Wecare At Sycamore Rehabilitation And Nursing Cent
Inspection history, citations, penalties and survey trends for this long-term care facility in Montoursville, Pennsylvania.
- Location
- 1445 Sycamore Road, Montoursville, Pennsylvania 17754
- CMS Provider Number
- 395379
- Inspections on file
- 32
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 39
Citation history
Health deficiencies cited at Wecare At Sycamore Rehabilitation And Nursing Cent during CMS and state inspections, most recent first.
Several residents reported receiving cold food, with meal trays arriving at inconsistent times and some not receiving their ordered items. Observation and temperature testing confirmed that food items were served below required temperatures, with puree eggs and bread tasting cold, milk tasting warm, and coffee tasting tepid. These findings were reviewed with the NHA and DON.
Multiple residents reported not receiving snacks when requested outside of scheduled meal times, with staff stating that no snacks were available in nourishment rooms. Observations confirmed the absence of snacks on all nursing units, and the food service director acknowledged the issue.
A resident who experienced an unwitnessed fall was not monitored according to the facility's neurological assessment protocol. Although initial assessments were performed and documented, required follow-up assessments throughout the night were missed. Staff interviews confirmed the lapse in following established post-fall monitoring procedures, and the resident was later found deceased, with chronic diastolic heart failure listed as the cause of death.
The facility failed to provide required notifications to residents whose payment coverage changed, affecting three residents. A resident did not receive the necessary CMS10123 or CMS10055 notices when her payment source changed from Medicare. Another resident's representative signed a CMS10055 notice but did not select an option box. A third resident received a verbal CMS10123 notice instead of a written one, despite no circumstances preventing timely written notice.
The facility failed to provide adequate bathing assistance to residents dependent on staff for activities of daily living. Five residents did not receive showers according to their preferences and care plans, with some receiving only bed baths or having inconsistent documentation of bathing activities. These deficiencies were reviewed with the Nursing Home Administrator and DON.
The facility failed to adhere to physician orders and medication protocols for several residents, including missing documentation of medication administration, inappropriate use of Midodrine, and lack of monitoring for Oxycodone administration. Additionally, a resident with a cardiac pacemaker lacked proper documentation and care plan interventions, while another resident's PICC line care was inadequately managed, lacking emergency procedures and proper documentation. These deficiencies indicate significant lapses in medication administration and care coordination.
The facility failed to provide appropriate pain management for two residents by not adhering to physician-ordered pain medication protocols. One resident received Oxycodone for pain levels that did not match the prescribed scale, and another resident was given medication for a pain level below the prescribed threshold. These discrepancies were discussed with the facility's administration.
The facility failed to obtain informed consent and educate residents or their representatives about the risks of bed rails for four residents. Additionally, the facility did not assess all potential entrapment zones for two residents, missing zone six, which could pose a risk. These deficiencies were confirmed through staff interviews.
The facility did not conduct annual performance reviews or provide the required 12 hours of in-service training for three nurse aides. Employee 10 lacked a review due in September 2024, Employee 11 had no evaluation after November 2023, and Employee 12, along with the others, did not receive mandatory training. The Nursing Home Administrator confirmed these deficiencies.
The facility failed to include laboratory reports in the clinical records of three residents. Despite physician notes indicating completed lab work, the results were not available in the records. Only the medical director and one other physician had access to view lab results, contributing to this deficiency.
The facility failed to store food properly in the main kitchen, with ground beef thawing above eggs and several food items past their use-by dates. The director of dining services confirmed the findings and discarded the items.
The facility failed to implement Enhanced Barrier Precautions for residents with chronic wounds or indwelling devices, as required by CMS guidelines. Observations showed that a resident with an indwelling urinary catheter and another with a central venous catheter and leg wounds lacked EBP. Additionally, an LPN did not follow proper hand hygiene protocols, and a resident on contact precautions for ESBL had no care plan addressing these precautions.
A facility failed to honor a resident's advance directive choices. Despite a completed POLST form indicating CPR should be performed, the facility did not update the resident's DNR order until identified by a surveyor. This issue was discussed with the DON and the Nursing Home Administrator.
A facility failed to report an allegation of narcotics theft involving a resident and a registered nurse to the appropriate authorities. Despite receiving emails from two nurses about the incident, the Director of Nursing did not notify the required agencies, violating facility policy and state regulations.
A facility failed to ensure accurate assessments for a resident, as an MDS assessment incorrectly indicated that the resident received insulin injections, despite the resident not having a diabetes diagnosis. This error was confirmed by the Nursing Home Administrator.
A facility failed to provide an ongoing program of activities for a resident who was dependent on staff for emotional, intellectual, physical, and social needs. Despite the care plan's interventions, the resident was observed sitting at the nurses' station without her busy blanket and attended only three activities over two months. The activity director confirmed the limited engagement, indicating a deficiency in meeting the resident's needs.
A facility failed to maintain or improve a resident's range of motion (ROM). Initially assessed with no impairments, the resident later showed limited ROM in both upper and lower extremities. Despite being discharged from physical and occupational therapy, the facility did not document any further assessment or intervention to address the decline. This was confirmed by the Nursing Home Administrator.
A facility failed to assess and implement individualized interventions for a resident frequently incontinent of bowel and bladder. The resident, dependent on staff for toileting due to impaired balance, had no attempts at a toileting program or interventions in place. The care plan noted the resident's self-care deficit but lacked specific interventions for incontinence. An interview with the Nursing Home Administrator and DON confirmed the absence of further assessment or interventions to promote continence.
The facility failed to provide appropriate respiratory care for three residents. One resident received oxygen without a physician's order, while another had discrepancies in oxygen settings and improperly stored equipment. A third resident had an oxygen concentrator set incorrectly and equipment was not properly dated or stored. These issues were confirmed by the DON and Nursing Home Administrator.
A facility failed to provide appropriate care for a resident requiring dialysis, as there was no emergency kit or signage to prevent complications from the dialysis access site. The resident, who received dialysis through a central venous catheter, was unaware of any equipment in his room for emergencies. Clinical records lacked orders for an emergency kit, and the care plan incorrectly referenced a graft. An LPN confirmed the absence of necessary materials, and a physician's order for an emergency kit was only added after surveyor intervention.
The facility failed to ensure nursing staff had the necessary competencies for managing medical devices such as indwelling catheters, Life Vests, and central venous catheters. This affected residents with complex medical needs, as staff lacked documented skills to manage these devices, confirmed through interviews and record reviews.
A facility failed to provide individualized behavioral health care for a resident with depression and dementia. Despite being on multiple psychoactive medications, the resident showed signs of detachment and poor appetite, and a care plan addressing her mood issues was discontinued without replacement. Staff confirmed the absence of an active care plan to address her depression, leading to a deficiency.
A facility failed to develop and implement a person-centered care plan for a resident diagnosed with dementia. Despite the resident's diagnosis and assessment indicating the need for a care plan, no such plan was documented. This deficiency was confirmed by the Nursing Home Administrator and DON during a survey.
A facility failed to properly dispose of and document controlled medications for a resident, as required by its policy. A nurse documented the disposal of Oxycodone and Lorazepam without dating the disposal or having a witness present. These discrepancies were confirmed during an interview with the facility's administration.
A facility failed to ensure proper medication labeling and physician orders for a resident. Employee 4 administered Dicyclomine and Diclofenac gel without specific dose strengths in the physician's orders, leading to discrepancies in medication administration. The nurse responsible for transcribing the orders did not select the desired medication strength, resulting in a failure to meet professional standards.
A resident admitted with Medicaid did not receive routine dental care as required, resulting in significant plaque buildup. Despite being due for cleanings every six months, the resident went over a year without dental services. Observations in February 2025 confirmed the deficiency, which was acknowledged by the facility's administration.
The facility's QAA committee failed to meet the required attendance criteria, with the medical director absent for nearly seven months and the DON absent for almost four months. The most recent meeting was in December 2024, and this deficiency was confirmed by the Nursing Home Administrator.
A facility failed to document that a resident's representative was educated on the risks and benefits of the influenza vaccine. The resident, with moderate cognitive impairment, had his flu vaccination refused by family without being provided necessary education for informed decision-making. This was confirmed by a corporate regional consultant, and the issue was reported to the Nursing Home Administrator and DON.
The facility did not designate a full-time Director of Nursing (DON) as required. An RN, serving as the interim DON, was instead utilized to cover nursing care units, working only two days in the DON role over several weeks. This was confirmed by the Nursing Home Administrator.
The facility failed to meet the required nurse aide-to-resident ratios during day, evening, and overnight shifts on multiple occasions. A review of staffing hours revealed consistent understaffing, confirmed by the Nursing Home Administrator. This deficiency highlights a pattern of inadequate staffing that could affect resident care.
The facility failed to meet the required LPN-to-resident ratios during day, evening, and overnight shifts over a 21-day review period. Specific instances include insufficient LPNs scheduled for the resident census on multiple days, as confirmed by the Nursing Home Administrator.
The facility did not meet the required minimum of 3.2 hours of direct resident care per patient day for 14 out of 20 days reviewed. Nursing care hours fell short on several days, with the lowest at 2.85 hours PPD. The Nursing Home Administrator confirmed this deficiency.
A facility failed to notify a resident's responsible party of a change in condition requiring interventions. A nurse aide reported wounds on a resident's toes, which were treated by a nurse and added to the wound nurse list. However, there was no documentation of notifying the responsible party about the wounds or the treatment. The responsible party learned of the condition during a visit. The DON and Nursing Home Administrator confirmed these findings.
A resident admitted with a fractured leg and at risk for pressure ulcers developed Stage 3 pressure ulcers on both buttocks, which were not identified by staff at an earlier stage. Despite requiring extensive assistance, the facility failed to document or assess the initial stages of the ulcers, leading to their progression. Interviews confirmed the lack of early identification and documentation.
The facility failed to ensure that three nurse aides received their annual performance reviews. Employees 3, 4, and 5, all hired on the same date, did not have documented performance reviews by the required date. This was confirmed by the Nursing Home Administrator.
The facility failed to provide written notice of the bed hold policy to six residents or their representatives upon transfer to the hospital for various medical conditions, as confirmed by the Nursing Home administrator.
The facility failed to follow physician orders for air mattress settings and insulin administration for two residents and did not integrate hospice care into the care plans for two other residents with terminal diagnoses. These deficiencies were confirmed through observations, clinical record reviews, and staff interviews.
The facility failed to assess and implement treatment and services to prevent and promote the healing of pressure ulcers for four residents. Observations revealed discrepancies in air mattress settings and delayed interventions for pressure ulcers, confirmed by the Nursing Home Administrator and the Director of Nursing.
The facility failed to ensure that nursing staff had the necessary competencies for tracheostomy, peg tube, and catheter care. Despite having residents with these specific needs, the facility could not provide documentation of staff competencies. This deficiency was confirmed by the Nursing Home Administrator and DON.
The facility failed to develop and implement individualized person-centered care plans for residents diagnosed with dementia and cognitive loss. Clinical record reviews and staff interviews revealed that four residents were admitted with diagnoses of dementia, but the facility did not create or implement the necessary care plans despite assessments indicating the need for them.
The facility failed to ensure that physicians addressed pharmacy recommendations for four residents and that the consulting pharmacist identified medication discrepancies. This included unauthorized medication administration and unaddressed recommendations for dose reductions and lab tests.
The facility failed to ensure that the medication regimens for three residents were free from potentially unnecessary medications. For one resident, there was no documentation of monitoring for side effects and behaviors as ordered by the physician. Similarly, two other residents had no documented evidence of behavior tracking or interventions used, despite physician orders. These deficiencies were confirmed during interviews with the Nursing Home Administrator and Director of Nursing.
The facility failed to implement comprehensive person-centered care plans for two residents regarding cognitive loss and psychotropic medication use. One resident's cognitive loss was assessed but not addressed in a care plan for nearly a year, while another resident's psychoactive medication use lacked a personalized care plan for targeted behaviors and interventions.
The facility failed to invite and ensure the attendance of residents and their responsible parties at care plan meetings for three residents. Documentation was missing for care plan meetings for Resident 8 and Resident 66 after specific dates, and Resident 62 had no documented care plan meetings or invitations within the past year.
The facility failed to maintain ROM for three residents. One resident was not placed on a recommended restorative nursing program, and two others had multiple instances where staff did not document the completion of their ROM exercises and other restorative tasks.
A resident identified as high risk for elopement followed a staff member off a locked dementia unit and was later found in another hall. The facility did not conduct an investigation into the incident, including staff interviews, staff education, or maintenance checks on the door lock.
The facility failed to provide appropriate respiratory care for a resident by not changing the oxygen tubing and bag for their CPAP device as ordered, and leaving the CPAP mask unbagged on the bedside stand. An LPN confirmed the continued use of outdated oxygen tubing.
The facility failed to provide timely and appropriate pain management for a resident upon admission. Despite having an order for Norco, the resident waited 59 minutes in excruciating pain due to a misreading of the medication availability by the supervising nurse. Documentation of the resident's pain level and medication effectiveness was also lacking.
The facility failed to ensure accurate acquiring and dispensing of medications for a resident. Upon admission, the resident's medications were not available, and she had to use her own pain medication. Additionally, other ordered medications were not administered as scheduled, and there was no documentation explaining why or if the pharmacy was contacted.
The facility failed to prevent the potential spread of infection to a resident on enhanced barrier precautions. An LPN performed tracheostomy care without wearing a gown, contrary to the specified precautions. The DON confirmed that the LPN should have worn a gown during the procedure.
Failure to Serve Food at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to serve food that was palatable and at safe, appetizing temperatures on four of six nursing units. According to the facility's policy, hot foods should be served at or above 135 degrees Fahrenheit and cold foods at or below 41 degrees Fahrenheit. Multiple residents reported that their food was frequently cold, with some stating that meal trays arrived at inconsistent times and that they sometimes did not eat the food if it was cold. One resident also reported not always receiving the food she ordered. A new admission confirmed that her food had been cold at times. Observation of a breakfast meal revealed that the meal cart left the kitchen and arrived at one unit at 7:34 AM, with trays being passed between 7:41 AM and 8:21 AM. Food temperature testing conducted by the surveyor and the food service director showed that puree eggs were 91.2°F and tasted cold, puree bread was 97.8°F and tasted cold, milk was 59.2°F and tasted warm, and coffee was 102.7°F and tasted tepid. These findings were reviewed with the Nursing Home Administrator and DON.
Failure to Provide Snacks Outside Scheduled Meal Times
Penalty
Summary
The facility failed to accommodate residents who wished to eat outside of scheduled meal service times on all six nursing units. Interviews with three residents revealed that they did not receive snacks, with staff informing them that there were no snacks available in the nourishment rooms. Observations of the nutrition rooms on each nursing unit confirmed that no snacks were available for residents who wanted to eat at non-traditional times. The food service director verified these findings during the survey, and the information was reviewed with the Nursing Home Administrator and Director of Nursing.
Failure to Complete Required Neurological Assessments After Unwitnessed Fall
Penalty
Summary
The facility failed to provide the highest practicable care regarding neurological assessments for a resident who experienced an unwitnessed fall. According to facility policy, neurological assessments are required following such incidents, with specific intervals for monitoring and documentation. The resident was found face down on the bathroom floor with lacerations to both elbows. The registered nurse assessed the resident's neurological status and contacted the on-call physician, who provided instructions regarding medication and monitoring for changes in neurological status. The nurse documented neurological assessments at 9:30 PM, 10:00 PM, 10:30 PM, and 11:00 PM, but no further assessments were recorded at the required intervals throughout the night. Review of the resident's clinical record and facility investigation confirmed that neurological assessments were not documented at 12 AM, 1 AM, 3 AM, and 5 AM, as required by facility policy. Staff interviews verified that the established protocol for post-fall neurological monitoring was not followed. The resident was later found deceased in the early morning hours, with the death certificate citing chronic diastolic heart failure as the main cause of death. The deficiency was confirmed by both nursing staff and the Nursing Home Administrator.
Failure to Provide Required Payment Coverage Notices
Penalty
Summary
The facility failed to provide the required notifications to residents whose payment coverage changed, affecting three residents. For Resident 72, the facility did not provide the necessary CMS10123 or CMS10055 notices when the payment source for her care changed from Medicare. This was confirmed during an interview with the Nursing Home Administrator and the Director of Nursing, who could not provide evidence of the appropriate notices being given. Resident 101's representative signed a CMS10055 notice, but failed to select an option box indicating whether they wished to continue receiving care or have the bill submitted to Medicare. This oversight was confirmed by the Nursing Home Administrator. For Resident 119, the facility provided a CMS10123 notice, but it was issued verbally rather than in writing at least two days before the end of Medicare coverage, despite no circumstances preventing timely written notice. This was confirmed by the Nursing Home Administrator.
Failure to Provide Adequate Bathing Assistance
Penalty
Summary
The facility failed to provide adequate bathing assistance to residents who were dependent on staff for activities of daily living. Specifically, five out of six residents sampled did not receive showers according to their preferences and care plans. Resident 22, admitted in September 2023, was assessed as dependent on staff for bathing but only received one shower and seven bed baths in the last 30 days, despite her preference for showers twice a week. Similarly, Resident 92, admitted in January 2024, also received only one shower and seven bed baths in the same period, with no documentation of refusal. Resident 7, who requires substantial assistance, was observed multiple times in her wheelchair without evidence of having received a shower on the scheduled day. The task documentation for Resident 7 indicated 'not applicable' for her shower, and there was no record of staff attempting to provide bathing assistance. Resident 43, who is cognitively impaired, was also not provided showers according to their preference, receiving bed baths instead on multiple occasions from January to February 2025. Resident 70, dependent on staff for bathing, had inconsistent documentation regarding showers, with several instances of bed baths being provided instead. There were also multiple occasions where staff documented refusal or did not document any bathing activity, without evidence of re-approaching the resident. These findings were reviewed with the Nursing Home Administrator and Director of Nursing, highlighting the facility's failure to adhere to residents' bathing preferences and care needs.
Medication and Care Plan Deficiencies in LTC Facility
Penalty
Summary
The facility failed to provide the highest practicable care for several residents by not adhering to physician orders and medication administration protocols. For Resident 42, there was no documentation of medication administration on a specific date, indicating a lapse in following prescribed treatment for conditions such as hyperlipidemia and GERD. Similarly, Resident 70's medication administration records showed missing documentation on two occasions, and the resident was inappropriately given Midodrine despite blood pressure readings that contraindicated its use. Resident 33's care was compromised as staff did not monitor her respiratory rate before administering Oxycodone, a medication that requires careful monitoring due to its potential effects on respiration. Resident 109 was observed with edema and wearing a compression stocking without a physician's order or a care plan intervention, indicating a lack of coordinated care and documentation. Resident 112, who had a cardiac pacemaker, did not have an active physician order or care plan intervention acknowledging the device, which is crucial for his ongoing cardiac management. Resident 114's care was deficient in several areas, including improper documentation and administration of Vancomycin via a PICC line, and the absence of emergency procedures and equipment related to the PICC line. Additionally, Resident 22 experienced chest pain, and the facility failed to complete physician-ordered vital sign checks, which are critical for monitoring her condition. These deficiencies highlight significant lapses in medication administration, documentation, and adherence to physician orders, impacting the quality of care provided to the residents.
Inappropriate Pain Management for Residents
Penalty
Summary
The facility failed to provide the highest practicable care regarding physician-ordered pain medications for two residents. For Resident 6, there were multiple overlapping orders for Oxycodone to manage different levels of pain, but the facility did not identify the duplication of orders for a pain scale of 8-10 between January 16, 2025, and February 6, 2025. The Medication Administration Record (MAR) showed that staff administered Oxycodone 5 mg two tablets for a pain scale of 8-10 on several occasions when the resident's pain level was recorded as 0 or 4, which did not align with the prescribed pain scale. Additionally, Oxycodone 5 mg one tablet was administered for a pain scale of 4-7, but it was given when the resident's pain level was recorded as 8, 9, and 10, which exceeded the prescribed pain scale. For Resident 43, the facility also failed to adhere to the physician's order for pain management. The MAR indicated that staff administered Oxycodone 5 mg one-half tablet for a pain scale of 8-10 when the resident's pain level was recorded as 4, which was below the prescribed pain scale. These discrepancies in administering pain medication were reviewed with the Nursing Home Administrator and Director of Nursing, highlighting a failure in providing appropriate pain management as per physician orders.
Failure to Obtain Consent and Assess Entrapment Risks for Bed Rails
Penalty
Summary
The facility failed to review the risks and benefits of using bed rails with the residents or their representatives and did not obtain informed consent for their use. This deficiency was identified for four out of five residents reviewed for accident hazards. Specifically, Residents 33, 42, 70, and 109 had enabler bars installed on their beds without documented consent or education provided to them or their responsible parties about the potential risks associated with these devices. The facility only addressed these issues after the surveyor's intervention. Additionally, the facility did not properly assess all zones that pose a risk for entrapment from bed rails for two of the residents reviewed. For Residents 33 and 109, the facility's assessments did not include a review of zone six, which could potentially pose a risk for entrapment between the end of the enabler device and the side of the headboard. These oversights were confirmed through interviews with facility staff, including the Nursing Home Director, Director of Nursing, and a corporate regional director.
Failure to Conduct Annual Reviews and In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that three nurse aides received an annual performance review and at least 12 hours of in-service education annually, as required by regulations. Employee 10, hired on September 12, 2023, did not have an annual performance review due in September 2024. Employee 11, hired on November 15, 2022, had a performance evaluation covering the period from November 15, 2022, to November 15, 2023, but lacked evidence of a subsequent evaluation. Employee 12, hired on May 30, 2023, along with Employees 10 and 11, did not receive the mandatory 12 hours of in-service training. The Nursing Home Administrator confirmed the absence of documentation for these requirements during interviews conducted in February 2025.
Missing Laboratory Reports in Clinical Records
Penalty
Summary
The facility failed to ensure that laboratory reports were included in the clinical records of three residents. For Resident 22, a physician's progress note indicated that several laboratory tests, including a CBC, BMP, BNP, and Troponin, were requested on January 13, 2025, with a stat turnaround time. However, there was no evidence of these tests in the resident's clinical record. Similarly, for Resident 92, a physician's progress note indicated that a CBC and BMP were to be repeated on January 13, 2025, and noted as completed, yet these results were not found in the clinical record. Resident 46's clinical record also lacked evidence of completed lab work, despite progress notes on February 7 and February 14, 2025, indicating that a CBC and BMP were completed. An interview with the Nursing Home Administrator, Director of Nursing, and a corporate consultant confirmed that the laboratory reports for these residents were not available for review. It was revealed that only the medical director and one other facility physician had access to view any resident's laboratory results in the system, which contributed to the unavailability of the lab results in the clinical records. This deficiency was identified during a review conducted on February 20, 2025.
Improper Food Storage in Kitchen
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety in the main kitchen. During an initial tour of the kitchen, it was observed that a tray of ground beef was thawing above a shelf containing eggs in the refrigerator. Additionally, there were three opened containers of beef base with a date of September 7, 2024, and a fourth container with no date. The refrigerator also contained a large container of lemon juice with a use-by date of January 18, 2025, a large container of salsa with a use-by date of January 25, 2025, a large container of mustard with a use-by date of April 8, 2024, and a large container of BBQ sauce with a use-by date of February 7, 2025. Employee 5, the director of dining services, confirmed these findings and discarded all the mentioned food items. It was revealed that dietary staff are expected to mark food items with received by, opened, and use-by dates.
Failure to Implement Infection Control Measures
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with chronic wounds or indwelling medical devices, as required by the Centers for Medicare and Medicaid Services (CMS) guidelines. Observations revealed that Resident 223, who had an indwelling urinary catheter, did not have EBP in place. Similarly, Resident 112, who had a central venous catheter for hemodialysis and open sores on his legs, also lacked EBP. Interviews with staff confirmed the absence of EBP for these residents, despite the facility's policy requiring such precautions. Additionally, the facility did not adhere to proper hand hygiene protocols. During medication administration, an LPN was observed turning off the faucet with clean hands after washing, contrary to the facility's policy of using a paper towel to maintain hand cleanliness. Furthermore, Resident 22, who was on contact precautions due to ESBL in her urine, had no care plan addressing these precautions, and staff were unaware of the reason for the precautions. The facility's failure to implement and maintain infection control measures was discussed with the Nursing Home Administrator and Director of Nursing.
Failure to Honor Advance Directive Choices
Penalty
Summary
The facility failed to honor the advance directive choices for Resident 53. A clinical record review revealed that the resident had a physician's order for Do Not Resuscitate (DNR) throughout their stay until February 20, 2025. However, on February 7, 2025, the facility contacted the resident's responsible party to complete a POLST form, which was completed on February 11, 2025, indicating that CPR should be performed if necessary. Despite this, there was no documentation that the facility recognized the change in the resident's wishes and discontinued the DNR order until it was identified by the surveyor. This oversight was discussed with the Director of Nursing and the Nursing Home Administrator during an interview on February 20, 2025.
Failure to Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident property involving a registered nurse, Employee 2, who was accused of stealing narcotics from Resident 118. The facility's policy on abuse, neglect, exploitation, or misappropriation requires that such allegations be reported immediately to the administrator and other relevant authorities, including state licensing agencies, the local/state ombudsman, adult protective services, law enforcement, the resident's representative, the attending physician, and the facility medical director. However, despite receiving emails from two nurses, Employee 6 and Employee 7, on January 21, 2025, alerting the Director of Nursing to the alleged theft, the facility did not notify the required agencies. The Department of Health received a complaint on January 24, 2025, regarding the alleged misappropriation, which was confirmed during an interview with the Director of Nursing and Employee 1 on February 21, 2025. The clinical record review of Resident 118 showed no documentation of the allegation, and the Director of Nursing and Employee 1 acknowledged that they were aware of the situation but failed to report it to the appropriate authorities. This oversight is a violation of the facility's policy and state regulations, specifically 28 Pa. Code 201.14(a)(c) and 28 Pa. Code 201.18(b)(1)(2)(e)(1).
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure that assessments accurately reflected a resident's status, specifically for Resident 113. A clinical record review revealed that the admission MDS assessment for Resident 113 incorrectly indicated that he received five insulin injections during the previous seven days. However, an interview with Resident 113 confirmed that he had never received an insulin injection and did not have a diabetes diagnosis. This discrepancy was acknowledged by the Nursing Home Administrator, who confirmed that the MDS assessment was completed in error.
Failure to Provide Adequate Activity Program for Resident
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet the individual needs and interests of a resident, identified as Resident 7. The resident's care plan indicated a dependency on staff for emotional, intellectual, physical, and social needs, with specific interventions to invite her to activities such as mass, musical programs, and craft activities. Observations over three consecutive days revealed that Resident 7 was consistently found sitting in a wheelchair at the nurses' station without her busy blanket, which she enjoys. The activity logs for January and February 2025 showed that Resident 7 attended only three activities in total, with no documentation of her refusing any activities. An interview with the activity director confirmed that Resident 7 had only been taken to three activities in the last two months. The facility employs two activity aides, one dedicated to the dementia unit and the other responsible for the remaining 87 residents. The deficiency was reviewed with the Administrator, highlighting the facility's failure to provide an ongoing program of activities to meet the needs of Resident 7, as required by resident rights regulations.
Failure to Maintain Resident's Range of Motion
Penalty
Summary
The facility failed to provide necessary services to maintain or improve a resident's range of motion (ROM). Resident 7, admitted on December 2, 2015, was assessed in a quarterly Minimum Data Set (MDS) on November 22, 2024, as having no impairments in upper or lower extremities. However, a subsequent MDS assessment indicated a limited ROM in both upper and lower extremities. Despite being discharged from physical therapy on December 26, 2024, and occupational therapy on November 15, 2024, the facility did not document any further assessment or intervention to address the decline in ROM. This lack of action was confirmed in an interview with the Nursing Home Administrator on February 20, 2025.
Failure to Address Bowel and Bladder Incontinence
Penalty
Summary
The facility failed to assess and implement individualized interventions to promote bowel and bladder continence for a resident identified as frequently incontinent. The resident was admitted on January 20, 2025, and the admission MDS assessment indicated frequent incontinence of bowel and bladder with no attempts at a toileting program. The resident was assessed as dependent on staff for toileting hygiene due to impaired balance and required extensive assistance from one staff member for toileting needs. The care plan initiated on January 21, 2025, noted the resident's self-care performance deficit related to impaired balance but did not include any assessment or treatment interventions to address the incontinence. An interview with the Nursing Home Administrator and Director of Nursing confirmed the lack of evidence for further assessment or implementation of interventions to promote continence. This failure to appropriately identify, assess, and provide treatment and services to maintain bowel and bladder function was noted as a deficiency.
Inadequate Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for three residents. Resident 22 was observed multiple times with a nasal cannula delivering oxygen at 4 liters per minute, despite having no physician's order for oxygen therapy. The resident's care plan noted a risk for ineffective breathing patterns related to oxygen use, yet there was no documentation supporting the necessity or authorization for the oxygen being administered. Resident 6 had a physician's order for oxygen at 2 liters per minute via nasal cannula and BiPAP at bedtime, but observations revealed discrepancies in the oxygen concentrator settings and improper storage of respiratory equipment. The BiPAP mask was found unbagged and hanging off the bedside stand, and the nasal cannula was lying on the floor. Resident 70 had orders for CPAP using room air, but observations showed an oxygen concentrator set to 4 liters per minute connected to a CPAP machine, with improperly stored and undated equipment. These findings were confirmed by the Director of Nursing and the Nursing Home Administrator.
Failure to Implement Dialysis Access Site Care
Penalty
Summary
The facility failed to implement appropriate care to prevent potential complications from a dialysis access site for a resident requiring dialysis. The resident, who needed dialysis treatments three times a week through a central venous catheter (CVC) in the right upper chest, reported being unaware of any equipment in his room to address complications from the dialysis access site. During an observation, there were no signs indicating right arm use restrictions, such as warnings for phlebotomists not to use the right arm for blood draws. The clinical record review revealed physician orders to avoid taking blood pressures on the resident's right arm and to monitor the catheter site for complications. However, there was no order restricting blood draws from the right arm or requiring an emergency kit in the resident's room. The facility's plan of care incorrectly referenced a graft in the arm, which the resident did not have. An LPN confirmed the absence of signage and emergency kit materials in the resident's room, despite believing there was a protocol for such measures. A physician's order to implement an emergency dialysis kit was only added after the surveyor's questioning.
Lack of Staff Competency in Managing Medical Devices
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies and skill sets for the care and assessment of residents with specific medical devices. This deficiency was identified for three employees, including a registered nurse and two licensed practical nurses, who lacked documented competencies related to the management of indwelling urinary catheters, cardiac pacemaker devices, and central venous catheters. The surveyor's review of facility documentation and interviews with the Nursing Home Administrator and other staff confirmed the absence of evidence for these competencies. The deficiency affected residents with complex medical needs, including those with indwelling catheters, a Life Vest for cardiac monitoring, and central venous catheters. For instance, Resident 114 had orders for the use of a Life Vest and PICC line care, while Resident 112 had an IJ catheter requiring specific care instructions. Despite these needs, the facility could not provide evidence that the involved staff had the necessary knowledge and confirmed competencies to manage these devices, as required by physician orders and regulatory standards.
Failure to Provide Individualized Behavioral Health Care
Penalty
Summary
The facility failed to provide individualized behavioral health care for a resident with mood and behavior concerns. The resident, who was admitted on February 12, 2025, was prescribed multiple psychoactive medications for depression and dementia. Despite these prescriptions, the resident's daughter expressed concerns about her mother's detachment and poor appetite, suggesting an increase in antidepressant dosage might help. The resident herself showed reluctance to participate in activities, and her meal intake was consistently low, with 50 percent or less consumption for 14 out of 25 meals reviewed. A care plan was initially created on February 13, 2025, to address the resident's mood issues, but it was discontinued two days later without replacement. Interviews with facility staff confirmed the absence of an active, individualized care plan to address the resident's depression, despite her ongoing medication treatment. The facility did not track or identify behavioral symptoms related to the resident's diagnoses, leading to a deficiency in providing necessary behavioral health care.
Failure to Implement Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement individualized person-centered care plans for a resident diagnosed with dementia. Resident 91 was admitted to the facility with a diagnosis of dementia, which affects memory, language, problem-solving, and other cognitive abilities. Despite the facility's assessment indicating the need for a care plan to address dementia and cognitive loss, a review of the resident's care plan revealed no evidence of such a plan being developed or implemented. The deficiency was confirmed during a meeting with the Nursing Home Administrator and Director of Nursing, where it was acknowledged that there was no documentation of an individualized care plan for Resident 91's dementia. This oversight was noted during a survey conducted on February 19, 2025, and confirmed the following day.
Improper Disposal and Documentation of Controlled Medications
Penalty
Summary
The facility failed to ensure the proper disposal and documentation of controlled medications for a discharged resident, identified as Resident 118. The facility's policy on controlled substances requires that the disposal of such medications be conducted in the presence of a nurse and a witness, both of whom must sign the disposition sheet. However, a review of Resident 118's closed clinical record revealed multiple instances where this protocol was not followed. Specifically, Employee 2, a registered nurse, documented the disposal of Oxycodone and Lorazepam without dating the disposal or having a witness present, as required by the facility's policy. The records showed discrepancies in the documentation of controlled substances, including Oxycodone and Lorazepam, received and disposed of for Resident 118. For example, Employee 2 documented the disposal of 45 and 55 tablets of Oxycodone on separate forms without proper dating or witnessing. Similarly, the disposal of Lorazepam tablets was documented without a witness or date. These findings were confirmed during an interview with the Nursing Home Administrator, Director of Nursing, and a corporate consultant, indicating a failure to comply with the established procedures for handling controlled substances.
Medication Labeling and Physician Order Deficiency
Penalty
Summary
The facility failed to ensure that medication labeling and physician orders were in accordance with currently accepted professional standards for one resident. During a medication administration pass, it was observed that Employee 4 prepared Dicyclomine for a resident, with the medication label indicating a strength of 10 mg per capsule. However, the physician's order did not specify the strength of the medication, only instructing staff to administer one capsule four times a day. This discrepancy indicates that the nurse responsible for transcribing the orders for pharmacy delivery did not select the desired strength of the medication. Additionally, during the same medication administration pass, Employee 4 administered 2 grams of Diclofenac NA one percent gel to the resident's lower back. The physician's order for this medication also lacked a specific dose strength, allowing for either two grams or four grams per administration. Employee 4 confirmed that the physician orders for both medications did not include the necessary details regarding the strength of the medications, leading to a failure in ensuring proper medication labeling and administration as required by professional standards.
Failure to Provide Routine Dental Care
Penalty
Summary
The facility failed to assist a resident in obtaining routine dental care, as evidenced by the case of a resident who was admitted on February 22, 2018, with Medicaid as a payment source. The resident was observed on two occasions in February 2025, showing signs of plaque buildup on his teeth. Despite being due for a prophylactic dental cleaning every six months, the resident did not receive dental services between April 2023 and July 2024, during which time he developed heavy food debris and plaque. The facility could not provide evidence of routine dental cleanings as required under the State plan. These findings were confirmed in an interview with the Nursing Home Administrator and Director of Nursing.
QAA Committee Attendance Deficiency
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee met the required membership and attendance criteria. Specifically, the medical director did not attend any QAA meetings for nearly seven months, and the Director of Nursing (DON) was absent from these meetings for almost four months. The most recent QAA meeting was held on December 23, 2024, and the deficiency was confirmed during an interview with the Nursing Home Administrator on February 21, 2025. This failure to meet the quarterly attendance requirement by key members of the QAA committee was in violation of the relevant state codes.
Failure to Document Vaccine Education for Resident's Representative
Penalty
Summary
The facility failed to ensure that a resident's medical record included documentation that the resident's representative was provided education regarding the risks and benefits of the influenza immunization. This deficiency was identified during a clinical record review and staff interview for one of five residents reviewed for immunization concerns. Specifically, Resident 92, who had a BIMS score indicating moderate cognitive impairment, had his influenza vaccination refused by his family on August 14, 2024. However, the facility did not provide the family with the necessary education related to the risks and benefits of the influenza vaccination, which is required for them to make an informed decision. The facility was unable to provide evidence that Resident 92's responsible party was educated on the risks and benefits of the influenza vaccine, despite the resident's incapacity to make his own medical decisions. This lack of documentation and education was confirmed during an interview with a corporate regional consultant. The Nursing Home Administrator and Director of Nursing were informed of these concerns on February 21, 2025. The deficiency is in violation of specific Pennsylvania Code regulations related to the responsibility of the licensee, medical records, and nursing services.
Failure to Designate Full-Time Director of Nursing
Penalty
Summary
The facility failed to designate a registered nurse (RN) as the Director of Nursing (DON) on a full-time basis from November 11, 2024, to December 7, 2024. An interview with the Nursing Home Administrator (NHA) on December 9, 2024, revealed that Employee 1, who was serving as the Interim Director of Nursing, did not work at least 35 hours a week in this role. Instead, she was required to cover as the RN on the nursing care units. A review of the interim DON's timecard for the specified weeks showed that Employee 1 only worked two days as the interim DON and was utilized as the RN on the nursing care units on multiple dates. The NHA confirmed these findings during a meeting on December 9, 2024, acknowledging that the facility did not have a designated RN serving as the DON on a full-time basis, as required by PA Code: 211.12(b)(c) Nursing services.
Plan Of Correction
1. 1st Shift RN Supervisor was sitting in as Interim Director of Nursing prior to Full-time Director of Nursing being hired. When no RN supervisor was available to work 1st shift, the Interim Director of Nursing was pulled to be RN Supervisor. 2. A full-time Director of Nursing was hired and had an official start date of 12/16/2024. 3. Administrator will ensure to monitor weekly that the Director of Nursing completes at least 35 hours a week of Director of Nursing duties.
Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide-to-resident ratios as mandated by the regulation effective July 1, 2024. Specifically, the facility did not provide the minimum number of nurse aides during the day, evening, and overnight shifts on several occasions. During the day shift, the facility was understaffed on three days, with the number of nurse aides falling short of the required ratio for the resident census. Similarly, during the evening shift, the facility did not meet the required staffing levels on four days. The most significant shortfall was observed during the overnight shift, where the facility failed to meet the required nurse aide-to-resident ratio on eleven days. The deficiency was identified through a review of nursing staffing hours and confirmed during an interview with the Nursing Home Administrator. The review covered specific periods in November and December 2024, revealing consistent understaffing across different shifts. The administrator acknowledged the failure to meet the regulatory requirements, confirming the findings of the surveyors. This deficiency indicates a pattern of inadequate staffing that could potentially impact the quality of care provided to residents.
Plan Of Correction
1. While the facility cannot retroactively correct; since the staffing citations, the facility has hired 2 CNAs. Also, the facility has seen a total of 2 CNAs come off of orientation in the last 2 weeks that will now be included in the facility's nurse aide ratio. 2. Facility will conduct an audit consisting of the last two-week period to be sure the facility is in compliance with the nurse aide to resident ratios. 3. The facility shall make reasonable attempts to acquire new staff, including offering competitive pay rates, shift differentials, partnering with local community schools, and offering employee benefits. 4. The NHA/Designee will educate the scheduler/designee on the requirements of meeting the nurse aide to resident ratios. 5. The Scheduling Manager/Designee will randomly audit the nurse aide to resident ratios weekly for 3 weeks to ensure regulatory compliance. Any concerns/issues will be reviewed monthly by the facility's QAPI Committee.
LPN Staffing Deficiencies
Penalty
Summary
The facility failed to meet the required LPN-to-resident ratios as mandated by regulations effective July 1, 2023. During the day shift, the facility did not provide the minimum of one LPN per 25 residents on six out of the 21 days reviewed. Specific instances include November 12, 2024, with a census of 106 residents and only 3.93 LPNs scheduled, when 4.24 were required, and November 25, 2024, with a census of 99 residents and only 3.51 LPNs scheduled, when 3.96 were required. Similar deficiencies were noted on other days within the reviewed period. The evening and overnight shifts also experienced staffing shortages. During the evening shift, the facility failed to provide one LPN per 30 residents on nine out of the 21 days reviewed. For example, on November 25, 2024, with a census of 99 residents, only 2.66 LPNs were scheduled, while 3.30 were required. The overnight shift was deficient on five days, such as November 26, 2024, with a census of 104 residents and only 2.09 LPNs scheduled, when 2.60 were required. These findings were confirmed by the Nursing Home Administrator during a meeting on December 9, 2024.
Plan Of Correction
1. While the facility cannot retroactively correct the citations. 2. Facility has hired 2 LPN's and 2 RN's since receiving deficiency. 3. Facility will conduct an audit consisting of the last two-week period to be sure the facility is in compliance with the LPN to resident ratios. 4. The facility shall make reasonable attempts to acquire new staff, including offering competitive pay rates, shift differentials, partnering with local community schools, and offering employee benefits. 5. The Facility has updated all job postings to attract more staff to fill the LPN open positions. 6. The NHA/Designee will educate the scheduler/designee on the requirements of meeting the LPN to resident ratios. 7. The Scheduling Manager/Designee will randomly audit the nurse aide to resident ratios weekly x's 3 weeks to ensure regulatory compliance. Any concerns/issues will be reviewed monthly to the facility's QAPI Committee.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per patient day (PPD) for 14 out of the 20 days reviewed. This deficiency was identified through a review of nursing staff care hours for specific weeks in November and December 2024. On several days, the facility's nursing care hours fell short of the required minimum, with the lowest recorded at 2.85 hours PPD. During a meeting on December 9, 2024, the Nursing Home Administrator confirmed the facility's failure to meet the required daily hours PPD as evidenced by the documented findings.
Plan Of Correction
1. While the facility cannot retroactively correct; since the staffing citations, the facility has hired 4 med nurses (2 RN and 2 LPN) along with 2 CNAs. Also, the facility has seen a total of 2 CNAs come off of orientation in the last 2 weeks that will now be included in the facility's HPPD. 2. Facility will conduct an audit consisting of the last two-week period of nursing staffing HPPDs. 3. The facility shall make reasonable attempts to acquire new staff, including offering competitive pay rates, shift differentials, partnering with local community schools, and offering employee benefits. 4. The NHA/Designee will educate the scheduler/designee on the requirements of meeting the minimum HPPD per the regulation. 5. The Scheduling Manager/Designee will randomly audit the HPPD weekly x's 3 weeks to ensure HPD regulatory compliance. Any concerns/issues will be reviewed monthly to the facility's QAPI Committee.
Failure to Notify Responsible Party of Resident's Condition Change
Penalty
Summary
The facility failed to notify the responsible party of a resident's change in condition requiring interventions. A clinical record review for a resident revealed that on August 31, 2024, a nurse aide informed a nurse about areas on the resident's toes observed during a shower. The nurse found wounds on the resident's toes, described as thick, brown/green scabbed-like areas without drainage. The nurse added the resident to the wound nurse list, left a communication note for the physician, cleansed the areas, applied betadine, and left them open to air. However, there was no documentation indicating that the responsible party was informed about the wounds, the treatment ordered, or the wound care consult. The responsible party only became aware of the wounds during a visit on September 3, 2024. An interview with the Director of Nursing and Nursing Home Administrator confirmed these findings.
Failure to Prevent and Identify Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary treatment and services consistent with professional standards of practice for the prevention of pressure ulcers for a resident admitted with a fractured right lower leg. Upon admission, the resident required extensive assistance with bed mobility, transfers, and toilet use, and was identified as being at risk for pressure ulcer development. Despite this, the resident did not have any pressure ulcers at the time of admission. However, a nursing progress note later revealed that the resident had developed openings on her bilateral buttocks, which were not initially assessed or documented by the staff. Subsequent evaluations by the wound nurse and a physician's assistant confirmed the presence of Stage 3 pressure ulcers on both buttocks, which were new and had not been identified at an earlier stage. The facility's records lacked documentation indicating that these pressure ulcers were discovered by staff at a Stage 1, despite the resident's need for assistance with daily activities. Interviews with the Director of Nursing and the Nursing Home Administrator confirmed these findings, highlighting the facility's failure to identify and address the pressure ulcers at an earlier stage, resulting in their progression to Stage 3.
Failure to Conduct Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides received an annual performance review for three nurse aides (Employees 3, 4, and 5). Employee 3, Employee 4, and Employee 5, all hired on November 15, 2022, should have had their annual performance reviews by November 15, 2023. However, there was no documented evidence that these reviews were completed. This was confirmed during an interview with the Nursing Home Administrator on March 14, 2023, at 10:50 AM.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to ensure that the resident or resident representative received written notice of the facility's bed hold policy at the time of transfer for six of ten residents reviewed for hospitalizations. Specifically, Residents 3, 10, 44, 45, 62, and 69 were transferred to the hospital for various medical conditions, including respiratory distress, pneumonia, swelling around a dialysis fistula, and changes in mental status. In each case, there was no documentation available that the facility provided written notice regarding a bed hold to the residents and/or their responsible parties upon transfer out of the facility. The deficiency was confirmed by the Nursing Home administrator during a meeting on March 14, 2024. The lack of documentation and failure to provide written notice of the bed hold policy at the time of transfer was identified through clinical record reviews and staff interviews. This failure to provide the required notice was in violation of the regulatory requirements, specifically 28 Pa. Code 201.14(a) Responsibility of licensee.
Failure to Follow Physician Orders and Integrate Hospice Care
Penalty
Summary
The facility failed to provide the highest practicable care for two residents by not adhering to physician orders regarding air mattress settings and insulin administration. For Resident 8, the air mattress pump setting was consistently observed to be incorrect, set at 380 pounds instead of the ordered 220 pounds. Additionally, there was no documentation that staff were monitoring Resident 8's blood sugars as ordered, which is critical for the administration of Detemir insulin. Similarly, for Resident 52, the air mattress pump setting was observed to be 540 pounds instead of the ordered 450 pounds, indicating a failure to follow physician orders for both residents. The facility also failed to integrate hospice care and services into the care plans for two residents with terminal diagnoses. Resident 75's care plan did not include evidence of all services that hospice would provide, nor did it identify the hospice entity or the frequency of care. Similarly, Resident 34's care plan lacked details on the hospice services for managing end-stage dementia, including who would provide for the resident's physical, psychosocial, spiritual, and emotional needs. These deficiencies were confirmed through staff interviews and clinical record reviews, indicating a lack of comprehensive care planning for residents on hospice.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to assess and implement treatment and services to prevent the development and promote the healing of pressure ulcers for four residents. Resident 15 had a chronic pressure ulcer on his left buttock, and despite physician orders to set his air mattress at 150 pounds, it was observed to be set at 660-750 pounds. Resident 22, admitted with multiple diagnoses including paraplegia and a non-pressure chronic ulcer, had an unstageable pressure ulcer on her left buttock. Her air mattress was observed to be set at 100 pounds, contrary to the physician's order to monitor its functioning every night shift. Resident 260, admitted with rhabdomyolysis and an open wound on her right hip, had her air mattress set at 620 pounds instead of the required setting per her weight of 159.4 pounds. These discrepancies were confirmed by the Nursing Home Administrator and the Director of Nursing on March 14, 2024. Resident 34 was admitted on May 22, 2023, and initially had no skin impairments. However, a pressure sore was noted on his right heel on September 6, 2023, but no further assessment or interventions were implemented until September 11, 2023. By then, the pressure ulcer had worsened, with the right heel being open with serosanguinous drainage. The assistant director of nursing confirmed that there was no further documentation or timely intervention to address the pressure ulcer when it was first identified. These findings indicate a failure in timely assessment and intervention for pressure ulcers in the facility.
Lack of Nursing Staff Competencies for Specialized Care
Penalty
Summary
The facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care and assessment of resident tracheostomy, peg tube, and catheter care. A review of facility documentation revealed that the facility had six residents with urinary catheters, one resident with a tracheostomy, and two residents with peg tubes. However, the facility was unable to provide any documentation of nursing staff competencies for these specific care needs. This deficiency was confirmed by the Nursing Home Administrator and Director of Nursing during a review on March 14, 2024.
Failure to Develop and Implement Dementia Care Plans
Penalty
Summary
The facility failed to develop and implement individualized person-centered care plans for residents diagnosed with dementia and cognitive loss. Clinical record reviews and staff interviews revealed that four residents (Residents 33, 50, 8, and 75) were admitted with diagnoses of dementia. Despite assessments indicating the need for dementia care plans, the facility did not create or implement these plans for the residents. For instance, Resident 33 was admitted on October 22, 2023, with a diagnosis of dementia, but her care plan lacked any indication of a person-centered approach to address her cognitive loss. Similarly, Resident 50, admitted on October 1, 2020, had no documented dementia care plan despite the facility's assessment indicating the need for one. Further reviews showed that Resident 8, diagnosed with dementia on November 2, 2016, and assessed in January 2024, also lacked an individualized dementia care plan. Resident 75, admitted with a diagnosis of dementia, had no evidence of a dementia care plan in her records. These findings were confirmed during interviews with the Nursing Home Administrator and Director of Nursing, who had no further documentation to show that the required care plans were developed and implemented. The deficiency was noted under 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services.
Failure to Address Pharmacy Recommendations and Medication Discrepancies
Penalty
Summary
The facility failed to ensure that the resident's attending physician addressed and responded appropriately to pharmacy recommendations for four of six residents reviewed. For Resident 64, the physician did not address the consultant pharmacist's recommendation to consider a gradual dose reduction of Zoloft, resulting in the resident continuing on the same dose for an additional two months. Additionally, an unauthorized extra 50 mg of Seroquel was administered to Resident 64, which was not identified by the consultant pharmacist. Resident 33's physician did not address recommendations for lab tests and a change in the indication for Seroquel. Resident 50's physician did not evaluate the potential for a gradual dose reduction of psychotropic medications as recommended by the consultant pharmacist. Resident 75's physician failed to provide an appropriate indication for the use of Olanzapine, despite acknowledging the consultant pharmacist's recommendation and the resident's hospice status with metastatic cancer. The deficiencies were confirmed through clinical record reviews and staff interviews. The Director of Nursing and the Assistant Director of Nursing confirmed the findings for the respective residents. The facility's failure to ensure proper physician response to pharmacy recommendations and the consulting pharmacist's oversight in identifying medication discrepancies contributed to these deficiencies.
Failure to Monitor Medication Side Effects and Behaviors
Penalty
Summary
The facility failed to ensure that the medication regimens for three residents were free from potentially unnecessary medications. For Resident 8, the clinical record revealed physician orders for multiple medications, including Seroquel, Depakote, and Duloxetine, with specific instructions for staff to monitor for various side effects and behaviors. However, a review of the medication administration records (MAR) for January, February, and March 2024 showed no documentation that staff were monitoring Resident 8 for the ordered signs, symptoms, or behaviors. This deficiency was confirmed during an interview with the Nursing Home Administrator on March 15, 2024. Similarly, Resident 2 had physician orders for Ativan, Remeron, and Risperdal, with instructions to monitor specific behaviors such as crying, hand-wringing, outbursts, and physical aggression. The MAR for March 2024 revealed no documented evidence that the facility was tracking these behaviors or the interventions used. Resident 64's clinical record showed orders for Seroquel and Zoloft, with instructions to monitor behaviors like agitation, restlessness, and sadness. Again, the MAR for March 2024 lacked documentation of behavior tracking. These findings were reviewed with the Administrator and Director of Nursing on March 14, 2023.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for two residents, specifically regarding cognitive loss and psychotropic medication use with behaviors. For Resident 64, the facility assessed cognitive loss on May 12, 2023, but did not develop a corresponding care plan until March 12, 2024. This delay was confirmed by the Director of Nursing on March 15, 2024. For Resident 75, the clinical record showed current physician orders for psychoactive medications including Xanax, Olanzapine, and Bupropion HCI. However, the facility did not develop a personalized care plan that identified targeted behaviors and individualized interventions related to her mood and behaviors. This was confirmed by Employee 7 from Social Services on March 15, 2024. The Nursing Home Administrator was made aware of these concerns on the same day.
Failure to Hold and Document Care Plan Meetings
Penalty
Summary
The facility failed to invite and ensure the attendance of residents and their responsible parties at care plan meetings for three residents. For Resident 8, there was no documentation after February 15, 2023, indicating that a care plan meeting was held or that the resident and/or her responsible party were invited. Similarly, for Resident 66, although a care plan meeting was documented on October 17, 2023, there was no subsequent documentation showing that further care plan meetings were held or that the resident and/or her responsible party were invited. Resident 62 and his wife indicated that they were scheduled to attend a care plan meeting on March 12, 2024, but there was no prior documentation of any care plan meetings or invitations within the past year. Interviews with Employee 7 from Social Services and the Nursing Home Administrator confirmed that no other care plan meetings were held for Resident 62 over the past year. These findings indicate a failure to comply with the regulatory requirements for care plan meetings and resident involvement.
Failure to Maintain Range of Motion for Residents
Penalty
Summary
The facility failed to provide services to maintain the range of motion (ROM) for three residents. Resident 69 expressed a desire to go home but stated that staff did not help him improve his walking. His clinical record revealed he was discharged from physical therapy with a recommendation for a restorative nursing program, which was not implemented. Documentation showed that the intervention to ambulate with Resident 69 was not followed after a certain date, and the physical therapy assistant confirmed the lack of documentation for the restorative nursing program. Resident 20 had a care plan for staff to provide ROM exercises to her bilateral lower and upper extremities twice daily. However, task documentation revealed multiple instances where staff did not document the completion of these restorative tasks. Similarly, Resident 66 had a care plan for a restorative nursing program for activities of daily living (ADLs), ambulation, active range of motion (AROM), and transfers, but documentation showed several dates where these tasks were not completed. The Nursing Home Administrator and Director of Nursing were informed of these findings.
Failure to Investigate Resident Elopement
Penalty
Summary
The facility failed to thoroughly investigate an elopement incident involving a resident identified as high risk for elopement. Resident 44, admitted on September 1, 2023, was noted to have a care plan indicating a high risk for elopement. On December 11, 2023, the resident followed a staff member off the locked dementia unit and was later found by a physical therapist in another hall. The resident resisted attempts to return to the dementia unit, requiring the intervention of three staff members. The resident was also noted to be experiencing delusions and was found sitting by the locked door to the unit. Interviews with the Nursing Home Administrator, Director of Nursing, and Assistant Director of Nursing revealed that the facility did not conduct an investigation into the elopement incident. They were unable to provide documentation of staff interviews, staff education, or maintenance checks on the door lock's functionality. The facility's failure to investigate the incident thoroughly was confirmed by the Nursing Home Administrator.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for Resident 8. The resident had a physician order for staff to change their oxygen tubing and bag for their CPAP device weekly on Friday during the night shift. However, observations on two separate days revealed that the oxygen tubing dated March 1, 2024, was still in use 12 days later, and the CPAP mask was found lying unbagged on the bedside stand. An additional oxygen tubing dated March 8, 2024, and a clean bag were found inside another bag hanging on the resident's bedside stand. Employee 10, an LPN, confirmed the continued use of the outdated oxygen tubing. This information was reviewed with the Director of Nursing and the Nursing Home Administrator.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to ensure the highest practicable pain management for Resident 103. Upon admission, there was no documented evidence indicating that Resident 103 was experiencing pain, despite her having an order for Norco 5 mg/325 mg for moderate to severe pain. Resident 103 reported waiting 59 minutes for a pain pill and experiencing excruciating pain. A nursing note later indicated that her medications were not available, and she was medicated with her own pain medication, but it did not document her pain level, the medication administered, or its effectiveness. The facility's Cubex system had Norco available, but it was not used due to a misreading by the supervising nurse. An interview with the supervising registered nurse revealed that she misread the Cubex list and did not realize that Norco was available for administration. This oversight led to Resident 103 experiencing severe pain without timely and appropriate pain management. The facility's failure to document the resident's pain level, the medication administered, and its effectiveness further compounded the issue, indicating a lapse in proper nursing services as required by the regulations.
Failure to Ensure Accurate Medication Dispensing
Penalty
Summary
The facility failed to ensure accurate acquiring and dispensing of medications for one resident. Resident 103 was transferred from the hospital with an order for Norco to be administered every six hours for pain. Upon admission, the resident's medications were not available, and she had to use her own pain medication. There was no documented evidence that the resident's physician was informed about the use of her own medication or that nursing staff ensured it was a medication ordered by her physician. Additionally, other medications ordered for Resident 103, including Allegra, Combigan, and Mirapex, were not administered as scheduled, and there was no documentation explaining why these medications were not given or if the pharmacy was contacted as required. Interviews with the Administrator and Director of Nursing confirmed the findings and revealed that they could not provide further documented evidence to explain the failure to administer the medications as ordered. The facility's policies required staff to call the pharmacy for new admission orders and to ensure essential medications were ordered by the resident's physician, but these procedures were not followed in this case.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to prevent the potential spread of infection to one of five residents reviewed for infection control. Observation of Resident 10's door revealed a sign indicating that she was on enhanced barrier precautions (EBPs) to prevent the spread of multi-drug resistant organisms. The sign specified the use of gloves and a gown during device care, including tracheostomy care. However, during an observation of Resident 10's tracheostomy care, an LPN performed the care without wearing a gown. An interview with the Director of Nursing confirmed that the LPN should have worn a gown during the procedure. This failure to adhere to infection control protocols potentially exposed Resident 10 to a multi-drug resistant infection.
Latest citations in Pennsylvania
Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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