Willow Grove Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Hatboro, Pennsylvania.
- Location
- 3485 Davisville Road, Hatboro, Pennsylvania 19040
- CMS Provider Number
- 396017
- Inspections on file
- 33
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Willow Grove Post Acute during CMS and state inspections, most recent first.
A resident with malnutrition, pressure injuries, and a physician-ordered weight gain regimen experienced significant weight loss and persistently poor intake of meals and snacks over multiple weeks. Despite facility policy requiring nutritional reassessment with changes in condition, the RD did not complete or document a new nutritional assessment for two consecutive months, and there were no revisions to the nutrition care plan beyond a regular pureed diet with house shakes and protein supplements. Nursing documentation showed inaccurate weight recording later corrected to a lower weight, and repeated poor food/fluid intake at breakfast, lunch, dinner, and evening snacks, which the DON confirmed. The resident’s wounds progressed to a Stage IV pressure injury and an unstageable ankle wound, and the resident was later hospitalized with osteomyelitis of the right leg.
A resident’s clinical record contained inaccurate weight documentation when nursing staff recorded a significantly higher weight than what was documented by the dietitian and later confirmed by the DON. The facility’s policy assigns responsibility for nutritional assessment and monitoring to the physician, dietitian, and nursing staff, requiring accurate data on intake, appetite, and clinical conditions. Despite this, the resident’s quarterly MDS and nursing notes reflected a weight inconsistent with the 122-pound value confirmed on multiple occasions, resulting in a failure to maintain accurate medical records in line with professional standards.
Surveyors observed multiple instances where medication carts were left unlocked and unattended on two nursing units, with resident information visible on computer screens and narcotic records left out. Nurses admitted to leaving carts unsecured while administering medications to residents, contrary to facility policy and standard practice.
Two residents did not receive their prescribed medications within the required time frames, with significant delays observed and documented. A nurse was seen leaving medications unattended and was still completing morning medication passes late into the day while assigned to 31 residents. Multiple grievances from residents and families confirmed ongoing issues with late medication administration.
Several residents reported excessive delays in call bell response, particularly during overnight shifts, and raised concerns about untimely hygiene care and inadequate cleaning after soiling. Facility grievance reports and call bell audits confirmed these issues, with audits often missing relevant shifts and rooms and documenting prolonged response times.
A resident's call bell system in the bathroom and bathing area was found to be non-functional, with the resident reporting it had not worked for an extended period and had not reported the issue due to other unresolved concerns. Facility policy requires functioning call lights and prompt reporting of defects, but observation confirmed the system was not operational.
The facility did not post required contact information for the State Survey Agency and State Long-Term Care Ombudsman on either nursing floor, with only a single posting found in the lobby entryway. Several alert and oriented residents reported not knowing how to contact these agencies and had not seen any postings in the building. Facility leadership confirmed the lack of postings on the nursing units.
Care plans were not updated in a timely manner for three residents with significant changes in condition, including one who began hospice services without a corresponding care plan, another with a gastrostomy and tube feeding order but no current care plan interventions, and a third with repeated IV dislodgement incidents related to intellectual disability and behavioral issues, without care plan adjustments to address these needs.
Two residents who were cognitively intact and able to communicate their toileting needs did not receive required assessments or interventions for urinary incontinence. Despite expressing willingness to participate in toileting programs and being dependent on staff for assistance, there was no documentation of voiding studies or toileting trials, and both continued to use briefs without individualized care plans.
The facility did not have documentation of annual training and competency assessments for two RNs in essential care areas such as medication administration, tube feeding, wound care, and safe transfers, despite serving residents with complex needs including fall risk, behavioral health issues, and pressure ulcers. The absence of these records was confirmed by the nurse trainer.
Annual performance evaluations were not completed for two nurse aides and two licensed nurses, with no documentation available for the current or previous year. The staff development employee confirmed that no evaluations had been conducted and that prior records were unavailable due to a change in company management.
Several staff members, including nurses, aides, and maintenance personnel, were not provided with required training on abuse, neglect, exploitation, and reporting procedures upon hire, as evidenced by missing or delayed training records and confirmed by staff interviews and policy review.
The facility did not document or provide evidence of the required annual training and competencies for two nurse aides, including essential topics such as dementia care, abuse prevention, and emergency preparedness, despite residents having complex care needs.
A resident with a history of falls and ongoing pain after admission did not receive a complete evaluation or timely physician notification regarding changes in condition and pain management needs. Despite reports of moderate to severe pain and limited progress in therapy, nursing staff did not adequately monitor or communicate the resident's pain to the physician, nor did they obtain or administer appropriate pain medication. This led to delayed treatment and the resident being hospitalized with a deformed femur fracture.
Grievance forms were not accessible to residents, family, or advocates on two nursing units, and there were no labeled locked boxes for anonymous submissions. Several alert and oriented residents reported not knowing how to file a grievance or where to find the forms, and the available form did not allow for anonymous filing.
A resident with multiple chronic conditions, including dementia and heart failure, experienced a significant and rapid weight loss along with poor nutritional intake. Although the weight loss was identified and dietary interventions were initiated, the facility did not complete a required MDS significant change assessment following this decline in condition.
A nurse administered TPN intended for another patient to a resident with complex medical needs, failing to verify the resident's identity or the TPN bag label as required by facility policy. The error was not detected by subsequent staff until a different team member noticed the wrong name on the TPN bag, resulting in the resident experiencing vomiting and low potassium.
A resident with End Stage Renal Disease did not have fully completed communication sheets between the facility and the dialysis provider, as required by facility policy. Several dates were identified where the section to be completed by the facility after the resident's return from dialysis was left incomplete, resulting in a failure to maintain effective communication regarding the resident's care.
A resident with multiple diagnoses, including muscle wasting and dementia, experienced significant unplanned weight loss over several months. Despite documentation of ongoing poor intake and substantial weight changes, there was no evidence that the physician was notified or that a medical assessment was completed. Staff confirmed the lack of physician involvement, resulting in a deficiency related to required physician notification and assessment.
Surveyors identified that the facility did not have a documented cleaning schedule for the dietary department's garbage and refuse disposal, and observed that waste in the outdoor loading area was not properly covered or contained. The area around the dumpster was littered with torn garbage bags and debris, and foul odors and waste fat were present, indicating a lack of proper sanitation and maintenance.
The facility failed to maintain the main kitchen's industrial ice machine in safe working condition, leaving it out of service for several months. Dietary staff had to rely on an ice machine from another unit or use bagged ice from an outside vendor due to the prolonged equipment outage.
Surveyors found that the facility did not maintain an effective pest control program in the dietary department, with heavy accumulations of food debris, dirt, and rodent droppings observed throughout the kitchen, especially under food service equipment. Doors to the loading area did not seal properly, allowing pest entry, and the dumpster area was left open and surrounded by scattered trash. Pest control reports documented ongoing rodent issues in the kitchen and lobby.
The facility failed to maintain a routine process for ensuring the functionality and timely response to call bell systems on weekends on two nursing floors. Despite a policy requiring prompt response to call lights, two residents reported delayed responses, and grievances were logged about long wait times and staff distractions. Call bell audits were insufficient, particularly on weekends.
A facility failed to document the administration of Hydrocortisone cream for a resident as per physician's orders. The Treatment Administration Record lacked entries for several shifts, and there was no documentation of the resident's refusal or any reason for the missed treatments, contrary to the facility's policy.
The facility failed to ensure the safe storage of medications for three residents, as medications were found unsecured in their rooms without assessments or care plans for safe self-administration. Staff confirmed these findings during a tour.
The facility was found to have unsecured handrails in the corridors of two nursing units, with observations noting loose, missing, or broken handrails in multiple locations. The Nursing Home Administrator confirmed the deficiency.
A facility failed to inform a resident's representative about a new prescription of Melatonin for a resident with cognitive impairment and dementia. The resident's daughter, who was designated to make medical decisions, was not notified about the medication, its risks, benefits, or alternatives. This oversight was confirmed by the DON, highlighting a breach in resident rights and nursing services.
The facility failed to maintain a clean and safe environment on both the first and second floors. Observations revealed strong odors of urine, uncleaned commodes, trash, and used medical supplies on the floor. Additionally, tangled cords and unbagged nebulizer masks were found, and corridor handrails were loose or broken. These issues were confirmed by staff and residents.
The facility failed to provide proper care and assessments for IV therapy for three residents. One resident's PICC line dressing was not changed for over two weeks, and there was no documentation of flushes or assessments. Another resident's PICC line was not flushed during the first week of admission, and flushes were missed on two occasions. The third resident had no orders for PICC line flushes, dressing changes, or assessments. The Regional Nurse confirmed the care did not meet professional standards.
The facility failed to ensure nursing staff had the necessary competencies to provide care, particularly for residents requiring IV therapy. Observations and file reviews revealed no documented skills competency evaluations for several staff members, including RNs and LPNs. This deficiency was confirmed by the DON and Regional Nurse, who could not provide evidence of training or competency evaluations, raising concerns about the facility's ability to meet residents' needs safely.
The facility did not implement pharmacist recommendations for three residents, including separating ophthalmic medication administration times and monitoring for bleeding and behavior changes due to medication use. Despite physician agreement, these recommendations were not reflected in the residents' orders.
The facility failed to maintain an effective infection control program, as three residents with infections were not included in the infection surveillance tracking logs. Additionally, the facility did not comply with infection data reporting requirements and had not conducted infection committee meetings since November 2023. The Director of Nursing confirmed these deficiencies, and the facility lacked access to the PA-PSRS system for required reporting.
The facility failed to maintain an effective antibiotic stewardship program for several residents, as required by its policy. Observations and reviews revealed that residents were receiving antibiotics without proper infection assessments or monitoring. The facility's infection surveillance logs lacked critical information, and interviews confirmed that necessary assessments were incomplete or not conducted.
The facility did not notify the State Long-Term Care Ombudsman of emergency transfers and discharges for the past three months. This was confirmed by the NHA, who stated that a new social worker would handle this task in the future.
The facility did not develop baseline care plans within 48 hours for two residents with PICC lines, one receiving antibiotics for osteomyelitis and the other undergoing chemotherapy for cancer. The absence of timely care plans for the maintenance of their PICC lines was confirmed by the Regional Nurse.
The facility failed to develop timely and comprehensive care plans for two residents. One resident required continuous oxygen therapy, and another had multiple wound treatment orders, yet neither had a care plan in place. These deficiencies were confirmed by nursing staff and management.
A resident with multiple health conditions did not receive scheduled showers for three weeks after admission, as required by the facility's policy. Despite being scheduled for showers twice a week, there was no documentation to confirm that these were offered, and only bed baths were recorded. This deficiency was highlighted by interviews with the resident's wife and the Unit Manager.
The facility failed to follow physician orders for two residents. One resident with septic arthritis had a dressing that was not changed daily as prescribed, confirmed by an LPN. Another resident, with dietary restrictions due to cerebral vascular disease and dementia, was served water against physician orders for a puree diet with thickened liquids. These incidents reflect deficiencies in adhering to medical directives.
A facility failed to maintain complete dialysis communication records for a resident with End-Stage Renal Disease. The resident's Hemodialysis Communication Record was incomplete on multiple occasions, lacking necessary information both before and after dialysis treatments. A nurse confirmed the lack of communication with the dialysis center, indicating a deficiency in nursing services.
The facility did not conduct required performance reviews for three nurse aides, hired in 2002, 2019, and 2022. When requested, the Nursing Home Administrator and DON could not provide the reviews, and it was confirmed that no reviews had been completed for any staff.
A facility failed to maintain a medication error rate below five percent when a nurse did not administer three prescribed medications to a resident due to unavailability. The medications, scheduled for morning administration, were Metoprolol Tartrate, Rosuvastatin Calcium, and Sertraline HCl. This resulted in a medication error rate of 11.54%, confirmed by nursing progress notes and an interview with the nurse.
The facility failed to offer pneumococcal vaccines to two residents, as revealed by clinical record reviews and staff interviews. Despite multiple requests, the facility's policies for vaccines were not provided during the survey. Hospital records indicated the residents were due for the vaccine, but there was no documentation of it being offered or administered.
The facility failed to provide a working call bell system in the bathrooms of three occupied rooms, leaving residents without a means to contact nursing staff if they did not have their handheld call bell. The issue was confirmed through interviews and observations, highlighting the need for a separate call bell system in the bathrooms.
The facility failed to maintain an effective training program for its staff, as evidenced by missing or incomplete training documentation for five employees. Required training topics such as abuse prevention, dementia care, and emergency preparedness were not adequately documented, indicating a systemic issue in staff training compliance.
A resident in a LTC facility reported grievances about unfriendly staff behavior, delayed call bell responses, and disturbances from other residents. The facility failed to document investigation steps, confirm grievances, or notify the resident of outcomes, violating grievance policy.
The facility failed to ensure a safe and orderly discharge for five residents, leading to issues such as missing medical supplies, delayed medication delivery, and inadequate communication with home health care providers. These deficiencies were due to ineffective discharge planning and miscommunication among staff.
A facility failed to monitor a resident's nutritional status, resulting in significant weight loss. The resident was not weighed upon admission, and daily food and fluid intake were not recorded for a period of time. The resident's weight dropped from a hospital-recorded 154 pounds to 134 pounds, despite a care plan goal to maintain weight. This deficiency was confirmed by the DON and a dietitian.
A resident with osteomyelitis was admitted to the facility and prescribed Linezolid and Meropenem. Due to the facility's failure to ensure timely delivery of these medications from the pharmacy, multiple doses were missed, leading to the resident's readmission to the hospital. Interviews confirmed the pharmacy's irregular delivery schedule and the facility's inability to administer the medications as ordered.
Failure to Reassess and Adjust Nutritional Care for Malnourished Resident With Pressure Injuries
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident maintained acceptable nutritional status and usual or desirable body weight, despite existing policies requiring comprehensive nutritional assessment and monitoring. The facility’s nutritional assessment policy from 2001 assigned responsibility to the physician, dietitian, and nursing staff, and required a nutritional assessment with any change in condition, including identification of usual intake, appetite, meal patterns, and clinical conditions affecting nutrition. For this resident, a quarterly MDS dated October 11, 2025 documented diagnoses of urinary tract infection and malnutrition, a height of 66 inches, weight of 130 pounds, and a physician-prescribed weight gain regimen. A subsequent quarterly assessment showed the resident still had malnutrition, a pressure ulcer, the same height, and a reduced weight of 122 pounds, with intake of 25% or less of total calories provided. A wound care assessment documented development of a right lateral ankle deep tissue injury, and the physician ordered daily wound care and a nutritional supplement of liquid protein on January 27, 2026. A later wound consultant assessment identified a Stage IV pressure injury on the right lateral calf with exposed tendon and an unstageable wound on the right lateral ankle, with specific wound treatments ordered. The DON confirmed these wound findings. The registered dietitian’s evaluation on October 8, 2025 recorded the resident’s ideal body weight as 142 pounds and actual weight as 129.6 pounds, with a care plan goal for weight gain to ideal body weight. A dietitian progress note on November 6, 2025 documented a significant weight loss to 122 pounds. On December 31, 2025, the dietitian clarified that the resident’s weight was 122 pounds, not 215.8 pounds as nursing staff had documented, and the DON later confirmed the 122‑pound weight on that date and again on February 26, 2026. Meal and snack intake records showed poor evening meal consumption of food and fluids on 12 of 28 days in February 2026 and poor evening snack consumption on 21 of 28 days that month, which the DON confirmed. For March 1 through March 4, 2026, the clinical record showed poor intake at meals and evening snacks, including poor breakfast and dinner intake on one day, no documented intake at the noon meal on another day, and poor dinner intake on a subsequent day, all confirmed by the DON. Despite the diagnosis of malnutrition, lack of weight gain, and documented poor intake over February and early March, there was no documentation that the registered dietitian completed a nutritional assessment for those months, and no nutritional care plan changes or updates were made; the resident remained on a regular pureed diet with a house shake 4 oz twice daily and protein liquid twice daily. The administrator confirmed the lack of documented assessment, monitoring, and nutrition care plan revision. Hospital records later showed the resident was admitted with osteomyelitis of the right leg involving the tibia, fibula, and ankle.
Inaccurate Weight Documentation in Clinical Record
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate clinical record documentation for a resident’s weight, as required by its nutritional assessment policy and professional standards. The facility’s policy from 2001 states that the physician, dietitian, and nursing staff share responsibility for nutritional assessment and care, and that a nutritional assessment is required when a resident experiences a change in condition. The policy further specifies that the interdisciplinary team must use data gathered throughout the resident’s stay, including usual intake, appetite, meal and snack patterns, preferred portion sizes, and current clinical conditions affecting nutritional status, and that the dietitian is responsible for assessing and monitoring nutritional intake and identifying increased caloric and protein needs. For one resident, a quarterly MDS assessment documented a height of 66 inches and a weight of 215 pounds. However, a dietitian’s progress note dated December 31, 2025, recorded the resident’s weight as 122 pounds, in contrast to the 215.8 pounds documented by nursing staff on the same date. In an interview, the DON confirmed that the correct weight recorded by nursing staff on December 31, 2025, was 122 pounds, and also confirmed a weight of 122 pounds recorded by nursing staff on February 26, 2026. These discrepancies show that the resident’s clinical record did not accurately reflect the resident’s actual weight, constituting a failure to maintain accurate medical records in accordance with accepted professional standards and the facility’s own policies.
Unattended and Unsecured Medication Carts
Penalty
Summary
Surveyors found that the facility failed to prevent accident hazards and did not provide adequate supervision regarding the security of medication carts and medications on both the first and second floors. Facility policy requires that medication carts remain closed and locked when not in direct view of the nurse or aide, with no medications left on top and resident information kept secure. However, observations revealed multiple instances where medication carts were left unattended, unlocked, and with sensitive resident information visible on computer screens. On the second floor, a nurse left two medication carts unlocked and unattended, with one cart displaying the narcotic book and resident information, while the nurse was away administering pain medication to a resident. The nurse admitted to confusion about her assignment and confirmed both carts were left unsecured. Further observations on the second floor showed another nurse leaving a medication cart unlocked and unattended while administering medications to a resident in a nearby room. This nurse also confirmed that leaving the cart unsecured was not standard practice. On the first floor, a medication cart was found unlocked with resident information visible until a nurse returned to secure it. Staff interviews confirmed that leaving carts unlocked and resident information visible was not the facility's standard practice. These findings demonstrate a failure to follow facility policy and state regulations regarding medication security and resident information confidentiality.
Failure to Ensure Timely and Accurate Medication Administration
Penalty
Summary
The facility failed to ensure timely and accurate medication administration for two of five residents reviewed. Facility policy requires medications to be administered safely and in accordance with prescriber orders, including specified time frames. For one resident with Parkinson's disease and seizure disorder, multiple medications scheduled for morning administration were significantly delayed, with some not given until late afternoon or evening. Another resident with congestive heart failure, hypertension, depression, and atrial fibrillation had not received their scheduled morning medications by mid-morning during surveyor observation. The facility's medication administration schedule allows for a one-hour window before or after the scheduled time, but these delays exceeded that window. Observations revealed a nurse assigned to 31 residents was still completing the morning medication pass well after the scheduled times. The nurse was also observed leaving medications unattended while assisting another resident, which is not standard practice. Additionally, the facility grievance log documented complaints from residents and family members regarding delayed medication administration, with findings confirming delays occurred. These events demonstrate a pattern of untimely medication administration and failure to follow facility policy.
Failure to Address Resident Grievances Regarding Call Bell Response Times
Penalty
Summary
The facility failed to address residents' concerns regarding delayed call bell response times for three of six residents reviewed. One resident reported experiencing excessively long waits for nursing staff response during overnight shifts. Grievance reports from two other residents documented concerns about untimely hygiene care and prolonged wait times for call bell responses, with one resident specifically noting not being cleaned properly after being soiled. Facility-provided call bell audits for the relevant month were primarily conducted during day and evening shifts, did not specify times, and excluded the rooms from which concerns were reported. Additionally, an audit noted a one-hour wait time for call bell response, but did not identify the shift or specific time.
Non-Functioning Call Bell System in Resident Bathroom
Penalty
Summary
Facility documentation review, resident interviews, and direct observation revealed that the call bell system in the bathroom and bathing area for one resident was not functioning. The facility's policy requires staff to ensure that call lights are plugged in, operational at all times, and that any defective call lights are promptly reported. However, during an interview, the resident stated that the call bell had not worked for some time and had not reported the issue due to other unaddressed concerns. Subsequent observation confirmed the call bell system was non-functional in the resident's environment.
Required State Contact Information Not Posted on Nursing Floors
Penalty
Summary
The facility failed to post the required contact information for the State Survey Agency and the State Long-Term Care Ombudsman program in readily accessible locations on both the first and second nursing floors. Observations on the first floor revealed no postings for the Department of Health or Ombudsman contact information, except for a single posting in the entryway between two glass doors in the lobby. During a Resident Council meeting on the second floor, four alert and oriented residents reported being unaware of how to contact the State Department of Health or Ombudsman Office and stated they had not seen any postings in the building. Further observations with the Director of Social Services confirmed the absence of required postings on the second floor. The Nursing Home Administrator acknowledged that the Ombudsman contact information was only posted in the entryway and that there was no Department of Health information posted anywhere in the facility.
Failure to Timely Revise Care Plans for Hospice, Enteral Feeding, and IV Devices
Penalty
Summary
The facility failed to ensure that care plans were revised in a timely manner for residents with significant changes in condition or new interventions, specifically related to hospice services, enteral feeding, and intravenous devices. For one resident with hypertensive heart disease, aphasia, and failure to thrive, hospice services were initiated, but there was no care plan developed to address goals or interventions for hospice care. Another resident with dysphagia, dementia, diabetes, and a gastrostomy had a physician order for tube feeding, but the care plan did not include current goals or interventions for enteral feeding after the previous plan was cancelled. A third resident with severe intellectual disability, borderline personality disorder, and anxiety disorder experienced multiple incidents of intravenous device dislodgement due to behavioral issues and lack of understanding of the necessity of the IV. Despite repeated incidents and documentation of the resident's non-compliance and mental status, there was no evidence of care plan goals or interventions addressing these issues. These findings were based on clinical record reviews, staff interviews, and incident reports, and were not in accordance with the facility's policy requiring timely care plan updates following significant changes in condition.
Failure to Assess and Implement Toileting Programs for Residents with Urinary Incontinence
Penalty
Summary
The facility failed to provide appropriate care for residents with urinary incontinence, specifically by not implementing assessments or interventions aimed at maintaining, restoring, or improving bladder function for two residents. For one resident, who was cognitively intact and dependent on staff for toileting, there was no documentation of a voiding study or toileting trial to determine voiding patterns or the type of incontinence. Despite the resident expressing a desire to participate in a toileting program and being able to communicate toileting needs, staff confirmed that no such program or assessment had been initiated, and the resident continued to use briefs. Similarly, another resident, who was alert, oriented, and dependent on staff for transfers and turning in bed, was frequently incontinent of urine and at risk for pressure ulcers. This resident also expressed willingness to use a bedpan instead of a brief and was able to communicate toileting needs to staff. However, there was no documentation of a voiding study or toileting trial for this resident either. Staff interviews confirmed the resident's abilities and needs, but no interventions or assessments were documented or implemented to address urinary incontinence as required by facility policy.
Missing Documentation of Nurse Training and Competency Assessments
Penalty
Summary
The facility failed to maintain records of annual training and competency assessments for two registered nurses in key areas of resident care, including medication administration, tube feeding administration and care, wound care assessment, monitoring and treatment, and safe transfers during care. The facility assessment indicated that residents were at risk for falls, required increased assistance with activities of daily living, had behavioral health and dementia needs, were prescribed psychoactive medications, had skin integrity issues, and required tube feedings and pressure ulcer care. During the review, it was found that there was no documentation available to confirm that the nursing staff had completed the necessary training and competency evaluations for these critical care areas. This was confirmed by the designated nurse trainer, who acknowledged the absence of the required records for the staff members reviewed.
Failure to Complete Annual Staff Performance Evaluations
Penalty
Summary
The facility failed to ensure that annual performance evaluations were completed for four staff members, including two nurse aides and two licensed nurses. Documentation requested for these employees was not provided, and interviews with the staff development employee confirmed that no performance reviews had been completed for the current or previous year. The staff development employee indicated that records from the previous year were not available because they had been taken by the previous company, and that current year evaluations were being delayed until June as instructed. As a result, there was no evidence of required annual performance evaluations for the identified staff members, in violation of facility personnel policies and procedures.
Failure to Provide Timely Abuse, Neglect, and Exploitation Training to Staff
Penalty
Summary
The facility failed to provide required training upon hire to staff on the topics of abuse, neglect, exploitation, and misappropriation of resident property, as well as procedures for reporting such incidents and prevention of resident abuse. This deficiency was identified through a review of facility policy, employee files, and staff interviews, which revealed that thirteen out of forty employees reviewed did not have documented evidence of receiving this training. The facility's policy mandates a commitment to protecting residents from abuse and requires all personnel to participate in annual in-service training programs, including abuse prevention. However, training records for several employees, including those in central supply, maintenance, nursing, and nurse aide roles, showed no evidence of abuse training upon hire. Further investigation included multiple requests for training records, with staff responsible for training unable to provide documentation for the required abuse training for several employees. Some employees did not receive the training until weeks after their hire date, while others had no record of training at all. Despite being given additional time, the facility did not submit documentation to demonstrate that the required training had been provided to the identified staff members.
Failure to Document Required Annual Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that nursing assistants completed and retained documentation of the required minimum of 12 hours of annual nursing training for two out of four nurse aides whose records were reviewed. Specifically, there was no documentation available for annual training and competencies in key areas such as dementia care, abuse prevention, accident prevention, restorative nursing techniques, emergency preparedness, resident rights, and cultural competency for two nursing assistants, one hired in March 2024 and another in September 2004. A review of the facility assessment indicated that residents were at risk for falls, required increased assistance with activities of daily living, had behavioral health and dementia care needs, were prescribed psychoactive medications, and required specialized care such as tube feedings and pressure ulcer management. An interview with the designated nurse trainer confirmed that the necessary trainings and competency sets for the nursing staff selected for review were not documented or available.
Failure to Evaluate and Communicate Change in Condition and Pain Management
Penalty
Summary
Facility staff failed to ensure a complete evaluation and timely physician notification regarding a resident's change in condition and pain management needs. The resident, who had a history of falls and was admitted with hip, pelvis, and knee pain, continued to experience significant pain and functional limitations after admission. Despite ongoing reports of pain from both the resident and therapy staff, and documentation of pain interfering with therapy progress, nursing staff did not adequately monitor or communicate the onset, duration, and severity of the resident's pain to the physician. On multiple occasions, the resident reported moderate to severe pain in the right hip and knee, which was not effectively managed with Tylenol. Therapy notes indicated that pain was constant and limited the resident's ability to participate in functional activities. Although Tramadol was indicated for pain management, there was no evidence that nursing staff obtained a physician's order or discussed the need for this medication with the physician. Additionally, there was no documentation that Tramadol was administered on the relevant dates. Interviews with staff confirmed that the physician was not notified of the significant change in the resident's medical condition, and pain management was not appropriately addressed. The lack of monitoring and communication contributed to the resident being sent to the hospital, where a deformed fracture of the right femur was diagnosed. The facility's failure to follow its policy for evaluating and reporting changes in condition resulted in inadequate pain management and delayed treatment for the resident.
Failure to Provide Accessible Grievance Forms and Anonymous Submission Options
Penalty
Summary
The facility failed to ensure that grievance forms were available and accessible to residents on both the first and second floor nursing units. According to the facility's own policy, residents and their representatives have the right to file grievances either orally or in writing, including anonymously, and the administrator is designated as the grievance officer. However, during a resident council meeting, four alert and oriented residents reported that they were not aware of how to file a grievance or where to find a grievance form within the facility. Additionally, a review of the Grievance/Concern Form showed there was no space to indicate that a grievance was being filed anonymously. A tour conducted with the Director of Social Services confirmed that there were no grievance forms accessible for residents, family, or advocates on either nursing unit. Furthermore, there were no labeled locked boxes available for submitting anonymous grievances. These findings were confirmed by the Nursing Home Administrator. The deficiency was cited under multiple Pennsylvania Codes related to the responsibility of the licensee, management, and resident rights.
Failure to Complete Significant Change Assessment After Notable Weight Loss
Penalty
Summary
The facility failed to conduct a significant change assessment for one resident after a notable decline in health status. The resident, who had diagnoses including dysphagia, muscle wasting and atrophy, heart failure, hypertension, and dementia, experienced a substantial weight loss. Upon admission, the resident weighed 175.4 pounds, but by mid-January, her weight had dropped to 155 pounds, representing a 9.4% loss in one week. Nursing documentation noted poor to fair intake, refusal of some food and drinks, and a recent positive test for Influenza A, which may have contributed to decreased appetite. The resident's diet was adjusted, and nutritional supplements were initiated, but concerns about the accuracy of the weight measurements were documented due to differences in weighing methods. Despite the identification of significant weight loss and ongoing poor intake, the clinical record showed that a Minimum Data Set (MDS) Change of Condition Evaluation was not completed in the month following the weight loss, as required by federal guidelines. The facility's failure to complete this comprehensive assessment within the mandated timeframe after a significant change in the resident's condition constituted the deficiency cited by surveyors.
Failure to Verify Resident Identity Leads to Administration of Incorrect TPN
Penalty
Summary
A deficiency occurred when a licensed nurse administered total parenteral nutrition (TPN) intended for one resident to a different resident who was also receiving TPN. The nurse failed to verify the resident's identity and did not check the name on the TPN bag before administration, contrary to facility policy. The incident involved a resident with a complex medical history, including hypokalemia, cardiac arrest, hypomagnesemia, tracheostomy, diabetes type 2, ileostomy, and abnormal blood chemistry. The TPN formula administered was not the one ordered for the resident, resulting in vomiting and a low potassium level. Multiple staff statements confirmed that the TPN bag was not checked for the correct patient name, formula, or rate during administration and subsequent shifts. The facility's policy required verification of the resident's identity and the use of a second nurse when administering TPN, but these procedures were not followed. The error was discovered when another staff member noticed the wrong patient's name on the TPN bag during a routine visit to the resident's room.
Incomplete Communication with Dialysis Provider
Penalty
Summary
The facility failed to maintain effective communication with a dialysis provider for a resident diagnosed with End Stage Renal Disease. According to the facility's policy, agreements with the contracted ESRD facility should include procedures for developing and implementing care plans and exchanging information between the two facilities. Review of the resident's clinical record and the dialysis communication binder revealed that several communication sheets were not fully completed, specifically the section to be filled out by the facility upon the resident's return from dialysis. This incomplete documentation was noted on multiple dates, indicating a lapse in the required communication process between the facility and the dialysis provider. The deficiency was identified through clinical record review, facility policy review, and staff interviews, and was cited under 28 Pa. Code 211.(5)(f) Clinical records and 28 Pa. Code 211.12 (d)(1) Nursing services.
Failure to Notify Physician and Obtain Assessment for Significant Weight Loss
Penalty
Summary
A deficiency was identified when the facility failed to ensure that a physician was notified and completed an assessment regarding a resident's significant unplanned weight loss. Clinical record review for a resident with diagnoses including muscle wasting, atrophy, dysphagia, and dementia showed multiple instances of significant weight loss over several months. Documentation indicated that the resident experienced a rapid and substantial decrease in weight, with notes questioning the accuracy of the measurements and suggesting possible scale discrepancies. Despite ongoing poor intake, changes in diet, and continued weight loss, there was no documented evidence that the physician was informed or that a medical evaluation was conducted to determine the causes of the weight loss. Interviews with facility staff, including the Regional Director of Nursing, confirmed that the resident's physician had not been notified and had not documented any assessment related to the significant weight loss. The clinical records lacked any indication of physician involvement or evaluation in response to the resident's ongoing and clinically significant weight changes. This failure to notify and involve the physician was cited as a violation of state regulations regarding nursing and physician services, as well as clinical record requirements.
Improper Disposal and Sanitation of Facility Garbage and Refuse
Penalty
Summary
Surveyors found that the facility failed to properly dispose of garbage and refuse, as required by their own policies and state regulations. A review of the cleaning and sanitizing policy for food service areas indicated that the food service director was responsible for creating and posting a comprehensive cleaning schedule, including tasks related to the disposal of kitchen garbage and trash. However, there was no documented or posted cleaning schedule for the routine cleaning, sanitizing, and storage of trash containers, cooking grease, garbage, and trash accumulated by the dietary department. This was confirmed in an interview with the director of dietary services, who acknowledged the absence of such schedules. During observations of the outdoor loading and receiving area adjacent to the food and nutrition services department, surveyors noted that waste was not properly covered or contained, as the dumpster/compactor unit lacked a lid. The surrounding driveway area was littered with torn open plastic bags containing soiled briefs, food debris, papers, and plastic gloves. Foul odors and waste fat were also present on the loading dock. The area, which served as the main storage for the facility's garbage and trash, was not maintained in a sanitary manner, creating conditions conducive to pests and rodents.
Failure to Maintain Essential Dietary Equipment
Penalty
Summary
Essential equipment in the food and nutrition services department, specifically the industrial-sized ice machine located in the main kitchen, was not maintained in safe operating condition. Observations confirmed that the ice machine was not functioning, and interviews with the maintenance director and the director of dietary services revealed that the equipment had been out of service since January 2025. Despite a work order being placed at that time, the ice machine remained non-operational for several months, forcing dietary staff to use an ice machine on the second floor nursing unit or to have ice delivered in bags from an outside vendor. A review of purchase order requisitions showed that a request for a new ice machine was only made in May 2025, and there was no confirmed delivery date for the replacement equipment.
Failure to Maintain Effective Pest Control in Dietary Department
Penalty
Summary
The facility failed to maintain an effective pest control program in the dietary department, as evidenced by multiple observations and documentation. During an inspection of the main kitchen, significant accumulations of food debris, dirt, cooking grease, and rodent droppings were found throughout the perimeter and especially under industrial-sized food service equipment such as ovens, stoves, grills, preparation tables, tray-line assembly areas, refrigerators, juice machines, and dry food storage shelves. The facility's pest control policy assigns responsibility to the food service director to address pest issues and requires a pest control contractor to perform preventative treatments and document all visits and actions taken. However, the observed conditions indicated a lack of effective implementation of this policy. Additionally, the metal doors leading to the loading and receiving area adjacent to the food and nutrition services department did not seal properly, leaving air gaps that allowed easy access for pests and rodents. Outside, the trash and refuse dumpster area was found to be malodorous, with the dumpster left open and surrounded by torn plastic bags of trash, soiled briefs, food debris, papers, and plastic gloves scattered around the driveway. Pest control operator reports from January through April documented ongoing treatment needs for rodents in the kitchen and front lobby, further indicating persistent pest issues in these areas.
Deficiency in Call Bell System Management
Penalty
Summary
The facility failed to ensure a routine process for the functioning and timely response to call bell systems during weekends on the 1st and 2nd nursing floors. The facility's policy, revised on June 1, 2021, mandates that patients have a call light or alternative communication device within reach at all times when unattended, and that staff respond promptly. However, interviews with two residents on the second floor revealed complaints about delayed responses from nursing staff when using call bells. Additionally, the facility's grievance log for November and December 2024 documented concerns about long wait times and staff being on their phones while call bells were active. Call bell audits for these months showed that audits were conducted primarily during the day shift, with only two during the evening shift, and none on weekends.
Plan Of Correction
Resident call system works properly, and call bells are answered timely. Initial whole house audit of the resident's call bell system (bathroom and bedside) will be completed to ensure function by the Maintenance Director/designee. A Center-wide Walk through was completed and all activated call bells were being addressed timely. NHA/designee will educate Center employees on timely response to call bells. Weekly Weekend audits x 4 then monthly x 2 are to be conducted at random locations to ensure the call bell system is working. NHA/designee will report all findings to be discussed in QAPI meeting x 3 months.
Incomplete Documentation of Treatment Administration
Penalty
Summary
The facility failed to ensure complete documentation related to treatment administration for a resident, identified as Resident R1. A review of the facility's policy on 'Treatments' indicates that a licensed nurse or medical technician is required to perform treatments as ordered and document the administration on the Treatment Administration Record (TAR), including the patient's response, refusal of treatment, and notification of the physician. However, the clinical record for Resident R1 revealed a lack of documented evidence for the administration of Hydrocortisone External Cream 2% on several specified dates, despite a physician's order for the treatment to be applied twice daily for a rash. There was also no documentation of the resident's refusal of treatment or any other reason for the missed treatments on the specified dates.
Plan Of Correction
Resident 1 no longer resides in the Center. An initial 30-day lookback audit will be conducted for all current residents to ensure that the licensed nursing staff has completed the treatment administration records. The Director of Nursing/designee will educate licensed nursing staff on the policy related to treatment administration record documentation. The Director of Nursing/designee will conduct random audits of resident treatment administration records weekly x 3 weeks and then monthly x 2 to ensure professional staff has completed the treatment administration documentation. The Director of Nursing or designee will report all findings to be discussed in QAPI meeting x 3 months.
Failure to Safely Store Medications for Residents
Penalty
Summary
The facility failed to ensure the safe storage of drugs and biologicals for three residents, as observed during a tour on September 9, 2024. In Resident R3's room, Fluticasone nasal spray was found on the bedside table without any evidence of an assessment for safe self-administration or a care plan for storing medication in the room. Similarly, in Resident R4's room, a bottle of Nystatin antifungal powder and two Albuterol inhalers were found on the bedside table, again with no assessment or care plan documented for safe self-administration or storage. In Resident R5's room, a bottle of Melatonin was discovered in the nightstand drawer, with no evidence of an assessment for safe self-administration or a care plan for medication storage. Interviews with staff members, including a Registered Nurse and Guest Service Staff, confirmed these findings. The facility's failure to conduct assessments and create care plans for the safe self-administration and storage of medications for these residents constitutes a deficiency in compliance with the relevant regulations.
Corridor Handrails Not Secure
Penalty
Summary
The facility failed to equip corridors with safe handrails on each side, as observed in two nursing units, specifically the First and Second floor nursing units. Observations revealed that the handrails in the corridors were either loose, missing, or broken. Specific locations with deficiencies included the corridor next to room [ROOM NUMBER] with a missing end piece, and rooms 219, 216, 213, 224, 221, 223, 228, 227, 116, 122, 123, 124, as well as the first shower room, all of which had loose or broken handrails. This deficiency was confirmed through an interview with the Nursing Home Administrator, who acknowledged the issue of broken or missing handrails.
Failure to Inform Resident's Representative of New Medication
Penalty
Summary
The facility failed to inform a resident's representative in advance of the proposed care, specifically regarding the prescription of Melatonin as a sleep aid for a resident with cognitive impairment and dementia. The resident had previously elected her daughter to make medical decisions on her behalf. Despite this, the facility did not notify the daughter about the new medication order, nor did they discuss the advantages, disadvantages, or alternative options for the medication. The deficiency was identified when the resident's daughter discovered the medication was being administered after noticing her mother was unusually sleepy and inquired with the nursing staff. The Director of Nursing confirmed that the facility did not inform the resident's representative about the new medication order, which is a violation of resident rights and nursing services regulations.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment on both the first and second floors, as observed during an initial tour. In one room, there was a strong odor of urine, and the commode was not emptied or cleaned, containing urine, feces, and bathroom tissue from the previous night, as confirmed by a resident. Another room had trash on the floor, including used medical supplies such as medicine cups, alcohol wipes, gauze, and tape with blood, as well as a yellow stain on the sheet and an old foam coffee cup with dried stains. These findings were confirmed by a registered nurse present during the observation. On the second floor, a strong odor of urine was noted, and another room had trash on the floor, gloves, and used gauze with tape. The window bed in this room had tangled cords, making it difficult for the resident to access that side of the bed, and a nebulizer mask was left unbagged on the nightstand. Additionally, the corridor handrail was found to be loose, missing, or broken in several locations, including next to multiple room numbers and the first shower room. These observations were confirmed by a guest service staff member.
Deficiency in IV Therapy Care and Assessment
Penalty
Summary
The facility failed to provide care and assessments consistent with professional standards of practice related to intravenous therapy for three residents. Resident R5 had a PICC line in his right upper arm, and the dressing was not changed for over two weeks, from July 21, 2024, through August 5, 2024. There were no physician orders or documentation indicating that the PICC line was flushed or what type of flush solution should be used. Additionally, there were no assessments or measurements of the PICC line, such as arm circumference and external catheter length. Resident R58 had a PICC line for chemotherapy, and during her first week of admission, the nursing staff did not flush her PICC line to maintain its patency. The MARs indicated that the flushes were not administered on July 30 and 31, 2024, due to the medication being on order. There was also no documentation of any PICC line assessments or measurements, such as arm circumference and external catheter length. Resident R265 had a PICC line for intravenous antibiotics due to right knee septic arthritis. The MARs and physician orders did not include any orders for PICC line flushes, dressing changes, or assessments/measurements. The Regional Nurse confirmed that PICC line care was not provided in accordance with professional practice standards for these residents.
Lack of Competency Evaluations for Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies and skill sets to provide appropriate care for residents, as required by the Pennsylvania Nurse Practice Act. This deficiency was identified through observations, personnel file reviews, and interviews, revealing that five employees, including registered nurses, licensed practical nurses, and nurse aides, did not have documented skills competency evaluations. The lack of evidence for skills competency evaluations was confirmed by the Director of Nursing and the Regional Nurse, who were unable to provide documentation of training or competency evaluations for intravenous (IV) therapy. The deficiency was particularly concerning for residents requiring intravenous therapy. Four residents were observed with PICC lines for various treatments, including antibiotic therapy and chemotherapy. Despite the critical nature of these treatments, there was no evidence that the nursing staff administering these therapies had received the necessary training or competency evaluations to perform these tasks safely and effectively. This lack of documented competency evaluations raises concerns about the facility's ability to meet the residents' needs safely. The facility's failure to conduct and document skills competency evaluations for its nursing staff, particularly in administering IV therapy, represents a significant oversight in ensuring resident safety and care quality. The absence of such evaluations contravenes the requirements set forth in the Pennsylvania Nurse Practice Act, which mandates that registered nurses and licensed practical nurses must have instruction and supervised practice in administering IV fluids, drugs, or blood. This deficiency was acknowledged by the facility's Director of Nursing and Regional Nurse, who could not provide the necessary documentation during the survey.
Failure to Implement Drug Regimen Review Recommendations
Penalty
Summary
The facility failed to implement a complete drug regimen review process for three residents, as required by their policy. For Resident R16, the pharmacist recommended separating the administration times of multiple ophthalmic medications by at least five minutes. However, the physician orders did not reflect these changes, and the Director of Nursing confirmed that the recommendations were not implemented. For Resident R5, the pharmacist advised monitoring for signs of bleeding and thromboembolism due to the use of Aspirin and Clopidogrel. Although the physician agreed with these recommendations, no orders were added to reflect them. Similarly, for Resident R270, the pharmacist recommended monitoring for bleeding and behavior changes due to Aspirin and Lorazepam use, and adding a stop date for Lorazepam. Despite the physician's agreement, these recommendations were not incorporated into the resident's orders. The Director of Nursing confirmed the lack of implementation for both residents.
Inadequate Infection Control and Reporting
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by inadequate infection surveillance for three residents with infections. Resident R5, who had a PICC line for antibiotic therapy due to osteomyelitis, was not included in the infection surveillance tracking logs. Similarly, Resident R16, who was receiving multiple antibiotic medications for various conditions, and Resident R56, who was being treated for a urinary tract infection, were also omitted from the infection tracking logs. The Director of Nursing confirmed that infection surveillance and tracking had not been completed for these residents. Additionally, the facility did not comply with the requirements for infection data reporting and infection committee meetings. The facility was unable to provide any utilization or infection reporting data from the Pennsylvania Patient Safety Reporting System (PA-PSRS) due to lack of access. Furthermore, the Nursing Home Administrator confirmed that the last documented infection committee meeting was conducted in November 2023, indicating a significant lapse in regular meetings. This lack of documentation and reporting is a violation of Act 52 of 2007, which mandates comprehensive infection control plans and reporting of healthcare-associated infections.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program for five residents who were reviewed for antibiotic use. The facility's policy, dated July 1, 2024, required the implementation of an antibiotic stewardship program with protocols and systems for monitoring antibiotic use. However, observations and reviews revealed that the facility did not adhere to these protocols. For instance, Resident R5 was receiving daily antibiotic therapy through a PICC line for osteomyelitis, but there was no evidence of proper infection assessment or antibiotic stewardship practices being conducted. Similarly, Resident R16 was prescribed multiple antibiotics for different conditions, including vancomycin and tobramycin eye drops, and azithromycin for bronchitis. Despite these prescriptions, there was no documentation of infection assessments or antibiotic stewardship practices. Resident R56 was also receiving antibiotics for a urinary tract infection, but again, there was no evidence of infection assessment or monitoring as per the facility's policy. Further deficiencies were noted with Residents R265 and R266, who were receiving intravenous antibiotics for septic arthritis and osteomyelitis, respectively. The facility's infection surveillance tracking logs lacked critical information such as the type of infection, organism, and antibiotic treatment for these residents. Interviews with the Director of Nursing confirmed that infection and antibiotic assessments were either incomplete or not conducted at all for these residents, indicating a systemic failure in the facility's antibiotic stewardship program.
Failure to Notify Ombudsman of Emergency Transfers and Discharges
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers and discharges as required by regulations. This deficiency was identified through a review of facility documentation and staff interviews. Specifically, documentation of such notifications for the past three months was requested from the Nursing Home Administrator (NHA) on August 15, 2024. During an interview on the same day, the NHA confirmed that the facility did not send the required notifications to the Ombudsman for the past three months. The NHA indicated that this responsibility would be assigned to a new social worker moving forward.
Failure to Develop Timely Baseline Care Plans for Residents with PICC Lines
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for two residents who required intravenous therapy. Resident R5, who was admitted with a PICC line for antibiotic therapy due to osteomyelitis, did not have a care plan initiated for the care and maintenance of the PICC line until several weeks after admission. Despite having a physician's order for intravenous ceftriaxone, the necessary care instructions were not included in the resident's care plan in a timely manner. Similarly, Resident R58, admitted with a PICC line for chemotherapy due to cancer and lymphoma, also lacked a baseline care plan addressing the care and maintenance of the PICC line within the required timeframe. The absence of these care plans was confirmed by the Regional Nurse, Employee E3, who acknowledged that the baseline care plans were not developed within 48 hours of admission for these residents, as required by facility policy and state regulations.
Failure to Develop Timely Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans in a timely manner for two residents. Resident R16 was admitted and had an Admission MDS indicating shortness of breath when lying flat. Despite having a physician's order for continuous supplemental oxygen to maintain saturation levels above 92%, there was no care plan developed for oxygen therapy. This was confirmed by both a Registered Nurse and the Director of Nursing during interviews. Similarly, Resident R27 had multiple treatment orders for various wounds, including a pressure wound on the sacrum and abrasions on the left elbow and right forearm. Despite these orders, there was no care plan developed for the wound treatments. This deficiency was confirmed by a Unit Manager, Registered Nurse, during an interview. The lack of timely and comprehensive care plans for both residents indicates a failure to adhere to the facility's policy on person-centered care planning.
Failure to Provide Scheduled Bathing for Resident
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living, specifically bathing, for one resident, identified as Resident R48. The facility's policy requires that residents be assessed for their ability to perform activities of daily living upon admission, quarterly, and with any significant changes. This policy also mandates that care provided, such as bathing, be documented in the resident's medical record on every shift. However, a review of Resident R48's records revealed a lack of documentation indicating that the resident was offered showers or tub baths from July 25, 2024, through August 14, 2024. Instead, only bed baths were recorded on specific dates. Interviews conducted with the resident's wife and the Unit Manager highlighted the deficiency. The resident's wife reported that it took the facility three weeks to provide her husband with a shower after his admission. The Unit Manager confirmed that the resident was scheduled for showers twice a week, on Wednesdays and Saturdays, but could not provide evidence from the clinical record to show that these showers were offered. Resident R48 had multiple diagnoses, including chronic kidney disease, hypertension, chronic pain syndrome, cerebral infarction, and encephalopathy, which may have necessitated regular bathing assistance. The lack of documentation and failure to offer scheduled showers constituted a breach of the facility's policy and a deficiency in care.
Failure to Follow Physician Orders for Diet and Wound Care
Penalty
Summary
The facility failed to adhere to physician orders for two residents, leading to deficiencies in care. Resident R265, who was admitted with a diagnosis of right knee septic arthritis, had a physician's order dated August 9, 2024, to cleanse the right knee surgical incision with normal saline, pat dry, and apply a clean dry dressing daily. However, an observation on August 12, 2024, revealed that the dressing on Resident R265's right knee was dated August 9, 2024, indicating that it had not been changed daily as prescribed. This was confirmed by Employee E4, a licensed nurse, who acknowledged the oversight and proceeded to change the dressing. Additionally, Resident R168, admitted for respite care with diagnoses including cerebral vascular disease, malnutrition, and dementia, had a physician's order for a puree texture diet with thick liquids of nectar consistency. During an observation on August 12, 2024, the resident was found with a cup of water, which was not in accordance with the prescribed diet. Employee E5, a licensed nurse, confirmed that the resident should not have been served water, indicating a failure to follow dietary orders. These incidents highlight the facility's failure to obtain and follow physician orders related to diet and wound care for the residents involved.
Incomplete Dialysis Communication Records
Penalty
Summary
The facility failed to maintain complete and accurate records related to dialysis communication for a resident with End-Stage Renal Disease, who required regular dialysis treatment. The resident was admitted to the facility with a diagnosis necessitating dialysis on specific days of the week. However, the Hemodialysis Communication Record for this resident was incomplete on multiple occasions. Specifically, on two dates, the record lacked all necessary information to be completed by a licensed nurse both prior to and after dialysis treatment, and on another date, it was missing post-treatment information. An interview with a licensed nurse confirmed the lack of communication with the dialysis center, highlighting a deficiency in the facility's nursing services as per the relevant state code.
Failure to Conduct Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to conduct performance reviews for three nurse aides, identified as Employees E16, E17, and E18, as required by their personnel policies and procedures. Employee E16 was hired on July 8, 2002, Employee E17 on April 19, 2022, and Employee E18 on December 30, 2019. On August 13, 2024, the Nursing Home Administrator and Director of Nursing were unable to provide the requested annual performance reviews for these employees. An interview with the Nursing Home Administrator on August 14, 2024, confirmed that no performance reviews had been completed for any staff, including the three nurse aides in question.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as observed during a medication administration session involving a resident. On the morning of August 12, 2024, a registered nurse, identified as Employee E9, was observed not administering three prescribed medications to a resident. These medications included Metoprolol Tartrate for tachycardia, Rosuvastatin Calcium for hyperlipidemia, and Sertraline HCl for depression. The nurse stated that the medications were unavailable at the time of administration. Further review of the nursing progress notes and the Medication Administration Record (MAR) confirmed that the medications were scheduled for administration at 9:00 a.m. on the same day. The notes indicated that the pharmacy was contacted, and the medications were expected to be delivered later in the day. The failure to administer these medications resulted in a medication error rate of 11.54%, which exceeds the acceptable threshold. The findings were confirmed through an interview with Employee E9.
Failure to Offer Pneumococcal Vaccines
Penalty
Summary
The facility failed to offer pneumococcal vaccines to two residents, as determined through clinical record reviews and staff interviews. The facility's policies for influenza and pneumococcal vaccines were requested multiple times over several days but were not provided for review during the survey. This lack of documentation and policy availability contributed to the deficiency identified by the surveyors. Clinical record reviews for two residents revealed no indication that they were offered the pneumococcal vaccine, despite hospital records showing they were due for it. The Director of Nursing confirmed that documentation of the vaccines was unavailable. Additionally, a Regional Nurse stated that the vaccination status was in the hospital records, but upon review, there was no evidence that the residents had received the pneumococcal vaccine.
Non-Functional Call Bell Systems in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that resident bathrooms were equipped with a functioning call bell system for three out of 25 residents reviewed, specifically in rooms 100, 102, and 104. During an interview with the maintenance assistant and the Nursing Home Administrator (NHA), it was reported that the call bell system was broken in rooms 116, 100, 102, and 104, with rooms 100, 102, and 104 being occupied by residents. Although the residents were provided with a handheld call bell system with a lanyard, the bathroom call bell systems in these rooms were not operational, leaving residents without a means to contact nursing staff for assistance if they did not have their handheld call bell with them. An observation conducted in the rooms confirmed that the bathroom call bell systems were non-functional. A discussion with the NHA and the Regional Nurse highlighted the necessity for a separate call bell system in the bathrooms to ensure resident safety and communication with nursing staff. This deficiency was noted under the regulation 28 Pa. Code 205.67(j) concerning electric requirements for existing construction.
Deficiency in Staff Training Compliance
Penalty
Summary
The facility failed to maintain an effective training program for its staff, as evidenced by deficiencies found in the personnel files of five employees. The review of the Facility Assessment indicated that staff training and competencies are essential for providing care to the short-term resident population, with required topics including effective communication, resident rights, abuse prevention, infection control, and recognizing changes in resident conditions. However, upon reviewing the personnel files of Employees E20, E18, E11, E14, and E15, it was found that these employees did not complete the necessary training as required by the facility's policies. Specifically, Employee E20 did not complete any annual training within the specified period. Employee E18 completed some training but lacked documentation for 12 hours of annual training and missed several required topics. Employees E11 and E15 had no documentation of abuse training, while Employee E14 lacked documentation for training in dementia care, restorative nursing techniques, emergency preparedness, QAPI, ethics, and behavioral health. The Director of Nursing confirmed the absence of these training records during an interview, indicating a systemic issue in maintaining staff training compliance.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to adequately address and document the grievances of a resident, identified as Resident R1, who was admitted for rehabilitation services with diagnoses including spinal stenosis, right foot drop, rotator cuff tear, and hypertension. The resident filed grievances on two occasions, reporting issues such as unfriendly behavior from a nurse aide, delayed response to call bells, and being scratched by a nurse aide. Additionally, the resident reported disturbances from a neighbor and an aggressive encounter with another resident. Despite these grievances, the facility did not provide a summary of findings, confirm or deny the grievances, or document corrective actions taken. The facility's grievance policy, revised in January 2024, mandates that the Nursing Home Administrator (NHA) oversee the grievance process, including issuing written decisions and maintaining confidentiality. However, the investigation sections of the grievance forms lacked detailed documentation of the steps taken to investigate the resident's concerns. For instance, there was no evidence of interviews with staff involved in the incidents or a clear conclusion of the investigations. The forms also omitted the date of the written decision and the method used to notify the resident of the outcomes. Interviews with the resident and facility staff confirmed the absence of documentation showing that the resident was informed of the grievance outcomes. The facility's failure to follow its grievance policy and provide timely and comprehensive responses to the resident's concerns resulted in a deficiency in honoring the resident's right to voice grievances without discrimination or reprisal.
Inadequate Discharge Planning for Multiple Residents
Penalty
Summary
The facility failed to ensure a safe and orderly discharge planning process for five residents, leading to deficiencies in their discharge procedures. Resident R1 was discharged without the necessary tracheostomy supplies, as the facility did not complete the required paperwork for the DME supplier, resulting in incorrect equipment being sent. The facility's discharge planning system, Parachute, was not effectively utilized, and the discharge was complicated by last-minute concerns. Resident R2 faced issues with medication prescriptions due to a name change of the provider, causing delays in medication delivery. Additionally, the DME was ordered but had to be reordered, and the original home care referral was refused, requiring the resident to contact an insurance adjuster for a new referral. These issues were compounded by the facility's inadequate discharge planning. Resident R3 was discharged without sufficient colostomy supplies, and the home health care agency was not informed of the discharge, delaying care. The facility struggled to find a DME company that accepted the resident's insurance, and the resident was discharged before a medical appointment. Resident R4's discharge was marked by miscommunication, with equipment arriving late and discharge paperwork not ready. Resident R5 experienced delays in home health care services due to provider refusals and insurance issues, with the facility failing to ensure a smooth transition.
Failure to Monitor Resident's Nutritional Status
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status, as evidenced by the lack of documentation and monitoring of the resident's weight and food/fluid intake. The facility's policy required that each resident be weighed upon admission and weekly for the first month. However, there was no documentation indicating that the nursing staff obtained an admission weight for the resident. The only available weight was a hospital weight of 154 pounds, while the resident's usual body weight was reported to be between 159 to 160 pounds. The resident's care plan aimed for the resident to maintain weight without significant loss, with a goal of consuming more than 50% of meals. Despite these requirements, the nursing staff failed to record daily food and fluid intake for the resident from April 9 to April 21, 2024. This lack of documentation was confirmed by the Director of Nursing and the registered dietitian. An admission comprehensive assessment dated April 19, 2024, indicated that the resident weighed 134 pounds, representing a significant weight loss of 20 pounds from the hospital weight. The absence of recorded weights and intake monitoring contributed to the deficiency in maintaining the resident's nutritional status.
Failure to Administer Prescribed Antibiotics
Penalty
Summary
The facility failed to acquire and dispense medications as ordered by the physician for a resident (R1) who was admitted with a history of osteomyelitis and required antibiotic therapy. Upon admission, the resident was prescribed Linezolid and Meropenem, but the facility did not have these medications available. As a result, multiple doses of both antibiotics were omitted over several days, leading to the resident being readmitted to the hospital due to the lack of necessary medication administration. The facility's policy required licensed nurses to verify and reconcile medication orders with the physician and communicate these orders to the pharmacy. However, the nursing staff failed to ensure the timely delivery of the prescribed antibiotics. Interviews with the nursing staff and the Director of Nursing confirmed that the pharmacy service was not delivering medications regularly, resulting in missed doses for the resident. The Nursing Home Administrator acknowledged the issue, confirming the lack of timely delivery and professional services from the outside pharmacy group. This deficiency in pharmaceutical services led to the resident missing critical doses of antibiotics, which were essential for treating their osteomyelitis, ultimately necessitating a return to the hospital.
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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