Seneca Place
Inspection history, citations, penalties and survey trends for this long-term care facility in Verona, Pennsylvania.
- Location
- 5360 Saltsburg Road, Verona, Pennsylvania 15147
- CMS Provider Number
- 395790
- Inspections on file
- 30
- Latest survey
- June 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Seneca Place during CMS and state inspections, most recent first.
The facility did not investigate or document incidents involving two residents—one with toe abrasions from a shower chair incident and another found without a required monitoring device—contrary to its policies. Additionally, two nursing staff members, an LPN and an RN, began employment without completed state criminal background checks, as confirmed by facility staff.
The facility did not identify or investigate incidents involving three residents, including a resident who sustained abrasions during care, another who attempted to leave the facility on multiple occasions, and a third who was found without a required safety device. These incidents were not documented or investigated as required, and facility leadership confirmed the lack of appropriate follow-up.
Care plans were not updated for three residents after significant changes in their health status, including two residents who tested positive for Norovirus and another who received an indwelling urinary catheter. The care plans lacked goals and interventions addressing these new needs, as confirmed by clinical record review and staff interviews.
The facility failed to follow physician orders and treatment protocols for several residents, including not changing or documenting IV dressings, not completing wound care as ordered, not arranging timely follow-up appointments with specialists, and not labeling medicated patches with the date and time of application. Staff confirmed these lapses during interviews and observations.
Three residents with orders for CPAP/BIPAP therapy were found to have their respiratory masks left unbagged on bedside tables, in violation of facility policy requiring proper storage. Despite clear care plans and physician orders, staff did not ensure masks were bagged when not in use, and this was confirmed by both nursing staff and the DON.
The facility failed to maintain consistent communication with the dialysis center for two residents, resulting in numerous days of incomplete or missing records. Additionally, two residents did not have physician orders for dialysis access device care, and care plans were incomplete or lacked necessary details about the access devices. These deficiencies were confirmed by staff interviews and record reviews.
Surveyors found that medications and biologicals were not properly stored or labeled in three medication carts. Issues included insulin pens and vials lacking dates opened or resident identifiers, an open insulin pen without a cap, oral medications repackaged in unapproved containers, and topical medications stored in the wrong cart. These deficiencies were confirmed by nursing staff and the DON.
The facility did not follow infection prevention protocols, including Enhanced Barrier Precautions for two residents with indwelling catheters, failed to implement Contact Precautions for four residents with norovirus, lacked infection surveillance for two months, and an LPN was observed applying a lidocaine patch without gloves.
A resident with multiple chronic conditions sustained skin injuries to the right foot after it was dragged on the carpet while being pushed in a shower chair. Although the incident was documented in the medical record, it was not reported to the State Department of Health as required by facility policy. The Nursing Home Administrator confirmed the omission during an interview.
Two residents with moderate cognitive impairment were able to leave or attempt to leave unsupervised areas due to inadequate supervision and failure to follow elopement prevention protocols, including missing required alarm devices and insufficient monitoring.
A resident with multiple medical conditions had an indwelling urinary catheter ordered without a documented diagnosis to justify its use, contrary to facility policy requiring clinical indications to be reviewed and documented prior to insertion. This lapse was confirmed by an RN during staff interviews.
The facility did not complete required annual performance evaluations for multiple nursing staff, including nurse aides and an LPN, as outlined in facility policy. Personnel records lacked documentation of these evaluations, and the administrator confirmed the omission.
A resident with a documented seafood allergy was served shrimp alfredo, resulting in vomiting and a grievance from the resident's family. The allergy was noted in the clinical record, nutrition assessment, and physician orders, but the dietary manager confirmed the resident did not receive the correct diet.
The facility did not verify that a resident with severe cognitive impairment had the capacity to understand and sign a binding arbitration agreement, and also failed to obtain a required signature for another resident's arbitration agreement, as confirmed by the admissions director and documented in facility records.
The facility did not ensure that all required QAA committee members, including the Infection Preventionist, were present at a quarterly meeting, as shown by attendance records and confirmed by the DON. This failure was not in accordance with facility policy and regulatory requirements.
The facility did not implement its antibiotic stewardship program for one month, as required by policy. Review of infection control records showed no documentation of antibiotic monitoring for that period, and the DON confirmed the lapse.
The facility did not have a qualified infection preventionist onsite to oversee infection prevention and control activities for a period after the previous infection preventionist resigned and before the new one completed required training and certification, as confirmed by the DON and facility records.
Essential emergency equipment audits were not completed for two crash carts, as daily logs showed missing entries and staff confirmed the required checks had not been performed.
The facility did not provide required training on effective communication to five direct care staff, including nurse aides, an LPN, and an RN, as mandated by facility policy. Review of education records and staff interviews confirmed the absence of this training for the staff reviewed.
The facility did not provide required QAPI training to five direct care staff members, including nurse aides, an LPN, and an RN, as mandated by facility policy and state regulations. This was confirmed through review of training records and staff interviews.
Two direct care staff members, an LPN and an RN, did not receive mandatory infection control training as required by facility policy. Review of education records confirmed the absence of this training for these staff, which was acknowledged by facility leadership.
The facility did not notify physicians or resident representatives of changes in condition or status for three residents, including incidents where a resident left the unit, another was found without a required monitoring device, and a third had a new medication order. Staff interviews confirmed that required notifications were not made in these cases.
A facility failed to inform a resident's representative about a medication dosage increase for a resident with moderate cognitive impairment and multiple diagnoses, including end-stage renal disease and dementia. The facility did not discuss the risks, benefits, or alternatives of the increased Mirtazapine dosage, as confirmed by the DON.
The facility failed to communicate necessary resident information to the receiving health care provider for two residents transferred to the hospital. This included missing details such as care plan goals, advanced directive information, and specific instructions for ongoing care. The Director of Nursing confirmed the oversight, which violated regulatory requirements for transfer and discharge.
The facility failed to provide written notification of the bed-hold policy to two residents during their hospital transfers, as required by regulations. Despite the facility's policy to inform residents at admission and transfer, documentation was missing for both cases. The DON confirmed the oversight.
The facility failed to provide necessary ADL assistance for two residents. One resident, with a partial-moderate need for assistance, did not receive a shower on a specific date. Another resident, with a substantial maximal need for assistance, missed multiple showers in January. The DON confirmed these deficiencies.
The facility failed to notify the Department of Health about a COVID-19 outbreak affecting 36 residents. The DON mistakenly believed only employee cases needed reporting, leading to non-compliance with health department notification requirements.
A resident with dementia and a history of elopement risk left the facility unsupervised after a staff member used an ID badge to override the security system, allowing the resident to exit with visitors. The security alarm was triggered, but the resident was already outside. The facility failed to properly identify the resident, leading to the unsupervised exit.
A resident with a history of nervous system degeneration, diabetes, and epilepsy eloped from the facility and was found in the parking lot. The facility failed to notify the State Agency of this reportable event in a timely manner, as confirmed by the DON.
A facility failed to provide necessary ADL assistance to a resident who was dependent on help for self-care tasks. Despite the resident's MDS assessment indicating full dependency, records showed missed showers on multiple occasions. This deficiency was confirmed by the Nursing Home Administrator.
A resident with a history of chronic pain experienced chest pain and requested Oxycodone. Despite the facility's policy requiring notification of a medical provider for significant changes in condition, the LPN did not notify a physician or take a full set of vitals. The Director of Nursing confirmed the failure to follow protocol.
A resident with a history of stroke and Multiple Sclerosis was neglected by a Nurse Aide (NA) who failed to change the resident before a scheduled MRI appointment, despite the resident's request. The resident returned from the appointment heavily soiled, with dried bowel movement from back to knees, indicating prolonged neglect. The incident was confirmed by staff and led to the termination of the responsible NA.
A facility failed to protect two residents from medication misappropriation by an RN, who diverted six doses of oxycodone. The facility's policies on controlled substances and prevention of misappropriation were not followed, as discrepancies in medication records and lack of co-signatures for destroyed medications were found. The Director of Nursing confirmed the unaccounted narcotics, highlighting the failure to safeguard residents.
The facility failed to store food products properly in the Main Kitchen, risking foodborne illness. An observation revealed unsealed plastic bags of rice and pureed bread mix in open boxes, contrary to the facility's policy requiring opened containers to be dated and sealed. This was confirmed by the Dietary Director.
The facility failed to maintain resident dignity and communication by not providing privacy during medication administration, lacking a communication plan for a resident with language barriers, and not respecting a resident's preferred name. A resident received medication without privacy, another struggled with communication due to language barriers, and a third was not addressed by her preferred name.
The facility failed to document a physician's discharge order for a resident and did not communicate necessary information to receiving health care providers for five residents transferred to a hospital. These residents had various medical conditions, and the lack of adherence to facility policies on discharge and transfer documentation was confirmed by the DON.
The facility failed to ensure accurate resident assessments for seven residents, leading to discrepancies in their MDS documentation. A resident was inaccurately coded as dependent for bed mobility, while another's MDS incorrectly indicated the use of side rails as restraints. Additionally, a resident's MDS failed to document hospice care, and another's did not reflect the use of oxygen therapy. These inaccuracies highlight a systemic issue in the facility's assessment process.
The facility failed to provide adequate pressure ulcer care and prevention for several residents, leading to worsening conditions and new pressure ulcers. One resident did not receive a personalized care plan or weekly skin assessments, while another developed a Stage 2 pressure ulcer without proper documentation or care planning. Additional residents experienced similar issues, with inadequate monitoring and documentation of pressure ulcers.
The facility failed to provide appropriate catheter care for three residents. A resident's catheter bag was found on the floor without a dignity bag, another resident had an indwelling catheter without a documented diagnosis, and a third resident's drainage bag was hanging from the bed frame without a dignity bag. These deficiencies were confirmed by staff and violated facility policies on catheter care and resident dignity.
The facility failed to monitor and address the nutritional needs of several residents, resulting in significant weight loss and inadequate dietary management. A resident experienced substantial weight loss due to inconsistent feeding, while another resident's tube feeding orders were mishandled, leading to hospitalization. Other residents were not weighed accurately, affecting their nutritional assessments and care plans.
The facility failed to provide appropriate respiratory care for three residents, as they lacked physician orders and care plans for oxygen therapy. Observations revealed undated nasal cannula tubing and humidification bottles, and an empty humidification bottle for one resident. The DON confirmed these deficiencies, which violated the facility's policy on oxygen administration.
The facility failed to maintain accurate care plans and conduct necessary assessments for the use of bed rails for several residents. Despite regulations requiring assessments to prevent entrapment risks, the facility did not document initial or ongoing evaluations for residents using bed rails for mobility and positioning. Care plans inaccurately reflected the use of side rails as restraints, and in one case, a resident did not have a physician's order for bed rails.
The facility failed to maintain accurate and timely documentation for three residents, leading to deficiencies in medical record-keeping. A resident's weekly skin checks were not documented as required, another resident's pressure ulcer was inaccurately staged, and a third resident's pressure ulcer documentation was delayed and incorrect. These issues were confirmed by the DON and a Wound Care Nurse, who cited being overburdened as a reason for the delays.
The facility failed to conduct infection surveillance for four months, prevent cross-contamination during a dressing change for a resident with multiple sclerosis, and ensure proper care for a resident with a urinary catheter. The DON confirmed these deficiencies, which included lapses in hand hygiene and catheter care policies.
The facility failed to implement an antibiotic stewardship program for four months, as identified through a review of infection control policies and staff interviews. The program, intended to monitor antibiotic use, was not documented from March to June 2024. The Director of Nursing confirmed this lapse, which violates specific resident care and nursing services codes.
The facility failed to ensure that nurse aides received the required 12 hours of annual in-service training, as mandated by regulations. Personnel records for five nurse aides lacked documentation of this training, and the Nursing Home Administrator confirmed the deficiency. This issue highlights a failure to comply with state codes related to staff development and the responsibility of the licensee.
A resident with high blood pressure, muscle wasting, and dementia was found with their call bell placed out of reach, contrary to facility policy requiring accessible call systems. This was confirmed by an LPN and the DON during a survey.
A facility failed to provide a resident with the opportunity to formulate an advance directive upon admission, as required by their policy. The resident, diagnosed with quadriplegia, high blood pressure, and dry eyes, had no documentation in their clinical record indicating they were offered this opportunity. This was confirmed by the Social Worker Director during an interview.
The facility failed to maintain confidentiality of resident medical information on the Third Floor, affecting two residents. An unattended medication cart displayed identifiable information, and signs with medical instructions were posted in residents' rooms. This was confirmed by staff and violated facility policy and state codes.
The facility failed to report and investigate neglect allegations for two residents within the required timeframe. One resident with quadriplegia was not assisted out of bed before lunch, and another resident with high blood pressure and blindness was not helped with eating and was found in an unclean state. These incidents were not reported to the state agency as required by the facility's policy.
Failure to Investigate Incidents and Complete Staff Background Checks
Penalty
Summary
The facility failed to implement and follow its own written policies and procedures regarding the prevention, identification, and investigation of abuse, neglect, and misappropriation of resident property. Specifically, the facility did not conduct a complete and thorough investigation of incidents involving two residents. One resident sustained abrasions to the toes after their right foot was dragged on the carpet while being pushed in a shower chair, but this incident was not documented or investigated as required by facility policy. Another resident, who had diagnoses including hypertension, cancer, and hyperlipidemia, was found on a different floor without their required monitoring device, indicating a potential elopement. This incident was also not documented or investigated, and the DON was unaware of the event. Additionally, the facility failed to conduct required state criminal background checks prior to the start of employment for two nursing staff members, an LPN and an RN. Personnel records for both staff members did not include completed background checks before their hire dates, contrary to facility policy and regulatory requirements. The Human Resources staff and the Nursing Home Administrator confirmed that these checks should have been completed prior to employment but were not. These deficiencies were identified through a review of facility documents, policies, clinical records, and staff interviews. The facility's failure to follow its own policies and regulatory requirements resulted in uninvestigated incidents involving potential neglect and incomplete staff background screening.
Failure to Investigate and Document Incidents of Possible Abuse or Neglect
Penalty
Summary
The facility failed to identify and investigate incidents of possible abuse and/or neglect for three residents. For one resident with hypertension, diabetes, and hyperlipidemia, abrasions were noted on the right toes after the foot was dragged on the carpet while being pushed in a shower chair. This incident was documented in the physician's progress note, but there was no corresponding entry or investigation in the facility's incident records, and the Nursing Home Administrator confirmed that no investigation was conducted as required by policy. Another resident with diabetes, post-traumatic stress disorder, and hypotension was found attempting to leave the facility on two separate occasions, including being recovered from the front door by staff. Despite these events, no investigation was conducted. A third resident with hypertension, cancer, and hyperlipidemia was found on the first floor without the required watchmate device on their wheelchair, as ordered. The Director of Nursing was unaware of this elopement, and the incident was not documented or investigated. These failures were confirmed by facility leadership during interviews.
Failure to Update Care Plans for Changes in Resident Condition
Penalty
Summary
The facility failed to update and revise care plans to reflect the specific care needs of three residents following significant changes in their health status. For two residents who tested positive for Norovirus, the care plans did not include goals or interventions related to their positive Norovirus status, despite physician documentation and lab results confirming the diagnosis. Additionally, another resident with a new physician order for an indwelling urinary catheter did not have corresponding goals or interventions added to their care plan to address this new care need. These deficiencies were confirmed through review of facility documents, clinical records, and staff interviews. The Director of Nursing and a Registered Nurse acknowledged that the care plans were not revised as required to address the residents' updated conditions, including Norovirus infection and the use of an indwelling urinary catheter. The facility's own policy requires ongoing assessment and revision of care plans as residents' conditions change, which was not followed in these cases.
Failure to Follow Physician Orders and Treatment Protocols
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for multiple residents. For one resident with an intravenous (IV) catheter, there was no physician order for IV dressing changes, and the dressing was observed to be loosened and half peeled away with an outdated change date. Staff confirmed that the dressing had not been changed as required by facility policy, which mandates dressing changes at least every seven days or when soiled, damp, or loose. Another resident with bilateral below-the-knee amputations had physician orders for daily wound care, including cleansing and application of antibiotic ointment dressings to both stumps. However, observation revealed that one stump had a dressing dated two days prior, and the other stump had no dressing in place. Staff confirmed that the treatments were not completed as ordered. Additionally, two residents did not have timely follow-up physician appointments ordered or scheduled as required, despite documented physician orders for follow-up with specialists such as urology, neurology, and endocrinology. Staff interviews confirmed that these appointments had not been made. Furthermore, a resident with an order for a daily lidocaine patch did not have the patch labeled with the date and time of application during a medication pass, as required by facility policy. The LPN administering the medication confirmed the omission. These findings demonstrate failures to follow physician orders, maintain proper documentation, and adhere to facility policies for treatment and care.
Failure to Properly Store CPAP/BIPAP Masks for Multiple Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents who required CPAP/BIPAP therapy. According to facility policy, CPAP/BIPAP masks are to be bagged when not in use, and staff are to document how residents tolerate the procedure. For all three residents, observations on two consecutive days revealed that their CPAP masks were left lying unbagged on their bedside tables, contrary to policy requirements. These findings were confirmed by a registered nurse during interviews. The residents involved had significant medical histories, including chronic obstructive pulmonary disease, diabetes, high blood pressure, stroke, hemiplegia, and anemia, and all had physician orders and care plans specifying the use and maintenance of CPAP/BIPAP equipment. Despite clear physician orders and care plan instructions regarding the application, cleaning, and storage of CPAP/BIPAP equipment, staff did not ensure that the masks were properly bagged when not in use. The Director of Nursing confirmed the failure to provide appropriate respiratory care for these residents. The deficiency was cited under state regulations concerning the responsibility of the licensee, resident care policies, and nursing services.
Deficient Dialysis Communication, Orders, and Care Planning
Penalty
Summary
The facility failed to provide consistent and complete communication with the dialysis center for two of three residents reviewed, as evidenced by numerous incomplete or missing dialysis communication records. Specifically, one resident with end stage kidney disease, diabetes, and anxiety had over twenty days of missing or incomplete communication records with the dialysis center, while another resident had fourteen days of incomplete or missing records. Staff interviews, including those with an LPN, RN, and the Director of Nursing, confirmed these lapses in communication documentation. Additionally, the facility did not have physician orders for the care and management of dialysis access devices for two residents. One resident with a right upper arm fistula and another with a tessio catheter did not have corresponding physician orders for access site care. Furthermore, care plans for these residents were incomplete, failing to specify the type and location of the access device or omitting care and management instructions altogether. These deficiencies were confirmed by the Director of Nursing and were not in accordance with the facility's own policy or regulatory requirements.
Improper Storage and Labeling of Medications and Biologicals
Penalty
Summary
Surveyors identified multiple instances where medications and biologicals were not stored or labeled according to facility policy and accepted professional standards. On the Third floor [NAME] Hall medication cart, an open Toujeo insulin pen was found without a cap, not labeled with the date opened, and not stored in a bag. Additionally, Humalog and Lantus insulin pens were not labeled with the date opened, and one Lantus pen lacked a resident identifier. These findings were confirmed by an LPN during the survey. On the Third floor North Hall medication cart, a bottle of Miralax was not labeled with the date opened, and two tubes each of Banophen anti-itch cream and Voltaren gel were present, which staff confirmed should have been stored in the treatment cart, not the medication cart. On the Fourth floor East Hall medication cart, a Lispro insulin vial was not dated, and Tramadol was found in a bag with an empty pharmacy container and several clear pouches containing pills, which staff stated was done for ease of counting. The DON confirmed that medications and biologicals were not stored properly and securely in three of five medication carts reviewed.
Failure to Implement Infection Control and Precautionary Measures
Penalty
Summary
The facility failed to follow its own infection prevention and control policies, as well as CDC guidelines, in several key areas. Two residents with indwelling medical devices (tessio catheters for dialysis) did not have physician orders or care plan interventions for Enhanced Barrier Precautions (EBP) as required. Observations confirmed the absence of EBP signage and documentation for these residents, and the Director of Nursing acknowledged the omission. Both residents had significant medical histories, including end stage kidney disease and dependence on dialysis, which necessitated the use of indwelling catheters. Additionally, the facility did not implement appropriate transmission-based (Contact) precautions for four residents who tested positive for norovirus. Despite positive lab results and physician documentation indicating concern for norovirus, there was no evidence in the clinical records that these residents were placed on Contact Precautions as required by facility policy and CDC guidelines. The Infection Preventionist confirmed that these precautions were not implemented for the affected residents. The facility also failed to maintain an ongoing infection surveillance program, as required by its own policies and the job description of the Infection Preventionist. Infection control documentation was missing for two out of ten months, and the DON confirmed the lack of surveillance during those periods. Furthermore, during a medication pass, an LPN was observed removing and applying a lidocaine patch to a resident without using gloves, which was confirmed by the staff member. This failure to use appropriate personal protective equipment during medication administration represents a lapse in infection control practices.
Failure to Report Neglect Allegation to State Authorities
Penalty
Summary
The facility failed to report an allegation of neglect involving a resident to the State Department of Health as required by policy and regulation. The facility's policies mandate that all incidents of abuse, neglect, or misappropriation, including injuries of unknown origin, must be reported to the appropriate authorities and thoroughly investigated. However, a review of the facility's incident records did not include documentation regarding a resident's right foot skin concerns, which were caused when the resident's right foot was dragged on the carpet while being pushed in a shower chair, resulting in several faint, scabbed areas on three toes. The resident involved had diagnoses of hypertension, diabetes, and hyperlipidemia. The incident was documented in the physician's progress note, but there was no evidence that it was reported to the State Department of Health. During an interview, the Nursing Home Administrator confirmed that the incident was not reported as required. This failure to report was identified through a review of facility policies, clinical records, and staff interviews.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents, resulting in elopement incidents involving two residents. According to the facility's Wandering and Elopements policy, residents at risk for unsafe wandering should be identified and protected from harm. One resident, with a history of diabetes mellitus, post-traumatic stress disorder, and hypotension, was assessed as moderately cognitively impaired but not at risk for elopement. Despite this, the resident was able to access the elevator and reach the lobby and front door without staff knowledge, and on another occasion attempted to exit the facility. Another resident, also moderately cognitively impaired and diagnosed with hypertension, cancer, and hyperlipidemia, was identified as at risk for elopement. Physician orders required a security bracelet to be attached to the resident's wheelchair at all times, with checks every shift. However, the resident was found on a different floor without the required alarm device on the wheelchair, contrary to the care plan and physician orders. The Nursing Home Administrator confirmed that the facility did not provide proper supervision for these residents as required.
Failure to Document Clinical Indication for Indwelling Catheter
Penalty
Summary
The facility failed to ensure that appropriate treatments and services were provided for the use of an indwelling urinary catheter for one resident. Specifically, the clinical record for a resident admitted with diagnoses including high blood pressure, hyperlipidemia, and muscle weakness showed a physician's order for an indwelling urinary catheter, but the order did not include a required diagnosis for the catheter. Review of facility policy indicated that clinical indications for catheter use should be reviewed and documented prior to insertion, and the ongoing need for the catheter should be assessed and documented by nursing and the interdisciplinary team. This deficiency was confirmed during an interview with a registered nurse, who acknowledged the failure to provide the required documentation and assessment for the catheter use.
Failure to Complete Annual Staff Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations for four out of five nursing staff members, as required by facility policy. Personnel records for two nurse aides and one LPN, with varying hire dates, did not contain documentation of annual performance evaluations. The facility's policy specifies that employee performance should be rated, strengths and areas for improvement noted, and the evaluation filed in the personnel record. During an interview, the Nursing Home Administrator confirmed that these evaluations had not been completed for the identified staff members.
Failure to Accommodate Documented Seafood Allergy in Resident Meal Service
Penalty
Summary
Resident R13, who had documented diagnoses including anoxic brain damage, cerebral infarction, and chronic obstructive pulmonary disease, was admitted to the facility with a known and recorded allergy to crab and seafood. Despite this, the resident was served shrimp alfredo for dinner, as confirmed by a review of the nutrition assessment, physician orders, and dietary manager interview. Following the meal, the resident vomited, with whole dinner contents present, and later reported the incident to staff. The resident's granddaughter also filed a grievance, expressing concern that seafood was served despite the known allergy. The deficiency was identified through observation, record review, and staff interviews, confirming that the facility failed to provide food in a form that met the resident's individual dietary needs.
Failure to Ensure Resident Capacity and Proper Signatures for Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents had the capacity to understand the terms of a binding arbitration agreement and failed to obtain required signatures for such agreements. For one resident with a diagnosis of non-Alzheimer's dementia, hyperlipidemia, and anxiety, the Minimum Data Set (MDS) indicated a Brief Interview for Mental Status (BIMS) score of 6, signifying severe cognitive impairment. Despite this, the resident personally signed a binding arbitration agreement, indicating the facility did not verify the resident's capacity to comprehend the agreement at the time of signing. The admissions director confirmed this lapse during an interview. Additionally, another resident with diagnoses including high blood pressure, weakness, and dementia, and a BIMS score of 14 (cognitively intact), was documented as having entered into a binding arbitration agreement. However, a review of the facility's records showed that the required signature was not obtained for this agreement. The admissions director also confirmed this failure to secure the necessary signature. These findings were based on reviews of facility documents, resident clinical records, and staff interviews.
Failure to Ensure Required QAA Committee Members Present at Quarterly Meeting
Penalty
Summary
The facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all required committee members present, as evidenced by a review of facility policy, QAA attendance records, and staff interviews. Specifically, for the first quarter of 2025, the attendance records did not show that the Infection Preventionist was present at the QAA meeting. This was confirmed by the Director of Nursing during an interview, who acknowledged that the required quarterly meeting did not include all mandated committee members for that quarter. The facility's QAPI policy requires an ongoing, facility-wide, data-driven program focused on care outcomes and quality of life, and mandates quarterly QAA meetings with specific committee members, including the Infection Preventionist. The absence of the Infection Preventionist at the required meeting constituted noncompliance with both facility policy and regulatory requirements.
Failure to Monitor Antibiotic Use for One Month
Penalty
Summary
The facility failed to implement its antibiotic stewardship program for one of ten months, specifically September 2024. Review of the facility's infection control policies and procedures, as well as the job description for the Quality Assurance/Infection Control Preventionist, indicated that monitoring antibiotic use is a required responsibility. However, documentation of antibiotic monitoring was missing for September 2024 in the facility's Infection Control surveillance records covering August 2024 through May 2025. During an interview, the Director of Nursing confirmed that antibiotic stewardship was not carried out for that month.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified individual onsite to be responsible for implementing infection prevention and control programs and activities from 2/10/25 to 3/5/25. According to staff interviews and facility records, the previous Infection Preventionist resigned effective immediately on a Saturday, and a new Infection Preventionist was assigned to the role. However, the newly assigned Infection Preventionist did not complete the required specialized training and certification in infection prevention and control until 3/6/25. The Director of Nursing confirmed that during this period, there was no qualified individual overseeing the infection prevention and control program, as required by facility policy and state regulations.
Failure to Maintain Crash Carts in Safe Operating Condition
Penalty
Summary
The facility failed to ensure that essential emergency equipment, specifically two crash carts located on the first and second floors, were maintained in safe operating condition. Observations revealed that the Crash Cart Daily Signature Log for the first-floor crash cart had not been completed for three consecutive days, with the last entry dated three days prior to the observation. Similarly, the second-floor crash cart log was missing an entry for the same date, with the signature line left blank. These lapses were confirmed by both the Director of Nursing and a Registered Nurse during interviews, who acknowledged that the required daily audits had not been conducted as documented.
Failure to Provide Required Communication Training to Direct Care Staff
Penalty
Summary
The facility failed to provide required training on effective communication to all five direct care staff members reviewed, including nurse aides, an LPN, and an RN. According to the facility's own in-service training policy, all staff are required to participate in both initial orientation and annual in-service training, which must include effective communication as a core topic. However, a review of education records for the year 2024 showed that none of the five staff members had documentation of having received this training. Interviews with the Human Resources Director confirmed that education is scheduled annually, and the Nursing Home Administrator acknowledged the lack of communication training for the staff in question. The deficiency was identified through a review of facility policy, staff education records, and staff interviews, and it was cited under 28 Pa. Code: 201.14(a) and 201.20(a) for failure to meet staff development requirements.
Failure to Provide QAPI Training to Direct Care Staff
Penalty
Summary
The facility failed to provide mandatory training on Quality Assurance and Performance Improvement (QAPI) to all staff as required by its own policy and state regulations. Review of the facility's in-service training policy indicated that all staff must participate in initial orientation and annual in-service training, with QAPI listed as a required topic. However, examination of facility education records for the year 2024 revealed that five direct care staff members, including nurse aides, an LPN, and an RN, did not receive training on QAPI. Interviews with the Human Resources Director and the Nursing Home Administrator confirmed that the facility did not provide QAPI training to these staff members. The deficiency was identified through review of facility documents and staff interviews, and it was determined that the facility was not in compliance with its own policies and state regulations regarding staff development and management responsibilities.
Failure to Provide Required Infection Control Training to Direct Care Staff
Penalty
Summary
The facility failed to provide mandatory infection control training to two of five direct care staff members reviewed, specifically an LPN and an RN. According to the facility's in-service training policy, all staff are required to participate in initial orientation and annual in-service training, which must include infection prevention as a topic. Review of facility education records for the year 2024 showed that neither the LPN nor the RN had documentation of having received infection control training. This was confirmed by the Human Resources Director and the Nursing Home Administrator during interviews. The deficiency was cited under 28 Pa Code: 201.14 (a) and 28 Pa Code: 201.18 (b)(1).
Failure to Notify Physician or Representative of Resident Status Changes
Penalty
Summary
The facility failed to notify the physician or resident representative of changes in condition or status for three residents, as required by facility policy. For one resident with diabetes, PTSD, and hypotension, there was no documentation of physician or representative notification after the resident left the unit and was found near the front door by nursing staff. Another resident with hypertension, cancer, and hyperlipidemia was found on a different floor without the required monitoring device on their wheelchair, and again, there was no evidence of notification to the physician or representative regarding this incident. A third resident, who had high blood pressure, bilateral below-knee amputations, renal insufficiency, and severe cognitive impairment, had a new medication order for pantoprazole due to a history of gastrointestinal bleeding. The clinical record did not show that the resident's representative was notified of this medication change. Staff interviews confirmed that in all three cases, the required notifications to physicians or resident representatives were not made following changes in the residents' conditions or status.
Failure to Inform Resident's Representative of Medication Change
Penalty
Summary
The facility failed to inform a resident's representative in advance of the proposed care, including the risks and benefits of a prescribed medication change for a resident. The resident, who had diagnoses of end-stage renal disease, dementia, and chronic kidney disease, was assessed with a BIMS score of 10, indicating moderate cognitive impairment. A physician's order increased the dosage of Mirtazapine from 30 mg to 45 mg at bedtime for mood management. However, there was no evidence in the nurse's progress notes that the resident's daughter or other representatives were notified of this new order or that the advantages, disadvantages, and alternative options were discussed. The Director of Nursing confirmed during an interview that the facility did not inform the resident's representative about the proposed care changes as required. This oversight was identified during a review of clinical records and staff interviews, highlighting a failure to comply with resident rights and nursing services regulations. The deficiency was noted under the Pennsylvania Code, specifically 28 Pa Code 201.29(j) regarding resident rights and 28 Pa. Code 211.12(d)(1) concerning nursing services.
Failure to Communicate Resident Information During Transfers
Penalty
Summary
The facility was found to be non-compliant with the requirements for transfer and discharge under 42 CFR Part 483, Subpart B, as well as the 28 Pa. Code, during an abbreviated survey conducted in response to complaints and an infection control survey. The deficiency was identified in the facility's failure to communicate necessary resident information to the receiving health care provider for two residents who were transferred to the hospital. This lack of communication included the omission of critical details such as care plan goals, advanced directive information, specific instructions for ongoing care, and resident representative information. The first resident, admitted to the facility in January 2025, had a medical history that included high blood pressure, diabetes, and cerebral infarction. This resident was transferred to the hospital shortly after admission, but the facility did not document or communicate the necessary information to the hospital, which was essential for the resident's continued care. Similarly, the second resident, admitted in October 2023, with diagnoses of depression, dementia, and Parkinson's disease, was also transferred to the hospital without the required documentation and communication of care details. During an interview, the Director of Nursing confirmed the facility's failure to ensure that the necessary information was communicated to the receiving health care provider for both residents. This oversight was a direct violation of the regulatory requirements for transfer and discharge, as it did not provide the receiving facility with the information needed to meet the residents' specific needs and ensure a safe and effective transition of care.
Plan Of Correction
1. Residents R1 returned to the facility on 1/15/25 and discharged home with family on 2/3/25, and R2 returned to the facility on 1/27/25. 2. A one-week retroactive review of all facility-initiated transfers will be followed-up by telephone to ensure that all necessary resident information was communicated to the receiving health care provider and provide any information if necessary. 3. The NHA or designee will educate all licensed nursing staff and social services staff on the necessary information requirement found at F622 for transfers to a receiving health care provider. 4. The NHA or designee will audit all facility-to-facility transfers to ensure all resident information requirements were met daily x3, then five resident facility-to-facility transfers weekly x8. Results will be reviewed through QAPI for further recommendation.
Failure to Notify Residents of Bed-Hold Policy During Transfers
Penalty
Summary
The facility failed to notify residents or their representatives of the bed-hold policy during hospital transfers, as required by §483.15(d). This deficiency was identified through a review of facility policy, clinical records, and staff interviews. The facility's policy, dated 5/12/24, mandates that residents or their representatives receive written information about the bed-hold policy at admission and at the time of transfer. However, for two residents, this requirement was not met during their respective hospital transfers. Resident R1, admitted on 1/13/25, was transferred to the hospital on 1/14/25 and returned on 1/15/25. The clinical record lacked evidence of written notification about the bed-hold policy at the time of transfer. Similarly, Resident R2, admitted on 10/23/23, was transferred to the hospital on 1/21/25 and returned on 1/27/25, with no documented evidence of notification. The Director of Nursing confirmed the oversight during an interview, acknowledging the failure to provide the required notifications for both residents.
Plan Of Correction
1. Resident R1 returned to the facility on 1/15/25 and resident R2 returned to the facility on 1/27/25. No negative outcomes to R1 and R2. No charges made to R1 and R2 accounts for bed-hold fees. 2. A retroactive 14-day review of all hospital/leave transfers will be completed to ensure resident/representatives have been provided information regarding the facility bed-hold policy. 3. NHA or designee will educate all licensed nursing staff and social services staff on the facility bed-hold policy and communicating information at time of transfer. 4. NHA or designee will audit all hospital/leave transfers daily x3, then five resident transfers weekly x8 to ensure bed-hold information was provided. Results will be reviewed through QAPI for further recommendation.
Failure to Provide ADL Assistance for Two Residents
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADL) for two residents, resulting in a deficiency. Resident R1, who was admitted on January 13, 2025, had a Minimum Data Set (MDS) assessment indicating a partial-moderate need for assistance with self-care activities such as bathing, dressing, and using the toilet. Despite this, documentation showed that Resident R1 did not receive a shower on January 25, 2025. Similarly, Resident R3, admitted on August 6, 2019, had an MDS assessment indicating a substantial maximal need for assistance with self-care. However, the facility's records revealed that Resident R3 did not receive showers on multiple dates in January 2025, specifically on the 1st, 4th, 8th, 11th, and 18th. The Director of Nursing confirmed the facility's failure to provide the required ADL assistance for these residents.
Plan Of Correction
Resident R1 received a shower on 1/26/2025 and R3 received a shower on 1/29/2025. A whole house audit 14 day look back was completed for shower documentation for all residents. The Director of Nursing or designee will educate all nursing staff on proper documentation and complete documentation of bathing. The Director of Nursing or designee will audit all residents bathing documentation daily at morning meetings for 2 weeks, and weekly for 2 weeks, and monthly for 2 months. Audits will be reviewed at the monthly QAPI for further recommendations.
Failure to Report COVID-19 Outbreak
Penalty
Summary
The facility failed to notify the Department of Health about a reportable disease outbreak, specifically a positive COVID-19 outbreak affecting 36 residents. This deficiency was identified during a review of facility documentation and staff interviews conducted on January 28, 2025. The documentation review revealed that the facility did not report the positive COVID-19 cases, which is a requirement for health department reportable diseases. During an interview, the Director of Nursing (DON) admitted to not reporting the positive COVID-19 cases, mistakenly believing that only positive cases among employees needed to be reported. This misunderstanding led to the facility's failure to comply with the notification requirements, thereby compromising the regulatory obligation to report such significant health events to the Department of Health.
Plan Of Correction
1. Residents to equal 36 total have been added to the Department of Health with health reportable events. 2. The NHA or designee will educate the Director of Nursing and Assistant Director of Nursing on notifying the Department of Health with health department reportable diseases. 3. The Director of Nursing or designee will audit all health reportable diseases for notification to the Department of Health daily at morning meetings for 2 weeks, 2 times a week for 2 weeks and then monthly. Results will be reviewed through QAPI for further recommendations.
Resident Elopement Due to Inadequate Supervision and Security Override
Penalty
Summary
The facility failed to provide adequate supervision for a resident identified as an elopement risk, resulting in the resident leaving the facility without permission. The resident, who had a history of attempts to leave the facility unattended and was diagnosed with dementia and a psychotic disorder, was equipped with a security bracelet designed to alert staff if they left a safe area. Despite this precaution, the resident was able to exit the building when a staff member used an identification badge to override the security system and open the door for visitors. On the day of the incident, the resident was observed on camera leaving the third floor and entering the lobby, where they followed visitors towards the exit. The visitors, unaware of the resident's status, did not inform staff that the resident was not with them. A dietary supervisor, believing the resident was part of the visitor group, used their badge to open the door, allowing the resident to exit. The security system alarm was triggered, but the resident had already crossed the threshold and was found outside in the parking lot by staff. Interviews with staff revealed that the security system was functioning correctly, but the use of an identification badge to open the door bypassed the alarm system. The facility's failure to properly identify the resident as a resident and not a visitor, combined with the staff's actions in overriding the security system, led to the resident's unsupervised exit from the facility. The incident was confirmed by the Director of Nursing, who acknowledged the lapse in supervision and identification procedures.
Plan Of Correction
1. The facility increased visual monitoring of Resident R1 and assigned staff to monitor for all residents including R1 usage of elevator during the times of reception employee vacancy. 2. All residents in the facility were reassessed for wandering and elopement risk. Resident care plans were reviewed and updated as needed. Security bracelet list was reviewed. 3. All facility staff are educated by Director of Nursing/Designee on elopement, security bracelet function, behaviors, and how to identify a resident exiting unaccompanied. 4. The Director of Nursing/designee will audit all residents with identified exit seeking behaviors for exit seeking behaviors relating to elevator use daily.
Failure to Report Resident Elopement
Penalty
Summary
The facility failed to notify the local State Agency of a reportable event in a timely manner involving a resident who eloped from the facility. The resident, who had been admitted with diagnoses including degeneration of the nervous system due to alcohol, diabetes mellitus, and epilepsy, was found in the parking lot in her wheelchair by a nurse aide. This incident occurred on 11/24/24, but the facility did not report the elopement to the State Agency field office within the required timeframe. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the resident had eloped through the lobby front doors to the parking lot. A review of reports submitted to the local State field office between 11/24/24 and 12/2/24 showed no notification of the elopement event, indicating a failure in the facility's reporting procedures for serious incidents that compromise patient safety.
Plan Of Correction
1. Facility notified the local state agency of the reportable event for Resident R1 on December 5, 2024 after recommendation by local state survey. 2. The Director of Nursing will be educated by Regional Director of Clinical Support on timely event reporting. 3. The Director of Nursing/designee will audit all events for reporting criteria daily for 2 weeks during morning meetings, weekly for 2 weeks, and monthly for 2 months. Audit results will be reviewed at monthly QAPI meetings.
Failure to Provide ADL Assistance
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADL) for a resident, identified as Resident R1, who was unable to perform these tasks independently. According to the facility's ADL policy, residents should receive care to maintain or improve their ability to carry out ADLs, including bathing, dressing, grooming, and oral care. Resident R1's MDS assessment indicated a dependency on assistance for self-care activities, with a coding of 1, meaning the helper does all the work. Despite this, the facility's records showed that Resident R1 did not receive showers on three specific dates in October 2024. This deficiency was confirmed by the Nursing Home Administrator during an interview on November 6, 2024.
Failure to Notify Medical Provider of Resident's Change in Condition
Penalty
Summary
The facility failed to notify a medical provider of a change in condition for a resident, identified as Closed Resident Record CR1, as required by their policy. The policy mandates prompt notification of the resident's physician and representative in case of significant changes in the resident's condition. However, the review of CR1's clinical progress notes revealed that there was no documentation of a discussion with the physician or other clinical staff regarding CR1's change in status, specifically related to chest pain, nor was there a full set of vitals taken after the onset of this symptom. CR1 had a history of chronic pain and was eager to discharge, as noted in a physician assistant's documentation. On the day of the incident, CR1 requested Oxycodone for pain, which was administered by LPN Employee E1. Despite CR1 expressing chest pain, LPN Employee E1 did not notify a physician or take a full set of vitals, as would be standard procedure for chest pain. Instead, the nurse attempted to manage the situation by talking to CR1 to alleviate anxiety and repositioning him, but did not document these actions thoroughly. Interviews with staff, including LPNs and nurse aides, confirmed that CR1 had complained of chest pain, but the necessary steps to address this change in condition were not taken. The Director of Nursing acknowledged the failure to notify a medical provider as required. The report highlights a deficiency in following the facility's policy for notifying medical providers of significant changes in a resident's condition.
Neglect of Resident's Care Needs During Medical Appointment
Penalty
Summary
The facility failed to protect a resident from physical neglect, as evidenced by the incident involving Resident R1. The resident, who was diagnosed with stroke, Multiple Sclerosis, and unspecified intellectual abilities, required moderate assistance with toileting and transfers. On the day of the incident, Resident R1 was scheduled for an MRI appointment and requested to be changed before leaving the facility. However, the Nurse Aide (NA) Employee E1, who was responsible for escorting the resident, did not attend to this request and took the resident to the appointment without changing him. Upon returning from the appointment, Resident R1 was found heavily soiled with dried bowel movement from his back to his knees. The resident had been sitting in the soiled condition for an extended period, as indicated by the red but unbroken skin. NA Employee E2, who took over the resident's care upon return, confirmed the resident's condition and provided the necessary incontinence care. The resident had informed NA Employee E2 that he had asked NA Employee E1 to take him to the bathroom, but the request was ignored. The facility's documentation and staff interviews corroborated the neglect incident. NA Employee E1 did not provide the required care and subsequently left the facility without addressing the resident's needs. The Nursing Home Administrator and other staff members confirmed the neglect, and the event was substantiated, leading to the termination of NA Employee E1. The facility's failure to protect the resident from neglect was acknowledged by the Nursing Home Administrator.
Medication Misappropriation by RN in LTC Facility
Penalty
Summary
The facility failed to protect residents from the misappropriation of medications, specifically involving two residents, R2 and R3. The facility's policy on Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, dated 5/12/24, mandates that residents should be free from such acts. Additionally, the Controlled Substances policy requires reconciliation of medications upon receipt, administration, and disposal, with proper documentation and co-signing by a witness. However, these protocols were not followed, leading to the misappropriation of medications by RN Employee E7. Resident R2, diagnosed with heart failure, diabetes, and COPD, had a physician's order for Oxycodone 30 mg every six hours as needed for pain. Resident R3, with diagnoses of heart failure, diabetes, and cirrhosis, had an order for Oxycodone 10 mg every four hours as needed. It was discovered that RN Employee E7 diverted six doses of oxycodone, as evidenced by discrepancies in medication records and the absence of required co-signatures for destroyed medications. The Director of Nursing confirmed the narcotics could not be accounted for, indicating a failure to ensure residents were free from medication misappropriation.
Improper Food Storage in Main Kitchen
Penalty
Summary
The facility failed to properly store food products in the Main Kitchen, which could lead to foodborne illness. During a review of the facility's policy on Food Receiving and Storage, it was noted that foods should be received and stored in compliance with safe food handling practices, with opened containers being dated and sealed or covered during storage. However, an observation in the Main Kitchen Dry storage area revealed an open box containing a plastic bag of rice and another open box with a plastic bag of pureed bread mix, both of which were not sealed. This was confirmed by the Dietary Director, Employee E13, during an interview.
Deficiencies in Resident Dignity and Communication
Penalty
Summary
The facility failed to uphold the dignity and privacy of its residents in several instances. One resident, identified as R51, was administered medication through a feeding tube without privacy, as a housekeeper was present in the room during the procedure. The Registered Nurse involved admitted to not asking the housekeeper to leave before administering the medication, and the Director of Nursing confirmed this breach of privacy. Another resident, R75, who primarily speaks Spanish and mixes it with Italian, was not provided with adequate communication support. The facility did not have a communication care plan in place to address the resident's language barrier, and staff members struggled to communicate effectively with her. The resident's family members were relied upon for translation, but no formal interpretive services or equipment were available to assist in communication when family members were not present. Additionally, the facility failed to respect the preferred name of a resident, R93. The resident's preferred name was not documented, and staff members did not address her by it. The Social Service Director confirmed that the resident's preference was not recorded, indicating a lack of respect for the resident's personal choice in how she wished to be addressed.
Deficiencies in Resident Transfer and Discharge Documentation
Penalty
Summary
The facility failed to acquire and document a physician's discharge order for one resident, identified as Resident R133, who was scheduled to return to her prior Independent Living Facility. Despite the clinical progress note indicating the discharge plan, there was no documented physician's order authorizing the discharge. This oversight was confirmed by the Director of Nursing during an interview. Additionally, the facility did not ensure that necessary resident information was communicated to the receiving health care provider for five residents who were transferred to a hospital and expected to return. These residents, identified as R28, R43, R64, R75, and R83, had various medical conditions including muscle weakness, quadriplegia, diabetes, high blood pressure, heart failure, anemia, septicemia, and dementia. The facility's failure to provide specific information such as care plan goals, advanced directive information, and instructions for ongoing care was noted in the clinical records and confirmed by the Director of Nursing. The facility's policies on Discharge Summary and Plan, as well as the Transfer Form, require comprehensive documentation and communication of resident information during transfers and discharges. However, the review of resident records revealed a lack of adherence to these policies, resulting in deficiencies in the transfer and discharge processes for the residents involved.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure accurate resident assessments for seven residents, leading to discrepancies in their Minimum Data Set (MDS) documentation. For Resident R2, the MDS inaccurately coded the resident as dependent for bed mobility, despite observations and staff confirmation that the resident used side rails for assistance. Similarly, Resident R6's MDS incorrectly indicated the use of side rails as restraints, although they were used for positioning, as confirmed by the resident and staff. Resident R21's MDS inaccurately reflected the use of side rails, which were no longer present on the bed due to a recent bed change. The resident had been performing bed mobility without them, yet the MDS was not updated to reflect this change. Additionally, Resident R38's MDS failed to document hospice care, despite a physician order and staff confirmation of hospice services being provided. Further inaccuracies were noted for Resident R64, whose MDS incorrectly coded side rails as restraints, and Resident R68, whose MDS did not reflect the use of oxygen therapy during the assessment period, despite documentation of its use. Lastly, Resident R285's MDS failed to document a stage 3 pressure ulcer, which was noted upon the resident's arrival at the facility. These inaccuracies highlight a systemic issue in the facility's assessment process, as confirmed by staff interviews.
Inadequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for several residents, leading to worsening conditions and the development of new pressure ulcers. For one resident, the facility did not create a personalized care plan for their wound, and weekly skin assessments were not conducted as ordered. The resident's dressing was not properly dated or initialed, and the wound care nurse delayed entering skin/wound notes by several days. The Director of Nursing confirmed these failures during an interview. Another resident, who was at low risk for pressure ulcer development, developed a facility-acquired Stage 2 pressure ulcer on the left heel. The facility failed to conduct weekly wound assessments as ordered, and the wound care nurse did not document the depth and stage of the pressure ulcer in several progress notes. The resident's care plan did not include the left heel pressure ulcer, and the Director of Nursing confirmed the absence of a care plan for this condition. Additional residents also experienced inadequate care. One resident's right heel pressure ulcer worsened and developed a second open area, with the wound care nurse failing to document the depth and stage of the ulcer. Another resident was admitted with a Stage 3 pressure ulcer, but the facility did not assess the wound upon admission or include it in the skin concerns list. The facility also failed to monitor the resident's pressure ulcer and did not include any interventions related to the pressure ulcer risk in the resident's care plan.
Failure to Provide Appropriate Catheter Care
Penalty
Summary
The facility failed to provide appropriate treatments and services for the use of urinary catheters for three residents. Resident R53 was observed with a urinary catheter bag lying on the floor without a dignity bag, which was confirmed by a Licensed Practical Nurse (LPN). Resident R93 had an indwelling catheter without a documented diagnosis for its use, as required by the physician's order. This omission was confirmed by the Director of Nursing (DON). Resident R129 was observed with a urinary drainage bag hanging from the bed frame without a dignity bag, which was also confirmed by an LPN. The facility's policies on catheter care and resident dignity were not adhered to, as evidenced by the observations and staff confirmations. The facility's policy required catheter tubing and drainage bags to be kept off the floor and covered to maintain resident dignity. The DON confirmed the facility's failure to ensure appropriate catheter care and services for the three residents, which is a violation of the facility's resident care policies and nursing services regulations.
Failure to Monitor and Address Nutritional Needs
Penalty
Summary
The facility failed to provide necessary services and properly monitor and assess weight and nutrition status for several residents, leading to significant weight loss and inadequate nutritional intake. Resident R28 experienced a substantial weight loss over several months, with a care plan that did not accurately reflect the need for staff assistance with feeding. Observations revealed that the resident's meals were not consistently provided or consumed, as staff failed to feed the resident as ordered, resulting in untouched meal trays being removed without being eaten. Resident R83 also suffered from significant weight loss, exacerbated by a lack of proper tube feeding orders during a transition to a new electronic charting system. The resident's caloric and fluid intake was reduced without explanation, and the facility did not adequately address the resident's weight loss or adjust nutritional strategies to meet the resident's needs. This oversight contributed to the resident's hospitalization due to hypernatremia. Other residents, including R91, R129, and R243, were not weighed upon admission or had inaccurate weights recorded, leading to improper nutritional assessments and care plans. These failures in monitoring and assessing nutritional status resulted in significant weight loss and inadequate dietary management, highlighting the facility's inability to provide essential nutritional care and services to its residents.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents, as identified through a review of facility policy, observations, interviews, and clinical record reviews. Resident R68 was observed with a nasal cannula tubing dated 6/29 and an undated humidification bottle, and it was confirmed that there was no physician order for oxygen therapy. Resident R285 was using 2 liters of oxygen via nasal cannula with an empty humidification bottle, and similarly lacked a physician order and care plan for oxygen. Resident R334 had a physician order for oxygen at bedtime but lacked a care plan for supplemental oxygen use, and both the nasal cannula tubing and humidification bottle were undated. The Director of Nursing confirmed the absence of physician orders and care plans for the residents' oxygen therapy, which is a violation of the facility's policy on oxygen administration. The facility's policy requires verification of a physician's order and a review of the resident's care plan before administering oxygen, as well as ensuring that the equipment is in good working order. The deficiencies were noted under the Pennsylvania Code sections related to the responsibility of the licensee, resident care policies, and care plans.
Inaccurate Care Plans and Lack of Bed Rail Assessments
Penalty
Summary
The facility failed to maintain accurate resident care plans and conduct ongoing assessments to ensure the safe use of bed rails for five residents. According to the report, the facility did not perform initial and ongoing assessments for the use of bed rails, which is a requirement under Title 42 Code of Federal Regulations (CFR) S483.25(n). This regulation mandates that facilities assess residents for the risk of entrapment from bed rails before installation and continue to evaluate the risks and benefits of their use. For Resident R2, the care plan inaccurately reflected the use of side rails as restraints, despite the resident using them for mobility and positioning. Observations confirmed the presence of bilateral upper side rails on the resident's bed, but there was no documentation of initial or ongoing assessments. Similarly, Resident R6's care plan also inaccurately indicated restraint use, and no assessments were documented, even though the resident used the side rails for positioning. Resident R21's care plan inaccurately listed side rails as restraints, and no assessments were documented, even though the resident had previously used them for mobility. Resident R28 did not have a physician's order for bed rails, and no assessment was completed. Lastly, Resident R64's care plan inaccurately reflected restraint use, and no assessments were documented, despite the resident using the side rails for bed mobility.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate documentation for three residents, leading to deficiencies in medical record-keeping. For Resident R4, the facility did not document weekly skin checks as required by the physician's order. The Skin/Wound Notes for this resident were entered weeks after the checks were supposed to be conducted, indicating a delay in documentation. The Director of Nursing confirmed the lack of complete and accurate documentation for this resident. Resident R9's records showed inaccuracies in the staging of a pressure ulcer. The resident was initially assessed with a Stage 3 pressure ulcer, but subsequent documentation inaccurately described it as a Stage 2 ulcer. This discrepancy was confirmed by the Director of Nursing and the Wound Care Registered Nurse, who provided incorrect descriptions of the ulcer stages, further highlighting the documentation errors. For Resident R38, the facility failed to maintain timely and accurate documentation of a Stage 3 pressure ulcer. The Wound Care Nurse admitted to delays in documentation due to being overburdened with tasks, resulting in inaccurate records that indicated the resident's skin was intact when it was not. This was confirmed by the Wound Care Nurse, who acknowledged the documentation errors for this resident.
Infection Control and Resident Care Deficiencies
Penalty
Summary
The facility failed to implement an effective infection control program, as evidenced by the lack of surveillance for tracking infections for four months within an 11-month period. The facility's policy required ongoing surveillance for healthcare-associated infections and other significant infections, but this was not conducted from March to June 2024. The Director of Nursing confirmed this lapse in the infection control program, which is a critical component of maintaining a safe and sanitary environment for residents. Additionally, there was a failure to prevent cross-contamination during a dressing change for a resident with multiple sclerosis, depression, and osteoarthritis. The Wound Care Registered Nurse did not adhere to proper infection control procedures, such as washing hands before putting on gloves and cleaning the bedside table before and after the procedure. This oversight was confirmed by the Director of Nursing, indicating a breach in the facility's wound care policy. Furthermore, the facility did not ensure appropriate care for a resident with a urinary catheter. The resident's catheter bag was observed lying directly on the floor, contrary to the facility's policy that requires the catheter tubing and drainage bag to be kept off the floor. This was acknowledged by a Licensed Practical Nurse and later confirmed by the Director of Nursing, highlighting a failure to provide necessary treatments and services for the resident's condition.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for four months, specifically March, April, May, and June 2024. This deficiency was identified through a review of the facility's infection control policies and procedures, as well as staff interviews. The facility's policy on Antibiotic Stewardship, dated May 18, 2024, outlines the purpose of the program as monitoring antibiotic use among residents. However, the facility's Infection Control surveillance records from August 2023 to June 2024 lacked documentation indicating that antibiotic monitoring was conducted during the specified months. The Quality Assurance/Infection Control Preventionist's job description includes the responsibility of overseeing the antibiotic stewardship program, yet this was not fulfilled. During an interview on July 12, 2024, the Director of Nursing confirmed the failure to implement the program for the mentioned months. This deficiency is in violation of 28 Pa. Code: 211.10(c)(d) regarding resident care policies and 28 Pa. Code: 211.12(d)(1)(2)(3)(5) concerning nursing services.
Deficiency in Nurse Aide Training Compliance
Penalty
Summary
The facility failed to ensure that all nurse aide staff received the required minimum of twelve hours of in-service education training each year, within 12 months of their hire date anniversary. This deficiency was identified through a review of facility in-service documentation, personnel records, and staff interviews. Specifically, the personnel records of five nurse aides (Employees E17, E18, E19, E20, and E21) did not include documentation of the required training hours as mandated under S483.95(g)(1). The facility's policy, titled Staffing, Sufficient and Competent Nursing, dated 5/18/24, indicates that the facility is responsible for providing sufficient numbers of nursing staff with the appropriate skills and competency necessary to care for residents, but this was not adhered to in practice. During interviews, the Nursing Home Administrator confirmed the facility's inability to provide documentation of the completed training for the mentioned nurse aides. The deficiency was further supported by the facility's failure to comply with the relevant state codes, 28 Pa. Code: 201.14(a) and 28 Pa. Code: 201.20(a)(d), which pertain to the responsibility of the licensee and staff development, respectively. This lack of compliance indicates a systemic issue in ensuring that nurse aides receive the necessary ongoing education to maintain their skills and competencies in dementia care and abuse prevention.
Failure to Provide Accessible Call Bell for Resident
Penalty
Summary
The facility failed to accommodate the call bell needs for Resident R38, as observed during a survey. The facility's policy, dated 5/18/24, mandates that residents must have access to a call system to request assistance from staff. However, during an observation on 7/8/24, Resident R38 was found lying in bed with the call bell placed at the top of the mattress, behind the pillow, making it completely out of the resident's visual sight and reach. This was confirmed by an LPN at 10:18 a.m. and later by the Director of Nursing at 3:05 p.m. Resident R38's clinical record indicated diagnoses of high blood pressure, muscle wasting, and dementia, which could affect the resident's ability to seek help without an accessible call bell.
Failure to Offer Advance Directive Opportunity
Penalty
Summary
The facility failed to provide a resident with the opportunity to formulate an advance directive, which is a written instruction such as a living will or durable power of attorney for health care. This deficiency was identified during a review of facility policy, clinical records, and staff interviews. The facility's policy, dated 5/18/24, mandates that upon admission, residents should be given written information about their rights to accept or refuse medical treatment and to create an advance directive. However, the clinical record of a resident with diagnoses of quadriplegia, high blood pressure, and dry eyes, admitted on an unspecified date, lacked documentation that they were offered this opportunity. This was confirmed by the Social Worker Director during an interview on 7/10/24.
Confidentiality Breach in Resident Medical Information
Penalty
Summary
The facility failed to maintain the confidentiality of residents' medical information on the Third Floor nursing unit, affecting two residents. During an observation, the medication cart at the nurse's station was left unattended with the computer screen open, displaying identifiable resident information. This was confirmed by an LPN and the Nursing Home Administrator. Additionally, signs with medical instructions were posted in residents' rooms, further compromising confidentiality. Resident R9, diagnosed with multiple sclerosis, depression, and osteoarthritis, had a sign posted in their room detailing specific medical instructions, which was confirmed by a registered nurse. Similarly, Resident R285, diagnosed with respiratory and heart failure, had a sign indicating dietary requirements posted in their room, confirmed by another LPN. These actions violated the facility's policy on safeguarding personal privacy and confidentiality, as well as state codes regarding clinical records and resident rights.
Failure to Report and Investigate Neglect Allegations
Penalty
Summary
The facility failed to implement its abuse and neglect policy for two residents, leading to deficiencies in reporting allegations of neglect. For Resident R15, who has diagnoses of quadriplegia, aphasia, and anxiety, a grievance was filed indicating neglect when the resident was not assisted out of bed before lunch, despite wanting to get up before breakfast. This allegation was not reported to the state within the required 24-hour timeframe, as confirmed by the Director of Nursing and the Nursing Home Administrator. Similarly, for Resident R38, who has high blood pressure, anxiety, and blindness in one eye, a neglect allegation was made by the resident's daughter. She reported that her mother was not assisted with eating and was found with a cold, untouched lunch tray, and in an unclean state. The grievance was not reported to the state agency within the required timeframe, and a thorough investigation was not completed. The Nursing Home Administrator acknowledged the failure to report and investigate the allegations as per the facility's policy.
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A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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