Reformed Presbyterian Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Pittsburgh, Pennsylvania.
- Location
- 2344 Perrysville Avenue, Pittsburgh, Pennsylvania 15214
- CMS Provider Number
- 395561
- Inspections on file
- 30
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Reformed Presbyterian Home during CMS and state inspections, most recent first.
The facility failed to provide and document required ADL assistance, including feeding and toileting, for three residents with conditions such as heart failure, stroke, dementia, malnutrition, and dysphagia. One resident needing complete ADL care had no feeding-assistance order for an extended period and lacked documentation of feeding help, intake amounts, and toileting on multiple shifts. Another resident reported delays in toileting assistance, with records showing no toileting documentation on several shifts. A third resident with dysphagia had orders and a care plan requiring upright positioning, slow eating, and staff assistance with meals, yet was observed eating rapidly in bed without being upright or assisted after a NA only set up the tray and left. Staff, including the DON, acknowledged that required ADL documentation for feeding and toileting was not completed.
A resident with multiple diagnoses, including adult failure to thrive, had a physician order for weekly head-to-toe skin assessments and later developed a sacral pressure ulcer requiring daily wound care. The facility failed to complete and document required skin assessments for several months and did not document ordered sacral wound treatments on multiple days, including a delay in starting a new treatment order and a missed documented dressing change. The DON confirmed the gaps in completion and documentation of both the skin observation tool and the ordered wound care, resulting in a deficiency related to pressure ulcer assessment and treatment.
The facility failed to coordinate hospice services with its own services for a resident receiving end-of-life care. The resident’s MDS reflected hospice services and diagnoses of anxiety, depression, and adult failure to thrive, and a physician order documented admission to hospice. However, the physician orders did not specify a hospice-related diagnosis, identify the hospice provider, or include the provider’s contact information. The comprehensive care plan also lacked the hospice agency’s contact details and instructions for accessing the hospice’s 24-hour on-call system. The DON confirmed these omissions and the resulting failure to ensure proper coordination of hospice services.
A resident who required a full body mechanical lift and assistance from two staff for transfers was moved by a CNA alone, resulting in the lift tilting and the resident being lowered to the floor. The resident reported hitting her head and shoulder and requested ER evaluation for head pain. Staff interviews confirmed that the required supervision and assistance were not provided, constituting neglect.
A resident with multiple medical conditions was able to leave the facility undetected and was missing for several hours before staff realized her absence at dinner. Despite regular risk assessments and monitoring protocols, the resident was not identified as an elopement risk and staff did not observe any warning behaviors. The resident was eventually found downtown by a staff member and returned safely, with no injuries noted upon assessment. The facility administrator confirmed that inadequate supervision led to the elopement.
The facility did not consistently monitor and record food temperatures for meals served, with numerous instances of missing documentation. Additionally, kitchen equipment in the walk-in cooler was observed to have a build-up of grime and debris, and these unsanitary conditions were confirmed by the Director of Food Service. The Nursing Home Administrator acknowledged failures in both food temperature monitoring and kitchen sanitation.
A resident's confidential medical information, including aspiration risk and fluid consistency order, was posted on a sign above the bed, making it visible to others. This action violated facility policy and state regulations requiring the protection of residents' personal and clinical records.
A resident with multiple medical conditions reported that a nurse aide used bleach wipes, intended for surfaces, on her skin during care, resulting in discomfort and mild skin redness. The resident's complaints were confirmed through interviews, product identification, and a subsequent skin assessment, indicating a failure to provide necessary care and maintain an environment free from neglect.
A resident with multiple medical conditions was transferred to a hospital after experiencing chest pain and right-sided weakness, but the facility did not document or communicate essential information—such as care plan goals, advance directives, and ongoing care instructions—to the receiving provider, as required by policy.
A resident's care plan was not updated to match a physician's order for transfer assistance, resulting in a documented discrepancy between the care plan and the medical order. Staff interviews confirmed that changes in the resident's care needs were not communicated or reflected in the care plan as required.
A resident with anemia, failure to thrive, and malnutrition, who required moderate assistance with bathing, did not receive scheduled showers for several weeks. The resident was observed with poor hygiene and reported not having a shower in weeks, while staff confirmed a lack of documentation for completed showers, indicating a failure to provide required ADL assistance.
A resident with a colostomy did not receive care and assessments as required by physician orders and the care plan. The clinical record lacked evidence of shift-by-shift stoma and skin assessments, and staff changed the colostomy bag only as needed rather than per order. The DON confirmed that appropriate treatments and services were not consistently provided.
A resident with COPD and other conditions did not have their oxygen tubing changed weekly as ordered and per facility policy, with staff confirming the tubing in use was overdue for replacement.
Two residents who required psychotropic medications and were at risk for adverse side effects did not have documented monthly medication regimen reviews by a licensed pharmacist for multiple months, as confirmed by staff and the administrator during the survey.
A resident with multiple diagnoses had Voltaren gel left at the bedside in a medicine cup, contrary to proper medication storage protocols. The resident confirmed the nurse left the gel at the bedside, and an RN acknowledged the failure to store the medication securely.
A resident with multiple health conditions and a moderate risk for pressure ulcers was not consistently assessed or provided with timely wound care as ordered. Required weekly skin assessments were missed, and there was a significant delay in initiating comprehensive wound assessment and treatment, resulting in a failure to follow professional standards of practice.
A resident with multiple chronic conditions did not receive prescribed Pregablim for several days due to the medication being unavailable, despite facility policy requiring timely pharmaceutical review and provision of contingency medications. The DON confirmed the failure to ensure medication availability and administration as required.
A resident with dementia was found outside unattended due to a malfunctioning door that was not properly secured by maintenance staff. The maintenance employee failed to inform the facility staff about the door's condition, leading to the resident's neglect.
A resident with dementia and other conditions eloped from the facility without staff knowledge, despite being assessed as a low wander risk. The resident exited the building unaccompanied and was found at a bus stop before being brought back inside by staff. The facility's investigation was incomplete, lacking key statements and re-education for staff, and the elopement prevention guidelines were not fully followed.
A facility failed to document the notification of elevated glucose levels for a resident with Diabetes Mellitus and hypertension. Despite the requirement to report glucose levels above 200, there was no documentation of any report or notification for occurrences in May and July. This was confirmed by the RN Unit Manager.
A facility failed to maintain a clean, safe, and homelike environment for a resident, as observed by missing drywall, gouges, and dents behind the resident's headboard. An LPN confirmed the issue and noted that protective sheets were being implemented. This deficiency contradicts the facility's policy on Resident Rights.
The facility failed to develop comprehensive care plans for two residents, both requiring the use of a FreeStyle Libre 3 reader device for diabetes management. Despite physician orders, the care plans lacked necessary interventions for the device, as confirmed by an RN. This deficiency was identified through a review of facility policies, clinical records, and staff interviews.
A facility failed to accurately monitor and document a resident's pressure ulcer care, as required by their wound management program. Despite physician orders for weekly skin assessments and specific wound care instructions, the facility did not maintain consistent documentation of the resident's wound status. Staff interviews confirmed the deficiency in adhering to care policies.
A facility failed to maintain sanitary conditions of respiratory equipment for a resident with COPD and other health issues. The nebulizer was found unbagged and unlabeled, contrary to facility policy, which requires weekly changes, rinsing, and proper storage and labeling. This was confirmed by an RN during an interview.
A resident with hypertension, end-stage renal disease, and diabetes did not have complete communication between the LTC facility and the dialysis center. The facility's policy required ongoing communication, but the dialysis communication binder showed incomplete and missing documentation for several dates. An LPN confirmed the dialysis center had not completed their portion of the forms.
The facility failed to ensure nursing staff had the necessary competencies to care for residents using the FreeStyle Libre 3 glucose monitoring system. Two residents with diabetes were affected, and interviews revealed that staff had not received formal training on the system. An RN and an LPN confirmed the lack of in-service education, and the RN Unit Manager acknowledged the oversight.
The facility did not complete annual performance evaluations for two nurse aides, as required by policy. The evaluations for both employees lacked review dates and were not discussed with them. This was confirmed by the Director of Human Resources.
A resident with an adjustment disorder and depression exhibited inappropriate behaviors, including exposing themselves to others. Despite these incidents being documented, the facility failed to provide necessary psychological services between the occurrences, as confirmed by a social service employee.
The facility failed to properly store and secure medications, as observed with unattended eye drops on a cart, a misplaced inhaler, and an opened saline solution on residents' nightstands. Additionally, an unlabeled medication tube and personal items were found in the medication room, indicating non-compliance with storage policies.
A facility failed to follow infection control practices during a dressing change and eye drop administration. An RN did not perform hand hygiene after cleansing a wound before applying a new dressing, and an LPN administered eye drops without gloves after handling oral medications. These actions were against the facility's policies, which require hand hygiene and glove use to prevent cross-contamination.
Failure to Provide and Document Required ADL Assistance for Feeding and Toileting
Penalty
Summary
The facility failed to provide and document required Activities of Daily Living (ADL) assistance, including feeding and toileting, for three residents. Facility policy dated 7/15/25 required staff to provide appropriate treatment and services to maintain or improve residents’ ability to perform ADLs, including toileting and feeding, and to document all ADL support in the electronic health record, including proper positioning for eating and maintaining an elimination schedule. One resident (CR1), admitted with heart failure, stroke, and diabetes mellitus, had hospice documentation and progress notes indicating a need for complete assistance with all ADLs, including feeding, and staff assistance with all aspects of care due to worsening fine motor function and difficulty feeding self. However, from 10/28/25 to 12/21/26 there was no physician order to assist with feeding, and documentation for multiple dates in December showed the resident was not provided help or staff oversight while eating, with no recorded percentages of food or fluid intake. The same resident’s documentation also lacked evidence of assistance with toileting for 18 shifts in December. Another resident (R2), admitted with heart failure, hypertension, and malnutrition, reported sometimes waiting a while for toileting assistance. Documentation for this resident showed no evidence of toileting assistance for six shifts in December. A third resident (R3), admitted with dementia, malnutrition, adult failure to thrive, and dysphagia, had a physician order for a pureed, thin-consistency diet with instructions for upright posture, slow rate, small bites/sips, and set-up and feeding from staff as needed, and a care plan directing staff to assist to an upright position for all meals, set up and assist with eating as needed, and monitor and document dysphagia symptoms. An undated facility list identified this resident as needing assistance with meals. During observation, a nurse aide set up the meal tray and left the room, and the resident was seen eating rapidly in bed without being in an upright position and without staff assistance. A registered nurse confirmed the resident was not upright and was not being assisted with meals. Staff interviews, including with a nurse aide and the DON, confirmed that staff are required to document feeding and toileting each shift and that the facility failed to document that ADL care was provided for the three residents.
Failure to Assess and Document Pressure Ulcer Care
Penalty
Summary
The deficiency involves the facility’s failure to assess and provide necessary treatment and services for a resident’s pressure ulcer in accordance with its wound management policy and professional standards of practice. The facility’s Wound Management Program policy required comprehensive wound care, including visual skin assessments on admission, readmission, and as needed, with documentation in the Nursing Admission Screening and/or Skin Observation Tool. For one resident with diagnoses including anxiety, depression, and adult failure to thrive, the clinical record showed a physician order for weekly head-to-toe skin assessments at bedtime every Thursday. However, review of the clinical record revealed that the skin observation tool was not completed for this resident between 9/15/25 and 12/20/25, despite the standing order for weekly skin assessments. Further record review showed that on 12/20/25 a physician ordered daily sacral wound care, specifying cleansing with normal saline and application of Medi honey, calcium alginate, and bordered gauze. The December treatment administration record did not show documentation that this dressing was completed until 12/22/25. A subsequent physician order dated 12/22/25 changed the sacral wound treatment to cleansing with soap and water and covering with a dry dressing daily and as needed on the night shift. The December treatment administration record showed that this dressing was not documented as completed on 12/30/25. In an interview, the DON confirmed the absence of documented skin assessments over the specified three-month period and the missed or undocumented wound treatments on the identified dates, supporting the finding that the facility failed to ensure appropriate assessment and treatment for the resident’s pressure ulcer.
Failure to Coordinate Hospice Services and Document Provider Information
Penalty
Summary
The facility failed to coordinate hospice services with facility services for one resident receiving end-of-life care. The resident was admitted on an unspecified date and had an MDS dated 11/30/25 showing diagnoses of anxiety, depression, and adult failure to thrive, with Section O indicating that hospice services were being provided while a resident. A physician order dated 9/13/24 documented that the resident was assessed and admitted to hospice. However, the physician orders did not include a diagnosis specifically associated with the hospice care, nor did they identify which hospice provider was responsible for the resident’s hospice services or provide the hospice provider’s contact information. Review of the resident’s current comprehensive care plan showed that it did not contain a plan of care demonstrating coordination of hospice services. The care plan lacked the hospice agency’s contact information and did not describe how staff could access the hospice provider’s 24-hour on-call system. During an interview on 1/22/26 at 2:25 p.m., the Director of Nursing confirmed that the facility had failed to include a hospice diagnosis, hospice agency contact information, and instructions for accessing the hospice’s 24-hour on-call system, and acknowledged that the facility did not ensure coordination of hospice services with facility services to meet the resident’s needs.
Failure to Ensure Adequate Supervision and Assistance During Resident Transfer
Penalty
Summary
The facility failed to ensure that a resident was free from neglect by not providing adequate supervision and assistance during a transfer. According to the clinical record, a resident with diagnoses including high blood pressure, hyperlipidemia, and arthritis required transfers using a full body mechanical lift with the assistance of two staff members, as indicated by physician orders and the resident's care plan. On the day of the incident, a Certified Nurse Aide (CNA) attempted to transfer the resident alone using the Hoyer lift. During the transfer, the lift tilted, and the CNA had to lower the resident to the floor. The resident reported hitting her head and left shoulder and subsequently requested to go to the emergency room for head pain. Staff interviews and documentation revealed that the CNA was pressured by the resident's spouse to expedite the transfer so they could go outside. The Nursing Home Administrator and Director of Nursing confirmed that the facility did not ensure the required supervision and assistance for the transfer, resulting in neglect as defined by facility policy. The incident was substantiated through review of facility policy, clinical records, and staff interviews.
Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent an elopement incident involving one resident. According to the facility's Elopement Prevention Guidelines, all residents are to be assessed for elopement risk upon admission, quarterly, annually, and as needed, with regular monitoring of their whereabouts at mealtimes, medication administration, and every two hours during nursing rounds. In this case, the resident's elopement risk assessment did not identify her as at risk, and staff did not observe any behaviors indicating intent to leave. However, the resident was able to leave the facility undetected, as confirmed by security camera footage, and was not noticed missing until the evening meal, approximately four hours after her departure. The resident, who had diagnoses including high blood pressure, dysphagia, and malnutrition, was last seen at lunch and was not found during the dinner meal. Staff initiated the elopement protocol after discovering her absence, searching the building and surrounding areas, and notifying the administrator, police, and the resident's family. The resident was eventually located downtown by a laundry worker, who assisted her in returning to the facility. Upon her return, the resident was assessed and found to have no injuries, and she refused to go to the emergency room for further evaluation. Interviews with staff confirmed that the resident had been gone for approximately seven hours before her safe return, and that there were no prior indications she intended to leave. The Nursing Home Administrator acknowledged that the facility failed to ensure adequate supervision, resulting in the resident's elopement. The deficiency was cited under relevant state codes for responsibility of the licensee, management, and nursing services.
Failure to Monitor Food Temperatures and Maintain Kitchen Sanitation
Penalty
Summary
The facility failed to properly monitor food temperatures and maintain kitchen equipment in a sanitary condition, as evidenced by observations and staff interviews. During an inspection of the main kitchen's walk-in cooler, a shelving unit and a sheet tray pan rack were found to have a build-up of fuzzy grime and dark colored debris. The Director of Food Service confirmed these unsanitary conditions, acknowledging the failure to maintain the equipment in a manner that would prevent cross contamination. Additionally, a review of the Trayline Temperature Log for June revealed that food temperatures were not consistently recorded prior to meal service, with 41 out of 50 meals lacking documented temperatures. This included missing temperature records for 13 breakfasts, 14 lunches, and 14 dinners. Staff interviews confirmed that the facility did not monitor food temperatures as required to prevent foodborne illness. The Nursing Home Administrator also acknowledged these failures in both food temperature monitoring and kitchen sanitation.
Failure to Maintain Resident Confidentiality by Posting Clinical Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's personal and medical records as required by its own policies and state regulations. During an observation, a sign was found posted above the head of a resident's bed that stated "Honey Thick and Aspiration Risk," which included clinical information visible to others. This was confirmed by a registered nurse during an interview. The facility's policies specifically prohibit posting signs with clinical or personal information in areas visible to others, and require the protection of residents' protected health information. The resident involved had diagnoses of muscle weakness, dementia, and anxiety, and was at risk for aspiration, with a physician's order for honey consistency fluids. The posted sign directly referenced these medical conditions and care needs, making confidential information accessible to anyone entering the resident's room. The deficiency was identified during a review of facility policies, clinical records, and staff interviews.
Resident Exposed to Bleach Wipes During Care
Penalty
Summary
A deficiency occurred when a resident with diagnoses including hyperlipidemia, neuropathy, and depression reported that a nurse aide used bleach wipes, intended for cleaning surfaces, directly on her skin during overnight care. The resident stated she told the aide to stop, but the aide continued wiping her back and buttocks with the bleach wipes. The resident subsequently experienced itching, discomfort, and a burning sensation, and was later found to have mild redness in the peri-area upon assessment. The wipes used were identified as germicidal bleach wipes, which are not intended for use on skin, and the resident confirmed the product by its blue lid and labeling. The incident was reported during a resident council group interview and subsequently relayed to facility administration. The nurse aide involved had received prior training on abuse and neglect. Facility documentation and staff interviews confirmed the use of bleach wipes on the resident, and the resident's skin evaluation corroborated her complaints of irritation. The facility failed to maintain an environment free from neglect and did not provide necessary goods and services as required by regulation.
Failure to Communicate Required Resident Information During Facility-Initiated Transfer
Penalty
Summary
The facility failed to ensure that all necessary resident information was communicated to the receiving health care provider during a facility-initiated transfer for one of two sampled residents. According to the facility's policy, when a resident is transferred or discharged, the transfer or discharge must be documented in the medical record, and appropriate information—including practitioner contact information, resident representative details, advance directive information, instructions for ongoing care, care plan goals, and a discharge summary—must be provided to the receiving provider. However, a review of the clinical record for a resident with diagnoses including anemia, adult failure to thrive, and malnutrition, who was transferred to the hospital after complaining of chest pain and right-sided weakness, revealed no documented evidence that this required information was communicated to the receiving health care provider. Staff interviews and record reviews confirmed that the necessary documentation and communication were not completed for the resident transferred and expected to return. Specifically, there was no evidence that the resident's care plan goals, advanced directive information, specific instructions for ongoing care, and all other necessary information were provided to ensure effective transitional care, as required by facility policy and regulatory standards.
Failure to Update Resident Care Plan to Reflect Physician Orders
Penalty
Summary
The facility failed to ensure that a resident's care plan was updated and revised to accurately reflect the resident's specific care needs. According to facility policy, resident care management should be conducted systematically by an interdisciplinary team and be consistent with the medical plan of care, including physician orders. For one resident, the clinical record showed a physician order for assist of one person with transfers, but the care plan documented a requirement for assistance of two persons with transfers. This discrepancy was identified during a review of the resident's records and care plan. Interviews with facility staff confirmed the inconsistency. The Registered Nurses Assessment Coordinator (RNAC) acknowledged that the care plan did not match the physician's order and stated that changes in care needs were not always communicated to them by nursing staff. The Director of Nursing also confirmed that the care plan was not revised to reflect the resident's current needs as required by facility policy and regulations.
Failure to Provide Scheduled ADL Assistance for Resident
Penalty
Summary
A deficiency was identified when a resident with diagnoses including anemia, adult failure to thrive, and malnutrition, who required partial to moderate assistance with showering and bathing, did not receive scheduled ADL (Activities of Daily Living) assistance. The resident's care plan indicated a decline in the ability to perform dressing and hygiene tasks, with interventions to monitor and document self-care ability and assistance provided each shift. Despite being scheduled for showers twice weekly, documentation and staff interviews confirmed that the last recorded shower was over a month prior to the survey. During the survey, the resident was observed with disheveled, sweaty, and greasy hair and reported a preference for showers, stating it had been weeks since the last one. Staff interviews confirmed that nurse aides are required to document completed showers, but records showed a significant lapse in this care. The facility failed to provide the necessary ADL assistance as outlined in the resident's care plan and scheduled routines.
Failure to Provide Required Colostomy Care and Documentation
Penalty
Summary
A deficiency was identified regarding the care of a resident with a colostomy. The resident, who had diagnoses including intellectual disabilities, urinary incontinence, and colostomy status, had a physician's order for colostomy care every shift, but the order lacked specific directions. Additionally, there was no documented order for changing the colostomy bag and wafer, including the size. The resident's care plan required assessment of the stoma and surrounding tissue every shift for signs of skin impairment, such as redness, irritation, drainage, and bleeding. Upon review of the clinical record, there was no evidence that the stoma and surrounding skin were assessed every shift as required by the care plan. Interviews with the resident and the DON revealed that staff changed the colostomy bag only as needed, typically once a week or if it was leaking, rather than following the prescribed schedule. The DON confirmed that the facility failed to ensure appropriate treatments and services were provided for the use of a colostomy for this resident.
Failure to Maintain Oxygen Equipment per Policy
Penalty
Summary
A deficiency was identified when the facility failed to provide appropriate respiratory care and maintain oxygen equipment for a resident with chronic obstructive pulmonary disease (COPD), hypertension, and depression. The resident had physician orders and care plans specifying that oxygen tubing and humidifier bottles should be changed weekly, in accordance with facility policy and best practices for infection control. However, during observations, it was found that the oxygen tubing in use was dated more than two weeks prior, indicating it had not been changed as required. Staff interviews confirmed that the oxygen line had not been changed according to the prescribed schedule, and the nurse acknowledged the oversight. The failure to follow physician orders and facility policy regarding the maintenance of oxygen equipment constituted a lapse in providing safe and appropriate respiratory care for the resident.
Failure to Document Monthly Medication Regimen Reviews by Pharmacist
Penalty
Summary
The facility failed to provide documentation that a licensed pharmacist performed monthly medication regimen reviews (MRR) for two of three sampled residents. According to facility policy, a consultant pharmacist is required to complete a drug regimen review for each resident at least monthly, with any irregularities reported. For one resident with diagnoses including depression, chronic pain due to trauma, and dementia, and who required psychotropic medication, there was no documentation of pharmacy review for several consecutive months. Similarly, another resident with intellectual disabilities, urinary incontinence, and colostomy status, also requiring psychotropic medication, lacked documented pharmacy review for multiple months. Staff interviews confirmed the absence of required MRR documentation for both residents during the specified months. The Nursing Home Administrator also acknowledged that the facility could not provide evidence of monthly medication regimen reviews as required by policy and state regulations. The deficiency was identified through review of facility policy, clinical records, and staff interviews.
Improper Storage of Medication at Bedside
Penalty
Summary
Facility staff failed to properly store medications for one resident diagnosed with anemia, adult failure to thrive, and malnutrition. According to the resident's physician order, Voltaren gel was to be applied topically every shift for pain management. During an observation, a cup containing Voltaren gel was found on the resident's bedside dresser, and the resident confirmed that the nurse had left the gel at the bedside earlier that morning. A registered nurse acknowledged that the medication was not properly stored, as required by facility policy and regulations.
Failure to Assess and Treat Pressure Ulcer as Ordered
Penalty
Summary
The facility failed to ensure that a resident with a pressure ulcer was properly assessed and provided with necessary treatment and services consistent with professional standards of practice. The resident, who had diagnoses including hypotension, protein-calorie malnutrition, and diabetes, was identified as being at moderate risk for developing pressure ulcers according to the Braden Scale. Upon admission, a new open area on the coccyx was noted, and a physician order was in place for weekly skin assessments. However, documentation showed that these weekly skin assessments were not completed on several occasions as ordered. Additionally, there was a lack of comprehensive wound assessment and wound treatment orders for the resident from the time the skin issue was first identified until over two weeks later. Progress notes indicated that the skin issue had not been evaluated during this period, and wound care orders were not initiated until much later. The deficiency was confirmed by the Nursing Home Administrator, who acknowledged the failure to assess and provide necessary treatment and services for the resident's pressure ulcer.
Failure to Ensure Availability and Administration of Prescribed Medication
Penalty
Summary
The facility failed to implement pharmaceutical services to ensure the availability and administration of prescribed medications for one resident. Specifically, a resident with diagnoses including diabetes, bipolar disorder, and hyperlipidemia was admitted and had a care plan to administer medications as ordered. The physician ordered Pregablim 150mg to be given once daily, but the Medication Administration Record (MAR) showed that the medication was not available and not administered on multiple days. The medication incident report confirmed that the resident missed doses of Pregablim over several consecutive days. The facility's policy required the pharmacist to review medication orders at the time of dispensing and to provide contingency and emergency medications for immediate needs. Despite this, the resident did not receive the prescribed medication due to its unavailability. The Director of Nursing confirmed that the facility did not ensure the availability and administration of the medication as required by policy and regulation.
Resident Neglect Due to Unsecured Door and Lack of Communication
Penalty
Summary
The facility failed to protect a resident from neglect, as evidenced by an incident involving a resident diagnosed with dementia and cerebral infarction. The resident was admitted to the facility and was observed outside the facility unattended by an employee entrance. The clinical record indicated that the resident was wearing an alarm bracelet, which was checked and found to be in working order earlier in the day. However, the resident was later found outside by the employee entrance in the upper parking lot, indicating a lapse in supervision and security. The deficiency was further compounded by a maintenance issue with the employee entrance door, which was not latching properly. A maintenance employee attempted to fix the door but was unable to secure it due to missing screws and a detached magnet. The maintenance employee failed to inform the staff that the door was not secure, leading to the resident's unsupervised exit. The Nursing Home Administrator confirmed the maintenance employee's failure to communicate the door's condition, which contributed to the neglect of the resident.
Resident Elopement Due to Inadequate Supervision and Risk Assessment
Penalty
Summary
The facility failed to ensure resident safety and prevent an elopement incident involving Resident R1, who was able to leave the premises without staff knowledge. Resident R1, who had diagnoses including dementia, hypertension, depression, mild intellectual disabilities, and lack of coordination, was assessed as a low risk for wandering. However, on the day of the incident, Resident R1 was observed on security footage exiting the facility without staff intervention, despite being scheduled for a Leave of Absence (LOA) later that day. The resident was found outside the building at a bus stop, unaccompanied, and was brought back inside by staff. The facility's investigation into the incident was incomplete, as it lacked a statement from the Activity Aide Employee E7, re-education with all staff related to the elopement, and an updated posting of Resident R1 as a wander risk. Interviews with staff revealed that there was no documented whole-house re-education about the elopement, and the facility's elopement prevention guidelines were not fully adhered to. Staff members were not present in key areas when Resident R1 exited the building, and the doors were unlocked, allowing the resident to leave without entering a code. Resident R1 expressed feelings of confinement and a desire for more freedom, which may have contributed to the elopement attempt. Despite having no prior history of elopement, the resident's impaired memory and judgment were not adequately addressed in the facility's risk assessment and prevention strategies. The incident highlighted gaps in supervision and the need for a more thorough investigation and staff education to prevent future occurrences.
Failure to Document Notification of Elevated Glucose Levels
Penalty
Summary
The facility failed to document the notification of changes in the condition of a resident, identified as Resident R36. The clinical records review revealed that Resident R36, who was diagnosed with Diabetes Mellitus and hypertension, had instances of elevated glucose levels above 200 on specific dates in May and July 2024. Despite the requirement to report glucose levels higher than 200, there was no documentation of any report or notification being made for these occurrences. This deficiency was confirmed during an interview with the Registered Nurse Unit Manager, who acknowledged that no report or notification was completed for the elevated glucose levels.
Deficiency in Maintaining a Homelike Environment
Penalty
Summary
The facility failed to provide a clean, safe, comfortable, and homelike environment for a resident, identified as R55. During an observation, it was noted that the wall area behind the resident's headboard had pieces of drywall missing, large gouges, and denting. This observation was confirmed by a Licensed Practical Nurse, Employee E3, who mentioned that the facility had started to put protective sheets behind the headboards. The facility's policy on Resident Rights, last reviewed on 7/22/24, indicates that residents have the right to a safe, clean, comfortable, and homelike environment, which was not upheld in this instance.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, R9 and R15, to address their medical, nursing, and psychosocial needs. Resident R9, who re-entered the facility with diagnoses of anemia, hypertension, and diabetes, had a physician's order for the use of a FreeStyle Libre 3 reader device to monitor blood sugar levels before meals and at bedtime. However, the care plan for Resident R9 did not include interventions related to the use of this device, as confirmed by RN Employee E5 during an interview. Similarly, Resident R15, who re-entered the facility with diagnoses of hypertension, end-stage renal disease, and diabetes, also had a physician's order for the use of the FreeStyle Libre 3 reader device. The care plan for Resident R15 similarly lacked interventions for the device, which was confirmed by RN Employee E5. These deficiencies were identified through a review of facility policies, clinical records, and staff interviews, indicating a failure to meet the residents' comprehensive care needs as required by the facility's care management policy and relevant state codes.
Failure to Monitor and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to accurately monitor and provide comprehensive assessments of a pressure area for Resident R17, as required by their wound management program. The program mandates that nurses complete visual skin assessments and document findings, including wound measurements and stages. However, a review of Resident R17's records revealed a lack of wound assessment with measurements for the week of 7/4/24. Additionally, a skin observation tool dated 7/17/24 noted a Stage two wound to the coccyx area but did not include measurements, indicating a lapse in documentation and monitoring. Resident R17, who has multiple diagnoses including vascular dementia, hyperlipidemia, obesity, and cellulitis, was identified as being at risk for skin integrity impairment due to incontinence. Despite physician orders for weekly skin assessments and specific wound care instructions, the facility did not maintain consistent and comprehensive documentation of the resident's wound status. Interviews with facility staff confirmed the failure to accurately monitor and assess the pressure area, highlighting a deficiency in adhering to established care policies and procedures.
Failure to Maintain Sanitary Conditions of Respiratory Equipment
Penalty
Summary
The facility failed to maintain sanitary conditions of respiratory equipment for a resident, identified as Resident R49. According to the facility's policy on respiratory equipment, nebulizer sets should be changed weekly or as needed, rinsed with hot tap water after treatments, allowed to dry, and stored in clean plastic bags between treatments. Additionally, the sets should be marked with the resident's name, date, and initials when changed. However, during an observation, it was noted that Resident R49's nebulizer was sitting on top of a dresser, not bagged, and lacked labeling with the resident's name and date. This was confirmed by a Registered Nurse (RN) during an interview. Resident R49 had been admitted to the facility with diagnoses including anemia, chronic obstructive pulmonary disease (COPD), and chronic kidney disease, and had physician orders for DuoNeb Solution to be inhaled as needed for wheezing.
Incomplete Dialysis Communication for Resident
Penalty
Summary
The facility failed to provide consistent and complete communication with the dialysis center for a resident receiving hemodialysis, identified as Resident R15. The facility's policy on Dialysis Services, dated 7/22/24, mandates ongoing communication between dialysis staff and nursing staff to ensure continuity of care. However, a review of Resident R15's dialysis communication binder revealed incomplete dialysis sheets on several dates, with the section for the dialysis unit left blank. Additionally, no dialysis sheets were found for specific days, indicating a lack of documentation and communication. Resident R15, who has a medical history of hypertension, end-stage renal disease, and diabetes, had physician orders for dialysis on Tuesdays, Thursdays, and Saturdays. Despite the nursing progress notes indicating attendance at dialysis sessions, the communication forms were not fully completed by the dialysis center, as confirmed by LPN Employee E3. This deficiency was identified during an interview on 8/12/24, where it was acknowledged that the dialysis center had not completed their portion of the forms, and some days were missing entirely.
Lack of Staff Training on FreeStyle Libre 3 System
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies and skill sets to care for residents using the FreeStyle Libre 3 continuous glucose monitoring system. This deficiency was identified for two residents, both of whom had diabetes and were using the system to monitor their blood sugar levels. Resident R9 had a history of anemia, hypertension, and diabetes, and was ordered to use the FreeStyle Libre 3 system to check blood sugar levels before meals and at bedtime. Similarly, Resident R15, who had hypertension, end-stage renal disease, and diabetes, was also ordered to use the system for blood sugar monitoring. Interviews with nursing staff revealed a lack of formal training or in-service education on the FreeStyle Libre 3 system. A Registered Nurse (RN) admitted to having no knowledge of the system beyond self-education through the instruction packet provided with the device. Another Licensed Practical Nurse (LPN) stated familiarity with the system from previous experience but confirmed the absence of in-service training at the facility. The RN Unit Manager acknowledged that no staff in-servicing had been conducted regarding the system, confirming the facility's failure to ensure staff competency in using the FreeStyle Libre 3 system.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance evaluations for two nurse aides, Employee E8 and Employee E9, as required by their policy. The Certified Nursing Assistant position description, last reviewed on 7/22/24, mandates that employees demonstrate the necessary knowledge and skills to provide care, with evaluations based on these standards. However, a review of Employee E8's personnel record showed that her performance evaluation for the period of 3/14/23 to 1/26/24 lacked a review date and was not discussed with her. Similarly, Employee E9's evaluation for the period of 7/12/23 to 7/24/24 also lacked a review date and was not discussed with her. The Director of Human Resources confirmed these omissions during an interview on 8/13/24.
Failure to Provide Appropriate Psych Services for Resident with Adjustment Disorder
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident diagnosed with an adjustment disorder with depression, which is a mental condition triggered by a serious event. The resident, identified as R28, was involved in incidents where they demonstrated inappropriate behaviors, such as exposing themselves to their roommate and another resident. These incidents were documented in the nursing notes on two separate occasions. Despite these documented behaviors, the clinical record for Resident R28 did not include any documentation or referral for psychological services between the dates of the incidents. This lack of action was confirmed during an interview with a social service employee, who acknowledged that the facility did not provide the necessary psych services to the resident between the first and second incidents. This inaction resulted in the facility's failure to help the resident achieve the highest practicable mental and psychosocial well-being.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to properly store and secure medications and biologicals, as observed in the third-floor medication room and on medication carts. An LPN left artificial tears eye drops unattended on top of a medication cart in a hallway, making it accessible to anyone passing by. Additionally, a Stiolto inhaler was found on a resident's bedside table, which should not have been left there, and an opened bottle of saline solution was noted on another resident's nightstand. These instances indicate a lack of adherence to the facility's policy on medication storage and security. Further observations revealed an unlabeled open tube of diclofenac sodium in a medication cart, and the medication room contained personal items and improperly stored items, such as a tuberculin solution without a date and a container of chocolate ice cream in the freezer. These findings demonstrate a failure to maintain a clean, organized, and secure environment for medication storage, as required by the facility's policies and state regulations.
Infection Control Deficiencies in Dressing Change and Eye Drop Administration
Penalty
Summary
The facility failed to implement proper infection control practices during a dressing change for a resident identified as R17. The facility's policy on dressing changes, which was last reviewed in July 2024, requires staff to remove soiled dressings, perform hand hygiene, and apply new gloves before proceeding with wound care. However, during an observation, a Registered Nurse (RN) failed to perform hand hygiene after cleansing the wound and before patting it dry and applying a new dressing. This lapse in protocol was confirmed by the RN during an interview. Additionally, the facility did not adhere to infection control practices during the administration of eye drops for a resident identified as R261. The facility's policy mandates hand washing and the use of clean gloves when administering ophthalmic medications. An LPN was observed administering eye drops without wearing gloves after handling oral medications. This failure to follow infection control procedures was acknowledged by the LPN during an interview.
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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