Patriot Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Somerset, Pennsylvania.
- Location
- 495 West Patriot Street, Somerset, Pennsylvania 15501
- CMS Provider Number
- 395840
- Inspections on file
- 26
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Patriot Village during CMS and state inspections, most recent first.
The facility failed to update care plans for several residents, leading to discrepancies between documented care needs and actual conditions. A resident's care plan was not updated to reflect the cessation of a restorative nursing program, another's care plan did not reflect the discontinuation of an anti-anxiety medication, and a third resident's care plan was not revised after a catheter was placed. Additionally, a resident's care plan was not updated to reflect the absence of a dialysis access site requiring specific checks, and another resident's care plan did not reflect the current transfer status as per physician's orders.
The facility failed to follow physician's orders and document care for several residents. A resident did not have their blood pressure and heart rate checked before receiving Hydralazine. Another resident received Oxycodone without proper documentation and missed wound care treatments. Additionally, a resident's heart rate was not checked before administering Lopressor, and another resident did not receive bowel medications as ordered. These deficiencies were confirmed by the DON and Nursing Home Administrator.
The facility failed to provide palatable and appropriately warm meals to residents, as evidenced by resident complaints and a test tray evaluation. Residents reported cold and bland food, with a lack of variety. Observations showed the use of a non-insulated cart for meal delivery, contributing to temperature issues. Deviations from recipes and the absence of salt in meals due to cardiac diets were noted by the food service director.
The facility failed to follow professional standards for food safety, with improper thawing of chicken in a sink without running water and incorrect storage of an ice scoop in a cooler. The Food Service Director admitted to not following the thawing policy, and the DON confirmed the ice scoop should not have been in the cooler.
A facility failed to maintain dignity for a resident with an indwelling urinary catheter. The resident's care plan required the catheter drainage bag to be covered and positioned away from the door. Observations showed the bag was uncovered and visible, confirmed by staff interviews. This violated the resident's rights under 28 Pa. Code 201.29(c).
The facility did not ensure that two residents were given the opportunity to develop an advance directive, as required by policy. There was no documentation in the residents' records indicating that they or their representatives were offered assistance or made decisions regarding advance directives. This was confirmed by the Nursing Home Administrator.
The facility failed to provide a homelike environment for three residents who were observed using recliners with heavily shredded and torn leather coverings. Interviews confirmed that the recliners should have had slipcovers, but difficulties in finding suitable ones were noted. The Nursing Home Administrator acknowledged that the condition of the recliners was not homelike and should not be used by residents.
The facility failed to provide written notice of emergency hospital transfers to the State LTC Ombudsman, residents, and their responsible parties for two residents. One resident was transferred due to symptoms like sweating and hypoxia, while another was transferred due to low blood pressure and clammy skin. The DON confirmed the lack of documentation for these notices.
The facility failed to accurately complete MDS assessments for two residents. One resident's assessment incorrectly indicated no injection was received, despite records showing administration of Tubersol Solution. Another resident's assessment inaccurately recorded no antianxiety medication received, although Buspirone was administered as prescribed. These errors were confirmed by the DON.
The facility failed to clarify physician's orders for two residents with end-stage renal disease. One resident had an unnecessary order for hemostats, while another had unclear instructions for administering Midodrine for hypotension on dialysis days. The lack of clarification led to confusion about the proper care and medication administration for these residents.
Two residents did not receive physician-ordered pressure ulcer treatments, including the absence of a bariatric air mattress for one resident and missed wound care treatments for both. The facility failed to document the administration of these treatments, as confirmed by staff interviews.
A facility failed to provide a restorative nursing program as ordered for a resident with cognitive impairment and functional limitations in ROM. The resident was care planned to receive daily PROM exercises to the lower extremities, but documentation showed multiple instances of non-compliance. The DON confirmed the lack of evidence for the completion of these exercises on specified dates.
A resident with an indwelling urinary catheter was observed with the catheter drainage bag and tubing lying on the floor, contrary to the care plan instructions. Interviews with an LPN and the DON confirmed that the catheter bag and tubing should not have been on the floor.
A resident with chronic obstructive pulmonary disease and heart failure was observed receiving oxygen at a higher flow rate than prescribed. Staff interviews confirmed the discrepancy, and it was suggested that the resident might have adjusted the flow rate herself, although this was not documented in her care plan.
A facility failed to document the administration of Oxycodone HCL for a resident with mild cognitive impairment and pain, despite the medication being signed out for use. The Director of Nursing confirmed the absence of documentation, indicating non-compliance with the facility's medication administration policy.
The facility exceeded the acceptable medication administration error rate, with errors involving two residents. An LPN administered Hydralazine without checking vital signs, and another LPN gave Lispro Insulin too early before a meal. The DON confirmed the errors.
The facility failed to properly label and store medications, as evidenced by an undated bottle of Systane eye drops and expired IV fluid bags. Additionally, two residents had their routine Tramadol doses incorrectly signed out from the as-needed medication card, as confirmed by the Nursing Home Administrator.
A facility failed to provide a resident with adaptive eating equipment as ordered by a physician. The resident, who was cognitively intact and required set-up assistance, was observed using regular utensils instead of the prescribed built-up utensils during a meal. Interviews with staff confirmed the oversight.
The facility's QAPI committee failed to address recurring deficiencies effectively, as evidenced by repeated issues in MDS assessments, care plan timing, quality of care, medication management, and food services. Despite previous plans of correction, the same deficiencies persisted, indicating ineffective implementation of corrective actions.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with an indwelling catheter and surgical wounds, as required by CMS and CDC guidelines. Observations revealed no signage indicating EBP on or outside the resident's room, despite the resident's documented need for such precautions. The Director of Nursing confirmed the oversight during an interview.
The facility failed to meet the required NA-to-resident staffing ratios, with insufficient NAs during the day and night shifts on multiple occasions. The deficiency was confirmed through a review of schedules and an interview with the Nursing Home Administrator, who acknowledged the shortfall.
The facility did not meet the required LPN-to-resident staffing ratios during overnight shifts on three occasions. With resident censuses requiring 1.95 and 1.93 LPNs, the facility provided fewer LPNs than needed, with no additional higher-level staff to compensate. The Nursing Home Administrator confirmed these deficiencies.
The facility did not conduct monthly exit sign inspections throughout 2024, as required by NFPA 101 standards. This deficiency was confirmed during a document review and interview with the Facility Administrator, Maintenance Director, and staff, revealing a lack of documentation for these inspections, which are essential for safety compliance.
The facility did not maintain its automatic sprinkler system according to NFPA 25 standards. It failed to provide documentation for inspections after a certain date, did not recalibrate expired gauges, and neglected a required five-year internal pipe inspection. These issues were confirmed by the Facility Administrator and Maintenance Director.
The facility did not conduct the required annual fire door assembly inspection, impacting the entire facility. During a review, it was found that there was no documentation to confirm the completion of this inspection. This was confirmed by the Facility Administrator and Director of Maintenance during an interview.
The facility failed to maintain corridor doors as required, with a door on the third floor not latching properly, affecting one of fifteen smoke compartments. This was confirmed by the Facility Administrator and Maintenance Director.
The facility did not conduct one of the twelve required fire drills, missing a third shift drill in the first quarter of 2024. Documentation review and interviews confirmed the absence of documentation for this drill, impacting the entire facility.
A resident with diabetes did not receive insulin as per physician's orders, resulting in significant medication errors. The facility's policy required holding insulin if blood sugar was below 150 mg/dL, but this was not followed on multiple occasions, as confirmed by the DON.
The facility failed to store an unopened Insulin Lispro Pen Injector in the refrigerator as required and did not ensure that controlled refrigerated medications were stored in a permanently-affixed container. These deficiencies were confirmed by LPNs during observations.
The facility failed to store food under sanitary conditions, ensure dietary staff wore appropriate hair coverings, and maintain a clean microwave. Ice accumulation was found in the walk-in freezer, a dietary aide was observed without a beard net, and a microwave in the first-floor pantry was dirty and rusty.
The facility failed to complete accurate MDS assessments for two residents. One resident's assessment incorrectly indicated the use of a limb restraint, while another resident's assessment failed to document multiple instances of aggressive behavior.
The facility failed to ensure that a resident's baseline care plan included necessary information for antipsychotic medication and colostomy care within 48 hours of admission. This was confirmed by the DON during a review of policies, clinical records, and staff interviews.
The facility failed to update and individualize care plans for two residents. One resident's care plan was not updated to reflect the discontinuation of an anticoagulant, and another resident's care plan did not reflect the use of a prescribed bariatric alternating air mattress. The deficiencies were confirmed by the Director of Nursing and the Registered Nurse Assessment Coordinator.
The facility failed to complete physician-ordered treatments for a resident with scabs on his toes. Despite orders to apply skin prep daily, there was no documented evidence of this treatment being administered over several days, as confirmed by the DON.
The facility failed to maintain accountability for controlled medications for a resident, as there was no documented evidence that signed-out doses of Norco were administered on specific dates. The Director of Nursing confirmed the lack of documentation, violating the facility's policy and state regulations.
The facility failed to ensure non-pharmacological interventions were attempted before administering anti-anxiety medication to a resident with cognitive impairment and anxiety. Multiple instances of Ativan administration were recorded without documented evidence of prior non-medication interventions. The DON confirmed the lack of documentation.
The facility failed to maintain accurate clinical records for two residents. One resident did not have documented evidence of prescribed treatments for a pressure ulcer, and another resident's records incorrectly indicated the use of a medical boot that had been disposed of.
The facility's QAPI committee failed to correct recurring deficiencies related to inaccurate MDS assessments, ineffective care plan revisions, not following physician's orders, improper food storage and preparation, and incomplete clinical records. These issues were identified in both the current and previous surveys, indicating ineffective corrective actions.
Failure to Update Resident Care Plans
Penalty
Summary
The facility failed to ensure that residents' care plans were updated or revised to reflect their specific care needs. For Resident 46, the care plan was not updated to indicate that the active range of motion restorative nursing program for her bilateral lower extremities was stopped after a decline in her lower extremity strength and mobility. This was confirmed by the Director of Nursing during an interview. Resident 54's care plan was not revised to reflect the discontinuation of her anti-anxiety medication, despite the Medication Administration Record and physician's orders indicating that the medication was no longer prescribed. The Director of Nursing confirmed this oversight during an interview. Similarly, Resident 65's care plan was not updated to reflect the placement of a catheter, which rendered the existing care plan regarding bladder incontinence inapplicable. For Resident 73, the care plan was not updated to reflect that the resident only had a med port and did not require staff to check for a bruit and thrill, as there was no other dialysis access site. This was confirmed by a Licensed Practical Nurse and the Director of Nursing. Additionally, Resident 77's care plan was not revised to reflect her current transfer status, which required only one assist with a front-wheeled walker, as per the physician's orders. This discrepancy was also confirmed by the Director of Nursing.
Plan Of Correction
1. The plan of care for R46, R54, R65, R73, and R77 will be reviewed and corrected. 2. The Director of Nursing or designee will audit the last comprehensive care plan completed for all current residents. The comprehensive care plan will be updated with all issues identified. 3. The Director of Nursing or designee will re-educate the interdisciplinary team on the comprehensive care plan requirements for completion and accuracy in accordance with the Resident Assessment Instrument, RAI, manual and federal regulation. 4. The Director of Nursing or designee will audit all newly completed comprehensive care plans for accuracy. The audits will be conducted weekly x4 and monthly x2. All findings will be submitted to the Quality Assurance Committee.
Failure to Follow Physician's Orders and Document Care
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards of practice for several residents. For Resident 27, the staff did not document obtaining the resident's blood pressure and heart rate before administering Hydralazine, a medication for hypertension, as required by the physician's orders. This oversight was confirmed by the Director of Nursing during an interview. Resident 50 experienced multiple deficiencies in care. The resident was administered Oxycodone HCL for pain on several occasions without the medication being signed out on the controlled medication record. Additionally, the resident did not receive prescribed wound care treatments on specific dates, as confirmed by the Nursing Home Administrator. These lapses indicate a failure to adhere to physician's orders and maintain accurate medication records. For Resident 77, there was no documented evidence that the resident's heart rate was checked before administering Lopressor, a medication for hypertension, as required by the physician's orders. Similarly, Resident 69 did not receive bowel medications according to the physician's bowel protocol, resulting in a lack of documented bowel movements over several days. These deficiencies were confirmed by the Director of Nursing, highlighting a pattern of non-compliance with physician's orders across multiple residents.
Plan Of Correction
1. The identified concerns for R27 and R77 were immediately corrected. The identified concern for R50 and R69 cannot be corrected. 2. The Director of Nursing or designee will audit current resident's antihypertensive medications for correct administration parameters if indicated in the physician order. The Director of Nursing or designee will audit current treatment administration records (TAR) for wound documentation of completion. The Director of Nursing or designee will audit current residents to ensure current bowel movement documentation accuracy. 3. The Director of Nursing or designee will re-educate all licensed professional nurses on the documentation of administration parameters for antihypertensive medications. The Director of Nursing or designee will re-educate all licensed professionals on the procedure for completion and documentation of wound care on the treatment administration record (TAR). The Director of Nursing or designee will re-educate all nursing staff on bowel movement documentation and start of bowel protocol if indicated. 4. The Director of Nursing or designee will audit 25% per unit of all parameters for antihypertensive medications for accuracy of administration. The Director of Nursing or designee will audit 25% of wound care treatment documentation on the treatment administration record (TAR). The Director of Nursing or designee will audit 10% of each unit for correct initiation of bowel protocol if indicated. The audits will be conducted weekly x4 and monthly x2. All findings will be submitted to the Quality Assurance Committee.
Deficiency in Food Palatability and Temperature
Penalty
Summary
The facility failed to serve food items that were palatable to the residents, as determined through resident interviews and a meal test tray. Multiple residents reported that their meals were not warm enough and lacked taste. Specifically, Resident 73 mentioned that the food was not as warm as preferred and lacked flavor, while Resident 74 and Resident 77 described the food as cold and unappetizing. A group of residents also expressed ongoing dissatisfaction with the food, citing issues such as cold and dry meals, and a lack of variety, with frequent servings of pork and chicken. Resident 45, while eating sweet and sour pork, noted the absence of the expected sweet and sour taste. Observations in the kitchen revealed that the facility used a non-insulated cart for overflow trays, which may have contributed to the temperature issues. A test tray removed from the open cart showed that the scalloped chicken with mushrooms was at 140 degrees Fahrenheit and bland, while the sweet and sour pork was at 122 degrees Fahrenheit, cool, and also bland. The food service director and dietician explained that salt was not added to the food due to cardiac diets, and salt packets were provided on trays instead. The food service director also noted deviations from recipes, such as using only pineapple juice instead of chunks and not visibly including green peppers or onions in the pork. The chicken lacked visible breadcrumbs and parmesan cheese, as called for in the recipe.
Plan Of Correction
1. The identified concern for R45 was immediately corrected. 2. Dietary manager and registered dietician will continue to monitor by completing monthly food committee meetings as well as completing random test tray audits. 3. Staff will be in-serviced on the importance of serving food and drinks that are palatable, attractive, and at safe and appetizing temperatures. Nursing staff will also be educated on serving meal trays promptly when trays are received on the unit to maintain adequate temperature of food. 4. Dietary manager and registered dietician will complete test trays daily for 2 weeks, followed by 4 trays a week for 2 weeks. Then weekly times two months. All findings will be submitted to the Quality Assurance Committee.
Improper Food Thawing and Ice Scoop Storage
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by improper thawing of frozen chicken. Observations on January 7, 2025, revealed a large bag of chicken in a sealed plastic bag submerged in water in the kitchen sink without running water, contrary to the facility's policy that requires running cold water to thaw frozen foods. The Food Service Director admitted that the chicken was placed in cold water to expedite meal preparation, acknowledging that the process did not comply with the policy. Further interviews revealed uncertainty about whether the water temperature was monitored, and the director could not confirm adherence to the policy. Additionally, the facility did not maintain proper storage of ice scoops, as observed on January 8, 2025. An ice scoop was found lying inside the ice cooler on the Third-floor South side nourishment station, which was confirmed by a Nurse Aide and the Director of Nursing as inappropriate. The cooler lacked a fixed container for the scoop, and a separate plastic container with another scoop was found under the cart. The Nurse Aide was unsure why there were two scoops, indicating a lack of clarity in procedures for ice scoop storage.
Plan Of Correction
1. The ice scoop was immediately removed from the chest. The thawing process of the chicken cannot be corrected. 2. The Dietary Manager or designee will audit all ice chests to ensure that the ice scoops are stored correctly. The Dietary Manager or designee will audit thawing processes for chicken for proper procedure. 3. The Dietary Manager or designee will re-educate all nursing staff and dietary aides on proper storage of ice scoops. The Dietary Manager or designee will re-educate all dietary staff on the proper thawing technique for frozen chicken. 4. The Dietary Manager or designee will perform ice chest audits for proper storage of scoops weekly x 4 and monthly x 2. The Dietary Manager or designee will perform thawing of food item audits weekly x 4 and monthly x 2. Findings will be reported to the Quality Assurance Committee.
Failure to Maintain Resident Dignity with Indwelling Catheter
Penalty
Summary
The facility failed to maintain dignity for Resident 34, who had an indwelling urinary catheter. The resident's quarterly Minimum Data Set (MDS) assessment indicated that the resident was capable of understanding and being understood by others and had an indwelling urinary catheter. The care plan for the resident specified that the urinary drainage bag should be covered with a dignity cover and positioned below the level of the bladder and away from the entrance room door. However, observations on January 7, 2025, revealed that the resident's urinary catheter drainage bag was hooked to the bedframe on the door side of the bed, uncovered, with yellow urine visible. Interviews with staff confirmed the deficiency. A Licensed Practical Nurse (LPN) confirmed that the resident's catheter bag was not covered and was positioned on the door side of the bed. The Director of Nursing (DON) also confirmed that the catheter drainage bag should have been covered with a dignity cover. This failure to adhere to the care plan and maintain the resident's dignity was a violation of the resident's rights as outlined in 28 Pa. Code 201.29(c).
Plan Of Correction
This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because Patriot Village OPCO LLC agrees with the allegations and citations listed on the statement of deficiencies. Patriot Village OPCO LLC maintains that the alleged deficiencies do not, individually and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as Patriot Village OPCO LLC's written credible allegation of compliance. By submitting this plan of correction, Patriot Village OPCO LLC does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Patriot Village OPCO LLC reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding. 1. The identified concern for R34 was immediately corrected. 2. The Director of Nursing or designee will audit indwelling urinary catheter bags for an appropriate privacy covering, positioning of the catheter bag and tubing below the level of the bladder. 3. The Director of Nursing or designee will re-educate nursing staff on having an appropriate privacy cover of urinary catheter bags and positioning of the catheter bag and tubing below the level of the bladder. 4. The Director of Nursing or designee will audit residents with indwelling urinary catheter bags for the appropriate privacy covering and positioning of the catheter bag and tubing below the level of the bladder. The audits will be conducted weekly x4 and monthly x2. All findings will be submitted to the Quality Assurance Committee.
Failure to Offer Advance Directive Assistance
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were given the opportunity to develop an advance directive, as required by their policy. This deficiency was identified for two residents during a review of facility policies, clinical records, and staff interviews. The facility's policy, dated August 28, 2024, mandates that upon admission, the social services director or designee should inquire about the existence of any written advance directive and provide information on the right to refuse or accept medical treatment and to formulate an advance directive. If no advance directive exists, the facility staff should offer assistance in establishing one, and document the offer and the resident's decision in the medical record. For Resident 10, who was cognitively impaired and dependent on care, and Resident 46, who was cognitively intact but required assistance for care needs, there was no documented evidence in their clinical records that they or their representatives were given the opportunity to develop an advance directive. Additionally, there was no documentation of their decisions to accept or decline assistance in formulating advance directives. This lack of documentation was confirmed during an interview with the Nursing Home Administrator.
Plan Of Correction
1. The identified concern for R10 and R46 cannot be corrected. The responsible party will be notified of the identified concern. 2. The Director of Nursing or designee will audit current resident's medical records to determine if there is an advanced directive on file. 3. The Director of Nursing or designee will re-educate admission staff on ensuring that the resident and/or resident representative are given the opportunity to develop or decline assistance in formulating an advanced directive. 4. The Director of Nursing or designee will audit new residents' medical records for the documented evidence of the resident and/or resident representative decision to accept or decline assistance in formulating advanced directives. The audits will be conducted weekly x4 and monthly x2. All findings will be submitted to the Quality Assurance Committee.
Failure to Provide Homelike Environment Due to Damaged Recliners
Penalty
Summary
The facility failed to provide a homelike environment for three residents, as observed during a survey. Resident 19 was found sitting in a facility recliner with heavily shredded and torn leather covering on the arms, seat, and back. To provide comfort, the resident used her own blanket to cover the back of the chair and expressed a preference for a brown slipcover like her roommate's recliner. Similarly, Resident 69 was observed sitting in a recliner with very heavily shredded and torn leather covering, and Resident 84's recliner also had shredded and torn leather-type covering on the arms and back. Interviews with the Maintenance Supervisor and the Nursing Home Administrator confirmed the condition of the recliners used by Residents 19, 69, and 84. The Maintenance Supervisor acknowledged that the recliners should have had slipcovers, while the Nursing Home Administrator admitted that most recliners have brown slipcovers, but there have been difficulties in finding more slipcovers that fit. The Administrator also confirmed that the torn and shredded recliners are not homelike and should not be used by the residents, indicating a failure to maintain a safe, clean, comfortable, and homelike environment as required by resident rights and administrative responsibilities.
Plan Of Correction
1. The identified concern for R19, R69, and R84 will be reviewed and corrected. 2. The Director of Nursing or designee will audit current recliners to determine the need for a slipcover. Chairs that are in bad shape will be discarded and replaced. 3. The Director of Nursing or designee will re-educate staff on the process of utilizing a slipcover, if needed, for a recliner. 4. The Director of Nursing or designee will audit recliners for usage of a slipcover if needed. The audits will be conducted weekly x4 and monthly x2. All findings will be submitted to the Quality Assurance Committee.
Failure to Provide Written Notice for Hospital Transfers
Penalty
Summary
The facility failed to provide a written notice regarding emergency hospital transfers to the State Long-Term Care Ombudsman, the residents, and their responsible parties for two residents. Resident 61, who was cognitively intact, experienced symptoms such as sweating, slurred speech, and hypoxia, followed by vomiting brown liquid, which led to an emergency room transfer. There was no documented evidence that the required written notices were provided to the relevant parties regarding this transfer. Similarly, Resident 73, who was also able to understand and be understood, was transferred to the hospital after being found with low blood pressure, pale and clammy skin, and only responding to physical stimuli. Despite the physician's order for hospital transfer, there was no documented evidence that the required written notices were provided to the State Long-Term Care Ombudsman, the resident, or the resident's responsible party. The Director of Nursing confirmed the absence of such documentation for both residents.
Plan Of Correction
1. The identified concern for R61 and R73 cannot be corrected. 2. The Director of Nursing or designee will audit the last three months of long term hospital transfers for notification that a written notice for transfer to the hospital was provided to the State Long-Term Care Ombudsman and that a written notice was provided to the resident and the resident's responsible party regarding the reason for transfer to the hospital for long-term residents. 3. The Director of Nursing or designee will re-educate staff on the process of notification to the State Long-Term Care Ombudsman and providing a written notice to the resident and or resident's responsible party regarding the reason for transfer to the hospital for long-term residents. 4. The Director of Nursing or designee will audit the process of notification to the State Long-Term Care Ombudsman and providing a written notice to the resident and or resident's responsible party regarding the reason for transfer to the hospital for long-term residents. The audits will be conducted weekly x4 and monthly x2. All findings will be submitted to the Quality Assurance Committee.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in the documentation of their care needs. For Resident 61, the MDS assessment inaccurately indicated that the resident did not receive an injection during the seven-day assessment period, despite physician's orders and Medication Administration Records (MARs) confirming that 0.1 mL of Tubersol Solution was administered intradermally on December 3, 2024. This discrepancy was confirmed during an interview with the Director of Nursing. Similarly, the MDS assessment for Resident 74 inaccurately recorded that the resident did not receive antianxiety medication during the seven-day look-back period. However, physician's orders and MARs showed that the resident was prescribed and received 10 mg of Buspirone twice daily during this period. This error was also confirmed by the Director of Nursing. These inaccuracies in the MDS assessments indicate a failure to properly document the residents' medication administration, as required by the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual.
Plan Of Correction
1. The Minimum Data Set, MDS, for R61 and R74 have been corrected and re-submitted to Internet Quality Improvement & Evaluation System (IQUIES). 2. The Director of Nursing or designee will audit the last Minimum Data Set, MDS, for each resident to determine accuracy of assessment in section J, section O and section N. All issues identified will be corrected per the Resident Assessment Instrument, RAI, manual and resubmitted if warranted. 3. The Director of Nursing or designee will re-educate interdisciplinary team on the Resident Assessment Instrument Manual, RAI, guidance for MDS accuracy and coding criteria. 4. The Director of Nursing or designee will audit 5% of all newly completed MDS's for accuracy in section J, section O and section N. The audits will be conducted weekly x4 and monthly x2. All findings will be submitted to the Quality Assurance Committee.
Failure to Clarify Physician's Orders for Two Residents
Penalty
Summary
The facility failed to ensure that physician's orders were clarified when needed for two residents. For Resident 29, who has end-stage renal disease and receives dialysis through a fistula, there was an order for hemostats to be placed in the resident's room. However, since the resident does not have a hemodialysis catheter, the hemostats were unnecessary. Both the Registered Nurse Supervisor and the Director of Nursing confirmed that the order did not make sense and should have been clarified. For Resident 73, who also has end-stage renal disease and receives dialysis, there was an order for Midodrine to be administered as needed for hypotension on dialysis days. However, there was no documented evidence that staff obtained the resident's blood pressure to determine the need for the medication. Additionally, it was unclear whether the medication should be administered at the facility or the dialysis center. The Director of Nursing and the resident's physician confirmed that the order should have been clarified to ensure proper administration of the medication.
Plan Of Correction
1. The physician's orders for R29 and R73 have been corrected. 2. The Director of Nursing or designee will audit current physician orders for hemostats for dialysis residents for accuracy and dialysis residents that are ordered midodrine for clarification. The physician orders will be updated with any issue identified of the affected residents. 3. The Director of Nursing or designee will re-educate all licensed professionals on the facility policy and procedure for providing hemostats for dialysis residents if applicable to care and clarification of physician orders for dialysis residents. 4. The Director of Nursing or designee will audit new dialysis resident physician orders for hemostat use if applicable to care and clarification of physician orders for dialysis residents. The audits will be conducted weekly x4 and monthly x2. All findings will be submitted to the Quality Assurance Committee.
Failure to Administer Ordered Pressure Ulcer Treatments
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and preventative measures as ordered by the physician for two residents. Resident 19, who had mild cognitive impairment and multiple pressure ulcers upon admission, did not receive the prescribed treatments for various pressure areas on January 4, 2025, during the day shift. This was confirmed by interviews with the Registered Nurse Supervisor and the Director of Nursing, who acknowledged the lack of documented evidence that the treatments were administered or that the resident refused care. Resident 50, who also had mild cognitive impairment and was dependent on assistance for mobility, did not have a bariatric air mattress as ordered, following a move to a different floor. Additionally, the resident did not receive the prescribed treatment for pressure ulcers on the buttocks on two occasions in December 2024. The Director of Nursing confirmed the absence of the bariatric air mattress, and the Nursing Home Administrator confirmed the lack of documented evidence for the administration of the prescribed treatments.
Plan Of Correction
1. The medical record for R19 and R50 cannot be corrected. 2. The Director of Nursing or designee will audit current treatment administration record (TAR) for wounds and mattress orders on current residents for completion and accuracy. 3. The Director of Nursing or designee will re-educate all licensed professionals on the procedure for completion and documentation of wound care on the treatment administration record (TAR) and mattress orders. 4. The Director of Nursing or designee will audit 25% of wound care treatment documentation on the treatment administration record (TAR) and mattress orders. The audits will be conducted weekly x4 and monthly x2. All findings will be submitted to the Quality Assurance Committee.
Failure to Provide Ordered Restorative Nursing Program
Penalty
Summary
The facility failed to ensure that a restorative nursing program was provided as ordered for a resident with cognitive impairment and functional limitations in range of motion (ROM) in both upper and lower extremities. The resident, who had a history of muscle contractures and traumatic brain injury, was care planned to receive passive range of motion (PROM) exercises to the bilateral lower extremities daily. However, documentation from September 2024 through January 2025 revealed multiple instances where the PROM exercises were not completed as per the care plan. The Director of Nursing confirmed the lack of documented evidence for the completion of the PROM exercises on several specified dates. This deficiency was identified during a review of clinical records and interviews with staff, indicating a failure to adhere to the resident's care plan aimed at maintaining or improving their physical abilities.
Plan Of Correction
1. The medical record for R10 cannot be corrected. 2. The Director of Nursing or designee will audit current residents ordered passive range of motion (PROM) for documentation of completion. 3. The Director of Nursing or designee will re-educate nursing staff on the procedure for completion and documentation of passive range of motion (PROM) for the restorative nursing program (RNP). 4. The Director of Nursing or designee will audit 25% of passive range of motion (PROM) for completion and documentation of the restorative nursing program (RNP). The audits will be conducted weekly x4 and monthly x2. All findings will be submitted to the Quality Assurance Committee.
Improper Care of Indwelling Urinary Catheter
Penalty
Summary
The facility failed to ensure proper care for an indwelling urinary catheter for one resident. A quarterly Minimum Data Set (MDS) assessment indicated that the resident was able to understand and communicate and had an indwelling urinary catheter. The resident's care plan required staff to position the catheter bag and tubing below the bladder level. However, observations on January 7, 2025, revealed that the resident's catheter drainage bag and tubing were lying on the floor. Interviews with a Licensed Practical Nurse and the Director of Nursing confirmed that the catheter bag and tubing should not have been on the floor.
Plan Of Correction
1. The medical record for R34 cannot be corrected. 2. The Director of Nursing or designee will audit current residents ordered urinary catheters for positioning below the level of the bladder and tubing off the floor. 3. The Director of Nursing or designee will re-educate nursing staff on the procedure positioning of urinary catheters below the level of the bladder and tubing off the floor. 4. The Director of Nursing or designee will audit 25% of residents with urinary catheters for proper positioning of the urinary catheter and placement of the tubing. The audits will be conducted weekly x4 and monthly x2. All findings will be submitted to the Quality Assurance Committee.
Oxygen Therapy Not Administered as Ordered
Penalty
Summary
The facility failed to ensure that a resident received oxygen therapy as ordered by the physician. The resident, who was cognitively intact and had diagnoses of chronic obstructive pulmonary disease and heart failure, was observed receiving oxygen at a flow rate of 3.5 liters per minute instead of the prescribed 3.0 liters per minute. This discrepancy was noted during multiple observations over two days. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and a Registered Nurse Supervisor, confirmed the incorrect oxygen flow rate. The LPN suggested that the resident might have adjusted the oxygen flow rate herself, although this was not documented in the resident's care plan. The Director of Nursing also confirmed the discrepancy and acknowledged that the oxygen should have been set at 3 liters per minute as per the physician's order.
Plan Of Correction
1. The physician order for R29 was immediately corrected. 2. The Director of Nursing or designee will audit current physician oxygen orders to ensure oxygen is administered in accordance with the physician order. 3. The Director of Nursing or designee will re-educate nursing staff on the procedure that oxygen is administered in accordance with the physician order and documented on the medication administration record. 4. The Director of Nursing or designee will audit 25% of residents with oxygen physician orders and that the correct oxygen rate is administered. The audits will be conducted weekly x4 and monthly x2. All findings will be submitted to the Quality Assurance Committee.
Failure to Document Administration of Controlled Medications
Penalty
Summary
The facility failed to maintain accountability for controlled medications for one resident, identified as Resident 50. The facility's policy required nurses to document all medications administered on the resident's medication administration record (MAR). However, for Resident 50, there was no documented evidence that doses of Oxycodone HCL, a narcotic drug prescribed for moderate to severe pain, were administered on two specific occasions in December 2024, despite being signed out for administration. Resident 50 had mild cognitive impairment and was able to understand and communicate with others. The resident was experiencing pain and had physician's orders for Oxycodone HCL to be administered as needed. The Director of Nursing confirmed the lack of documentation for the administration of the medication on the specified dates, indicating a failure to adhere to the facility's medication administration policy.
Plan Of Correction
1. The medication administration record for R50 cannot be corrected. 2. The Director of Nursing or designee will audit current resident's controlled substance accountability records for accuracy of administration times in comparison to the medication administration record (MAR). 3. The Director of Nursing or designee will re-educate all licensed professional nurses on the facility policy and procedure for administration of controlled substances. 4. The Director of Nursing or designee will audit 25% per unit of all administered controlled substances for accurate documentation at the time of administration. The audits will be conducted weekly x4 and monthly x2. All findings will be submitted to the Quality Assurance Committee.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication administration error rate of less than five percent, resulting in a rate of 6.25 percent. During medication administration observations, two errors were identified out of 36 opportunities. One error involved a Licensed Practical Nurse (LPN) administering Hydralazine to a resident without first checking the resident's blood pressure and pulse, as required by the physician's orders. The LPN confirmed that she did not obtain these vital signs prior to administration, and there was no documentation in the resident's clinical record to indicate that the necessary checks were performed. Another error involved the administration of Lispro Insulin to a resident. The LPN administered six units of Lispro Insulin based on the resident's blood glucose reading, but the insulin was given approximately 41 minutes before the resident received her meal, contrary to the manufacturer's instructions that it should be administered 15 minutes before or immediately after a meal. The Director of Nursing confirmed that the insulin should have been administered according to the manufacturer's guidelines.
Plan Of Correction
1. The medication administration for R54 cannot be corrected. The parameters for antihypertensive medication for R54 was immediately corrected. 2. The Director of Nursing or designee will audit current resident's insulin medication administration record (MAR) for accuracy of timing of insulin administration and antihypertensive medications for correct administration parameters if indicated in the physician order. 3. The Director of Nursing or designee will re-educate all licensed professional nurses on the facility policy and procedure for timing of administration of insulin and administration parameters for antihypertensive medications. 4. The Director of Nursing or designee will audit 25% per unit of all timing of insulin administration and parameters for antihypertensive medications. The audits will be conducted weekly x4 and monthly x2. All findings will be submitted to the Quality Assurance Committee.
Medication Labeling and Documentation Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication labeling and storage protocols, as evidenced by the presence of an undated 10 ml bottle of Systane eye drops in the first-floor medication cart. This oversight was confirmed by an LPN, who acknowledged that the eye drops should have been labeled with the date they were opened. Additionally, the facility did not discard expired medical supplies, as observed in the first-floor medication room, where 12 expired IV fluid bags were found. These included various bags of normal saline solution and dextrose solutions, which were confirmed to be expired by the same LPN, who mistakenly believed that the overnight staff was responsible for checking outdated supplies. Furthermore, the facility failed to properly document the administration of narcotic medications for two residents. Both residents, who were cognitively intact and experienced frequent pain, had physician's orders for Tramadol, a narcotic pain reliever, to be administered routinely and as needed. However, the controlled drug accountability records revealed that staff signed out routine doses of Tramadol from the as-needed medication card, which was confirmed by the Nursing Home Administrator. This mismanagement of narcotic medication documentation was identified for both residents, indicating a lapse in following proper procedures for controlled substances.
Plan Of Correction
1. The identified concern for the eye drop solution and intravenous, IV, fluids was immediately corrected. The identified concern R37 and R69 cannot be corrected. 2. The Director of Nursing or designee will audit all current medication rooms for outdated IV fluids and all medication carts for proper labeling and storage of eye drops. The Director of Nursing or designee will audit residents controlled opioid medication cards for accuracy of administration from the correct card. 3. The Director of Nursing or designee will re-educate all licensed professional nurses on the facility policy and procedure for disposing of expired medications, labeling of open containers in medication cart, which includes monthly audits and opioid medication administrations to be given from the correct medication card. 4. The Director of Nursing or designee will audit 25% per unit of disposal of expired medications, labeling of open containers in medication carts and opioid administrations from the correct medication card. The audits will be conducted weekly x4 and monthly x2. All findings will be submitted to the Quality Assurance Committee.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide adaptive eating equipment as ordered by the physician for a resident. A quarterly Minimum Data Set (MDS) assessment indicated that the resident was cognitively intact and required set-up assistance with eating. The physician's orders included the use of built-up utensils for all meals, and the care plan also specified the use of these utensils. However, during an observation of the resident's breakfast meal, it was noted that the resident was using regular utensils instead of the prescribed built-up utensils. The resident's meal ticket did include the order for built-up utensils. Interviews with a nurse aide and the Director of Nursing confirmed that the resident should have been provided with built-up utensils as per the physician's orders and care plan.
Plan Of Correction
1. The identified concern for R69 was immediately corrected. 2. Residents requiring adaptive utensils with meal set up will be identified on the meal ticket and a task in the nurse aide care plan will be generated. 3. The Director of Nursing or designee will provide education to nursing staff on the process to identify residents that require adaptive utensils for meals. 4. The Director of Nursing or designee will perform adaptive utensil audits at meal times weekly x 4 and monthly x 2. Findings will be reported to the Quality Assurance Committee.
Recurring Deficiencies in Quality Assurance Processes
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address recurring deficiencies effectively, as evidenced by repeated issues identified in the current survey ending January 9, 2025. These deficiencies included inaccuracies in Minimum Data Set (MDS) assessments, improper timing and revision of care plans, and failure to provide quality care. Additionally, there were issues with the accountability of controlled medications, improper storage and labeling of medications, and inadequate food preparation and serving. These deficiencies were also noted in a previous survey ending February 29, 2024, indicating a lack of effective corrective action by the QAPI committee. The facility had previously developed plans of correction that included conducting audits and reporting results to the QAPI committee for review. However, the current survey revealed that these plans were not successfully implemented, as the same deficiencies persisted. The QAPI committee's failure to maintain compliance with regulations regarding assessments, care plans, medication management, and food services highlights ongoing issues in the facility's quality assurance processes.
Plan Of Correction
1. All areas identified during this annual survey have submitted plans of correction. All identified resident concerns that are correctable will be corrected. 2. Audits will be completed for all federal regulations identified as not in compliance to ensure any additional residents have been identified and corrective measures have been implemented. 3. All submitted plans of correction have specific education/re-educations listed for all appropriate disciplines that will be provided by the listed facility employees. The Executive Director will re-educate the QAPI committee of the expectations of the facility and role of the committee per federal regulation. 4. Audits for each citation will be submitted to the Quality Assurance Committee for review. The Executive Director or designee will audit the QAPI minutes monthly x3 to ensure all audits have been submitted and all identified areas have been addressed.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection control guidelines from CMS and CDC, specifically regarding Enhanced Barrier Precautions (EBP) for a resident with an indwelling catheter and surgical wounds. The facility's policy, dated August 28, 2024, required EBP for residents with wounds and/or indwelling medical devices, regardless of MDRO colonization. However, during observations on January 7 and 8, 2025, it was noted that there was no signage on or outside the resident's room to indicate the need for EBP, despite the resident having an indwelling catheter and unhealed surgical wounds. The resident in question, identified as Resident 50, had mild cognitive impairment, was dependent on assistance for mobility, and had multiple medical conditions, including two Stage 2 pressure ulcers and a surgical wound with infection. The resident's care plan included EBP for both the surgical wound and the indwelling catheter. Despite these documented needs, the facility did not display the required signage to alert staff and visitors of the necessary precautions, as confirmed by the Director of Nursing during an interview.
Plan Of Correction
1. The identified concern for R50 was immediately corrected. 2. The Director of Nursing or designee will audit all residents to ensure that appropriate enhanced barrier precaution (EBP) signage is present for the affected residents. 3. The Director of Nursing or designee will re-educate all staff on appropriate placement of enhanced barrier precaution (EBP) signage. Education will include when residents require enhanced barrier precautions that signage is put in place in addition to appropriate personal protective equipment (PPE). 4. The Director of Nursing or designee will audit residents to ensure that appropriate enhanced barrier precaution (EBP) signage is present outside the room in addition to appropriate PPE of the affected residents weekly x4 then monthly x2. All findings will be submitted to the Quality Assurance Committee.
Failure to Meet Nurse Aide Staffing 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 during the day shift on two occasions and during the night shift on five occasions over a 21-day review period. On November 24 and 29, 2024, the facility census required 7.50 NAs during the day shift, but only 7.20 and 7.02 NAs were provided, respectively. Additionally, on several nights, the facility did not meet the required NA-to-resident ratio, with staffing levels falling short of the required numbers. The deficiency was confirmed through a review of nursing schedules, staffing information, and an interview with the Nursing Home Administrator. The administrator acknowledged that the facility did not meet the required staffing ratios on the specified days. There were no additional higher-level staff available to compensate for these deficiencies, indicating a failure to adhere to the staffing requirements set forth by the regulation.
Plan Of Correction
The nursing schedule will be reviewed by the scheduler and Director of Nursing to ensure that nursing assistant ratios are met prior to posting of the schedule. The daily schedule will be reviewed during the daily stand-up meeting. In the event of call-offs by staff, all other staff will be contacted to cover any open shifts to ensure ratios are met. The staffing tool audit will be completed daily for 4 weeks, then 3 times a week for 3 weeks, then 2 times a week for 2 weeks, then weekly ongoing, to ensure that nursing ratios are met for the daylight, evening, and overnight shifts. The audit will be monitored by the Director of Nursing or Designee.
Failure to Meet LPN Staffing Ratios
Penalty
Summary
The facility failed to meet the required LPN-to-resident staffing ratios during the overnight shifts on three separate occasions. Specifically, on November 26, 2024, with a census of 78 residents, the facility required 1.95 LPNs but only had 1.93 LPNs on duty. On November 27, 2024, with a census of 77 residents, 1.93 LPNs were needed, but only 1.60 LPNs were present. On November 30, 2024, again with a census of 77 residents, 1.93 LPNs were required, but only 1.05 LPNs were available. There were no additional higher-level staff available to compensate for these deficiencies. The Nursing Home Administrator confirmed the failure to meet the required staffing ratios during an interview on January 9, 2025.
Plan Of Correction
The nursing schedule will be reviewed by the scheduler and Director of Nursing to ensure that nursing assistant ratios are met prior to posting of the schedule. The daily schedule will be reviewed during the daily stand-up meeting. In the event of call-offs by staff, all other staff will be contacted to cover any open shifts to ensure ratios are met. The staffing tool audit will be completed daily for 4 weeks, then 3 times a week for 3 weeks, then 2 times a week for 2 weeks, then weekly ongoing, to ensure that nursing ratios are met for the daylight, evening, and overnight shifts. The audit will be monitored by the Director of Nursing or Designee.
Failure to Conduct Monthly Exit Sign Inspections
Penalty
Summary
The facility failed to perform monthly exit sign inspections for the entire year of 2024, as required by NFPA 101 standards for exit signage. This deficiency was identified during a document review and interview conducted on January 7, 2025. The review revealed a lack of documentation for the monthly inspections of exit signs, which are crucial for ensuring safety and compliance with emergency lighting requirements. The absence of these records was confirmed in an interview with the Facility Administrator, Maintenance Director, and staff, indicating a systemic oversight in maintaining the necessary safety protocols for the facility.
Plan Of Correction
This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because Patriot Village OPCO LLC agrees with the allegations and citations listed on the statement of deficiencies. Patriot Village OPCO LLC maintains that the alleged deficiencies do not, individually and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as Patriot Village OPCO LLC's written credible allegation of compliance. By submitting this plan of correction, Patriot Village OPCO LLC does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Patriot Village OPCO LLC reserves all rights to raise all possible contentions and defenses in any civil or criminal proceedings. The exit sign inspections were completed, but not documented appropriately. A new exit sign inspection form was developed and includes all exit signs throughout the facility. The Maintenance Director was educated on K 0293 and how it applies to Patriot Village. The Executive Director will review the exit sign inspections monthly for two months to ensure compliance. Results will be reviewed at the Quality Assurance Performance Improvement meeting.
Failure to Maintain Automatic Sprinkler System
Penalty
Summary
The facility failed to maintain its automatic sprinkler system in compliance with NFPA 25 standards, as evidenced by document review, observation, and interview. On January 7, 2025, it was found that the facility could not provide documentation for sprinkler system inspections conducted after February 7, 2024. Additionally, the facility did not change or recalibrate the sprinkler system gauges, which had expired in 2024. Furthermore, the facility failed to perform a required five-year internal pipe inspection within the last five years. These deficiencies were confirmed during an interview with the Facility Administrator and the Maintenance Director.
Plan Of Correction
The five-year internal pipe inspection, gauge replacement, and sprinkler inspection are scheduled to be completed on 01/24/2025. The Maintenance Director was educated on K 0353 and how it applies to Patriot Village. The schedule maintenance items were added to the annual calendar. Any issues that arise from the inspection will be corrected. Results will be reviewed at the Quality Assurance Performance Improvement meeting.
Failure to Conduct Annual Fire Door Inspection
Penalty
Summary
The facility failed to perform the required annual fire door assembly inspection, which affects the entire facility. During a documentation review and interview conducted on January 7, 2025, it was discovered that the facility did not have documentation to confirm that an annual fire door assembly inspection had been completed. This deficiency was confirmed through an interview with the Facility Administrator and Director of Maintenance, who acknowledged the absence of the necessary documentation at the time of the survey.
Plan Of Correction
The facility is unable to determine what happened to the door rating on the third floor soiled utility room door. Other doors were inspected and documented on the newly created fire door inspection sheet. No discrepancies were noted. The door will be inspected and appropriately rated or replaced with an approved door. Maintenance staff were re-educated on K 0761. The Executive Director will audit fire door assembly inspections monthly for two months. Results will be reviewed at the Quality Assurance Performance Improvement meeting.
Failure to Maintain Corridor Door Latching
Penalty
Summary
The facility failed to maintain corridor doors in compliance with NFPA 101 standards, specifically in one instance affecting one of fifteen smoke compartments. During an observation on January 7, 2025, at 10:30 a.m., it was noted that the door to room 347 on the third floor did not latch when tested. This deficiency was identified as a failure to ensure that corridor doors resist the passage of smoke and are equipped with positive latching hardware, as required by CMS regulations. The deficiency was confirmed through an interview with the Facility Administrator and Maintenance Director on the same day at 1:00 p.m. The report does not provide additional details about the residents or specific conditions in room 347 at the time of the observation. The focus of the deficiency is on the failure of the door to latch properly, which is a critical component of maintaining fire safety and smoke containment in the facility.
Plan Of Correction
The door on room 347 was adjusted and now latches properly. Other doors in the facility were inspected and all have been verified to latch correctly. Maintenance staff are aware of K 0363 and how it is applicable to Patriot Village. Maintenance staff will conduct an audit of 15 doors monthly for two months. Results will be reviewed at the Quality Assurance Performance Improvement meeting.
Failure to Conduct Required Fire Drill
Penalty
Summary
The facility failed to conduct one of the twelve required fire drills, specifically missing a third shift fire drill in the first quarter of 2024. This deficiency was identified during a documentation review on January 7, 2025, at 8:30 a.m., which revealed the absence of documentation for the required drill. An interview with the Facility Administrator and Maintenance Director confirmed the lack of documentation for a fire drill conducted between January and March 2024, affecting the entire facility.
Plan Of Correction
The facility is unable to make up the missed drill. No other discrepancies were noted for other drills conducted during 2024. A schedule for 2025 fire drills was developed and meets the requirements of K 0761. Maintenance staff were educated on K 0761. The Executive Director will audit fire drills monthly for one quarter. Results will be reviewed at the Quality Assurance Performance Improvement meeting.
Failure to Adhere to Physician's Orders for Insulin Administration
Penalty
Summary
The facility failed to provide medication as ordered by the physician, resulting in significant medication errors for one resident. The facility's policy required that medications be administered according to the physician's orders, including the right dose, route, rate, time, and resident. Resident 7, who was alert and oriented and had a diagnosis of diabetes, was ordered to receive 5 units of Insulin Lispro subcutaneously twice a day, with instructions to hold the insulin if the resident's blood sugar was less than 150 mg/dL. However, the Medication Administration Record (MAR) for December 2023 and January 2024 showed that the resident's insulin was not held on multiple occasions when the blood sugar levels were below the specified threshold. The Director of Nursing confirmed that the insulin was not held as ordered on the specified dates and times. This failure to adhere to the physician's orders resulted in significant medication errors for Resident 7. The facility's non-compliance with the medication administration policy was evident through the documented blood sugar levels and the corresponding administration of insulin, which did not align with the physician's parameters.
Improper Storage of Medications
Penalty
Summary
The facility failed to store unopened multi-dose containers of insulin according to the manufacturer's instructions for one resident and did not ensure that controlled refrigerated medications were stored in a separately-locked, permanently-affixed container. Specifically, Resident 22's unopened Insulin Lispro Pen Injector was found in the top drawer of the medication cart instead of being stored in the refrigerator as required by the manufacturer's directions. This was confirmed by an LPN during an observation of the medication cart. Additionally, in the third-floor east medication room refrigerator, a clear plastic box containing three boxes of Ativan Intensol was not permanently affixed to the refrigerator. The box was attached to a removable shelf, which does not comply with the requirement for controlled drugs to be stored in a separately-locked, permanently-affixed container. This was also confirmed by an LPN during an observation of the medication room refrigerator.
Food Storage and Hygiene Deficiencies
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety. Observations in the outside walk-in freezer revealed an accumulation of ice on the ceiling, floor, and on food products such as a plastic jug containing water, a case of ham, and a case of roast beef stored below the freezer condenser. The Dietary Manager confirmed the presence of ice accumulation on the food products. Additionally, during lunch meal service, a dietary aide was observed handling food without a beard net/restraint, which was confirmed by the Registered Dietitian as a violation of the facility's uniform dress code policy. Further observations in the first-floor pantry revealed a microwave with food splatters on the top, sides, and back inside walls. The paint was worn off and rusty below the floor of the microwave. A Registered Nurse confirmed that the microwave needed to be cleaned. These deficiencies indicate a failure to maintain sanitary conditions in food storage and preparation areas, as well as a failure to ensure dietary staff adhered to proper hygiene standards.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to complete accurate comprehensive Minimum Data Set (MDS) assessments for two residents. For Resident 30, the quarterly MDS assessment inaccurately indicated the use of a limb restraint less than daily. Observations and interviews with Licensed Practical Nurses (LPNs) confirmed that Resident 30 did not have a limb restraint, indicating an error in the assessment documentation. For Resident 72, the admission MDS assessment inaccurately recorded that the resident did not display any behavioral symptoms during the seven-day assessment period. However, multiple nursing notes documented several instances of aggressive and combative behavior, including physical and verbal aggression towards staff and other residents. An interview with the Social Service Director confirmed the inaccuracy of the MDS assessment for Resident 72.
Failure to Include Necessary Information in Baseline Care Plan
Penalty
Summary
The facility failed to ensure that baseline care plans included the necessary information and instructions to provide person-centered care for a resident within 48 hours of admission. Specifically, Resident 80, who was admitted with diagnoses including dementia, psychotic disturbances, and a colostomy, did not have his baseline care plan updated to include the care and services required for his antipsychotic medication and colostomy care. The facility's policy mandates that within 24-48 hours of admission, a baseline care plan should be developed, incorporating all necessary healthcare information from various sources, but this was not adhered to in Resident 80's case. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the absence of information regarding the treatment with an antipsychotic medication and colostomy care in Resident 80's baseline care plan. This oversight was identified during a review of facility policies, clinical records, and staff interviews, highlighting a failure to meet the regulatory requirements for nursing services as stipulated by 28 Pa. Code 211.12(d)(5).
Failure to Update and Individualize Care Plans
Penalty
Summary
The facility failed to ensure that residents' care plans were reviewed and revised to reflect their current care needs. For Resident 35, a significant change Minimum Data Set (MDS) assessment dated December 18, 2023, indicated that the resident was cognitively intact and required extensive assistance for daily care tasks. The resident's care plan, dated November 14, 2023, noted that the resident was medicated with an anticoagulant, which was discontinued on December 13, 2023. However, there was no documented evidence that the care plan was updated to reflect this change. The Director of Nursing confirmed that the care plan should have been updated but was not. For Resident 42, a significant change MDS assessment dated December 15, 2023, revealed that the resident was cognitively intact, required extensive assistance for bed mobility, was dependent on staff for transfers and toileting, and had a diabetic foot ulcer and a fall with a fracture. The resident's care plan regarding skin integrity, dated September 28, 2023, indicated the use of a pressure-reducing mattress. A physician's order dated January 20, 2024, prescribed a bariatric alternating air mattress. Observations on February 26 and February 28, 2024, confirmed the resident was lying on an air mattress. The Registered Nurse Assessment Coordinator confirmed that while a pressure-reducing mattress would meet the care plan's needs, the care plan was not individualized to reflect the resident's specific care needs.
Failure to Complete Physician-Ordered Treatments
Penalty
Summary
The facility failed to complete treatments as ordered by the physician for one resident. An admission skin assessment revealed that the resident had scabs on his second, fourth, and fifth toes of the left foot, and a physician's order was given to apply skin prep to these toes every day shift. However, a review of the resident's Treatment Administration Records (TARs) showed no documented evidence that the skin prep was applied as ordered from February 25 to 28, 2024. This was confirmed by an interview with the Director of Nursing.
Failure to Maintain Accountability for Controlled Medications
Penalty
Summary
The facility failed to maintain accountability for controlled medications for one of the 37 residents reviewed. The facility's policy required accurate accountability of controlled drugs, including documentation of the date and time of administration, amount administered, remaining quantity, and the initials of the nurse administering the dose. However, for Resident 42, who was cognitively intact and required extensive assistance for bed mobility and other activities, there was no documented evidence that the signed-out doses of Norco were actually administered on specific dates and times in October, November, and December 2023. The resident's controlled drug record indicated that doses of Norco were signed out for administration on October 28, November 23, December 14, and December 19, but the clinical record, including the Medication Administration Records (MARs) and nursing notes, did not contain any documentation confirming the administration of these doses. The Director of Nursing confirmed the lack of documented evidence during an interview on February 29, 2024. This failure to document the administration of controlled substances is a violation of the facility's policy and state regulations.
Failure to Attempt Non-Pharmacological Interventions Before Administering Anti-Anxiety Medication
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were attempted prior to the administration of anti-anxiety medications for Resident 53. The quarterly Minimum Data Set (MDS) assessment for Resident 53 indicated cognitive impairment and a diagnosis of anxiety. Physician's orders included an as-needed prescription for 0.5 mg of Ativan for anxiety. The Medication Administration Records (MARs) for February 2024 showed multiple instances of Ativan administration. However, there was no documented evidence of any non-medication interventions being attempted before administering Ativan on these occasions. The Director of Nursing confirmed the lack of documentation for non-medication interventions prior to administering the medication.
Failure to Maintain Accurate Clinical Records
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for two residents. For Resident 7, the admission Minimum Data Set (MDS) assessment indicated the resident was cognitively intact and had a Stage 3 pressure ulcer on the left heel, requiring specific treatments. However, the Treatment Administration Records (TARs) for February 2024 showed no documented evidence that the prescribed treatments were applied on multiple dates. The Director of Nursing confirmed that staff did not document the completion of the resident's treatment as ordered. For Resident 42, a significant change MDS assessment revealed the resident was cognitively intact, required extensive assistance for bed mobility, and had a fall with a major injury. Physician's orders included the use of a boot on the right ankle, which was to be removed only for hygiene and wound treatment. An orthopedic consult recommended offloading the heel. However, observations revealed the resident was not wearing the boot, and the resident stated that her husband had disposed of it. Despite this, the TAR for February 26, 2024, incorrectly documented that the boot was in place. The Director of Nursing confirmed the documentation was inaccurate.
Repeated Deficiencies in Quality Assurance Performance Improvement
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. The current survey identified repeated deficiencies related to the failure to complete Minimum Data Set (MDS) assessments accurately, revise care plans, follow physician's orders, prepare and store food under sanitary conditions, and maintain complete and accurate clinical records. These deficiencies were also noted in the previous survey ending March 2, 2023, indicating that the QAPI committee's corrective actions were ineffective. Specifically, the facility's plans of correction included completing audits and reporting the results to the QAPI committee for review. However, the current survey revealed that the QAPI committee failed to successfully implement these plans. Deficiencies were cited under F641 for inaccurate MDS assessments, F657 for ineffective care plan revisions, F684 for not following physician's orders, F812 for improper food storage and preparation, and F842 for incomplete and inaccurate clinical records. These repeated deficiencies demonstrate the QAPI committee's ineffectiveness in addressing and correcting the identified issues.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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