Willow Terrace
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- One Penn Boulevard, Philadelphia, Pennsylvania 19144
- CMS Provider Number
- 396129
- Inspections on file
- 36
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 10 (1 serious)
Citation history
Health deficiencies cited at Willow Terrace during CMS and state inspections, most recent first.
A resident with HF, major depressive disorder, muscle weakness, and a left leg amputation, who was cognitively intact, was involved in two substantiated abuse incidents with the same CNA. In the first event, a CNA engaged in a loud argument with the resident at the nurses’ station, repeatedly speaking in Spanish and refusing to open the locked unit door, which escalated the resident’s agitation; another CNA intervened by helping the resident sign out and reported the incident to the nursing supervisor. In a later incident, after the resident complained to the ADON that the CNA would not assist or open the door, the CNA again spoke in Spanish, triggering further agitation. When the resident wheeled toward the CNA and grabbed the CNA’s sweater, the CNA refused to move away, then placed an arm around the resident’s neck in a choke-hold and a hand on the resident’s face, requiring the ADON to physically pry the CNA’s hands off the resident. The DON and administrator were not informed of the first incident until the second was investigated, and the facility’s investigation concluded that the staff-to-resident actions constituted abuse and caused actual harm, showing a failure to keep the resident free from physical abuse.
A resident with Major Depressive Disorder and intact cognition reported that a CNA verbally, physically, and mentally abused the resident, and further stated that the CNA frequently argued with the resident. Facility policy required immediate protection of residents upon identification of suspected abuse, including prompt reporting, investigation, and suspension of the alleged perpetrator. However, a substantiated verbal abuse incident between the CNA and the resident was not reported to the DON or NHA at the time it occurred, no timely investigation documentation was available, and the CNA continued working until a later physical abuse incident was reported. This sequence of unreported and unaddressed abuse incidents led to a failure to immediately protect the resident from staff-to-resident abuse.
The facility failed to ensure timely reporting of alleged staff-to-resident abuse as required by its abuse policy and state/federal regulations. A cognitively intact resident with Major Depressive Disorder reported verbal, physical, and mental abuse by a nurse aide, including an incident where the aide placed the resident in a choke hold and put a hand on the resident’s face, witnessed by the ADON. During the DON’s investigation of this event, a prior substantiated verbal abuse incident involving the same aide and the same resident was discovered, which had not been reported to the DON or the NHA at the time it occurred. Both incidents were reported to the State Survey Agency the day after the later event, and the facility could not provide a written investigation for the earlier verbal abuse incident, demonstrating noncompliance with required abuse reporting timeframes.
A resident with Major Depressive Disorder and intact cognition reported that a nurse aide verbally, physically, and mentally abused them, including an incident in which the aide placed a hand around the resident’s neck and then on the resident’s face after a confrontation witnessed by the ADON. Facility policy required immediate examination by the DON/designee, documentation of findings, and prompt physician and representative notification after reports of abuse. However, there was no documentation that a licensed nurse assessed the resident after the verbal or physical abuse incidents, no evidence that a physician was notified or examined the resident, and no record of psychological evaluation or emotional support being provided.
A resident who was alert and oriented, but experiencing confusion and distress, expressed a desire to leave AMA and ultimately left the facility without being properly informed of their rights or completing the required AMA documentation. Staff interviews confirmed that the resident did not receive the mandated education about the AMA process, and the necessary forms were not completed, in violation of facility policy.
A resident with a history of polysubstance use disorder and recent anoxic brain damage was admitted and exhibited withdrawal symptoms and agitation. Despite physician orders for suboxone, the medication was not available or administered, and staff did not notify the physician of the resident's immediate needs. The resident, placed on one-to-one supervision, was able to leave the facility unsupervised due to inadequate supervision and lack of timely intervention.
A resident with a history of anoxic brain damage and high elopement risk became agitated, expressed a desire to leave, and exited the facility through a fire exit while under 1:1 supervision. The NHA and DON did not conduct a required investigation, failed to collect staff witness statements, and did not complete AMA documentation, instead treating the incident solely as an AMA discharge.
A resident with multiple medical conditions, including protein-calorie malnutrition, experienced a significant weight loss over 30 days. Facility staff did not complete a timely reweigh, failed to notify the dietician and physician as required, and did not document that recommended nutritional interventions, such as providing two snacks twice daily, were implemented. Interviews with the DON and dietician confirmed these deficiencies.
A deficiency was cited when a facility area was not kept free from accident hazards and supervision was inadequate to prevent accidents. The environment and oversight did not meet required standards to minimize accident risks.
The facility did not manage its operations in a way that ensured effective and efficient use of its resources, as identified by surveyors.
The facility failed to maintain safe and comfortable temperature levels in resident rooms, with temperatures recorded above the required range of 71 to 81°F. Residents, including one with COPD, reported discomfort and difficulty sleeping due to the excessive heat. The Maintenance Director confirmed the elevated temperatures, indicating a failure to provide a safe and comfortable environment as required by regulations.
A facility failed to inform three residents or their representatives about changes in psychotropic medications, including the risks and benefits, and did not offer alternative treatment options. This deficiency involved residents with varying levels of cognitive impairment who were prescribed medications like risperidone, aripiprazole, and olanzapine without proper notification or documentation.
A resident reported an incident of inappropriate behavior by another resident and filed a grievance, but the facility failed to document or resolve the complaint. Despite the facility's policy requiring prompt grievance handling, the grievance form was lost, and no follow-up was conducted, as confirmed by interviews with the DON and Social Worker.
A facility failed to report an alleged sexual abuse incident involving a resident who reported that another resident entered her room and engaged in inappropriate behavior. Despite the facility's policy requiring immediate reporting to the Administrator and State Agency, the incident was not reported until a surveyor intervened. The Director of Nursing was unaware of the incident's details, and the grievance form completed by the resident did not prompt timely action.
A facility failed to meet professional standards by not documenting the rationale for a psychotropic medication change for a resident with brain dysfunction and delirium. The resident was switched from olanzapine to Depakote without documented clinical indication, despite no noted behavioral changes. The ADON confirmed the lack of documentation for the medication change.
A facility failed to follow a wound care practitioner's recommendations for a resident with shin wounds. The resident's treatment did not align with the practitioner's specific instructions, as the same treatment was applied to both wounds despite differing recommendations. The Director of Nursing confirmed the recommendations were not followed, indicating a lapse in communication and adherence to the care plan.
A resident with vision impairment and a language barrier did not receive necessary corrective lenses due to the facility's failure to arrange timely vision services. Despite an eye examination confirming the need for corrective lenses, the facility did not follow up, leaving the resident unable to read provided materials. The resident's preferred language was Creole, requiring an interpreter for communication with healthcare staff.
A facility failed to follow wound care practitioner recommendations for a resident with a sacral pressure ulcer. The resident had two active wound care orders that were inconsistent with the consultant's recommendations. An observation showed a nurse performing wound care based on one of these orders. The ADON confirmed the inconsistency and the facility's usual practice of following consultant recommendations unless otherwise directed by a physician.
A resident with smoking privileges was found on the floor after attempting to smoke secretly in the bathroom. The facility failed to conduct a smoking safety assessment or create a care plan, despite the resident being identified as a smoker. Staff interviews confirmed the oversight, contributing to the resident's fall and potential for further accidents.
A resident at risk for nutritional issues due to impaired skin integrity and dietary needs experienced significant weight loss, but the facility failed to adhere to its policy for regular weight checks and timely assessments. The resident was not weighed as ordered, and the dietician's assessment was delayed by over two weeks. Additionally, there was no evidence that the physician was notified or conducted an assessment in response to the weight loss.
A facility failed to ensure proper communication with a dialysis provider for a resident with end-stage renal disease. The facility's policy required pre-dialysis information to be completed by a nurse and sent with the resident to the dialysis center. However, documentation for several treatment dates was incomplete, lacking the necessary pre-dialysis information. This deficiency was confirmed by a unit manager.
A facility failed to ensure a physician assessment for a resident with unplanned weight loss. The resident, at nutritional risk due to a pressure ulcer, experienced significant weight loss, but was not weighed as ordered, and there was no evidence of physician notification or assessment. The registered dietician confirmed the lack of timely assessment and documentation.
The facility failed to ensure agency nurses had the necessary competencies for medication administration and infection control. An agency nurse made medication errors by administering insulin post-meal and misapplying lidocaine patches. Another nurse did not document narcotic counts, and a third performed wound care without proper precautions. Personnel files showed incomplete or delayed competency evaluations, with no training on key practices. The DON confirmed the training inadequacies.
A resident with mental health diagnoses did not receive necessary behavioral health services, despite being eligible and having a comprehensive care plan. The resident expressed boredom and a lack of suitable activities, and staff confirmed the absence of required services since 2021. A care plan was delayed pending a future physician visit.
The facility failed to maintain accurate drug records and ensure medication availability for residents. Observations revealed incomplete narcotic log documentation and unavailable medications for residents, despite being listed in the emergency inventory. Staff confirmed the lack of training and incomplete shift-to-shift counts, highlighting the need for proper medication management.
A facility was found to have a 12.5% medication error rate during a review, exceeding the acceptable limit of 5%. Errors included administering insulin after a resident had eaten, contrary to physician orders, and failing to remove lidocaine patches at the scheduled time, leading to immediate reapplication. These issues were confirmed by the LPN involved.
The facility failed to label insulin pens and vials according to professional principles, as several insulin products on a medication cart were found opened and undated. A licensed nurse confirmed these findings, indicating non-compliance with labeling policies.
The facility failed to ensure that two residents with cognitive impairments understood the terms of a binding arbitration agreement. Despite their moderate to severe cognitive deficits, both residents signed the agreements, which were also signed by the facility's Admission Director. The Director of Nursing confirmed the residents' communication and cognitive deficits, indicating they should not have been provided with the arbitration agreement.
A facility failed to maintain enhanced barrier precautions during wound care for a resident with a sacral wound. Despite a policy requiring gowns and gloves for high-contact care, a nurse aide and a licensed nurse were observed wearing only gloves. The licensed nurse, an agency nurse, stated that gowns were not readily available and she had not received training on enhanced barrier precautions.
The facility failed to complete physician discharge summaries within 30 days for two residents, one who expired and another discharged home. This was confirmed by the DON.
The facility failed to document the timely disposition of medications for a resident who expired, as required by their policy and state regulations. The policy lacked proper guidelines for the timely and safe identification and removal of medications for disposition. An interview with the DON confirmed the absence of documentation for the medication disposition.
The facility failed to meet required nurse aide staffing ratios on multiple occasions, as evidenced by a review of staff schedules and punch reports. On several days, the facility did not provide the necessary hours of nurse aide care based on the resident census, falling short of the mandated ratios for day, evening, and overnight shifts. These deficiencies were confirmed by the DON.
The facility failed to meet the required LPN-to-resident ratios on six days, with insufficient LPN hours provided during day, evening, and overnight shifts. This deficiency was identified through a review of nursing staff schedules and punch reports, revealing a consistent shortfall in meeting the mandated staffing levels.
The facility failed to meet the required LPN staffing ratios and did not provide the mandated minimum of 3.20 hours of direct nursing care per resident on multiple days. The Director of Nursing confirmed these deficiencies during a review of staffing schedules and punch reports.
The facility did not maintain smoke doors according to NFPA 101 standards, affecting one of six floors. Observations revealed that the double corridor smoke doors near room 443 did not close smoke tight. This was confirmed in an interview with the Facility Administrator and Maintenance Director.
The facility did not maintain heating units free of combustible materials, as required by NFPA 101. Combustible materials were observed on heating units in two resident rooms, which was confirmed by the Facility Administrator and Maintenance Director.
The facility was found to have damaged duplex receptacles in various locations, including the Day Kitchen Area, Beauty Salon, Laundry Room, corridor next to a resident room, and Day Lounge. These deficiencies were confirmed during an exit interview with the Facility Administrator and Maintenance Director.
The facility failed to maintain proper oxygen storage requirements on one of its floors, as observed in the Clean Utility Room where 'empty' and 'full' cylinder signage was missing. This deficiency was confirmed during an exit interview with the Facility Administrator and Maintenance Director.
The facility failed to follow physician orders and provide timely care for three residents. A resident did not receive appropriate wound care, missed medication doses, and was not given recommended snacks. Another resident's wound treatments were not implemented, and medications were missed due to pending delivery. A third resident's insulin doses were held without prescribed parameters. The facility's emergency medication supply was not utilized, and there was no documentation of physician notification for missed doses.
A resident requiring Enhanced Barrier Precautions due to a wound and PICC line felt undignified after overhearing staff express reluctance to enter her room. Despite facility policy allowing movement, staff instructed her to stay in her room. Interviews confirmed she did not require isolation, highlighting a failure to respect her rights and adhere to policies.
A resident with severe cognitive impairment was pushed by a nurse aide, resulting in a fall and wrist fracture. The incident occurred in the dining room when the resident became agitated. Despite training, the aide's actions were deemed abusive, leading to her termination. The facility failed to protect the resident from harm, violating state regulations.
The facility did not maintain safe temperature levels as required by its policy, with several rooms on a unit exceeding 81 degrees. Residents reported discomfort due to inadequate cooling measures, and temperature logs did not accurately reflect the high temperatures observed. Despite attempts to adjust air conditioning, the issue persisted.
A facility failed to inform a resident of their Hemoglobin A1C test results and did not document or follow up on these results, leading to a delay in communication. Additionally, a CT scan showing nodules was not acted upon until weeks after the test was conducted. The resident, who was cognitively intact, was not made aware of these findings in a timely manner.
A facility failed to properly accommodate a resident's needs regarding bed size and mattress. The resident, who was dependent on staff for mobility and experienced significant pain, was observed in a bed that was too small, causing discomfort. Despite an inspection, the issue was not resolved, leading to the resident's feet pressing against the bed frame and his head extending past the mattress.
The facility failed to provide a resident with assistance for showers as required by physician orders and the resident's care plan. Despite multiple missed showers, there was no documentation of reasons for refusal or meetings with the interdisciplinary team to address the issue, resulting in a deficiency.
A resident with Obstructive Sleep Apnea and frequent oxygen use was escorted to an appointment without an oxygen tank, resulting in shortness of breath and hospital admission. The facility failed to document a continued order for a C-pap machine and did not include a care plan for oxygen use and respiratory care.
The facility failed to provide timely behavioral health services for two residents. One resident with severe psychiatric diagnoses did not receive a follow-up consultation within the recommended timeframe, leading to increased anxiety and other symptoms. Another resident with dementia and anxiety also did not receive a timely follow-up, despite experiencing nightmares and feelings of hopelessness.
The facility failed to assist a resident with community placement options until completion, despite the resident's interest and the son's willingness to provide supervision. Multiple attempts to schedule a discharge meeting were canceled due to the son's car troubles, and no further efforts were made to find outside housing for the resident.
The facility failed to provide pharmaceutical services to meet the needs of two residents, resulting in missed medication doses. One resident with a history of stroke and quadriplegia missed multiple doses of Tramadol for pain management, while another resident with chronic heart failure and a urinary tract infection missed doses of Carvedilol and Nitrofurantoin. There was no evidence that physicians were informed or that backup pharmacy procedures were activated.
The facility failed to provide food that was palatable, attractive, and served at the proper temperature. Observations revealed that several food items did not meet the required temperature standards, and a resident's pureed meal was not prepared to the appropriate consistency. These issues were confirmed by the Food Service Director and a resident's interview.
Failure to Protect Resident From Repeated Verbal and Physical Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident from staff-to-resident physical abuse. The resident had diagnoses including heart failure, muscle weakness, major depressive disorder, and an above-knee amputation of the left leg, and was admitted with these conditions. The facility’s abuse policy stated that the facility prohibits mistreatment, neglect, and abuse of residents, and that staff must be trained, in control of their behavior, and able to respond appropriately to resident behavior. Despite this policy, the resident reported being verbally, physically, and mentally abused by a CNA, identified as Employee E4. On one occasion, the resident and CNA E4 had a verbal altercation at the nurses’ station. A nurse aide witness, Employee E6, observed CNA E4 and the resident engaged in a loud back-and-forth argument, with CNA E4 repeatedly speaking to the resident in Spanish, which caused the resident to become increasingly agitated. Employee E6 did not understand the Spanish language content but heard CNA E4 say in English, “I won’t open the door!” Both the resident and CNA E4 were speaking in raised voices. To calm the resident, Employee E6 assisted the resident in signing the logbook to leave the locked unit and opened the door. Employee E6 then reported the incident to the Nursing Supervisor, Employee E8, after the supervisor had already heard the raised voices from the office. This verbal abuse incident was later substantiated by the facility during the investigation of a subsequent event. On a later date, a second, more serious incident occurred between the same resident and CNA E4. The resident approached the ADON, Employee E3, and complained that CNA E4 would not open the door or do anything for the resident. As the resident began to wheel away, CNA E4 said something in Spanish that caused the resident to become suddenly very agitated and propel toward CNA E4. ADON E3 instructed CNA E4 to move away, but CNA E4 refused, stating, “I will not move!” When the resident reached CNA E4, the resident grabbed CNA E4’s sweater collar. ADON E3 removed the resident’s hands from the collar, at which point CNA E4 placed a hand around the resident’s neck in a choke-hold position. ADON E3 called for help while attempting to pry CNA E4’s hand from the resident’s neck. After E3 removed that hand, CNA E4 placed the other hand on the resident’s face and pushed it, and E3 again had to remove the CNA’s hand and redirect the resident’s wheelchair away. The facility’s investigation documented that CNA E4 placed the resident in a choke-hold and put a hand on the resident’s face, and that this was staff-to-resident abuse. The report concluded that a reasonable person would determine that holding a resident with major depression and heart failure in a choking hold caused actual harm and placed the resident at risk for psychological trauma. The investigation also revealed that the earlier verbal abuse incident involving CNA E4 and the same resident had not been reported in a timely manner to the DON or the Nursing Home Administrator. The DON stated she was unaware of the first incident until she investigated the second incident, and confirmed that both incidents were reported to the State Survey Agency together at a later date. A staff member reported that she had witnessed the earlier event but did not initially recognize it as abuse until after an in-service training where examples of abuse were presented. The facility’s own documentation noted that this was not the first time CNA E4 had been suspended or suspected for abuse. The combination of the substantiated verbal abuse and the subsequent physical altercation, in which the CNA’s hands had to be pried from the resident’s neck and face, demonstrated that the facility failed to ensure the resident was free from physical abuse as required by its policies and state regulations.
Failure to Immediately Protect Resident After Initial Staff-to-Resident Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to immediately protect a resident from staff-to-resident abuse in accordance with its abuse prevention and management policy. The facility’s policy required immediate protection of any resident upon identification of suspected abuse, including immediate suspension of the suspected employee, prompt initiation of the reporting process by the shift supervisor, and immediate examination and notification by the DON or designee for reports of physical or sexual abuse. The policy also stated that when abuse is identified, the facility must take all appropriate steps to remediate noncompliance and protect residents from additional abuse immediately, and that investigations must begin immediately upon notification while preventing further potential abuse. Resident R1, who was cognitively intact with a BIMS score of 15 and had a diagnosis of Major Depressive Disorder, reported that a nurse aide (Employee E4) verbally, physically, and mentally abused the resident. During the investigation of a physical abuse incident that occurred on February 23, 2026, it was determined that there had been a prior verbal abuse incident between the same nurse aide and the same resident on February 21, 2026. The earlier incident was substantiated as abuse, and the resident had reported that the aide always argued with the resident. The facility was unable to provide a written investigation related to the February 21, 2026, incident. Interviews with the DON and the Nursing Home Administrator revealed that neither was informed of the February 21, 2026, verbal abuse incident at the time it occurred. The DON stated that she only became aware of the February 21 incident while investigating the February 23 physical abuse incident, and confirmed that the first incident was not reported in a timely manner. Both the DON and the Administrator confirmed that the aide continued to work after the February 21 incident and was not suspended until after the later physical abuse incident was reported. As a result, the facility did not implement its own policy requirements for immediate reporting, investigation, and protection of the resident following the initial substantiated abuse incident.
Failure to Timely Report Alleged Staff-to-Resident Abuse Incidents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that all alleged violations of abuse were reported immediately, and no later than two hours after the allegation, as required by policy and regulation. The facility’s abuse policy, last reviewed in August 2025, states that the facility prohibits mistreatment, neglect, abuse, and misappropriation/exploitation of resident property, and that the Shift Supervisor/Charge Nurse is responsible for immediate initiation of the reporting process. The policy further assigns the Administrator and DON responsibility for investigation and reporting, including timely notification to the appropriate state agency per federal and state requirements. Resident R1 was admitted with a diagnosis of Major Depressive Disorder and had a BIMS score of 15 on the January 5, 2026 MDS, indicating cognitive intactness. On February 23, 2026, at 2:45 PM, the resident reported that a nurse aide verbally, physically, and mentally abused them. The aide, identified as Employee E4, was involved in an incident in which, after saying something in Spanish to the resident, the resident grabbed the aide’s sweater and the aide responded by placing the resident in a choke hold and putting a hand on the resident’s face. This incident was witnessed by the Assistant DON, who had to separate the aide and the resident. During the investigation of this event, it was also determined that a prior verbal abuse incident between the same aide and the resident had occurred on February 21, 2026, and that this verbal abuse was substantiated. The DON stated that she was not made aware of the February 21 verbal abuse incident at the time it occurred and only learned of it while investigating the February 23 incident. The Nursing Home Administrator similarly reported that she did not learn of the February 21 incident until the investigation of the February 23 event. Both the DON and the Administrator confirmed that both abuse incidents were reported to the State Survey Agency on February 24, 2026, rather than immediately or within two hours of the allegations, and the facility was unable to provide a written investigation related to the February 21 abuse incident. These findings demonstrate that the facility did not follow its own abuse reporting policy and did not ensure timely reporting of alleged abuse as required by federal and state regulations.
Failure to Assess Resident After Reported Staff Verbal and Physical Abuse
Penalty
Summary
The facility failed to assess and evaluate a resident following incidents of alleged verbal and physical abuse by a nurse aide, as required by its abuse policy. The resident, who had a diagnosis of Major Depressive Disorder and was documented as cognitively intact with a BIMS score of 15 on the January 5, 2026 MDS, reported that a nurse aide verbally, physically, and mentally abused them. The facility’s Abuse Policy-Prevention and Management, reviewed August 2025, required that upon receiving reports of physical or sexual abuse, the DON or designee immediately examine the resident, document findings in the clinical record, and ensure the nurse immediately notifies the physician and the resident or representative. Despite this policy, there was no documented evidence that a licensed nurse assessed the resident after a verbal abuse incident on February 21, 2026, or after a physical abuse incident on February 23, 2026. According to the facility’s investigation and staff interviews, the resident had complained that the nurse aide did not want to open doors or provide care and that the aide “always argue[s]” with them. On the day of the physical altercation, the Assistant DON reported that the resident approached her to complain about the aide, then began to wheel away when the aide said something in Spanish that upset the resident, prompting the resident to move toward the aide. The aide refused to move away when instructed, the resident grabbed the aide’s sweater collar, and the aide responded by placing a hand around the resident’s neck in a choke-hold position and then placing a hand on the resident’s face and pushing it, requiring the Assistant DON to intervene and separate them. The clinical record contained no documentation that the resident was examined by a licensed nurse or physician after this physical abuse incident, no evidence that a physician was notified, and no documentation that the resident was evaluated by a psychologist or provided emotional or psychological support after the verbal abuse incident.
Failure to Inform Resident of Right to Leave Against Medical Advice
Penalty
Summary
The facility failed to ensure that a resident was informed of and allowed to exercise their right to leave Against Medical Advice (AMA). According to the facility's policy, a Discharge Against Medical Advice form must be completed when a cognitively intact resident or their legal representative insists on leaving AMA, and the attending physician, CEO, and DON must be notified. In this case, a resident admitted with anoxic brain damage was assessed as alert and oriented to person and place, but with some confusion, and was identified as a high elopement risk. The resident expressed a desire to leave, was observed crying and demanding to leave, and was placed on 1:1 supervision for safety. Despite these events, the resident left the facility AMA without signing the required AMA documents or receiving the mandated education about their rights and the AMA process. Interviews with staff revealed that the assigned nurse briefly mentioned the AMA process but did not review the AMA documents with the resident. The supervisor nurse also did not ensure the resident was informed of their rights or completed the necessary documentation. The DON and Administrator confirmed that the resident was not properly informed of their right to leave AMA and did not receive the required education, as stipulated by facility policy. This deficiency was identified for one out of five residents reviewed.
Failure to Provide Behavioral Health Services and Supervision for Resident with Substance Use Disorder
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with a history of polysubstance use disorder and recent anoxic brain damage. Upon admission, the resident was noted to be alert but confused, with a documented need for buprenorphine-naloxone (suboxone) to manage opioid withdrawal, as ordered by the hospital physician. Despite these orders, the medication was not available or administered during the resident's stay, and there was no evidence that the physician was notified of the resident's immediate request for the medication. Staff interviews revealed that the resident exhibited signs of withdrawal, anxiety, and agitation, including pacing, crying, and attempting to leave the facility. The resident was placed on one-to-one supervision, but the assigned nursing assistant was unable to maintain continuous supervision when the resident exited the building and ran toward the parking lot. The nursing assistant reported being physically unable to pursue the resident, resulting in the resident leaving the premises unsupervised. Documentation showed a lack of timely intervention and communication regarding the resident's behavioral health needs, including the absence of counseling or education about leaving the facility and failure to ensure the availability of prescribed medication. The facility's policies required staff to provide appropriate behavioral health interventions and maintain close supervision, but these were not effectively implemented for this resident.
Failure to Investigate and Document Resident Elopement and AMA Discharge
Penalty
Summary
The facility failed to properly investigate and document an incident involving a resident who was not informed of, nor allowed to exercise, their right to leave the facility Against Medical Advice (AMA). The resident, who had a diagnosis of anoxic brain damage and was considered a high elopement risk, expressed a desire to leave, became agitated, and ultimately exited the facility by pushing open a fire exit door. Although the resident was under 1:1 supervision at the time, she managed to leave the premises before security could intervene. The staff involved reported the resident's behaviors and actions, but the required AMA documentation was not completed, and the incident was not treated as an elopement. The Nursing Home Administrator (NHA) and Director of Nursing (DON) did not follow facility policy regarding incident investigation. They failed to collect and review staff witness statements and did not conduct a formal investigation into the circumstances of the resident's departure. The incident was handled solely as an AMA discharge, despite the resident leaving without authorization and without following proper discharge procedures. This lack of investigation and documentation was confirmed by the NHA and DON during interviews.
Failure to Address Significant Weight Loss and Implement Nutritional Interventions
Penalty
Summary
The facility failed to ensure timely completion of weights, nutritional assessments, physician notifications regarding significant weight loss, and implementation of nutritional interventions for one resident. According to facility policy, any weight change greater or less than 5 pounds within 30 days requires a reweigh the next day, confirmation by a licensed nurse, and immediate written notification to the dietician and physician if the weight loss is verified. The resident was admitted with a weight of 110 lbs and diagnosed with left wrist and ankle fractures, hypertension, and unspecified protein-calorie malnutrition. Within 30 days, the resident experienced a 6% weight loss, dropping to 103.5 lbs. There was no documented evidence that a timely reweigh was performed, nor that the dietician or physician was notified of the significant weight loss. Further review of the resident's records showed that the nutritional assessment identified the resident as high risk for malnutrition and recommended two snacks daily as an intervention. The resident's care plan also included nutritional supplements and additional snacks. However, there was no documentation that the resident received the recommended two snacks twice a day. Interviews with the Regional Dietician and the DON confirmed the absence of documentation addressing the weight loss and the lack of evidence that the prescribed nutritional interventions were provided.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Administer Facility Resources Effectively
Penalty
Summary
The facility failed to administer its operations in a manner that enabled it to use its resources effectively and efficiently. This deficiency was identified based on observations and findings by surveyors, indicating that the facility did not meet the required standard for resource management. Specific actions or inactions leading to this deficiency are not detailed in the report provided.
Facility Fails to Maintain Safe Temperature Levels
Penalty
Summary
The facility failed to maintain comfortable and safe temperature levels in resident rooms, as required by §483.10(i)(6). Observations and interviews conducted on January 28, 2025, revealed that the temperatures in four resident rooms (301, 302, 311, and 328) exceeded the mandated range of 71 to 81°F, with recorded temperatures ranging from 82.2 to 84°F. Residents expressed discomfort due to the excessive heat, with one resident, who has COPD, specifically requesting a room temperature of 72°F to alleviate her discomfort. Another resident mentioned the need for a fan to cope with the heat, and several residents reported difficulty sleeping due to the high temperatures. The Maintenance Director confirmed the elevated temperatures during checks conducted with a facility thermometer. Despite the residents' complaints and the maintenance staff's acknowledgment of the issue, the facility did not maintain the required temperature range, leading to discomfort among the residents. The report highlights the facility's failure to provide a safe and comfortable environment as mandated by federal regulations, impacting the residents' quality of life and well-being.
Plan Of Correction
This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. Air temps were addressed immediately by Maintenance staff and were returned to range of 71-81 degrees. Maintenance staff were educated on the Temperature Extremes policy. The Maintenance Director or designee will audit air temperatures in affected unit/rooms that were out of range daily as well as an additional 5 rooms from every resident unit. Audits will be done daily x 4 weeks and monthly x 2 months. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.
Failure to Inform Residents of Psychotropic Medication Changes
Penalty
Summary
Willow Terrace was found to be non-compliant with federal and state regulations regarding the rights of residents to be informed and make treatment decisions. The facility failed to ensure that residents or their representatives were informed of treatment options, as well as the risks and benefits of proposed care, for three residents who were reviewed for psychotropic medications. This deficiency was identified during a survey conducted on January 31, 2025. Resident R142, who was severely cognitively impaired, was prescribed risperidone by a neurology consultant without documentation that the resident or their responsible party was informed of the medication change, its risks, or alternative options. The medication was later discontinued by psychiatry due to the resident already being on another antipsychotic, aripiprazole. Similarly, Resident R139, who was moderately cognitively impaired, was prescribed aripiprazole after discontinuing risperidone, but there was no documentation that the resident or their representative was informed of the change or offered alternatives. The medication was eventually discontinued due to patient refusal. Resident R158, who was severely cognitively impaired, was prescribed olanzapine upon admission, which was later changed to Depakote by psychiatry. Again, there was no documentation that the resident or their responsible party was informed of the medication change, its risks, or alternative options. The Assistant Director of Nursing confirmed the lack of documentation during an interview with surveyors.
Plan Of Correction
This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. R142 and the responsible party were notified of medication recommendations and of the risks and benefits were explained to them. R139 and responsible party were notified of the medication recommendations and of the risks and benefits. R158 and responsible party were notified of the medication recommendations and of the risks and benefits. The psychiatrist documented the reason for changing the medication. An initial audit of the last 2 weeks of psychiatry recommendations was done to ensure if any medication changes were done, the resident and responsible party were notified of the recommendations and of the risks and benefits as well as alternative treatment options. The DON/designee educated the psychiatrist and licensed staff to document reasons for psychoactive medication changes as well as informing residents and responsible party of medication changes and the risks and benefits associated with the change. Alternative treatment options will also be discussed and documented. The DON/designee will audit psychiatry consults to ensure reasons for medication changes are documented and that the resident and responsible party are informed of the medication change as well as the risks and benefits associated with the changes and alternative treatment options. Audits will be done weekly x 4 weeks then monthly x 2 months. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.
Failure to Document and Resolve Resident Grievance
Penalty
Summary
The facility failed to demonstrate evidence that a grievance filed by a resident was promptly documented and resolved. A resident reported a serious incident where another resident entered her room and engaged in inappropriate behavior. The resident, feeling harassed, reported the incident to the staff and completed a grievance form. However, the facility did not follow up with the resident regarding the grievance, and there was no evidence of the grievance being documented or resolved. The facility's policy requires that grievances be documented and resolved promptly, with the resident being informed of the findings and actions taken. Despite this policy, the facility was unable to locate the grievance form submitted by the resident, and the content of the grievance was unknown to the facility staff. Interviews with the Director of Nursing and the Social Worker confirmed that the grievance was filed, but the facility failed to track or address it appropriately. This deficiency highlights a failure in the facility's grievance process, as the resident did not receive any follow-up or resolution to her complaint. The lack of documentation and communication regarding the grievance indicates a significant oversight in handling resident concerns, particularly those involving serious allegations.
Plan Of Correction
This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. R110 A grievance form was completed with the resident and resolution reviewed with her. The last 2 weeks of grievances were reviewed to ensure prompt documentation of the grievance and timely follow-up with the resident and or resident representative. The Director of Social Service/designee educated staff on the grievance process. The Director of Social Service/designee will audit grievances submitted to ensure timely documentation of the grievance as well as prompt follow-up and communication to the resident and or resident representative. Audits will be done weekly x 4 weeks then monthly x 2 months. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.
Failure to Report Alleged Sexual Abuse Incident
Penalty
Summary
The facility failed to report an incident of alleged sexual abuse involving a resident, identified as R110, to the State Agency and the Administrator as required. The incident involved another resident, R34, who entered R110's room and engaged in inappropriate sexual behavior. R110, who was cognitively intact with a BIMS score of 15, reported the incident to the staff and completed a grievance form. However, the facility did not take immediate action to report the incident to the necessary authorities. The facility's policy on abuse investigation and reporting mandates that any allegations of abuse, neglect, or exploitation must be reported immediately to the Administrator and the State Agency. Despite this policy, the Director of Nursing confirmed that the Administrator was not notified of the incident immediately, and the incident was not reported to the State Survey Agency as required. The failure to report was only rectified after the surveyor brought the issue to the facility's attention. Interviews with the Director of Nursing revealed a lack of awareness regarding the details of the incident, such as the exposure and masturbation by R34. The facility's documentation showed that the incident was reported late, and the grievance form filled out by R110 did not result in timely action. This oversight in reporting and addressing the incident highlights a significant deficiency in the facility's adherence to its own policies and federal/state requirements for handling allegations of abuse.
Plan Of Correction
This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. The alleged violation was reported to the state agency. The DON/designee conducted a 2-week look back of incident reports and grievance reports to ensure any abuse allegations made were reported to the state survey agency as required. The DON/designee educated staff on the abuse policy. The DON/designee will audit incident reports and grievance reports to ensure any abuse allegations made are reported to the state survey agency as required. Audits will be done weekly x 4 weeks then monthly x 2 months. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.
Failure to Document Rationale for Psychotropic Medication Change
Penalty
Summary
The facility failed to ensure that psychotropic medication changes met professional standards of practice for a resident. Resident R158, who was admitted with diagnoses including non-traumatic brain dysfunction, delirium, and encephalopathy, was prescribed olanzapine for delirium. This medication was administered from the time of admission until a psychiatric evaluation on January 8, 2025, recommended discontinuing olanzapine and starting Depakote. However, the psychiatric consultant did not document a clinical indication or rationale for this medication change. Further review of the resident's progress notes revealed no documented changes in behavior prior to the psychiatric evaluation. Despite this, the resident began receiving Depakote the day after the evaluation, with the medication records indicating it was needed for a cognitive communication deficit. An interview with the Assistant Director of Nursing confirmed the absence of documented rationale or clinical indication for the medication change, highlighting a failure to meet professional standards of quality in the management of psychotropic medications for the resident.
Plan Of Correction
This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. R158 was seen by the psychiatrist. The reason for the medication change was documented in the Psychiatry progress note. The DON/designee audited the last 2 weeks of psychiatry recommendations to ensure if a medication change was made there is documentation indicating the reason for the medication change. The DON/designee educated the consultant psychiatrist on documenting reasons for medication changes on the consultant form. The DON/designee will audit psychiatry recommendations to ensure if a medication change was made there is documentation indicating the reason for the medication change. Audits will be done weekly x 4 weeks then monthly x 2 months. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.
Failure to Follow Wound Care Recommendations
Penalty
Summary
The facility failed to ensure that the wound care practitioner's recommendations were appropriately addressed for a resident with wounds. The resident, who was readmitted to the facility, had a left shin wound and a right distal shin wound, both with arterial etiology and documented as full thickness wounds. The wound care practitioner recommended specific treatments for each wound, including cleansing with Dakin's solution and applying betadine for the left shin wound, and using medical grade honey and covering with border gauze for the right shin wound. However, the clinical records showed no evidence that these recommendations were communicated to or approved by the attending physician. Furthermore, the active physician's orders and the Medication Administration Record indicated that the resident received the same treatment for both shin wounds, which did not align with the wound care practitioner's recommendations. The Director of Nursing confirmed that the resident's wound care was consistent with the wound consultant's recommendations, yet the documentation and treatment records did not reflect this. This discrepancy highlights a failure in following the recommended wound care treatment plan for the resident.
Plan Of Correction
This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. R151 wound recommendations were addressed. The DON/designee audited the most recent wound report recommendations to ensure current recommendations are addressed and orders are in place. The DON/designee educated licensed staff on ensuring that the wound care practitioner recommendations are addressed and orders are in place. The DON/designee will audit the wound care practitioner recommendations to ensure recommendations are addressed and orders are in place. Audits will be done weekly x 4 weeks and then monthly x 2 months. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.
Failure to Provide Vision Care and Assistive Devices
Penalty
Summary
The facility failed to ensure that a resident, identified as R138, received proper treatment and assistive devices to maintain vision. The clinical record review revealed that the resident's preferred language was Creole, and he required an interpreter to communicate with healthcare staff. Despite this, the facility did not arrange for timely vision services or provide corrective lenses, which were necessary for the resident to read and enjoy activities such as reading a newspaper. Observations showed that the resident was given a newsletter in Creole, but the staff member could not confirm if the resident could read it due to the language barrier and lack of corrective lenses. Further investigation revealed that the resident had undergone an eye examination in July 2024, which confirmed vision impairment. However, the facility did not follow up on the specialist's findings to provide the necessary corrective lenses. The resident expressed uncertainty about his ability to pay for the lenses, indicating a lack of communication and support from the facility in addressing his vision needs. The deficiency was identified through observations, interviews, and a review of the facility's policies, which highlighted the failure to arrange for necessary vision consultations and assistive devices.
Plan Of Correction
This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. R138 has a vision exam scheduled. The DON/designee conducted an audit of residents' last eye exam to ensure that residents with impaired vision have appropriate follow-up. The DON/designee educated licensed staff on the importance of residents receiving proper treatment and assistive devices to maintain vision. The DON/designee will audit eye consults to ensure there is appropriate follow-up. Audits will be done weekly for 4 weeks, then monthly for 2 months. Results of the audits will be submitted to the quality assurance committee to determine if further action is needed.
Inconsistent Wound Care Orders for Resident's Pressure Ulcer
Penalty
Summary
The facility failed to ensure that wound care practitioner recommendations were appropriately addressed for a resident with a sacral pressure ulcer. The resident, who was readmitted to the facility, had a wound consultant report indicating the presence of a sacral pressure ulcer. The consultant recommended specific treatments, including cleansing with 0.125% Dakin's solution, applying medical grade honey and calcium alginate, and covering with a bordered foam dressing. However, the facility had two active wound care orders for the resident's sacrum that specified different treatments, neither of which were consistent with the wound consultant's recommendations. An observation revealed that a licensed nurse performed wound care on the resident's sacrum, following one of the inconsistent orders. The Assistant Director of Nursing confirmed the discrepancy in the treatment orders and acknowledged that the facility typically follows the wound consultant's recommendations unless the attending physician specifies an alternative treatment. This inconsistency in following the recommended wound care protocol led to the deficiency noted in the report.
Plan Of Correction
This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. R271 wound treatment was corrected to the recommendations made by the wound consultant. The DON/designee audited the most recent wound report recommendations to ensure current recommendations are addressed and orders are in place and prior orders are discontinued. The DON/designee educated licensed staff on ensuring that the wound care practitioner recommendations are addressed and orders are in place and prior orders are discontinued. The DON/designee will audit the wound care practitioner recommendations to ensure recommendations are addressed and orders are in place as well as making sure prior orders are discontinued. Audits will be done weekly x 4 weeks and then monthly x 2 months. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.
Failure to Conduct Smoking Assessment for Resident
Penalty
Summary
The facility failed to conduct a smoking assessment for a resident identified as a smoker, leading to a deficiency in ensuring a safe environment. The resident, who was included in the facility's smoking list and had smoking privileges, was found on the floor after attempting to smoke secretly in the bathroom. Despite being identified as a smoker, the resident's clinical records did not contain any evidence of a smoking safety assessment or a smoking care plan. Interviews with facility staff confirmed the oversight. The Activities Director acknowledged that the resident was a smoker and had been educated not to smoke in his room, yet no formal assessment or care plan was in place. The Director of Nursing also confirmed the absence of a smoking safety assessment for the resident, which is a requirement for residents who wish to smoke. This lack of assessment and planning contributed to the resident's fall and the potential for further accidents.
Plan Of Correction
This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. R14 was reassessed and has an updated smoking assessment and care plan. The DON/designee conducted an audit of residents on the smoking list to ensure smoking assessments are accurate and that care plans are in place. The DON/designee educated licensed staff on ensuring that residents that smoke have an accurate smoking assessment and a care plan. The DON/designee will audit the smoking list to ensure any new smokers added to the list have an appropriate assessment and a care plan. Audits will be done weekly x 4 weeks and monthly x 2 months. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.
Failure to Maintain Nutritional Parameters for Resident
Penalty
Summary
The facility failed to maintain appropriate nutritional parameters for a resident, identified as Resident 65, who was at risk for nutritional and hydration issues due to impaired skin integrity and a need for a mechanically altered and therapeutic diet. The facility's policy required residents to be weighed on admission, weekly for the first four weeks, and monthly thereafter. However, the facility did not adhere to this policy, as evidenced by the lack of a recorded weight for Resident 65 on December 30, 2024, despite a physician's order for weekly weights. The resident experienced a significant weight loss of 11.4 pounds (9.96%) over seven days, and further weight loss was noted over 30 days, yet the facility did not reweigh the resident or confirm the weight loss as ordered. Additionally, the facility did not assess the resident in a timely manner following the initial weight loss. The dietician did not evaluate the resident until more than two weeks after the weight loss was documented, and there was no evidence that the physician was notified or conducted an assessment in response to the weight loss. An interview with the Registered Dietician confirmed these deficiencies, acknowledging that the resident was at nutritional risk and that the required assessments and notifications were not completed as per the facility's policy and physician's orders.
Plan Of Correction
This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. R65 the facility cannot go back retroactively to correct this issue. The Dietician/designee conducted an audit of residents with significant weight loss in the last 30 days to ensure timely assessment with interventions, as well as physician notification and documentation completed by the physician in response to the weight loss. The DON/designee educated the Dietician on timely follow up on residents with significant weight loss as well as physician notification of residents with significant weight loss. The Dietician/designee will audit residents with significant weight loss to ensure timely follow up as well as physician notification of the weight loss. Audits will be done weekly x 4 weeks then monthly thereafter. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.
Incomplete Dialysis Communication for Resident
Penalty
Summary
The facility failed to ensure proper communication with the dialysis provider for a resident requiring dialysis, as evidenced by incomplete documentation in the resident's dialysis communication binder. The facility's policy on 'Dialysis Management (Hemodialysis)' mandates that pre-dialysis information be completed by the facility nurse and sent with the resident to the dialysis center on treatment days. However, for Resident R47, who has end-stage renal disease and is dependent on dialysis, the communication pages for several treatment dates were found to be incomplete. Specifically, the facility nurse did not complete the required pre-dialysis information on November 28, December 5, December 30, 2024, and January 23, 2025. Resident R47 entered the facility with a diagnosis of end-stage renal disease, necessitating regular dialysis treatments. The facility's failure to adhere to its own policy resulted in a lack of proper communication between the facility and the dialysis center, potentially impacting the coordination of care for the resident. This deficiency was confirmed by a licensed nurse, unit manager Employee E13, during an interview on January 31, 2025.
Plan Of Correction
This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. R47 The facility cannot go back retroactively to correct this issue. The DON/designee conducted an audit of residents' dialysis communication binders to ensure that communication pages have complete documentation on them from the facility and the dialysis unit. The DON/designee educated licensed staff on the dialysis policy which includes completing the documentation on the dialysis communication sheet prior to leaving for dialysis and upon returning from dialysis. The DON/designee will audit dialysis communication binders to ensure documentation is complete. Audits will be done weekly for 4 weeks, then monthly for 2 months. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.
Failure to Conduct Physician Assessment for Unplanned Weight Loss
Penalty
Summary
The facility failed to ensure that a physician assessment was completed for a resident experiencing unplanned weight loss. The facility's policy required residents to be weighed on admission, weekly for the first four weeks, and monthly thereafter. However, the weight data for the resident showed a significant weight loss of 11.4 pounds over seven days, and there was no evidence that the resident was weighed as ordered on December 30, 2024. Additionally, the clinical record lacked documentation that the physician was notified of the weight loss or that an assessment was conducted in response. The resident was identified as being at nutritional risk due to a pressure ulcer and other dietary needs. Despite this, the facility did not follow its policy to monitor the resident's weight effectively. The registered dietician confirmed that the resident was not assessed in a timely manner and that there was no documented evidence of physician notification or assessment. This oversight in monitoring and assessing the resident's nutritional status contributed to the deficiency noted in the report.
Plan Of Correction
This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. R65 The facility cannot go back retroactively to correct this issue. The DON/designee conducted an audit of residents with significant weight loss in the last 30 days to ensure the residents' physician was made aware of the weight loss and that documentation was completed by the physician in response to the weight loss. The DON/designee educated the residents' physician that when a weight loss occurs, the physician is expected to complete an assessment of the resident and document it on the clinical record. The DON/designee will audit residents with significant weight loss to ensure physician notification of the weight loss and that documentation was completed by the physician in response to the weight loss. Audits will be done weekly x 4 weeks then monthly thereafter. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.
Deficiency in Agency Nurse Competency and Training
Penalty
Summary
The facility failed to ensure that agency licensed nurses possessed the necessary competencies and skills to meet residents' needs, particularly in medication administration and infection control practices. During a morning medication pass, an agency nurse administered insulin doses after a meal instead of before, and applied lidocaine patches without allowing sufficient time between doses, resulting in medication errors. Another agency nurse did not document shift-to-shift narcotic counts and lacked training in controlled substances management. Additionally, a third agency nurse performed wound care without adhering to enhanced barrier precautions, wearing only gloves instead of the required gown and gloves. Personnel file reviews revealed that competency evaluations for these agency nurses were either incomplete or conducted after they began working at the facility. There was no evidence of training related to medication administration, controlled substances, or enhanced barrier precautions. The Director of Nursing confirmed the lack of adequate training for these agency nurses and acknowledged the need to revise the facility's orientation process for agency staff.
Plan Of Correction
This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. R132 physician was made aware of the residents insulin given after breakfast instead of before breakfast. E8, E7, and E10 were trained on medication administration, narcotic management, and enhanced barrier precautions by the facility educator/designee. The facility educator/designee provided training on medication administration, narcotic management, and enhanced barrier precautions to licensed agency staff currently coming to the facility. New agency staff will be educated on specific competencies and skill sets as it relates to medication administration, narcotic management, and enhanced barrier precautions prior to working a shift at the facility. The DON/designee will audit new agency licensed nurse personnel files to ensure trainings/competencies have been completed as it relates to medication administration, narcotic management, and enhanced barrier precautions. Audits will be done weekly x 4 weeks and monthly thereafter. The audits will be submitted to the quality assurance committee to determine if further action is required.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident, identified as R17, who was diagnosed with anxiety, depression, schizophrenia, and traumatic brain injury. Despite the resident's comprehensive assessment and care plan indicating eligibility for specialized mental health services, the facility did not offer these services. The resident expressed feelings of boredom and a lack of activities that met his interests and capabilities, indicating a gap in the provision of structured social activities and behavioral health interventions. Interviews with facility staff, including a social worker and the director of nursing, confirmed that the resident had not received the required behavioral health services since April 2021. The social worker had requested the physician to arrange for these services, and the physician acknowledged the resident's eligibility. However, a care plan was not implemented until a future physician visit was scheduled. This inaction resulted in the resident not receiving the necessary support to attain the highest practicable well-being, as mandated by the facility's policies and federal regulations.
Plan Of Correction
This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. R17 was seen by the psychiatrist. The Director of social service/designee audited residents PASARR's to ensure that if a resident qualifies for specialized behavioral health services the resident is receiving specialized behavior health services. The Director of social service educated the social service department on making sure if a PASARR indicates that a resident qualifies for specialized behavioral health that the resident is receiving those services. The Director of social service will audit new admissions PASARR's to ensure if the resident qualifies for specialized behavior health services the resident will be scheduled to see the psychiatrist. Audits will be done weekly x 4 weeks then monthly x 2 months.
Medication Management Deficiencies
Penalty
Summary
The facility failed to maintain accurate drug records and ensure the availability of medications for residents. During an observation of the fourth floor south medication cart, it was found that there was no documentation in the narcotic log book indicating that shift-to-shift counts were completed. The index in the narcotic log book was incomplete and did not match the individual residents' countdown records. Employee E7, a licensed nurse, confirmed these findings and stated that it was his first day at the facility as an agency nurse, and he did not receive any training regarding medication administration. Additionally, Employee E9, the unit manager, confirmed that the shift-to-shift counts and index were not completed, emphasizing the need for staff to conduct these counts to prevent potential drug diversion. Furthermore, the facility failed to ensure that medications were readily available for administration to residents. During the morning medication pass, Employee E8, a licensed nurse, was unable to administer amlodipine to Resident R132 because it was not available in the medication cart, despite being listed in the facility's emergency pharmacy medication inventory. Similarly, Employee E7 was unable to administer potassium chloride to Resident R55 due to its unavailability in the medication cart. Additionally, Resident R142 missed several doses of levetiracetam due to a back order, as noted in the medication administration records and progress notes. Employee E4, the Assistant Director of Nursing, stated that nurses should check the emergency supply or call the physician if medications are not available in the medication cart.
Plan Of Correction
This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. The facility cannot go back retroactively to correct the issue. The DON/designee conducted an audit of narcotic books to ensure shift to shift count is being completed and the index of the narcotic log book is complete and matches the individual resident count down record. The DON/designee will do a 2 week look back on documentation of meds not available to ensure appropriate follow up was done. The DON/designee will educate licensed including agency staff on narcotic management and the policy of what to do if a medication is not available. The DON/designee will audit narcotic books to ensure shift to shift count is being completed as well as complete documentation in the index portion of the log book. Audits will be done weekly x 4 weeks then monthly x 2 months. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed. The DON/designee will audit documentation of medications not available to ensure appropriate follow up was done. Audits will be done weekly x 4 weeks then monthly x 2 months. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.
Medication Administration Errors and Patch Mismanagement
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by a 12.5% error rate observed during a medication administration review. This was based on 32 medication administration opportunities, where four errors were identified. One significant error involved a resident who was supposed to receive aspart insulin before breakfast. However, the insulin was administered after the resident had already eaten, which was not in accordance with the physician's orders. The licensed nurse, Employee E8, confirmed the error during the observation. Additionally, there was a failure to adhere to the prescribed schedule for lidocaine patch application and removal. The resident had orders for lidocaine patches to be applied to both knees at 9:00 a.m. and removed at 9:00 p.m. However, the patches were not removed until the following day, and new patches were applied immediately after the old ones were removed. This oversight was acknowledged by Employee E8, who confirmed that the patches should have been removed the previous evening, as per the physician's orders.
Plan Of Correction
This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. R132 physician was made aware that the resident received insulin after breakfast and was made aware of the lidocaine patches that were not removed per order. The DON/designee educated licensed staff including agency licensed staff on the medication administration policy which includes timely administration of insulin and topical lidocaine patch removal per orders. The DON/designee will conduct random medication pass observations of 5 licensed staff focusing on residents with orders for insulin and topical lidocaine patches. Audits will be done weekly x 4 weeks then monthly x 2 months. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.
Failure to Label Insulin Products Properly
Penalty
Summary
The facility failed to ensure that insulin pens and vials were labeled in accordance with currently accepted professional principles. During an observation of the fourth floor north medication cart, it was found that several insulin products were opened and undated. Specifically, a Lantus insulin pen for one resident, a Lantus insulin vial for another, a Lispro insulin vial for a third resident, and an Admelog insulin vial for a fourth resident were all found to be opened without any recorded date of opening. The facility's policy, "Medication Administration/Disposition," which was reviewed in December 2024, requires that the date of opening be recorded on multi-dose containers. However, this policy was not adhered to, as evidenced by the undated insulin products. Employee E8, a licensed nurse, confirmed these findings during the observation. This deficiency indicates a failure to comply with both state and federal regulations regarding the labeling and storage of drugs and biologicals.
Plan Of Correction
This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. R17 insulin pen was removed and replaced. R132 insulin vial was removed and replaced. R95 insulin vial was removed and replaced. R83 insulin vial was removed and replaced. The DON/designee audited the remaining medication carts to ensure insulins were labeled and dated. Licensed staff were educated on the medication administration/disposition policy which includes dating a multi-dose container with the date it was opened. The DON/designee will audit medication carts to ensure insulins are labeled and dated per policy. Audits will be done weekly x 4 weeks then monthly x 2 months. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.
Failure to Ensure Residents' Capacity for Arbitration Agreement
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident R147 and Resident R151, had the capacity to understand the terms of a binding arbitration agreement. Resident R147 was admitted with a diagnosis of non-traumatic brain dysfunction and cognitive communication deficit, scoring a 12 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. Despite this, the resident signed the arbitration agreement shortly after admission. Similarly, Resident R151, who was admitted with altered mental status and scored a 2 on the BIMS, indicating severe cognitive impairment, also signed the arbitration agreement. Both agreements were signed by the facility's Admission Director, Employee E20. The deficiency was confirmed through a review of facility documents, resident clinical records, and staff interviews. The Director of Nursing, Employee E2, acknowledged that both residents had communication and cognitive deficits, which should have precluded them from being presented with the arbitration agreement. This failure to ensure residents' understanding of the arbitration agreement violated the regulatory requirements for entering into such agreements.
Plan Of Correction
This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. The facility cannot go back retroactively to correct the issue. The NHA/designee conducted a 30-day look back of new admissions to ensure residents that have signed the arbitration agreement have the capacity to understand the terms of a binding arbitration agreement. The NHA/designee educated the Admissions Director that if a resident lacks capacity, the resident cannot sign an arbitration agreement. The NHA/designee will audit new admissions arbitration agreements to ensure that the resident has the capacity to understand the agreement to sign it. Audits will be done weekly x 4 weeks, then monthly x 2 months. Results of these audits will be submitted to the quality assurance committee to determine if further action is required.
Failure to Maintain Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to maintain enhanced barrier precautions during wound care for Resident R271, who had a sacral wound. The facility's policy on 'Transmission Based Precautions' required the use of gowns and gloves for high-contact care activities, such as wound care, to reduce the transmission of multidrug-resistant organisms. However, during an observation, it was noted that a nurse aide and a licensed nurse provided wound care to Resident R271 while wearing only gloves, despite a sign on the resident's door instructing staff to wear both gowns and gloves. The licensed nurse, identified as an agency nurse, revealed that there were no gowns readily available and admitted to not having received training on enhanced barrier precautions. This lack of adherence to the facility's infection control policy was observed during the provision of continence and wound care, which are considered high-contact activities requiring enhanced barrier precautions. The deficiency was identified through observations, review of facility policies, clinical record reviews, and staff interviews.
Plan Of Correction
This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. The facility cannot go back retroactively to correct the issue. E11 and E10 were educated on Enhanced Barrier Precautions and location of PPE. The DON/designee educated staff on Enhanced Barrier Precautions and location of PPE. The DON/designee will do random observations of 5 staff members entering rooms requiring EBP to ensure appropriate PPE is worn. Audits will be done weekly x 4 weeks then monthly x 2 months. Results of these audits will be submitted to the quality assurance committee to determine if further action is required.
Failure to Complete Discharge Summaries Timely
Penalty
Summary
The facility failed to ensure that a physician's discharge summary was completed within 30 days of discharge for two residents. Resident 167, who expired on December 12, 2024, did not have a discharge summary completed by the physician within the required timeframe. Similarly, Resident 168, who was discharged home on November 19, 2024, also lacked a timely discharge summary. This deficiency was confirmed during an interview with the Director of Nursing on January 31, 2025, at 12:30 p.m., who acknowledged that the discharge summaries for both residents were not completed within the mandated 30-day period.
Plan Of Correction
This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. The facility cannot go back retroactively to correct the issue. The NHA/designee educated physicians on timely completion of discharge summaries. The Medical Records Director/designee will audit discharged residents' charts to ensure a discharge summary is completed within 30 days of discharge by the physician. Audits will be done weekly x 4 weeks then monthly thereafter. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.
Failure to Document Timely Medication Disposition
Penalty
Summary
The facility failed to document the timely disposition of medications for a resident, identified as Resident 167, whose clinical record was reviewed during a survey. The facility's policy on medication administration and disposition, dated September 6, 2023, outlines procedures for the timely identification and removal of medications for disposition, storage methods, control and accountability, and documentation of the actual disposition of medications. However, the policy did not provide documented evidence of proper guidelines for the timely and safe identification and removal of medications for disposition as required by 28 Pa. Code:211.9(j) Pharmacy services for discharged residents. Upon review of Resident 167's clinical record, it was found that the resident had expired on December 12, 2024, but there was no documented evidence indicating that a disposition of medications was completed upon discharge from the facility before the survey began on January 28, 2025. An interview with the Director of Nursing on January 31, 2025, confirmed the absence of documented evidence that the medication disposition for Resident 167 was completed in a timely manner.
Plan Of Correction
This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. The facility cannot go back retroactively to correct the issue. The DON/designee will audit the last 30 days of discharged residents to ensure timely documentation of medication disposition. Licensed staff were educated on the policy of Medication administration/disposition. The DON/designee will audit discharged resident records to ensure that the medication disposition assessment is completed timely. Audits will be done weekly x 4 weeks then monthly x 2 months. Results of these audits will be submitted to the quality assurance committee to determine if further action is required.
Failure to Maintain Required Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to maintain the required staffing ratios for nurse aides on seven out of fourteen days reviewed. Specifically, the facility did not meet the mandated ratios of one nurse aide per 10 residents during the day shift, one nurse aide per 11 residents during the evening shift, and one nurse aide per 15 residents during the overnight shift. This deficiency was identified through a review of nursing staff schedules, punch reports, and interviews with staff. The facility's census data and staffing records revealed discrepancies in the number of nurse aide hours provided compared to the required hours based on the resident census. On several specific dates, the facility's staffing fell short of the required hours. For instance, on December 29, 2024, the facility provided only 72.00 hours of nurse aide care during the day shift when 131.20 hours were required. Similar shortfalls were noted on other dates, such as January 25, 2025, where the facility provided 83.59 hours of care during the day shift against a requirement of 130.40 hours. These findings were confirmed with the Director of Nursing, who acknowledged the failure to meet the staffing ratios on the specified dates.
Plan Of Correction
This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. The facility cannot go back retroactively to correct this issue. The NHA, DON, and staffing coordinator were educated by the regional nurse on the CNA staffing ratios for dayshift, evening shift, and nightshift. The NHA/designee will audit staffing ratios daily as well as projected ratios for the upcoming shifts using the PA DOH staffing grid to ensure the required CNA ratios are met. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.
Failure to Maintain Required LPN Staffing Ratios
Penalty
Summary
The facility failed to maintain the required staffing ratios for Licensed Practical Nurses (LPNs) on six out of 21 days reviewed. Specifically, the facility did not meet the mandated LPN-to-resident ratios during the day, evening, and overnight shifts on January 24, 25, 26, 27, 28, and 29, 2025. The regulation requires one LPN per 25 residents during the day, one LPN per 30 residents during the evening, and one LPN per 40 residents overnight. However, the facility's staffing schedules and punch reports indicated that these ratios were not met, leading to a deficiency in nursing services. On January 24, 2025, the facility's census was 163, necessitating 34.64 hours of LPN care during the overnight shift, but only 34.00 hours were provided. Similarly, on January 25, 2025, the evening shift required 46.18 hours of LPN care, but only 25.50 hours were provided. On January 26, 2025, with a census of 162, the overnight shift required 34.43 hours, but only 24.00 hours were provided. The pattern continued on January 27, 28, and 29, 2025, where the required LPN hours were not met, indicating a consistent failure to adhere to the staffing regulations set forth for the facility.
Plan Of Correction
This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. The facility cannot go back retroactively to correct this issue. The NHA, DON, and staffing coordinator were educated by the regional nurse on the LPN staffing ratios on the evening shift and the night shift. The NHA/designee will audit staffing ratios daily as well as projected ratios for the upcoming shifts using the PA DOH staffing grid to ensure the required LPN ratios are met. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.
Failure to Meet Required Nursing Care Hours
Penalty
Summary
The facility failed to meet the required staffing ratios for Licensed Practical Nurses (LPNs) during the overnight shift on January 29, 2025. The facility census required 35.06 hours of LPN care, but only 34.00 hours were provided. This discrepancy was confirmed by the Director of Nursing during a review of staffing calculations, nursing staff schedules, and punch reports on January 31, 2025. Additionally, the facility did not provide the mandated minimum of 3.20 hours of direct nursing care per resident on five out of fourteen days reviewed. On December 29, 2024, and January 24, 25, 26, and 27, 2025, the facility's direct nursing care hours per resident fell short, with the lowest being 2.37 hours on January 25, 2025. These findings were also confirmed by the Director of Nursing, indicating a consistent failure to meet the required staffing levels and direct care hours for residents.
Plan Of Correction
This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. The facility cannot go back retroactively to correct this issue. The NHA, DON, and staffing coordinator were educated by the regional nurse on the state required PPD of 3.2 per patient day. The NHA/designee will audit the daily PPD as well as the projected PPD for the upcoming day using the PA DOH grid to ensure the required PPD is being met. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.
Smoke Doors Failed to Close Smoke Tight
Penalty
Summary
The facility failed to maintain smoke doors in compliance with NFPA 101 standards, specifically affecting one of six floors. During an observation on January 29, 2025, at 10:15 a.m., it was noted that the double corridor smoke doors next to room 443 did not close smoke tight when tested. This deficiency was confirmed during an exit interview with the Facility Administrator and Maintenance Director at 11:10 a.m. on the same day.
Plan Of Correction
This provider submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrongdoing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. K0374 The closer was adjusted on the Double corridor smoke doors next to room 443, to allow doors to fully close. Maintenance staff will be educated on smoke barrier doors and the importance for doors to close smoke tight. Maintenance Director will perform monthly audits x3 months of facility smoke doors to ensure doors close smoke tight. Audits will be brought to QAPI Committee for review. QAPI Committee will determine the need for continuance of audits.
Combustible Materials Found on Heating Units
Penalty
Summary
The facility failed to ensure that heating units were free of combustible materials, which is a requirement under NFPA 101 for HVAC systems. During an observation on January 29, 2025, at 10:00 a.m., it was noted that combustible materials were placed on top of heating units in resident rooms 414 and 412. This deficiency was confirmed during an exit interview with the Facility Administrator and Maintenance Director at 11:10 a.m. on the same day.
Plan Of Correction
Combustible materials were removed immediately from tops of heating units in resident rooms 412 and 414. Maintenance and nursing staff on fourth floor will be educated on the importance of heating units to be clear of combustible materials. Maintenance director or designee will conduct weekly audits x 4 weeks and monthly audits x 2 months to ensure compliance. Audit results will be reviewed/reported to QAPI Committee. QAPI Committee will determine the need for continued audits.
Damaged Electrical Receptacles Found in Facility
Penalty
Summary
The facility failed to maintain the protection of electrical wiring, as evidenced by damaged duplex receptacles observed on multiple floors. Specifically, on January 29, 2025, between 9:15 a.m. and 10:35 a.m., surveyors identified damaged receptacles in several locations: the Day Kitchen Area on the sixth floor, the Beauty Salon on the fourth floor, the Laundry Room on the third floor, the corridor next to resident room 327 on the third floor, and the Day Lounge on the third floor. These observations were confirmed during an exit interview with the Facility Administrator and Maintenance Director.
Plan Of Correction
Damaged duplex receptacles identified were repaired by Maintenance staff. Maintenance staff was educated on the importance of maintaining protection of electrical wiring, and receptacles free of damage. Maintenance director/designee will conduct monthly audits x 3 months to ensure all facility receptacles are free of damage. Audits will be reviewed/reported to QAPI Committee. QAPI Committee will determine the need for continued audits.
Oxygen Storage Signage Deficiency
Penalty
Summary
The facility failed to maintain proper oxygen storage requirements on one of its six floors. During an observation on January 29, 2025, at 9:07 a.m., it was noted that the Clean Utility Room on the first floor lacked the necessary signage to distinguish between 'empty' and 'full' oxygen cylinders. This deficiency was identified as a failure to comply with the National Fire Protection Association (NFPA) standards for gas equipment storage, which require clear labeling to prevent confusion and ensure safety. The absence of appropriate signage was confirmed during an exit interview with the Facility Administrator and Maintenance Director later that morning. This oversight in maintaining the required oxygen storage protocols could potentially lead to mishandling of oxygen cylinders, although the report does not specify any direct consequences or risks resulting from this deficiency.
Plan Of Correction
Empty and Full Oxygen cylinder signage was hung in the clean utility room identified. Maintenance staff was educated on the importance of Oxygen cylinder signage. Maintenance director/designee will conduct monthly audits x 3 months to ensure all Oxygen storage areas have necessary signage. Audits will be reviewed/reported to QAPI Committee. QAPI Committee will determine the need for continued audits.
Failure to Follow Physician Orders and Provide Timely Care
Penalty
Summary
The facility failed to obtain and follow physician orders related to medications, wound care, and dietary recommendations for three residents. Resident R1 did not receive appropriate wound care upon admission, missed several doses of medications including intravenous antibiotics and insulin, and was not provided with recommended snacks. The facility's records showed that wound treatment was not administered as ordered, and there was no assessment of the resident's wounds until three days after admission. Additionally, several medications were not administered due to unavailability, despite being in the facility's emergency stock, and there was no documentation of physician notification for missed doses. Resident R2 was admitted with wounds and required specific wound care treatments that were not implemented upon admission. The resident also missed doses of prescribed medications due to pending delivery, and there was no indication that the physician was notified of these missed doses. The facility's emergency medication supply had some of the medications available, yet they were not utilized. Resident R3, who had diabetes, did not receive scheduled doses of insulin due to the medication being held without prescribed hold parameters. There was no documentation of physician notification to obtain hold parameters. Interviews with the Nursing Home Administrator and Director of Nursing confirmed that medications should be obtained from the emergency supply if unavailable, but they could not explain why treatments and recommendations were not timely implemented for the residents.
Failure to Ensure Resident Dignity and Adherence to Precaution Policies
Penalty
Summary
The facility failed to treat a resident in a dignified manner, as evidenced by the staff's inappropriate comments and actions. A resident, who required Enhanced Barrier Precautions due to a wound and a PICC line, reported overhearing staff outside her room expressing reluctance to enter, with one staff member saying, "I'm not going in there, I don't know what she's got." This made the resident feel embarrassed and undignified. The resident also reported that staff instructed her not to leave her room, despite there being no restrictions on her movement within the facility. The resident's care plan indicated the need for Enhanced Barrier Precautions due to a wound infection and the use of intravenous antibiotics. However, the facility's policy allowed residents on such precautions to leave their rooms and participate in activities. Interviews with the Nursing Home Administrator and Director of Nursing confirmed that the resident did not have an infectious disease requiring isolation and was permitted to move about the facility. Despite this, the resident was redirected back to her room when she attempted to leave, indicating a failure to adhere to the facility's policy and respect the resident's rights.
Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident from abuse, resulting in actual harm. A resident, identified as R2, who had a history of dementia, arthritis, thyroid disorder, diabetes mellitus, and cirrhosis, was involved in an incident where a nurse aide, Employee E4, pushed the resident, causing him to fall and sustain an acute fracture of the distal radial metaphysis. The resident was known to have severe cognitive impairment and was at risk for falls, with a care plan in place to manage his behaviors and ensure a safe environment. On the day of the incident, Resident R2 was in the dining room and became agitated, yelling and cursing. The Director of Rehab, Employee E3, witnessed the resident approaching Nurse aide, Employee E4, and grabbing her hands. In response, Employee E4 pushed the resident, causing him to fall against the wall and then to the floor. The Director of Rehab intervened, assisted the resident, and reported the incident to the Nursing Supervisor, who assessed the resident's injuries and contacted the physician for further orders. The facility's investigation included statements from the involved staff and a review of video footage, which confirmed that the nurse aide pushed the resident. Despite having received training on elder abuse prevention and de-escalation, Employee E4's actions were deemed abusive, leading to her termination. The facility's failure to ensure the resident's safety and freedom from abuse resulted in significant harm, violating state regulations on resident rights and management responsibilities.
Failure to Maintain Safe Temperature Levels
Penalty
Summary
The facility failed to maintain a safe and homelike environment by not adhering to its policy on temperature extremes, which mandates maintaining temperatures between 71 and 81 degrees Fahrenheit. During an inspection, it was observed that several rooms on the third-floor unit had temperatures exceeding 81 degrees, with some rooms reaching as high as 86.4 degrees. The facility's policy requires specific interventions when temperatures fall outside the designated range, but these were not effectively implemented, as evidenced by the presence of non-functional or insufficient fans in residents' rooms. Interviews with residents and staff confirmed the discomfort caused by the high temperatures, with residents reporting that the fans provided were inadequate in cooling their rooms. The facility's temperature logs for July did not reflect the high temperatures observed during the inspection, indicating a failure in accurate temperature monitoring and documentation. Despite attempts to adjust air conditioning valves, the temperatures remained above the acceptable range, highlighting a deficiency in maintaining a comfortable environment for residents.
Failure to Inform Resident of Test Results and Follow-Up
Penalty
Summary
The facility failed to inform a resident of test results and did not follow up on these results, leading to a delay in communication. Resident R1, who was cognitively intact, underwent a Hemoglobin A1C test on February 6, 2024, but the results were not documented in the clinical record. The Director of Nursing (DON) indicated that the results were likely communicated verbally by the laboratory, but the staff member who received them did not document them. Consequently, there was no evidence that Resident R1 was informed of the test results. Additionally, a CT scan conducted to rule out a lung mass showed nodules, and the results were not followed up until May 29, 2024, when they were faxed to the facility. The DON confirmed that the facility did not act on the CT scan results until that date. The physician's note recommended a consultation with a pulmonary specialist, but there was no documentation of any follow-up action taken prior to May 29, 2024.
Failure to Accommodate Resident's Bed Size and Mattress Needs
Penalty
Summary
The facility failed to ensure proper accommodation of needs for a resident (R17) regarding appropriate bed size and mattress. The resident, who was cognitively intact and diagnosed with a history of cerebrovascular accident, arthritis, and quadriplegia, was completely dependent on staff for bed mobility and all activities of daily living. The resident's MDS indicated that pain frequently affected his sleep and daily activities, with the resident rating his pain intensity as 8 out of 10. The care plan included interventions for chronic pain management and the use of bilateral side rails for bed mobility and repositioning. During an observation, an LPN attempted to reposition the resident, who was tall and thin, in a bed that provided limited space for repositioning. The resident's feet were pressed against the bottom of the bed frame, and the mattress was observed to be bulging and not smooth. The resident expressed discomfort with the bed, stating that a man had inspected it over the weekend and dismissed his concerns. When the NHA and DON were called to the room, an attempt to reposition the resident resulted in his feet no longer touching the bed frame, but his head extended approximately six inches past the head of the bed's mattress.
Failure to Provide Assistance with Showers
Penalty
Summary
The facility failed to provide assistance with showers for a resident, as required by physician orders and the resident's care plan. The resident was supposed to receive showers on Mondays and Thursdays during the 7-3 shift, but records show that the resident did not receive showers on multiple dates in January, February, and March 2024. The facility's policy on Refusal of Care requires the nurse to monitor recurring refusals and for the interdisciplinary team (IDT) to meet with the resident or their representative to understand the reasons for refusal and offer alternative interventions. However, there was no documentation of such meetings or alternative interventions in the resident's clinical records. An interview with the resident's power of attorney confirmed that the resident was not provided assistance with showers. The administrator also confirmed the lack of documentation regarding the reasons for missed showers and the absence of IDT meetings to address the issue. The facility's failure to follow its own policy and provide the necessary care resulted in a deficiency under 28 Pa Code 211.12(d)(5) Nursing services.
Failure to Provide Necessary Respiratory Care
Penalty
Summary
The facility failed to ensure that a resident requiring respiratory care received the necessary care and services in accordance with professional standards of practice and the resident's plan of care. Resident R96, diagnosed with Obstructive Sleep Apnea, had a physician's order to use a C-pap machine at bedtime and remove it in the morning. However, after being transferred to the hospital and returning to the facility, there was no documented evidence of an order to continue the use of the C-pap machine or that the physician was contacted regarding its use. Additionally, the resident's care plan did not include a plan for oxygen use and respiratory care, despite the resident's frequent use of oxygen via nasal cannula in the 30 days leading up to the incident. On the day of the incident, the resident was escorted to an ophthalmologist appointment without an oxygen tank, resulting in the resident experiencing shortness of breath and being admitted to the hospital. The Director of Nursing confirmed that the resident's oxygen levels were not assessed prior to leaving for the appointment and that there was no documented evidence of the resident being cleared by the physician to proceed without a portable oxygen tank.
Failure to Provide Timely Behavioral Health Services
Penalty
Summary
The facility failed to ensure that Resident R18 received timely behavioral health services. Resident R18, who was admitted with multiple severe psychiatric diagnoses including Traumatic Brain Injury, Major Depressive Disorder, and Schizoaffective Disorder, had a psychiatric consultation on August 9, 2023. The physician recommended monitoring behaviors and a follow-up appointment in three months. However, the facility did not reschedule the appointment within the recommended timeframe, and the next consultation did not occur until February 21, 2024, when the resident exhibited increased anxiety and other symptoms. This delay was confirmed by the Nursing Home Administrator on March 27, 2024, with no additional documentation available for review. Similarly, the facility failed to reschedule a timely follow-up psychiatric consultation for Resident R61, who was admitted with diagnoses including Unspecified Dementia, Anxiety Disorder, and Major Depressive Disorder. A psychiatric consultation on November 29, 2023, recommended a follow-up in three months due to the resident experiencing nightmares and expressing feelings of hopelessness. However, no further appointments were scheduled within the recommended timeframe. This delay was also confirmed by the Nursing Home Administrator on March 27, 2024, with no additional documentation available for review.
Failure to Complete Discharge Planning for Resident
Penalty
Summary
The facility failed to provide services to help a resident achieve the highest practicable physical, mental, and psychosocial well-being by not assisting in community placement options until completion. Resident R61, who was admitted with diagnoses including unspecified dementia, anxiety disorder, major depressive disorder, and insomnia, expressed interest in housing options and attended meetings to gather more information. Despite the resident's interest and the son's willingness to provide 24-hour supervision, the facility did not follow through with the discharge planning process effectively. The social services notes indicate multiple attempts to contact the resident's son to schedule a care conference discharge meeting, but these were repeatedly canceled due to the son's car troubles. The last documented attempt was in December 2023, with no further attempts made to find outside housing for the resident. The Director of Social Services confirmed that no additional efforts were made after the son's transportation issues. This lack of follow-up and completion of the discharge planning process led to the deficiency noted in the report.
Failure to Provide Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of two residents, resulting in missed medication doses. Resident R17, who has a history of cerebrovascular accident, arthritis, and quadriplegia, was on a scheduled pain management regimen with Tramadol. However, multiple doses of Tramadol were not administered on various dates due to the medication being unavailable. There was no documented evidence that the physician was informed of the missed doses or that an alternate treatment was requested. Additionally, the licensed nurse did not activate backup pharmacy procedures to obtain the medication, and one nurse was unaware that the emergency supply included Tramadol. Resident R96, who was admitted with chronic systolic congestive heart failure, atrial fibrillation, and obstructive sleep apnea, also experienced missed medication doses. The resident was prescribed Carvedilol for hypertensive chronic kidney disease and Nitrofurantoin for a urinary tract infection, but these medications were not administered due to unavailability. Similar to Resident R17, there was no documented evidence that the physician was notified of the missed doses or that backup pharmacy procedures were activated to obtain the medications.
Failure to Provide Palatable and Properly Prepared Food
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and served at the proper temperature for one of the five nursing units observed. The facility's policy required hot items to be 135 degrees or higher and cold items to be 45 degrees or below at the point of service. However, during a test tray conducted with the Food Service Director, it was observed that several food items did not meet these temperature requirements. Specifically, the hot coffee registered at 133.7 degrees Fahrenheit, macaroni and cheese at 135.7 degrees Fahrenheit, green beans at 138.4 degrees Fahrenheit, mashed potatoes at 124.9 degrees Fahrenheit, milk at 56 degrees Fahrenheit, rice pudding at 62.8 degrees Fahrenheit, and cranberry juice at 61 degrees Fahrenheit. An interview with a resident revealed that food was always cold and coffee was never hot, confirming the issue with food temperatures. Additionally, during the lunch meal observation in the third-floor dining room, a resident received a meal consisting of pureed peas, pureed rice, and pureed potatoes. The consistency of these foods appeared as liquid and spread throughout the whole plate, which was not the appropriate pureed consistency. The Food Service Director confirmed that the meal was not prepared correctly and that the pureed foods needed one and a half packets of thickening powder to achieve the appropriate consistency. These findings indicate a failure to adhere to the facility's dietary services policies, resulting in unpalatable and improperly prepared meals for the residents.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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