheter care until a specific date several months after the order was in place. Another resident with urinary retention and cerebral palsy also had an indwelling catheter, with orders and care plans specifying catheter care every shift, but the treatment administration record did not show that this care was being completed or signed off. A third resident with urinary retention and a long-standing catheter similarly had no documentation indicating that catheter care was performed every shift as ordered. These findings were confirmed by interviews with the DON, who acknowledged the lack of documentation for all three residents.
Failure to Provide Trauma-Informed, Culturally Competent Care
Penalty
Summary
The facility failed to ensure that a resident who is a trauma survivor received trauma-informed and culturally competent care in accordance with professional standards. Clinical record review showed that the resident, who has paraplegia and depression resulting from surviving a plane crash at age 19, did not have any documentation of trauma screening in his record. Interviews with the resident confirmed his traumatic history, and further interviews with facility staff, including the DON and Nursing Home Administrator, revealed that trauma screenings had not been completed for this resident. The facility only created a policy for trauma-informed care after the deficiency was identified, and there was no evidence that trauma triggers had been assessed or addressed for this resident.
Deficient Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to store food and beverages and utilize equipment in accordance with professional standards for food service safety, as evidenced by multiple observations and staff interviews. During a kitchen tour, surveyors found a half-full bag of onions sitting directly on the floor in the walk-in cooler, an ice machine vent covered with a moderate amount of fuzzy gray debris, and several food items in refrigerators and freezers that were not labeled or dated as required by facility policy. Additionally, dry storage areas contained unlabeled and undated food items, opened packages that were not securely closed, a dented can of cherry pie filling on a rack for use, and cases of food stored directly on the floor. The three-compartment sanitation sink lacked test strips for verifying sanitation solution strength at the time of observation. Further inspection of a nourishment refrigerator in the activity room revealed dried spills on shelves and drawers, beverages in facility cups without names or dates, and a chocolate dessert labeled with a resident's name that was past the three-day discard policy. Staff interviews confirmed that nursing was responsible for labeling and dating foods in the activity room refrigerator, while dietary was responsible for cleaning it. There was also confusion among staff regarding responsibility for the refrigerator and proper food storage practices, as well as a lack of awareness about the requirement to keep food off the floor and to use only undamaged cans. Additional observations included the presence of test strips for the sanitation sink, but one container was missing the results grid and expiration date, making it unusable for accurate testing. A case of canned gravy was also found sitting directly on the floor in the walk-in cooler. The NHA confirmed expectations for proper labeling, dating, and storage of foods, as well as the need for valid test strips, but could not verify the accuracy of previous sanitation testing due to missing documentation.
Failure to Update and Revise Resident Care Plans
Penalty
Summary
The facility failed to review and revise the care plans for two residents as required by both facility policy and federal regulations. For one resident with chronic kidney disease and chronic diastolic congestive heart failure, there were conflicting fluid restriction interventions documented in the care plan: one section listed a restriction of 1500 ml per 24 hours, while another listed 2000 ml per 24 hours. The care plan was not updated to reflect the most current physician order for fluid restriction, and the Director of Nursing confirmed that the care plan should have been revised when the fluid restriction order changed. For another resident with Parkinson's Disease, a history of repeated falls, and lumbar compression fractures, the care plan did not include a new fracture sustained after a recent fall and subsequent hospital transfer. Additionally, the care plan still included an intervention for a urinary tract infection (UTI) that was no longer current, as there was no documentation of ongoing treatment for a UTI. The Nursing Home Administrator confirmed that the new fracture was not added to the care plan and that the resolved UTI was not promptly removed.
Care Plan Lacked Required ADL Assistance Details
Penalty
Summary
The facility failed to ensure that the care plan for one resident was properly reviewed and revised as required. Clinical record review showed that the resident had diagnoses including atrial fibrillation and congestive heart failure. The resident's comprehensive care plan included focus areas for activities of daily living (ADLs) and falls, but did not specify the level of assistance required for ADL care. During an interview, the Director of Nursing confirmed that the type and level of assistance should have been indicated on the care plan.
Facility Fails to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required minimum staffing ratios for nurse aides (NAs) across multiple shifts from November 29 to December 5, 2024. Specifically, the facility did not provide the mandated number of NAs per resident during the day, evening, and night shifts. For instance, on November 29, 2024, the day shift had 79 residents but only 7.13 NAs, falling short of the required 7.9 NAs. Similar deficiencies were noted on subsequent days, with the number of NAs consistently below the required ratios for the resident census. The deficiency was identified through a review of staffing documents and staff interviews, which revealed that the facility did not comply with the staffing regulations effective July 1, 2024. The facility's failure to maintain the required staffing levels was consistent across several days and shifts, indicating a systemic issue in meeting the regulatory requirements for nurse aide staffing ratios.
Plan Of Correction
Staffing ratios cannot be corrected for dates as this is a past occurrence and the facility needs to hire more CNA's to meet the staffing ratio regulation. Calculations of shift CNA ratios will be completed and reviewed daily for accuracy by the scheduler, ADON and/or DON while the facility is recruiting more CNA staff to meet the ratios. The facility continues to put effort into recruitment and retention of CNA staff members. This includes pickup shift bonuses for all staff pickups effective 6/29/24 and continues to present, new hire incentives ongoing, such as sign-on bonus and facility has revised and rolled out new wage scales for CNA staff effective November 2024. The facility has also initiated recruitment bonuses to staff that contribute to the recruitment of new CNA hires effective in November 2024. On 7/28/24, the facility initiated 8hr CNA shifts, from 7.5hr CNA shifts. The facility initiated utilizing licensed nursing staff, including floor and management staff to fill CNA holes. An additional Emergency Staffing Nursing Manager on Duty was initiated for weekend coverage, every weekend. Staff have been reeducated on staffing ratios and potential for mandation due to call off coverage at nurse staff meetings held on July 24th and July 25th, as well as additional meetings with RN supervisors on 11/20/24. The facility has hired individuals to attend CNA training in January and the facility plans to continue to hold CNA training classes on campus until CNA staffing needs are met. CNA ratios will be audited by the scheduler and DON/Designee daily for 11 weeks or until substantial compliance is achieved. The results will be reported monthly at the facility's Quality Assurance Performance Improvement Meeting.
Failure to Meet LPN Staffing Ratios
Penalty
Summary
The facility failed to meet Pennsylvania State minimum nursing staffing regulations for Licensed Practical Nurses (LPNs) across multiple shifts from November 29, 2024, to December 5, 2024. Specifically, the facility did not maintain the required LPN-to-resident ratios on several occasions. On the day shift of November 29, 2024, there were 79 residents with only 3.0 LPNs, falling short of the required 3.16 LPNs. Similar deficiencies were noted on the night shift of November 30, 2024, with 79 residents and only 1.0 LPNs, not meeting the required 1.98 LPNs. These staffing shortfalls continued on various shifts throughout the week, including both day and night shifts on December 1, 2024, and evening and night shifts on December 3, 2024. The report further details that on December 4, 2024, the facility had 82 residents with only 2.66 LPNs on the day shift, not meeting the required 3.28 LPNs, and similar deficiencies were observed on the evening shift. On December 5, 2024, both day and night shifts were understaffed, with 82 residents and only 2.66 LPNs during the day and 81 residents with 2.00 LPNs at night, failing to meet the required ratios. These findings were confirmed during an interview with the Nursing Home Administrator and Director of Nursing on December 9, 2024, where it was acknowledged that the facility did not comply with the state staffing regulations.
Plan Of Correction
Staffing ratios cannot be corrected for dates as this is past occurrence and facility will need to hire more LPN staffing to meet staffing ratio regulation. Calculations of shift LPN ratios will be completed and reviewed daily for accuracy by the scheduler and DON to assure enough LPN coverage is scheduled to meet the ratios. The facility continues to put forth efforts to recruit and retain new nursing staff members. This includes: pickup shift bonuses for all staff pickups effective 6/29/24 and continue at this time, new hire incentives ongoing, such as sign-on bonus, increased LPN wage matrix effective 7/9/24, and tuition assistance and reimbursement programs offered by facility for nursing degrees. Staff have been re-educated on staffing ratios and potential for mandating due to call off coverage at nurse staffing meetings held on July 24th and 25th as well as additional meetings with RN supervisors on 11/20/24. Additional Emergency Staffing Nursing Manager on Duty initiated for weekend coverage, every weekend during staffing shortages. Schedules and LPN ratios will be audited daily by the scheduler and DON/designee for 11 weeks or until substantial compliance is achieved. The results will be reported monthly at the facilities Quality Assurance Performance Improvement Meeting.
Failure to Meet Minimum Nursing Staffing Requirements
Penalty
Summary
The facility failed to meet the Pennsylvania State minimum nursing staffing regulations, which require a minimum of 3.2 hours of direct resident care per resident in each 24-hour period. A review of staffing documents for the week of November 29, 2024, through December 5, 2024, revealed that the facility provided less than the required hours on six out of seven days. Specifically, the facility provided 3.10 hours on November 29, 2.81 hours on November 30, 2.57 hours on December 1, 2.85 hours on December 2, 2.56 hours on December 3, and 2.90 hours on December 5. During an interview on December 9, 2024, the Nursing Home Administrator and Director of Nursing acknowledged that the staffing levels did not meet the state requirements.
Plan Of Correction
Total staff hours cannot be corrected for dates. Calculations of PPD will be completed and reviewed daily for accuracy by the scheduler and DON to assure enough staff hours per patient day is scheduled to cover PPD of 3.2. Pickup shift bonuses for all staff pickups effective 6/29/24 and continue at this time, new hire incentives ongoing, such as sign-on bonus, LPN and RN wage scale as well as waging analysis and increased starting wages for CNA, LPN and RN staff as well as current staff. Facility will continue to offer facility CNA training site. Effective on 7/28/24 facility had all CNA'S move to an 8 hours work day increasing from 7.5 hours. Education will continue staffing ratios and potential for mandating due to call off coverage. Nurse staff meetings held on July 24th and 25th reviewing this as well as additional meetings with RN supervisors on 11/20/24. Schedules and CNA ratios will be audited daily by the scheduler and DON/designee for 11 weeks or until substantial compliance is achieved. The results of the findings will be reported monthly at the facility Quality Assurance Performance Improvement meeting.
Failure to Maintain Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and home-like environment for two residents. Observations of one resident's room revealed a pedestal fan with gray fuzzy debris on the blades, which was blowing from the front of the fan. Similarly, another resident's room had a small fan on a nightstand with gray fuzzy debris on the blades, also blowing from the front of the fan. The Nursing Home Administrator confirmed that the facility did not have a policy for cleaning fans and that housekeeping staff were only wiping down the outside of the fans without disassembling them to clean the blades of debris.
Failure to Implement Pressure Ulcer Care Interventions
Penalty
Summary
The facility failed to provide adequate care and services to promote healing and prevent the worsening of pressure ulcers for a resident with a stage 4 pressure ulcer on the right heel. The resident's clinical record indicated diagnoses of stage 4 pressure ulcer, type 2 diabetes mellitus with foot ulcer, and hypertension. Physician orders were in place for the resident to have heels elevated when in bed and to wear an offloading boot on the right lower extremity. Additionally, wound consultation notes recommended floating the heels while in bed, limiting sitting to 60 minutes, using a bed cradle to keep the weight of blankets off the toes, and elevating the legs. Observations on multiple occasions revealed that the resident's feet were exposed and laying directly on the mattress, indicating non-compliance with the physician's orders and wound care recommendations. Interviews with the Director of Nursing (DON) and the Nursing Home Administrator confirmed the lack of implementation of the recommended interventions, such as the bed cradle and offloading boot. The DON could not find any documentation indicating that the facility physician disagreed with the wound physician's recommendations, and there was no documentation of the resident refusing the prescribed interventions.
Failure to Document and Apply Prescribed Palm Protector
Penalty
Summary
The facility failed to provide appropriate care for a resident with limited mobility, specifically in maintaining or improving their range of motion. Resident 54, who has diagnoses including dementia and muscle weakness, was observed without the prescribed palm protector on multiple occasions. The palm protector was ordered to address a contracture in the resident's right hand, but it was found lying on a chair in the resident's room during an activity and again absent while the resident was seated in the common area. A review of the resident's Treatment Administration Record for May, June, and July 2024 showed no documentation of the application of the palm protector. The Nursing Home Administrator confirmed that there was no documentation available for the application or usage of the palm protector since it was ordered. The facility considers a palm protector to be a splint, and the NHA acknowledged that staff should have been documenting its application or any refusal by the resident.
Failure to Monitor Resident's Fluid Restriction
Penalty
Summary
The facility failed to effectively monitor and manage the hydration status of a resident with a fluid restriction order. The resident, who was admitted with diagnoses including congestive heart failure and an acute upper respiratory infection, had a physician's order for a fluid restriction of 2000 ml per day. However, the resident's care plan did not include this fluid restriction, nor was there a breakdown of fluids provided by dietary and nursing staff each shift. Observations and record reviews revealed discrepancies in fluid documentation, with the resident receiving more fluids than prescribed. Interviews with staff highlighted a lack of awareness and understanding of the resident's fluid restriction. A nurse aide, unaware of the restriction, documented fluids provided by dietary but not additional fluids. The Director of Nursing acknowledged that new employees might not be informed about specific restrictions. The surveyor raised concerns about the facility's overall management and monitoring of the resident's fluid restriction, but no further information was provided by the facility.
Deficiencies in IV Medication Administration
Penalty
Summary
The facility failed to ensure proper administration of intravenous (IV) therapy for two residents, leading to deficiencies in medication management. Resident 64, diagnosed with osteomyelitis and discitis, had an empty Meropenem IV medication bag hanging on the IV pole, with the tubing not dated and improperly capped. The Director of Nursing (DON) confirmed that the IV tubing should have been dated and capped, indicating a lapse in following the facility's medication administration guidelines. Resident 326, diagnosed with bacteremia and excoriation disorder, was observed with an IV medication bag labeled for another resident, indicating a medication error. The IV tubing was not dated, and the tubing end was improperly connected to itself. Interviews with staff revealed that the night shift registered nurse was responsible for hanging IV medications, and the Registered Nurse Supervisor acknowledged the error, removing the incorrect medication bag and tubing. The DON stated that it was the facility's expectation for residents to be free from medication errors and for IV tubing to be properly dated and capped.
Failure to Maintain Sanitary Oxygen Equipment
Penalty
Summary
The facility failed to maintain oxygen equipment in a sanitary manner and provide respiratory care consistent with professional standards for a resident. The facility's policy required oxygen tubing to be dated and changed bi-weekly by the 11-7 Licensed Staff. However, observations revealed that the resident's oxygen tubing was dated June 2, 2024, and had not been changed by July 1, 2024, and July 2, 2024. The resident had a clinical history that included Covid-19, shortness of breath, and muscle weakness, and had tested positive for Covid-19 on June 20, 2024. During an interview, the DON acknowledged that the tubing had not been changed bi-weekly as required, citing the resident's refusal when awakened as the reason. The DON also noted that staff did not reapproach the resident at a later time or document the refusals. The tubing was eventually changed on July 2, 2024, but was incorrectly dated as July 1, 2024. The DON expressed an expectation for staff to reapproach the resident, document refusals, and ensure correct dating of the tubing.
Infection Control Deficiencies in Isolation Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by deficiencies in managing isolation precautions for two residents. Resident 52, diagnosed with herpes zoster (shingles), was initially placed on contact precautions with an order for Acyclovir. However, the contact precautions were not maintained consistently. Observations revealed that the isolation sign was removed from the resident's door, and there were no nurse's notes documenting the resident's condition between June 28 and July 2, despite ongoing treatment for shingles. The Director of Nursing confirmed that precautions should have continued or that the physician should have been consulted for further guidance. Resident 326, diagnosed with bacteremia and excoriation disorder, was ordered to be on enhanced barrier precautions (EBP) due to a midline IV. However, observations on two separate occasions showed a lack of EBP signage and PPE caddy outside the resident's room. The facility's policy required such measures to be in place for residents with chronic wounds or indwelling medical devices during high-contact care activities. Interviews with the Nursing Home Administrator and Director of Nursing confirmed that EBP should have been implemented as per the physician's order. These deficiencies indicate a failure to adhere to the facility's infection control policies and CDC guidelines, which are designed to prevent the transmission of infectious agents. The lack of consistent implementation of contact precautions and EBP for residents with specific medical conditions and treatments highlights gaps in the facility's infection prevention and control program.
Latest citations in Pennsylvania
Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
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