Windber Woods Senior Living & Rehabilitation Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Windber, Pennsylvania.
- Location
- 277 Hoffman Avenue, Windber, Pennsylvania 15963
- CMS Provider Number
- 395090
- Inspections on file
- 36
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Windber Woods Senior Living & Rehabilitation Ctr during CMS and state inspections, most recent first.
A resident with diabetes experienced a significant medication error when an LPN administered Insulin Lispro over an hour before the meal, contrary to the manufacturer's instructions. This led to critically low blood sugar levels, requiring emergency intervention. The resident's condition improved after receiving Glucagon and being fed by staff.
The facility failed to follow physician's orders and document medication administration for several residents. A resident did not have their blood pressure and heart rate checked before receiving Metoprolol, and another resident's blood pressure was not checked before administering Verapamil. A diabetic resident missed accu checks, and two residents did not receive bowel protocol treatments as ordered. Additionally, there was a lack of documentation for the administration of Oxycodone-Acetaminophen to a resident.
The facility failed to document the flushing of PICC lines with normal saline before and after medication administration for three residents, despite physician's orders and facility policy. This deficiency was confirmed by the Nursing Home Administrator, indicating a systemic issue in maintaining IV catheter care.
A facility failed to create a comprehensive care plan for a cognitively impaired resident with high blood pressure and diabetes, who was observed using smokeless tobacco without a documented care plan addressing this behavior. This deficiency was confirmed by the Nursing Home Administrator.
The facility failed to update care plans for three residents, leading to inaccuracies in their documented care needs. A resident's care plan lacked contact isolation precautions for ESBL, another resident's care plan incorrectly stated that her glasses were lost, and a third resident's care plan inaccurately indicated the use of Bumex. These deficiencies were confirmed by facility staff.
A resident with pressure ulcers did not receive wound care as ordered, as an LPN applied dressings without cleansing the wounds, contrary to physician's orders and facility policy. The LPN assumed the resident had been cleaned during morning care, which was confirmed by the Nursing Home Administrator.
A cognitively impaired resident who was ambulatory with assistance was found in the basement of the facility on two occasions, indicating a failure to maintain a safe environment. Despite the resident's known tendency to wander, no interventions were documented to prevent further incidents. The facility staff did not recognize these incidents as elopements, revealing a deficiency in management and resident care policies.
A facility failed to maintain accurate records for controlled medications for a resident. The policy required documentation of medication administration, but for a cognitively intact resident receiving opioids, there was no evidence in the MAR that the medication was administered, despite being signed out. The DON confirmed the lack of documentation.
The facility failed to properly store and label medications, including insulin and inhalers, according to manufacturer's instructions and facility policy. Two residents had undated insulin pens, and another resident had an undated Trelegy Ellipta inhaler. An undated bottle of Aplisol was also found. Staff confirmed these deficiencies, indicating a lapse in adherence to medication protocols.
The facility failed to obtain ordered laboratory tests for a resident on anticoagulant therapy and did not secure physician orders for straight catheterization to collect urine specimens for two residents with renal insufficiency. These deficiencies were confirmed by facility administrators.
The facility's QAPI committee failed to address recurring deficiencies in care plans, accident hazards, and pharmacy procedures, despite developing plans of correction. The deficiencies were repeatedly cited in surveys, indicating a systemic issue in the facility's quality assurance processes.
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents with pressure sores, as required by updated CMS guidelines. One resident with a Stage 3 pressure ulcer and another with an unstageable pressure ulcer and diabetic foot ulcer did not have EBP in place, and there was no signage or PPE supplies outside their rooms. Additionally, an LPN did not wear a gown while performing wound care, as confirmed by the Nursing Home Administrator.
A facility failed to notify a physician in a timely manner about a resident's change in condition, which included increased confusion and abnormal behavior. Despite staff observations of these changes and the resident's daughter expressing concerns, the physician was not informed until approximately twenty hours later, delaying necessary medical intervention.
A resident with severe cognitive impairment and multiple diagnoses exhibited increased confusion and abnormal urine characteristics, but there was no documented RN assessment following these changes. The facility's policy and state regulations require such assessments, which were confirmed as missing by the Nursing Home Administrator.
A resident, who was cognitively impaired and required assistance, was injured after being improperly transported in a wheelchair without leg rests, leading to a fall and head injury. The incident occurred while the resident was asleep, and the facility's policy on wheelchair safety was not followed, resulting in a deficiency citation.
A resident, who was cognitively impaired and required assistance, fell from a wheelchair and sustained a head injury due to a nurse aide's failure to use leg rests during transportation, contrary to facility policy.
A cognitively impaired resident with Alzheimer's and anxiety fell when a housekeeper failed to secure the mattress to the bed with straps after cleaning the room, resulting in the mattress being completely off the bed.
The facility failed to ensure that food stored in the kitchen was labeled, dated, and secured. Observations revealed unlabeled and unsecured chicken tenders, dated but unsecured chicken patties, and dated but open sausage patties. Interviews with the Dietary Manager and Nursing Home Administrator confirmed the deficiency.
The facility failed to maintain a clean and homelike environment for a resident who required extensive assistance and had significant medical needs. Observations revealed that a fan blowing directly on the resident had visible dirt and debris, and staff confirmed it should have been clean but was not.
The facility failed to update a resident's care plan to reflect a change in the size of an indwelling foley catheter as ordered by the physician. The resident's care plan indicated a 16 French, 10 cc balloon catheter, while the physician's order specified an 18 French, 10 cc balloon catheter. This discrepancy was confirmed by the Nursing Home Administrator.
The facility failed to ensure a resident was transported safely in a wheelchair with leg rests and did not conduct thorough investigations for a cognitively impaired resident with a history of falls. Witness statements were photocopied and signed without individual accounts.
A facility failed to display a no smoking/oxygen-in-use sign for a resident receiving oxygen therapy, despite policy requirements. The resident, who was cognitively impaired and had diagnoses including pulmonary embolism and anemia, was observed receiving oxygen without the required signage. Staff confirmed the oversight.
The facility failed to maintain accountability for controlled medications for a resident. The policy required double signatures for discarding narcotic patches, but there was no documented evidence of this for multiple dates. The Nursing Home Administrator confirmed the deficiency.
The facility's QAPI committee failed to correct recurring deficiencies related to accident hazards, respiratory care, pharmacy services, and food procurement/storage/prepare/serve-sanitary. Despite previous plans of correction, the current survey revealed ongoing non-compliance in these areas.
The facility failed to maintain an effective pest control program, as evidenced by the presence of ants and gnats in the kitchen area. Observations revealed a large number of ants around the handwashing sink and several gnats in the same area. Staff interviews confirmed that the pests should not be present, and the facility's pest control measures were insufficient to prevent this issue.
A resident's privacy was breached when a cognitively impaired individual with dementia was photographed by a nurse aide while on the toilet. The picture, which exposed a small portion of the resident's upper leg, was taken in violation of the facility's cell phone policy and subsequently posted on social media. The incident was confirmed by the Nursing Home Administrator and involved two nurse aides.
A nurse aide violated facility policy by taking a photo of a cognitively impaired resident on the toilet and posting it on social media, leading to a failure to protect the resident from mental abuse. The incident was confirmed by staff interviews and acknowledged by the Nursing Home Administrator.
A facility failed to ensure accurate documentation and performance of wound treatment for a resident. An LPN documented that a treatment was completed, but an investigation revealed the treatment had not been performed as the dressing was found intact and dated two days prior. This discrepancy was confirmed by the Nursing Home Administrator.
The facility failed to follow physician's orders for two residents. One resident did not receive the prescribed Triamcinolone cream for a rash, and another resident did not have their wound dressing changed as ordered. These deficiencies were confirmed through staff interviews and record reviews.
A resident at risk for falls fell because therapy staff did not place the required chair alarm on his wheelchair after a transfer. The resident was found on the floor with no injuries, and the Nursing Home Administrator confirmed the oversight.
The facility failed to ensure complete and accurate documentation of a resident's clinical records. A physician's order for wound care was not performed as required, and the LPN inaccurately documented the treatment as completed. This discrepancy was discovered through an investigation, revealing the treatment had not been performed as documented.
Failure to Follow Insulin Administration Guidelines
Penalty
Summary
The facility failed to adhere to the manufacturer's instructions for administering Insulin Lispro, resulting in a significant medication error for one resident. The manufacturer's directions specified that Insulin Lispro should be administered within 15 minutes before or immediately after a meal. However, a Licensed Practical Nurse administered 22 units of Insulin Lispro to a resident more than an hour before the meal was delivered. This deviation from the prescribed timing led to the resident experiencing a critically low blood sugar level, requiring medical intervention. The resident, who had a diagnosis of diabetes, was found with a blood sugar level of 35 mg/dL, which is significantly below the normal range. The resident exhibited symptoms of lethargy and diaphoresis and was minimally responsive. Emergency treatment with Glucagon was administered, and the resident's condition gradually improved as their blood sugar levels increased. The Nursing Home Administrator confirmed that the insulin should have been administered closer to the meal time, as per the manufacturer's instructions.
Failure to Follow Physician's Orders and Document Medication Administration
Penalty
Summary
The facility failed to ensure that residents received care and treatment in accordance with professional standards of practice. For Resident 19, staff did not document obtaining the resident's blood pressure and heart rate before administering Metoprolol, as required by the physician's orders. Similarly, for Resident 41, there was no documented evidence that staff obtained the resident's blood pressure before administering Verapamil, which was necessary to determine if the medication should have been held. Resident 60, who had diabetes, did not receive the required accu checks on specific dates as per physician's orders. Additionally, the facility did not follow the bowel protocol for Resident 52, who experienced extended periods without bowel movements. Staff failed to administer the necessary laxatives and enemas as ordered by the physician, leading to non-compliance with the prescribed bowel management plan. For Resident 102, there was a lack of documented evidence that doses of Oxycodone-Acetaminophen were signed out on the controlled medication record, despite being recorded as administered on the MAR. This discrepancy indicates that the medication may not have been administered as documented. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed these deficiencies in following physician's orders and documentation practices.
Failure to Document IV Catheter Flushing
Penalty
Summary
The facility failed to ensure proper care and maintenance of intravenous catheters for three residents, as evidenced by the lack of documented flushing of PICC lines with normal saline before and after medication administration. The facility's policy required flushing before and after each infusion, but this was not adhered to for the residents in question. Resident 1, who was cognitively intact and receiving IV medications, had multiple physician's orders for Vancomycin administration, yet there was no documented evidence of PICC flushing on the specified dates. Similarly, Resident 45 had physician's orders for a normal saline flush every shift for IV patency and was receiving IV Ceftriaxone. However, the MARs indicated that the required saline flushes were not documented on several occasions, and there was no evidence of flushing before and after Ceftriaxone administration. This lack of documentation was confirmed by the Nursing Home Administrator. Resident 255, admitted with a right knee infection and a PICC line, was also affected by this deficiency. Despite orders for a normal saline flush every shift and IV Ceftriaxone administration, there was no documented evidence of PICC flushing before and after medication administration. The Nursing Home Administrator confirmed the absence of documentation for the required saline flushes, indicating a systemic issue in following physician's orders and facility policy for IV catheter care.
Failure to Develop Comprehensive Care Plan for Resident's Tobacco Use
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, identified as Resident 60, who was cognitively impaired and required assistance for daily care needs. The resident had diagnoses including high blood pressure and diabetes. During an observation, it was noted that the resident possessed two containers of smokeless tobacco and an empty milk carton used as a spittoon. Despite these observations, there was no documented evidence of a care plan addressing the resident's use of smokeless tobacco. This deficiency was confirmed through an interview with the Nursing Home Administrator.
Failure to Update Resident Care Plans
Penalty
Summary
The facility failed to ensure that care plans were updated or revised to reflect specific care needs for three residents. For Resident 48, the care plan did not include contact isolation precautions for ESBL, despite physician's orders and posted signage indicating the need for such precautions. The Director of Nursing confirmed the omission in the care plan. Resident 90's care plan inaccurately stated that her glasses were lost, although observations confirmed she had them in her possession. The Nursing Home Administrator acknowledged that the care plan should have been updated to reflect the current status of the resident's glasses. Resident 94's care plan inaccurately indicated that the resident was on Bumex, a medication that increases urination, despite no documented evidence in the clinical record that the resident was currently receiving this medication. The Nursing Home Administrator confirmed that the care plan should have been updated to reflect the resident's current medication status. These deficiencies highlight the facility's failure to maintain accurate and up-to-date care plans for residents, as required by their policies and regulatory standards.
Failure to Follow Wound Care Orders
Penalty
Summary
The facility failed to ensure that pressure ulcer dressing changes were completed as ordered for a resident, leading to a deficiency in care. The resident, who was dependent on staff for turning, transfers, and lower body care, had an unstageable pressure ulcer on the left heel and a diabetic foot ulcer on the right plantar heel. Physician's orders required cleansing of the wounds with wound cleanser and application of specific dressings. However, during an observation, an LPN applied dressings without cleansing the wounds, assuming the resident had been cleaned during morning care. This was confirmed by the LPN and the Nursing Home Administrator. The facility's policy required a no-touch care approach, ensuring wounds and surrounding skin were cleaned and dried with gauze without contamination. Despite the availability of wound cleanser, the LPN did not follow the prescribed procedure, resulting in a failure to adhere to the physician's orders. This oversight was acknowledged by the Nursing Home Administrator, confirming the deficiency in executing the required wound care treatments for the resident.
Failure to Prevent Resident Elopement and Ensure Safety
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for a resident who was cognitively impaired and ambulatory with assistance. The resident, who was known to wander and self-propel in a broda chair, was found in the basement of the facility on two separate occasions. Despite these incidents, there was no documented evidence in the resident's clinical record indicating that interventions were implemented to prevent further occurrences. Interviews with facility staff revealed a lack of recognition of the incidents as elopements, as the resident did not leave the building. The Director of Nursing did not consider the resident's movement from the second floor to the basement as an elopement, indicating a potential gap in understanding or policy regarding resident safety and supervision. The absence of documented interventions highlights a deficiency in the facility's management and resident care policies.
Failure to Document Administration of Controlled Medications
Penalty
Summary
The facility failed to maintain a complete and accurate accounting of controlled medications for one resident. The policy for medication administration required that medications be administered following the 5 Rights, with an additional requirement for the right documentation. This includes signing out the narcotic on the controlled drug record before administration and recording the signature in the resident's Medication Administration Record (MAR) after the medication is taken by the resident. For Resident 102, who was cognitively intact and receiving an opioid medication for pain, there was a discrepancy in the documentation. The controlled drug records indicated that Oxycodone-Acetaminophen was signed out on two occasions, but there was no documented evidence in the MAR that the medication was administered. The Director of Nursing confirmed the lack of documentation for these doses, indicating a failure to adhere to the facility's medication administration policy.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly store and label multi-dose containers of insulin and other medications according to manufacturer's instructions and facility policy. Specifically, for two residents, the facility did not date the opened pen injectors of Lantus and Lispro insulin, which are required to be dated upon opening and discarded after 28 days. Additionally, an opened bottle of Aplisol solution was found undated in the medication refrigerator, contrary to the manufacturer's instructions that require it to be discarded after 30 days of use. Furthermore, a Trelegy Ellipta inhaler for another resident was found opened and undated on the medication cart, despite the manufacturer's instructions to date the inhaler upon opening and discard it six weeks later. Interviews with nursing staff confirmed these deficiencies, acknowledging that the medications should have been dated when opened. These findings indicate a failure to adhere to proper medication storage and labeling protocols, as outlined in the facility's policy and the manufacturer's guidelines.
Failure to Obtain Laboratory Tests and Physician Orders for Invasive Procedures
Penalty
Summary
The facility failed to obtain laboratory studies as ordered by the physician for one resident and did not secure a physician's order for an invasive procedure to collect a specimen for laboratory tests for two other residents. For the first resident, who was cognitively intact and diagnosed with atrial fibrillation, the physician ordered a PT/INR test to monitor the therapeutic levels of Coumadin, a blood-thinning medication. However, there was no documented evidence that the PT/INR tests were completed as ordered, which was confirmed by the Nursing Home Administrator. For the other two residents, both of whom had renal insufficiency, the facility failed to obtain a physician's order for straight catheterization to collect urine specimens for UA/C&S tests. In one case, the urine was collected via straight catheterization without a documented physician's order. In the other case, an attempt was made to collect the urine specimen via straight catheterization due to incontinence, but the resident refused further attempts after two unsuccessful tries. The lack of documented physician's orders for these procedures was confirmed by the Director of Nursing and the Nursing Home Administrator.
Recurring Deficiencies in Care Plans, Accident Hazards, and Pharmacy Procedures
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address recurring deficiencies effectively, as identified in multiple surveys. The deficiencies were related to the revision of care plans, accident hazards, and pharmacy procedures, services, and records. Despite developing plans of correction that included quality assurance systems and audits, the facility did not maintain compliance with nursing home regulations. The deficiencies were first cited in a State Survey and Certification survey ending April 18, 2024, and a complaint investigation survey ending October 23, 2024, and were found again in the current survey ending March 27, 2025. Specifically, the facility failed to update residents' care plans, address accident hazards, and maintain proper pharmacy procedures, services, and records. The QAPI committee was responsible for reviewing audit results and ensuring compliance, but they did not successfully implement their plans. The repeated deficiencies were cited under F657 for care plans, F689 for accident hazards, and F755 for pharmacy procedures, indicating a systemic issue in the facility's quality assurance processes.
Failure to Implement Enhanced Barrier Precautions for Residents with Pressure Sores
Penalty
Summary
The facility failed to adhere to infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to prevent the spread of infections and cross-contamination. Specifically, the facility did not implement Enhanced Barrier Precautions (EBP) for residents with pressure sores or indwelling medical devices, as required by updated CMS guidance. Resident 47, who was cognitively impaired and had a Stage 3 pressure ulcer on the sacrum, did not have EBP in place, and there was no signage or PPE supplies outside her room. This was confirmed during an interview with the Nursing Home Administrator. Similarly, Resident 106, who was also cognitively impaired and had an unstageable pressure ulcer on the left heel and a diabetic foot ulcer on the right plantar heel, did not have EBP in place. Observations revealed that there was no signage or PPE supplies outside her room, and a Licensed Practical Nurse (LPN) failed to wear a gown while performing wound care. The Nursing Home Administrator confirmed that EBP should have been in place for Resident 106 due to the presence of pressure sores, and staff should have worn a gown during wound care.
Failure to Timely Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to ensure timely notification of a physician regarding a change in condition for a resident. According to the facility's policy dated December 14, 2023, nurses are required to notify the resident's physician when there is a change in the resident's condition. However, for one resident who was severely cognitively impaired with diagnoses including dementia, depression, and Alzheimer's disease, this protocol was not followed. On September 13, 2024, at 9:30 p.m., staff observed that the resident was more confused than usual, exhibited abnormal behavior such as swearing and yelling, and had dark-colored, foul-smelling urine. Despite these observations, there was no documented evidence that the physician was notified at that time. The physician was only informed the following day, on September 14, 2024, at 5:24 p.m., after the resident's daughter expressed concerns about her mother's condition, suspecting a urinary tract infection. This resulted in a delay of approximately twenty hours before the physician was notified and a urine culture was ordered. An interview with the Nursing Home Administrator confirmed that the physician should have been notified sooner about the resident's change in mental and physical condition, as per the facility's policy.
Failure to Conduct RN Assessment After Change in Condition
Penalty
Summary
The facility failed to ensure that a registered nurse conducted an assessment after a change in condition for one of the residents. According to the Pennsylvania Code and the facility's policy, a registered nurse is required to assess, document, and update the physician when a resident experiences a change in condition. However, for a resident with severe cognitive impairment and diagnoses including dementia, depression, and Alzheimer's disease, there was no documented evidence of an assessment by a registered nurse after the resident exhibited increased confusion, swearing, and yelling, along with dark-colored, foul-smelling urine. On a subsequent day, the resident's daughter noted her mother's increased confusion and suspected a urinary tract infection, prompting a physician to order a urine culture. An interview with the Nursing Home Administrator confirmed the absence of a registered nurse's assessment for the resident's change in condition, which was required by both state regulations and the facility's policy.
Resident Injury Due to Improper Wheelchair Transport
Penalty
Summary
The facility failed to ensure that residents were free from abuse or neglect, as evidenced by an incident involving a resident who was improperly transported in a wheelchair without leg rests. This resulted in the resident falling forward and sustaining a head injury that required sutures. The resident, who was cognitively impaired and required assistance for daily care needs, was being transported by a nurse aide while asleep in the wheelchair. The absence of leg rests, contrary to the facility's policy on wheelchair safety, led to the resident falling and hitting her head on the floor. The incident was witnessed by another nurse aide, who confirmed that the resident was being pushed without leg rests, leading to the fall. The facility's abuse policy required staff to be educated on preventing abuse and neglect, but in this case, the staff member failed to adhere to the policy, resulting in harm to the resident. The nursing home administrator confirmed that the nurse aide should have used leg rests during the transport, highlighting a lapse in following established safety protocols.
Failure to Ensure Wheelchair Safety Leads to Resident Fall
Penalty
Summary
The facility failed to maintain a safe environment for a resident, resulting in a fall that required medical attention. The resident, who was cognitively impaired and required assistance for daily care needs, fell out of her wheelchair and hit her head on the floor in the solarium. This incident occurred while the resident was being transported by a nurse aide without the use of leg rests on the wheelchair, which was against the facility's policy on wheelchair safety. The resident sustained a 2-centimeter laceration on the left side of her head and a bruised right eye, necessitating four sutures. The incident report and witness statement confirmed that the resident was asleep in the wheelchair when the fall occurred, and the nurse aide failed to apply the leg rests as required. The Nursing Home Administrator acknowledged that the leg rests should have been used during transportation.
Failure to Secure Mattress Leads to Resident Fall
Penalty
Summary
The facility failed to maintain an environment free from accident hazards for a resident who experienced a fall. The resident, who was cognitively impaired and required extensive assistance with personal hygiene, had diagnoses including Alzheimer's disease and anxiety. On June 19, 2024, the resident was found on the floor with the mattress completely off the bed. An interview with the Nursing Home Administrator revealed that the housekeeper did not secure the mattress to the bed with straps, as required, after cleaning the room.
Failure to Properly Label, Date, and Secure Food Items
Penalty
Summary
The facility failed to ensure that food stored in the kitchen was labeled, dated, and secured. Observations in the walk-in freezer revealed a bag containing six chicken tenders that was not labeled, dated, or secured, and a bag containing five chicken patties that was dated but unsecured. Additionally, observations in the cook's cooler revealed approximately eighteen sausage patties in a box that was dated, but the bag holding the sausage patties was open and unsecured. Interviews with the Dietary Manager and the Nursing Home Administrator confirmed that all food items in the kitchen should be labeled, dated, and secured, as per the facility's policy dated December 14, 2023.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for one of the residents reviewed. The facility's policy on cleaning and disinfecting required housekeeping to remove visible debris from surfaces to ensure a healthy environment. However, observations revealed that a fan in Resident 7's room, which was blowing directly on the resident, had a moderate amount of visible dirt and debris accumulated on the blade cover. This was observed on two separate occasions, and staff interviews confirmed that the fan should have been clean but was not. Resident 7 was cognitively impaired, required extensive assistance for daily care needs, and had diagnoses including pulmonary embolism and anemia. The resident's care plan indicated a potential for altered respiratory status and required oxygen as needed. Despite these needs, the fan, which was essential for the resident's comfort, was not properly cleaned, potentially compromising the resident's environment and care. Interviews with housekeeping and nursing staff, as well as the Nursing Home Administrator, confirmed the deficiency in maintaining the cleanliness of the fan.
Failure to Update Care Plan for Catheter Change
Penalty
Summary
The facility failed to ensure that care plans were updated to reflect changes in care needs for one of 32 residents reviewed. An annual Minimum Data Set (MDS) assessment for Resident 51 revealed that the resident was cognitively intact, required assistance with daily care needs, and had diagnoses including obstructive and reflux uropathy. The care plan for Resident 51, revised on February 16, 2024, indicated that the resident had an indwelling foley catheter size 16 French, 10 cc balloon. However, physician's orders dated February 2, 2024, included an order to change the size of the indwelling foley catheter to an 18 French, 10 cc balloon. There was no documented evidence in Resident 51's clinical record to indicate that her care plan was revised when the size of the indwelling foley catheter was changed. An interview with the Nursing Home Administrator confirmed that Resident 51's care plan should have been revised when the size of the indwelling foley catheter was changed.
Failure to Ensure Accident-Free Environment and Conduct Thorough Investigations
Penalty
Summary
The facility failed to ensure that the residents' environment remained as free of accident hazards as possible. Specifically, a resident who was cognitively intact and required extensive assistance for all care was observed being transported in a wheelchair without leg rests. The leg rests were in a bag hanging off the back of the wheelchair, and the LPN pushing the resident was aware that leg rests should be used. The Director of Nursing confirmed that staff should use leg/footrests when transporting residents in wheelchairs. Additionally, the facility failed to conduct thorough investigations for a cognitively impaired resident with a history of falls. The resident had multiple unwitnessed falls, and the witness statements for these incidents were photocopied and signed by multiple witnesses without individual accounts. There was no evidence of thorough investigations being conducted for these falls. The Nursing Home Administrator confirmed that witnesses needed to write statements in their own words, not just sign a photocopy of someone else's statement.
Failure to Display Oxygen-In-Use Signage
Penalty
Summary
The facility failed to ensure that a no smoking/oxygen-in-use sign was in place for a resident who was receiving oxygen therapy. The facility's policy, dated December 14, 2023, required that a sign be in place indicating that oxygen was in use. However, during observations on April 15 and April 16, 2024, it was noted that there was no signage on the resident's door frame indicating that oxygen was in use, despite the resident receiving oxygen at a flow rate of 2 liters per minute via nasal cannula. The resident in question was cognitively impaired and required extensive assistance from staff for daily care needs. The resident had diagnoses including pulmonary embolism and anemia, and physician's orders dated September 27, 2023, included orders for oxygen therapy as needed. Interviews with a Licensed Practical Nurse and the Nursing Home Administrator confirmed that the resident was receiving oxygen and that there was no signage in place, which was against the facility's policy.
Failure to Maintain Accountability for Controlled Medications
Penalty
Summary
The facility failed to maintain accountability for controlled medications for one resident. The policy required that all narcotic patches be placed immediately in a sharps container when discarding and require a double signature. However, for Resident 64, who was cognitively intact and received routine pain medication including an opioid, there was no documented evidence of two signatures when the old Fentanyl patches were removed and discarded on multiple dates in January, February, and March 2024. The deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the absence of the required two witness signatures for the destruction of Fentanyl patches on the specified dates. This failure to adhere to the facility's policy regarding the handling of narcotic patches was identified during a review of policies, clinical records, and staff interviews.
Recurring Quality Deficiencies Due to Ineffective QAPI Committee
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct recurring quality deficiencies and ensure effective plans to improve the delivery of care and services. The deficiencies identified in the current survey included issues related to accident hazards/supervision/devices, respiratory care, pharmacy services/procedures/records, and food procurement/storage/prepare/serve-sanitary. These deficiencies were previously cited in surveys ending March 16, 2023, and March 12, 2024, and were supposed to be monitored by the QAPI committee as part of the facility's plans of correction. However, the current survey ending April 18, 2024, revealed that the QAPI committee was ineffective in maintaining compliance with these regulations, leading to repeated deficiencies in the same areas. Specifically, the facility's plan of correction for accident hazards/supervision/devices, cited under F689, respiratory care cited under F695, pharmacy services/procedures/records cited under F755, and food procurement/storage/prepare/serve-sanitary cited under F812, were all found to be ineffective. The QAPI committee's failure to maintain compliance with these regulations indicates a systemic issue in addressing and rectifying the cited deficiencies. The repeated nature of these deficiencies suggests that the corrective actions taken were insufficient or improperly implemented, leading to ongoing non-compliance with state and federal regulations.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as evidenced by the presence of ants and gnats in the kitchen area. Observations on April 15, 2024, revealed a large number of ants around the handwashing sink and several gnats in the same area. The Dietary Manager was unaware of the ants but acknowledged the presence of gnats and confirmed that such pests should not be in the kitchen. The Maintenance Director indicated that the pest control company was last on-site on February 27, 2024, and was scheduled to return on April 24, 2024. He mentioned that the facility has a good working relationship with the pest control company and that they visit four times a year or as needed. Despite these measures, the presence of pests persisted, particularly due to recent rain pushing ants and spiders to the surface. He also confirmed that ants and gnats should not be around the handwashing sink in the kitchen. The Nursing Home Administrator confirmed that the presence of ants and gnats in the kitchen is unacceptable. The facility's policy on pest control, dated December 14, 2023, states that treatment will be rendered as required to control insects. However, the observations and staff interviews indicate that the facility did not effectively implement this policy, leading to the deficiency. The report cites specific regulations under 28 Pa. Code 207.2(a) and 28 Pa. Code 201.18(e)(2)(3) that were not adhered to, highlighting the administrator's responsibility and management's failure to maintain a pest-free environment in the kitchen area.
Breach of Resident Privacy Due to Unauthorized Photograph
Penalty
Summary
The facility failed to maintain the personal privacy of a resident, identified as Resident 2, who was cognitively impaired and had a diagnosis of dementia. The incident involved a violation of the facility's cell phone usage policy, which prohibits staff from using cell phones in resident care units and from taking photographs of residents. Despite these policies, Nurse Aide 1 took a picture of Resident 2 while he was sitting on the toilet, with his pants pulled up almost entirely, exposing a small portion of his upper leg. The picture, which did not include the resident's face, was then posted on social media. The investigation confirmed that Nurse Aide 1 took the picture and posted it online, as corroborated by statements from both Nurse Aide 1 and Nurse Aide 2, who saw the picture on social media. The Nursing Home Administrator confirmed the incident and reiterated that employees were not allowed to take pictures of residents on their cell phones. This breach of privacy was identified as a deficiency in the facility's adherence to resident rights and privacy regulations.
Resident Mental Abuse Due to Unauthorized Photograph
Penalty
Summary
The facility failed to protect a resident from mental abuse, as evidenced by an incident involving a nurse aide. The facility's abuse policy, dated December 14, 2023, outlined procedures for preventing and addressing abuse, including prohibiting the use of cell phones in resident care areas and forbidding the photographing of residents. Despite these policies, Nurse Aide 1 took a picture of a cognitively impaired resident, who was sitting on the toilet, and posted it on social media. The resident, identified as having dementia and being frequently incontinent, was photographed from the waist down, with a small portion of the upper leg exposed. The incident was confirmed through investigative interviews with both Nurse Aide 1 and Nurse Aide 2, who saw the picture on social media. The Nursing Home Administrator also confirmed the incident, acknowledging that employees were not allowed to take pictures of residents. This breach of policy resulted in a failure to ensure the resident's right to be free from mental abuse, as outlined in the facility's policies and state regulations.
Failure to Accurately Document and Perform Wound Treatment
Penalty
Summary
The facility failed to ensure that a nurse documented treatments accurately for one of the residents reviewed. Specifically, a Licensed Practical Nurse (LPN) documented that a treatment to cleanse and dress a resident's left shin wound was completed on a certain date. However, an investigation revealed that the treatment had not been performed as the dressing was found to be intact and dated two days prior. This discrepancy was confirmed by the Nursing Home Administrator during an interview. The resident's clinical records and the LPN's personnel file were reviewed, revealing that the LPN had falsely documented the completion of the treatment. The physician's order required the treatment to be performed every other day, but the LPN failed to follow this order and inaccurately recorded the treatment as completed. This failure to document and perform the treatment as ordered led to the citation of the deficiency.
Failure to Follow Physician's Orders for Resident Care
Penalty
Summary
The facility failed to ensure that residents received care and treatment in accordance with professional standards of practice by not following physician's orders for two residents. For Resident 4, a physician's progress note recommended the application of 0.025 percent Triamcinolone cream to a rash on the resident's back twice a day. However, there was no physician's order entered into the electronic medical record, and the Treatment Administration Record for January and February 2024 showed no evidence that the cream was applied. This was confirmed by an interview with Registered Nurse 2, who admitted to missing the physician's order, and the Nursing Home Administrator, who confirmed the resident did not receive the recommended treatment. For Resident 6, the care plan indicated a potential for pressure ulcer development, and physician's orders required the application of Xeroform gauze and border foam dressing to an abrasion on the resident's left shin every other day. However, a disciplinary action revealed that the treatment was not performed as ordered on January 14, 2024, as the dressing was found intact with a date of January 12, 2024. This failure was confirmed by the Nursing Home Administrator, who acknowledged that the Licensed Practical Nurse did not complete the treatment as ordered.
Failure to Ensure Chair Alarm Placement Leads to Resident Fall
Penalty
Summary
The facility failed to provide an environment free of accident hazards for Resident 6, who was at risk for falls due to weakness, balance problems, and poor safety awareness. Despite physician's orders requiring bed and chair alarms to be checked every shift, the resident fell on November 22, 2023, because the chair alarm was not placed on his wheelchair after being transferred by therapy staff. The resident was found on the floor beside his wheelchair with no injuries, and it was confirmed that the chair alarm was missing at the time of the fall. The fall investigation revealed that therapy staff did not place the chair alarm on the resident's wheelchair after transferring him from his recliner. This oversight was confirmed by the Nursing Home Administrator, who acknowledged that therapy staff should have ensured the alarm was in place. The deficiency was cited as past non-compliance, and the facility took corrective actions to address the issue, including re-educating therapy staff and conducting a whole-house assessment of alarm placements.
Incomplete and Inaccurate Documentation of Resident's Clinical Records
Penalty
Summary
The facility failed to ensure that residents' clinical records were complete and accurately documented for one of the residents reviewed. Specifically, a physician's order for a resident required staff to cleanse the resident's left shin with wound cleanser, apply Xeroform gauze, and secure it with a border foam dressing every other day. However, the treatment was not performed as ordered on one of the specified days. The resident's Treatment Administration Record (TAR) indicated that the treatment had been completed, but an investigation revealed that the dressing was still intact from a previous date, indicating the treatment had not been performed as documented. The deficiency was confirmed through a review of the resident's clinical records, personnel files, and staff interviews. The Licensed Practical Nurse (LPN) responsible for the treatment documented that the treatment was completed, but an intact dressing from a previous date indicated otherwise. This discrepancy was discovered by the wound nurse, leading to a disciplinary action against the LPN and confirmation from the Nursing Home Administrator that the treatment was not performed as ordered and was inaccurately documented in the resident's TAR.
Latest citations in Pennsylvania
Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
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