Latest Serious Citations
Stay informed about the most recent serious citations (J-L severity) issued to long-term care facilities nationwide.
A resident with cognitive impairment and a mechanical soft diet began choking during a meal. Instead of immediately performing the Heimlich maneuver, staff moved the resident to his room and bed, delaying emergency intervention by about ten minutes. Multiple staff were present but did not initiate abdominal thrusts until the resident's condition had deteriorated, resulting in the resident's death.
A resident with a mechanical soft diet and specific speech therapy recommendations for bite-size food was given a large portion of food that was not cut as required. Despite staff cues, the resident consumed the entire piece, resulting in choking and death. The lack of communication and adherence to dietary instructions placed other residents with similar needs at high risk.
A deficiency occurred when a hazardous sanitizing chemical was mistakenly served as a beverage to ten residents after a cook, lacking documented training, used a drink pitcher to mix the chemical and left it unlabeled in the kitchen. The solution was then served by another staff member, who assumed it was pink lemonade. Several residents with chronic illnesses and cognitive impairment were affected, and required monitoring and assessment were not documented as completed. Staff interviews and personnel file reviews revealed a lack of formal training and orientation regarding chemical safety and labeling procedures.
A deficiency was cited when a resident's right to request, refuse, or discontinue treatment, participate in or refuse experimental research, and formulate an advance directive was not honored by the facility. The facility did not ensure these rights were upheld as required.
A deficiency was cited when a facility area was not kept free from accident hazards and adequate supervision was not provided to prevent accidents. The lack of proper safety measures and oversight increased the risk of accidents for residents.
A resident was not protected from a significant medication error, as required, with no further details provided regarding the circumstances or the resident's condition.
Delayed Emergency Response to Choking Incident
Penalty
Summary
A deficiency occurred when staff failed to provide timely emergency care to a resident experiencing a choking incident. The resident, who had a history of cognitive impairment, decreased safety awareness, and was on a mechanical soft diet with thin liquids, began choking during a meal. Staff observed the resident struggling to breathe and expressing an inability to cough, but instead of immediately initiating emergency measures such as the Heimlich maneuver, they moved the resident from the dining room to his room, a distance of approximately 138 feet, and transferred him to bed before attempting further interventions. During this period, staff encouraged the resident to cough and attempted oral suctioning, but did not perform the Heimlich maneuver until approximately ten minutes after the onset of the choking episode. Multiple staff members, including nursing, therapy, and aide personnel, were present and involved in the response, but there was a delay in recognizing the need for and initiating abdominal thrusts. Witness statements and progress notes confirm that the Heimlich maneuver was not started until the resident was already in his room and in bed, despite clear signs of airway obstruction and the resident's inability to clear the blockage himself. The delay in providing appropriate emergency intervention resulted in the resident losing consciousness and ultimately being pronounced dead. The facility's failure to follow established emergency procedures for choking, as outlined in their own policy and professional standards of practice, directly contributed to the adverse outcome for the resident. The deficiency was identified as an Immediate Jeopardy situation due to the delay in emergency response and the resulting death.
Plan Of Correction
We were unable to correct deficiency F0684 related to Resident 1 as the resident expired in the facility. All nursing staff were educated on the revised choking policy and signs and symptoms to look for when choking. Employee 2 received one-on-one education by Anthony Clark, Director of Nursing, on October 10, 2025, regarding CPR training and emphasis placed on choking resident and employee 2 demonstrated proper technique for the Heimlich maneuver. Employee 2 was placed on a Performance Improvement Plan to demonstrate full knowledge, demonstration of proper Heimlich technique, and adherence to emergency choking protocol. Dysphagia/Choking Procedure in-service was provided to the staff by Anthony Clark, Director of Nursing, and Talayne Gates, SLP, on Tuesday, October 14th at 7am, 1pm, and 3pm, and will be held also on Thursday, October 16th at 7am, 1pm, and 3pm for licensed staff and nursing assistants. DON reviewed the emergency response for a choking resident's times one week. The results of this audit will be reported at the October 23rd QAPI meeting and determined if further staff audits are needed. The facility will begin conducting quarterly mock drills of emergency events, including choking drill, code drill, elopement drill, and active shooter drill, beginning in January 2026. The results will be reviewed at the quarterly QAPI meetings. The QAPI committee will determine if more frequent mock drills for emergency events need to be held.
Removal Plan
- Choking policy was reviewed and updated to American Heart Association Standards.
- All nursing staff will be educated by the Assistant Director of Nursing on the revised choking policy.
- All other nursing staff will be educated by the Registered Nurse Supervisor prior to the start of their shift.
- This will include all full-time, part-time, and prn nursing staff.
- The Assistant Director of Nursing will educate all nursing staff on the signs to look for when someone is choking.
- The Rehab Manager audited all residents on current caseload to ensure current Speech Therapy diet recommendations were being followed.
- The Rehab Manager will audit all residents who have had current Speech Therapy diet recommendations to ensure their current diet order reflects Speech Therapy recommendations.
Failure to Follow Dietary Recommendations Results in Choking Incident
Penalty
Summary
The facility failed to ensure that a resident with specific dietary needs received adequate supervision and assistance to prevent accidents, resulting in a choking incident. The resident had a history of unspecified protein-calorie malnutrition, dehydration, and generalized muscle weakness, and was on a mechanical soft diet with thin consistency. Speech therapy recommendations specified that the resident's food should be cut into bite-size pieces and that small bites or sips should be facilitated during meals. However, these recommendations were not communicated on the resident's meal tray ticket, nor were they consistently followed by staff. On the day of the incident, an occupational therapist handed the resident half of a beef enchilada, approximately 2.5 inches in size, which was not cut into bite-size pieces as required. Despite verbal and visual cues to take small bites, the resident placed the entire portion in his mouth, leading to choking and labored breathing. Staff present attempted to assist the resident, but the food size and lack of adherence to the recommended feeding techniques contributed to the choking event. The speech therapist later confirmed that staff should have cut the food into smaller portions and that such instructions should have been clearly communicated and followed. Further review revealed that other residents with similar dietary needs had varying instructions on their meal tray tickets, such as "cut up meats" or "cut food into bite size pieces," but the process for ensuring these directions were consistently applied was lacking. The nursing home administrator acknowledged that speech therapy recommendations should be properly communicated and documented on meal tray tickets, and that staff should follow these recommendations. The failure to communicate and implement individualized dietary precautions resulted in a choking incident and subsequent death, placing additional residents at high risk for similar events.
Plan Of Correction
We were unable to correct deficiency F0689 related to Resident 1 as resident expired in the facility. Residents 6-14 were screened by Speech Therapy for appropriate diet and checked to see if at risk for choking or require any new safety measures. Director of Rehab audited all current residents that have had a speech therapy diet recommendation to ensure their current diet order reflects speech therapy recommendations. Director of Rehab educated all therapy staff on the new procedure of diet recommendations to be written on the speech therapy recommendation form and physician order as well as provided to nursing. Speech Therapy was also educated to give the speech therapy recommendation form to Dietary. Speech Therapists were instructed if trialing any changes to the diet, the therapist must stay with the resident until the trial item is completed. The Director of Rehab is conducting an ongoing audit for any new speech therapy recommendations to ensure they match the diet order. All nursing staff was educated prior to the start of their shift on the new choking policy and signs and symptoms to look for with a choking resident. Education was given to all nursing staff prior to the start of their shift on diet and diet textures. Dietary Manager educated all dietary staff prior to the start of their shift on diet and diet textures and cutting up food as indicated on the meal ticket. Dysphagia/Choking Procedure in-service was provided to the staff by Anthony Clark, Director of Nursing, and Talayne Gates, SLP, on Tuesday, October 14th at 7am, 1pm, and 3pm, and will be provided on Thursday, October 16th at 7am, 1pm, and 3pm to licensed staff and nursing assistants. The Director of Nursing and Assistant Dietary Manager are conducting audits of all new dietary orders or changes and recommendations for meal ticket accuracy through October 31, 2025. The Dietary Manager audited all meals during tray line service to ensure meal ticket matches diet order and visually observe meal served is accurate through 10/10/25. Beginning 10/13/25, the Dietary Manager will audit 3 meals per week during tray line to ensure meal ticket matches diet order and visually observe meal served is accurate through October 31, 2025. Direct in-service training on F0689, Accidents and Incidents, for all licensed staff and nursing assistants will be provided by Sophie Campbell, MSN, RN, CRRN, RAC-CT, CNDLTC. Sophie Campbell is the Executive Director of the Pennsylvania Association of Directors of Nursing Administration and is an approved directed in-service provider on the list from the Department of Health. The in-service will be held on Wednesday, October 29th at 7am, 1pm, and 3pm. This in-service will be recorded for staff that is unable to attend. Licensed staff unable to attend the in-service will be required to watch the recorded in-service prior to the start of their next shift. All ongoing audits will be reviewed at the monthly QAPI to determine if further auditing is needed. <End of formatted text>
Removal Plan
- Choking policy was reviewed and updated to American Heart Association Standards.
- All nursing staff currently working in the building will be educated by Employee 6 (Assistant DON) on the revised choking policy.
- All other nursing staff will be educated by the Registered Nurse (RN) Supervisor prior to the start of their shift. This will include all full time, part-time and nursing staff.
- Employee 6 will educate all nursing staff currently working on the signs to look for when someone is choking.
- All other nursing staff will be educated by the RN Supervisor prior to the start of their shift. This will include all full time, part-time and nursing staff.
- Employee 7 audited all residents on current caseload to ensure current speech therapy diet recommendations were being followed.
- Employee 7 will audit all residents who have had current speech therapy diet recommendations to ensure their current diet order reflects speech therapy recommendations.
- Employee 7 will educate speech therapists on new procedure to write recommendations on speech therapy recommendation form and physician orders.
- Employee 7 will educate Employee 1 on following dietary orders.
- Employee 12 (Dietary Manager) will educate dietary staff currently working on diet and diet textures.
- All other dietary staff members will be educated by Employee 12 prior to the start of their shift. This will include all full time, part-time, and as needed staff.
- All nursing staff currently working in the building will be educated by Employee 6 on diets and diet textures and to read and follow meal tickets.
- RN Supervisor will educate all nursing staff currently working on diets and diet textures and to read and follow meal ticket directions.
- Employee 12 (Dietary Manager) audited evening meal service tray line to ensure meal tickets matched diet order and visually observed meal service was accurate.
- All meals will be audited during tray line to ensure meal ticket matches diet order and visually observe meal served is accurate.
Improper Chemical Labeling and Storage Leads to Residents Being Served Sanitizer
Penalty
Summary
A deficiency occurred when the facility failed to implement safe and sanitary food handling practices in the kitchen, specifically by not ensuring that hazardous chemical cleaning and sanitizing solutions were properly labeled, stored, and used according to manufacturer instructions and facility policy. A cook, who had not received any documented orientation or training, used a clear plastic drink pitcher to mix a red sanitizing chemical solution due to a lack of available sanitation buckets. After cleaning, the cook left the pitcher containing the chemical in the sink, and it was later mistaken for pink lemonade by another staff member, who then served it to residents on the East unit. Ten residents were served the chemical solution, and the facility could not determine how much was consumed by each individual. The affected residents included individuals with chronic kidney disease, dementia, cerebral infarction, COPD, and cerebral palsy, with varying levels of cognitive impairment. One resident experienced vomiting after lunch, and all affected residents were assessed for symptoms, with physicians and poison control notified. However, clinical record reviews revealed that the ordered monitoring, fluid administration, and oral assessments were not documented as completed at the time of the incident for any of the residents involved. Interviews with dietary staff and review of personnel files showed that most kitchen staff were newly hired and had not received formal education or training regarding their job responsibilities, chemical safety, or labeling procedures. The contracted dietary company did not provide written job descriptions or documented orientation for the staff. The lack of proper labeling, storage, and staff training directly led to the accidental serving of a hazardous chemical to residents, resulting in Immediate Jeopardy to resident health and safety.
Plan Of Correction
Investigation was completed on 9/22/2025. Root cause determined to be isolated staff member improperly using a drink pitcher to store a cleaning sanitizer. Medical team made aware. Poison Control Center consulted. East Unit residents were assessed, and additional orders were implemented for the 10 residents found to have ingested some of the diluted sanitizer. These orders included vital sign monitoring, additional fluids, and oral assessments. Resident Representatives notified. Completed on 9/22/2025. DON/designee to complete follow-up clinical needs determined by post-incident evaluations of affected residents. Completed on 9/23/2025. The chemicals in the kitchen were reviewed for proper storage and labeling; sanitizing solutions were secured. Dietary staff are to store drink pitchers on the shelf under the beverage preparation station. Open chemicals that are in current use are to be stored under the 3-compartment sink. All other chemicals are to be stored in a remote storage area. Dietary staff are to complete pH testing on diluted 3-compartment sink chemicals and keep a log. Chemicals are only to be used for intended purposes and in labeled containers. Completed on 10/3/2025. DON/designee to complete chemical safety education for nursing staff for specifics on chemical storage and container labeling. Date of completion 10/3/2025. Dietary policies for labeling and storing of chemicals were reviewed and updated. Dietary Manager/designee to complete chemical safety training for dietary staff to include Food and Chemical Storage (NO chemicals can be in food storage containers), Sanitation Bucket Use, Labeling and Dating, Hazardous Chemicals, Food Storage, SDS, and Hazard Communications. Chemicals that are in current use are to be stored under the 3-compartment sink. All other chemicals are to be stored in a remote storage area. Dietary staff are to complete pH testing on diluted 3-compartment sink chemicals and keep a log. Chemicals are only to be used for intended purposes and in labeled containers. Completed on 10/3/2025. DON/designee to complete chemical safety education for nursing staff for specifics on chemical storage and container labeling. Date of completion 10/3/2025. Dietary policies for labeling and storing of chemicals were reviewed and updated. Dietary Manager/designee to complete chemical safety training for dietary staff to include Food and Chemical Storage (NO chemicals can be in food storage containers), Sanitation Bucket Use, Labeling and Dating, Hazardous Chemicals, Food Storage, SDS, and Hazard Communications. Chemicals that are in current use are to be stored under the 3-compartment sink. All other chemicals are to be stored in a remote storage area. Dietary staff are to complete pH testing on diluted 3-compartment sink chemicals and keep a log. Chemicals are only to be used for intended purposes and in labeled containers. Completed on 10/3/2025. DON/designee to complete chemical safety education for nursing staff for specifics on chemical storage and container labeling. Date of completion 10/3/2025. Dietary policies for labeling and storing of chemicals were reviewed and updated. Dietary Manager/designee to complete chemical safety training for dietary staff to include Food and Chemical Storage (NO chemicals can be in food storage containers), Sanitation Bucket Use, Labeling and Dating, Hazardous Chemicals, Food Storage, SDS, and Hazard Communications. Dietary Manager/designee to complete post-education audits to ensure compliance with remediation. Audits to be completed 5 times weekly for 4 weeks. Audit findings to be reviewed at the facility QAPI. Audits initiated on 10/3/2025 and continue. DON/designee to complete post-education audits to ensure compliance with remediation. Audits to be completed 5 times weekly for 4 weeks. Audit findings to be reviewed at the facility QAPI. Audits initiated on 10/3/2025 and continue.
Removal Plan
- A root-cause analysis determined that a staff member had improperly used a drink pitcher to mix and store a sanitizing chemical in the kitchen.
- All residents on the East Unit were reassessed for injury or adverse effects, and physician orders were implemented for care and monitoring.
- All chemicals in the kitchen were reviewed for proper labeling and storage.
- Education was provided to all dietary and nursing staff regarding chemical safety, labeling, and segregation of food and cleaning supplies.
- All chemicals not in active use were removed from the kitchen area and placed in a secure, designated chemical-storage area.
- Facility dietary policies regarding chemical labeling, storage, and use were reviewed and revised.
- Post-education audits were initiated to verify continued staff compliance with labeling and storage procedures.
Failure to Honor Resident Rights Regarding Treatment and Advance Directives
Penalty
Summary
A deficiency was identified regarding the failure to honor a resident's right to request, refuse, or discontinue treatment, to participate in or refuse experimental research, and to formulate an advance directive. The report notes that the facility did not ensure these resident rights were upheld, as required by regulations. Specific actions or omissions by facility staff led to this deficiency, but no further details about the residents involved or their medical conditions are provided in the report. The deficiency centers on the lack of adherence to protocols that protect resident autonomy in making decisions about their care and participation in research, as well as the formulation of advance directives.
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 did not meet safety standards, which could contribute to the occurrence of accidents. The deficiency centers on the lack of appropriate measures to identify and eliminate hazards, as well as insufficient oversight to safeguard residents from potential harm.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident received a significant medication error, but does not provide further details regarding the specific actions, inactions, or events that led to the deficiency. No additional information about the residents involved or their medical conditions at the time of the incident is included in the report.
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