Citations in Pennsylvania
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Pennsylvania.
Statistics for Pennsylvania (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Pennsylvania
Surveyors found that the facility did not maintain room temperatures within the policy range of 71–81°F and did not monitor residents for hypothermia when the heating system was not fully functional. The NHA knew the heat was not working properly, but only limited room audits were done and staff did not systematically assess or interview all residents about cold-related needs. Temperature checks showed many rooms on upper floors below 71°F, with some as low as the upper 50s, and several residents reported feeling cold and were observed bundled in multiple blankets, coats, or caps. Staff acknowledged that residents complained of being cold and that extra blankets were brought in, yet residents reported that staff had not proactively offered extra blankets or warm fluids. Record reviews for several residents showed no physician orders for hypothermia monitoring and no recent temperature documentation despite the environmental issue, and the NHA confirmed the failure to maintain required temperatures and to monitor all residents for hypothermia, which was cited at the Immediate Jeopardy level.
Surveyors found that the facility did not follow its own garbage and refuse disposal policy, which requires adequate receptacles and a clean surrounding area to minimize debris and pest attractions. During observation, the outdoor trash compactor area contained shopping carts, an oversized chair, numerous empty cardboard boxes, and many filled garbage bags left outside the dumpster rather than properly contained. In an interview, the Nursing Home Administrator confirmed that trash and debris were accumulating in the disposal area and that the facility failed to properly contain and dispose of garbage in the outside dumpster area.
The facility failed to maintain sufficient nursing staff, resulting in repeated missed showers, delayed call-light responses, and cold meals. Residents and their representatives reported long waits for assistance, including extended delays for toileting and help with meals, and noted that staffing levels varied by day and shift. Staff, including NAs, an RN, and an LPN, confirmed that when staffing was low, showers were not completed, trays were slow to be passed, and call lights had to wait. Several residents with conditions such as HTN, GERD, multiple sclerosis, atrial fibrillation, aphasia, depression, and renal failure missed scheduled showers or experienced prolonged call-light activation while needing pain medication or assistance with a Foley catheter. Facility staffing data also showed excessively low weekend staffing, and the DON acknowledged that the facility did not have enough nursing staff to meet residents’ needs during the identified periods.
The facility failed to ensure call bells were consistently accessible to residents. During a Resident Council meeting, all residents present reported that staff did not leave call bells within reach, and in a separate group meeting, two residents stated that call bells were often placed where they could not reach them. One resident with HTN, GERD, and multiple sclerosis, care planned to have the call light within reach, was observed in bed with the call bell clipped to a pillow in a position that could not be activated using head movement, the only method available due to inability to move the arms. After a NA repositioned the pillow, the resident could activate the call light, and the NA confirmed it had been inaccessible in its prior position. The NHA confirmed the facility’s failure to accommodate these call bell needs.
Surveyors found that the facility did not ensure necessary pressure ulcer prevention and treatment services for two residents. One resident with quadriplegia was observed using Prafo and bunny boots on a routine schedule described by the resident, but there were no corresponding physician orders or documented schedule for these devices. Another resident with multiple comorbidities had a physician’s order for twice-daily cleansing of the coccyx and peri/groin area with soap and water and application of zinc-based barrier cream, but the Treatment Administration Record showed the treatment was missed on an evening shift. The DON confirmed that ordered pressure ulcer prevention measures were not consistently provided or monitored for these residents.
Surveyors found that the NHA and DON did not ensure that indoor air temperatures were kept within the required 71–81°F range and did not monitor or assess any residents for hypothermia, despite job descriptions requiring them to oversee operations, perform rounds, and ensure resident needs were met. Review of job descriptions, clinical records, observations, and staff interviews showed that these omissions affected all residents and resulted in an Immediate Jeopardy situation due to noncompliance with federal and state regulations.
Surveyors found that, several days after a snowstorm, the facility had not adequately cleared snow from two parking lots, sidewalks, and multiple exits. The main parking lot used for visitors, transport, and ambulances had only one plowed entrance, with the exit blocked by snow, and sidewalks to the building were not shoveled. A second parking area remained unplowed with vehicles stuck. A family member reported that the area was a disaster and that you could not get in or out. The NHA stated the contracted snow removal company never arrived and acknowledged that the facility failed to evaluate the snow hazard and implement an effective snow removal plan, leaving two of three exits with uncleared walkways.
Surveyors found that three of four medication carts (Vineyard, Rosewood, and Rosewood 2) were left unlocked and unattended in hallways, contrary to the facility’s Medication Storage policy requiring all drugs and biologicals to be kept in locked compartments or under direct observation during medication passes. An LPN and two RNs each confirmed that their respective carts were unsecured while they were not present at the carts, and the Nursing Home Administrator acknowledged that the carts were not properly secured as required by policy and state regulations.
A resident with dementia, anemia, and HTN, and a BIMS score indicating moderate cognitive impairment, was found in bed with a cup containing four pills left on the bedside table and no nurse present. Facility policy required an IDT assessment, physician order, and care plan before allowing self-administration of medications, but the resident’s record lacked a self-administration assessment, an order for self-administration, and any care plan addressing it. An RN acknowledged leaving the medications at the bedside as an oversight, and the DON confirmed the facility had not determined whether it was safe for the resident to self-administer medications.
Surveyors found that three medication carts (Vineyard, Rosewood, and Rosewood 2) were left unattended in hallways with computer screens open, displaying identifiable resident medical information visible to anyone passing by. An LPN and two RNs acknowledged that the carts had been left with confidential information on the screens while they were away from the carts, including when one RN was in a resident room. The administrator confirmed that this practice failed to maintain the confidentiality of residents' medical records as required by facility policy and state regulations.
Failure to Maintain Safe Room Temperatures and Monitor Residents for Hypothermia
Penalty
Summary
The deficiency involves the facility’s failure to maintain resident room temperatures within the facility’s own policy range of 71–81°F and to monitor and assess residents for hypothermia when the heating system was not functioning properly. The facility’s Safe and Homelike Environment policy required provision of a safe, comfortable environment, and the Loss of Heating or Cooling policy required immediate actions to maintain temperatures between 71–81°F, including monitoring temperatures, increasing rounding, layering clothing, providing extra blankets and warm foods/fluids, and monitoring for signs of hypothermia with physician notification as needed. The Nursing Home Administrator (NHA) reported being aware that the heat was not working the prior week and that a heating company came on a Saturday to install a control board, later determining that an additional gas valve was needed. The NHA presented audits of only 5–6 random rooms per floor and did not have staff check all resident rooms or assess/interview residents to ensure their needs were being met. Observations on the third and fourth floors showed that the heating system was not working at full capability, with room temperatures ranging from 68°F to 81°F and some residents stating they were cold while others felt comfortable. Some windows were observed not fully closed, and some residents reported they had opened their windows. Although residents had extra blankets and clothing, all interviewed residents stated that no staff member had offered extra blankets or warm fluids. Subsequent facility-provided temperature audits documented that, during early-morning checks, the vast majority of rooms on both the third and fourth floors were below 71°F, with the lowest recorded temperatures at 63°F on the third floor and 58.6°F on the fourth floor. During a tour, surveyors noted that the third and fourth floors felt cold overall, and spot temperature checks with maintenance staff showed multiple rooms in the upper 60s to about 70°F. Multiple residents were observed in bed with three or four blankets, winter coats, or tassel caps, and several reported feeling cold, especially at night or when getting up. One resident stated her legs were cold and that her window had been cracked open the previous night; another said he had been cold and that it gets very cold at night; others reported that their rooms were cold or that they had been cold but were warm at the time due to multiple blankets. Few residents were seen in hallways, and those present were covered with blankets. A nurse stated that residents complained of being cold and that she had brought in two bags of blankets to keep them warm. Record review for selected residents showed that there were no physician orders to monitor for hypothermia or to monitor body temperatures in response to the environmental issue, despite the facility’s policy requiring monitoring for signs of hypothermia when heating is compromised. For one resident, the last documented temperature was from early in the month; for another, the last temperature was several days prior; and for a third, the last temperature was from the previous month. The NHA confirmed that the heaters were not working at 100%, that the facility had noticed the problem in the middle of the prior week, and that repairs were in progress. The NHA also confirmed that the facility failed to ensure comfortable air temperature levels between 71–81°F and failed to monitor and assess all residents for hypothermia, resulting in an Immediate Jeopardy situation for all 82 residents.
Removal Plan
- Complete heating system repair and continue ongoing monitoring of system performance.
- Conduct room temperature audits in every resident room every two hours until all resident rooms are at 71°F or higher, then once every four hours daily for seven days, weekly for three weeks, then monthly for three months.
- Include in temperature audits ensuring windows are closed and residents are offered plastic covering for windows.
- Evaluate all residents for signs and symptoms of hypothermia, including residents unable to independently express needs and residents with a temperature over the last three days and/or during whole house audit of 97.6°F or lower.
- Address any identified concerns immediately with individualized interventions and place orders for ongoing monitoring as needed.
- Document resident temperatures in the weights/vitals section of the electronic medical record and document hypothermia evaluation in progress notes.
- Conduct an audit of resident observations for cold intolerance, distress, or changes in condition related to temperature in every resident room every shift daily for seven days, weekly for three weeks, then monthly for three months.
- Ask interviewable residents about comfort level and offer interventions as needed.
- Evaluate non-interviewable residents for observable signs of discomfort related to temperature.
- Educate nursing staff (including agency) on signs and symptoms of hypothermia, risk factors, interventions to prevent hypothermia, comfort measures, and appropriate response when signs/symptoms are identified.
- Educate nursing assistants on non-clinical signs and symptoms of hypothermia and to alert a nurse if observed.
- Complete staff education; staff educated by phone/email to sign education prior to next working shift; reinforce education as needed.
- Provide additional blankets, layering, and environmental adjustments as needed.
- Offer room relocation as appropriate to maintain resident comfort.
- Implement a plan to utilize outside resources as necessary to maintain safe air temperatures during future weather events or mechanical issues, including an updated rental company in place.
- Review relevant policies and procedures related to environmental safety, resident monitoring, and emergency response.
- Update policies as indicated based on audit findings and QAPI review.
- Report audit findings, trends, and corrective actions to the QAPI committee; QAPI to evaluate effectiveness and recommend changes as needed.
- Apply plastic coverings to every resident room and hallway window in resident care areas to prevent drafts.
- Clarify/register controls after identifying some knobs on registers were turned off to prevent inadvertent turning off of heat.
- Have heating vendor send a technician back to ensure correct functionality and further explore the system for any additional needed corrections and complete repairs as soon as possible pending parts/resources.
- Install rental one-ton heating units and rent for at least one week.
- Order and install additional rental heating units.
- For rooms reading under 71°F with a laser thermometer, re-check using a room air thermometer and verify temperatures above 71°F.
- Order air thermometers for each room.
Improper Containment and Disposal of Garbage in Outdoor Dumpster Area
Penalty
Summary
The facility failed to properly contain and dispose of garbage and refuse in accordance with its own policy, which requires sufficient receptacles, a clean surrounding area, and prevention of debris accumulation and insect/rodent attractions, including not allowing garbage to accumulate outside the dumpster. During an observation, the outdoor trash compactor area was found to have two shopping carts, an oversized chair, many empty cardboard boxes, and an uncountable number of filled garbage bags sitting around the dumpster instead of being properly contained. In an interview, the Nursing Home Administrator confirmed that trash and debris were collecting in the disposal area and acknowledged that the facility failed to properly contain and dispose of garbage in the outside dumpster area to prevent potential rodent and insect infestation. No residents or specific patient conditions were mentioned in the report, and the deficiency focused solely on environmental sanitation and waste management practices in the outdoor trash disposal area, as cited under 28 Pa. Code 201.18(b)(3) Management.
Insufficient Nursing Staff Leading to Missed Showers and Delayed Call-Light Responses
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and competent nursing staff to meet residents’ needs, resulting in missed care, delayed responses to call lights, and unmet basic care needs across multiple timeframes and care areas. Facility policy on sufficient and competent nursing staffing states that the facility will provide enough nursing staff with appropriate skills and competency to deliver care and services in accordance with resident care plans and the facility assessment. However, review of Payroll Based Journal data for one quarter showed excessively low weekend staffing, and resident council minutes from two meetings documented multiple residents’ concerns about long wait times for call lights to be answered. Grievance and concern forms also documented complaints that one staff member was covering half a floor, that it took two to two and a half hours to get a resident on a bedpan, and that this had happened repeatedly. Additional concerns from residents and resident representatives described cold meals and inadequate assistance with showers due to insufficient staffing. Resident council documentation and group resident interviews indicated that staffing adequacy varied by day and shift, and that residents who required a Hoyer lift often did not receive showers on days when staffing was low because two staff were needed to operate the lift. Several residents reported missing scheduled showers for this reason, and multiple residents reported waiting between 30 minutes and two hours for assistance on various shifts. Staff interviews with NAs, an RN, and an LPN corroborated these concerns, with staff stating that when staffing was low, showers were not completed, tray passing was delayed, residents could not always be gotten out of bed, and call lights had to wait. Specific resident records and observations further demonstrated the impact of insufficient staffing. One resident with diagnoses including hypertension, GERD, and multiple sclerosis was scheduled for showers twice weekly but reported frequently missing showers, and documentation showed missed showers on three specified dates, which the DON confirmed. Another resident with atrial fibrillation, hypertension, and pancreatic cancer had a care plan requiring prompt response to call lights; observation showed this resident’s call light active for 17 minutes for pain medication, with the final activation time reaching 22 minutes. A resident with hypertension, aphasia, and hypokalemia, scheduled for showers twice weekly at a set time, missed multiple scheduled showers, and reported that staff attributed missed showers to lack of staffing. Another resident with aphasia, depression, and lack of coordination, scheduled for showers twice weekly on day shift, also missed a scheduled shower and indicated they did not receive showers as scheduled. A further resident with atrial fibrillation, hypertension, and renal failure, care-planned for prompt call light response, had a call light active for 25 minutes for assistance with an indwelling Foley catheter, with the final activation time at 26 minutes, which was confirmed by an RN. The DON acknowledged that the facility failed to have sufficient nursing staff to provide necessary nursing and related services during the identified periods and for the identified residents.
Failure to Ensure Call Bells Were Accessible to Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ call bell needs, as required by its own policy on accommodation of needs. Resident Council meeting minutes documented that all 19 residents present unanimously reported that staff do not leave their call bells within reach. During a subsequent resident group meeting, two of seven residents stated that call bells are not always left where they can reach them and that staff put the call bells where residents cannot access them, noting that this happens frequently. These resident reports indicate a pattern of staff inaction in consistently positioning call bells so residents can independently summon assistance. In addition, surveyors reviewed the clinical record of one resident with diagnoses including hypertension, GERD, and multiple sclerosis, whose care plan directed staff to ensure the call light was within reach and to encourage its use for assistance. During observation, this resident was found lying in bed with the call bell clipped to the pillow beside the resident’s head. When asked how the call bell was activated, the resident explained an inability to move the arms and reliance on head movement to trigger the call bell. The resident attempted to move the head vigorously from side to side but could not reach the call bell and stated that even with such effort it could not be activated, and that the pillow needed to be moved to the left. When a nurse aide entered and repositioned the pillow, the resident was then able to activate the call light, and the aide confirmed the resident had been unable to activate it in the original position. The Nursing Home Administrator acknowledged that the facility failed to accommodate call bell needs for the residents identified in the council, group meeting, and observation.
Failure to Follow Pressure Ulcer Prevention and Treatment Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents received necessary services to prevent and treat pressure ulcers in accordance with physician orders and facility policy. For one resident with quadriplegia, high blood pressure, and a neurogenic bladder, surveyors observed the resident in bed on multiple occasions wearing Prafo boots and later reported use of bunny boots according to a schedule the resident described (Prafo boots in the morning while in bed and bunny boots starting at 5:00 p.m.). However, review of the clinical record and physician orders showed no documented orders or schedule for either the Prafo or bunny boots. A registered nurse confirmed that there were no current physician orders or schedules for these devices, despite their ongoing use. For another resident with high blood pressure, malnutrition, and heart failure, the clinical record contained a physician’s order to wash the coccyx and peri/groin area twice daily with soap and water and apply a zinc-based barrier cream, with instructions to report any decline in wound condition. Review of the Treatment Administration Record showed that this ordered treatment was not provided on one evening shift. The DON confirmed that the ordered pressure ulcer prevention treatment was not administered as prescribed and further acknowledged that the facility failed to ensure residents were monitored, assessed, and received necessary services to prevent pressure ulcers or wounds from developing for two of three residents reviewed.
Failure to Maintain Safe Temperatures and Monitor Residents for Hypothermia
Penalty
Summary
The deficiency involves the failure of the Nursing Home Administrator (NHA) and the Director of Nursing (DON) to ensure that comfortable air temperature levels, defined as between 71–81 degrees Fahrenheit, were maintained throughout the facility for all residents. Job descriptions for both the NHA and DON specified responsibilities that included leading and directing facility operations in accordance with federal and state regulations, performing rounds to observe residents and ensure their needs were met, and fulfilling responsibilities during implementation or activation of the facility’s emergency plan. Despite these defined duties, the facility did not provide air temperatures within the required range for any of the 82 residents. In addition to the temperature issue, the NHA and DON failed to ensure that all residents were monitored and assessed for hypothermia, which is described in the report as a life-threatening medical emergency occurring when the body loses heat faster than it can produce it. This lack of monitoring and assessment applied to all 82 residents in the facility. Based on review of job descriptions, clinical records, observations, and staff interviews, surveyors determined that these failures constituted noncompliance with federal and state guidelines and regulations and created an Immediate Jeopardy situation affecting all residents. During an interview, the NHA was informed of these failures and the resulting Immediate Jeopardy determination.
Failure to Clear Snow and Maintain Safe Parking Lots and Exits
Penalty
Summary
The facility failed to ensure that the outside environment was free of accident hazards and did not provide adequate supervision to prevent accidents related to snow and ice. Three days after a snowstorm, surveyors observed that the front parking lot, which is used for visitors, transport, and ambulances, was largely impassable. Only one entrance was plowed, and the exit was not plowed, with snow impeding the ability to leave the lot quickly. Sidewalks leading to the building were not shoveled. A second parking area was completely covered with snow, had not been plowed, and vehicles were stuck in the lot. A family member concern documented that the area was a “disaster” with snow, stating that you could not get in or out. During interviews, the NHA reported that the contracted snow removal company never arrived during or after the snowstorm to maintain the grounds and that, as of the survey date, the facility was still in the process of finding a contractor to remove the snow and clear the remaining parking lot and entrance. The NHA stated that only a portion of the lot had been cleared by the local road crew. Later observations showed that the walkways to the Virginia Ave emergency exit and the courtyard emergency exit were not shoveled; although both doors opened, the surrounding areas were not clear for walking. The NHA confirmed that the facility failed to ensure the outside environment was free of potential hazards, failed to evaluate the snow hazard, and failed to implement a plan for snow removal for both parking lots and for two of three exits, several days after the snowstorm ended.
Unlocked and Unattended Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to secure multiple medication carts in accordance with its own Medication Storage policy and accepted professional standards. The policy dated 12/11/25 requires that all drugs and biologicals be stored in locked compartments, including medication carts, and specifies that during a medication pass, medications must either be under the direct observation of the person administering them or locked in the cart. Surveyors observed that these requirements were not followed for three of four medication carts. On one observation, the Vineyard and Rosewood medication carts were found sitting in the hallway next to each other, both unlocked and unattended. An LPN confirmed that the Vineyard cart was unlocked and unattended, and an RN confirmed the same for the Rosewood cart, acknowledging that the facility failed to properly secure the carts while not in use. On another observation, the Rosewood 2 medication cart was also seen in the hallway, unlocked and unattended, while the responsible RN reported being in a resident room at the time and confirmed the cart was not secured. The Nursing Home Administrator later confirmed that the facility failed to properly secure three of four medication carts (Vineyard, Rosewood, and Rosewood 2), as required by facility policy and applicable state regulations.
Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
The deficiency involves the facility’s failure to determine whether it was safe for a resident to self-administer medications before leaving medications at the bedside. Facility policy dated 12/11/25 stated that residents may only self-administer medications after the interdisciplinary team determines which medications can be self-administered safely. The clinical record showed that the resident was admitted on an unspecified date and had diagnoses including hypertension, anemia, and dementia, with a BIMS score of 10 indicating moderate cognitive impairment. Despite this, there was no documented self-administration assessment, no physician order authorizing self-administration, and no care plan addressing self-administration of medications. During an observation, the resident was found lying in bed with a clear medication cup containing four pills (one white, one brown, one peach, and one black) on the bedside table, with no nurse present in the room. An RN acknowledged that it was an oversight and confirmed the presence of the medication cup at the bedside. Review of the resident’s physician orders and care plan did not show any authorization or planning for self-administration of medications, and review of the clinical record did not reveal a completed self-administration assessment. The DON confirmed that the facility failed to determine whether it was safe for this resident to self-administer medications.
Unattended Medication Carts Exposed Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of residents' medical information by leaving three of four medication carts unattended in hallways with computer screens open displaying identifiable resident information. Facility policy titled HIPAA Security Measures, dated 12/11/25, required the implementation of reasonable and appropriate measures to protect and maintain the confidentiality, integrity, and availability of residents' identifiable information and electronic records. Despite this policy, surveyors observed the Vineyard and Rosewood medication carts on 1/29/26 sitting beside each other in a hallway, unattended, with computer screens open and visible to any passerby, displaying residents' personal and confidential information. During interviews conducted immediately following these observations, an LPN (Employee E1) confirmed that the Vineyard cart computer screen had been left unattended and open with identifiable information visible, and an RN (Employee E2) similarly confirmed the same issue with the Rosewood cart. On 1/31/26, surveyors again observed the Rosewood 2 medication cart left unattended in the hallway with its computer screen open and displaying identifiable resident information. An RN (Employee E3) stated they had been in a resident room and confirmed that the Rosewood 2 cart was left unattended with confidential information visible. The Nursing Home Administrator later confirmed that the facility failed to maintain the confidentiality of residents' medical information on the Vineyard, Rosewood, and Rosewood 2 medication carts, as required by applicable Pennsylvania regulations regarding licensee responsibility, resident rights, medical records, and nursing services.
Some of the Latest Corrective Actions taken by Facilities in Pennsylvania
- Re-educated the management team on conducting a thorough investigation, including suspending the alleged perpetrator, ensuring resident safety, obtaining statements from all potentially involved staff, identifying all assignments/units where the perpetrator worked and interviewing applicable residents, and using the Abuse Critical Element Pathway throughout the investigation (K - F0600 - PA)
- Re-educated staff on reporting allegations of abuse or concerns about any staff member (K - F0600 - PA)
- Provided staff education on facility abuse policies, including allegations of sexual abuse (J - F0600 - PA)
- Provided education to nurse aides and licensed nurses on documenting resident behaviors (J - F0600 - PA)
- Monitored documentation of resident behaviors and updated resident care plans as needed (J - F0600 - PA)
- Provided education to all staff on Abuse/Neglect and reporting of incidents and accidents (J - F0600 - PA)
- Educated all staff on abuse protocols, resident rights, and refusal of care and administered a quiz with the education (J - F0600 - PA)
- Implemented ongoing presentation of audit results at QAPI meetings for review (K - F0600 - PA)
- Implemented weekly then monthly audits of potential abuse allegations with results discussed at the QAPI committee (J - F0600 - PA)
Failure to Maintain Safe Room Temperatures and Monitor Residents for Hypothermia
Penalty
Summary
The deficiency involves the facility’s failure to maintain resident room temperatures within the facility’s own policy range of 71–81°F and to monitor and assess residents for hypothermia when the heating system was not functioning properly. The facility’s Safe and Homelike Environment policy required provision of a safe, comfortable environment, and the Loss of Heating or Cooling policy required immediate actions to maintain temperatures between 71–81°F, including monitoring temperatures, increasing rounding, layering clothing, providing extra blankets and warm foods/fluids, and monitoring for signs of hypothermia with physician notification as needed. The Nursing Home Administrator (NHA) reported being aware that the heat was not working the prior week and that a heating company came on a Saturday to install a control board, later determining that an additional gas valve was needed. The NHA presented audits of only 5–6 random rooms per floor and did not have staff check all resident rooms or assess/interview residents to ensure their needs were being met. Observations on the third and fourth floors showed that the heating system was not working at full capability, with room temperatures ranging from 68°F to 81°F and some residents stating they were cold while others felt comfortable. Some windows were observed not fully closed, and some residents reported they had opened their windows. Although residents had extra blankets and clothing, all interviewed residents stated that no staff member had offered extra blankets or warm fluids. Subsequent facility-provided temperature audits documented that, during early-morning checks, the vast majority of rooms on both the third and fourth floors were below 71°F, with the lowest recorded temperatures at 63°F on the third floor and 58.6°F on the fourth floor. During a tour, surveyors noted that the third and fourth floors felt cold overall, and spot temperature checks with maintenance staff showed multiple rooms in the upper 60s to about 70°F. Multiple residents were observed in bed with three or four blankets, winter coats, or tassel caps, and several reported feeling cold, especially at night or when getting up. One resident stated her legs were cold and that her window had been cracked open the previous night; another said he had been cold and that it gets very cold at night; others reported that their rooms were cold or that they had been cold but were warm at the time due to multiple blankets. Few residents were seen in hallways, and those present were covered with blankets. A nurse stated that residents complained of being cold and that she had brought in two bags of blankets to keep them warm. Record review for selected residents showed that there were no physician orders to monitor for hypothermia or to monitor body temperatures in response to the environmental issue, despite the facility’s policy requiring monitoring for signs of hypothermia when heating is compromised. For one resident, the last documented temperature was from early in the month; for another, the last temperature was several days prior; and for a third, the last temperature was from the previous month. The NHA confirmed that the heaters were not working at 100%, that the facility had noticed the problem in the middle of the prior week, and that repairs were in progress. The NHA also confirmed that the facility failed to ensure comfortable air temperature levels between 71–81°F and failed to monitor and assess all residents for hypothermia, resulting in an Immediate Jeopardy situation for all 82 residents.
Removal Plan
- Complete heating system repair and continue ongoing monitoring of system performance.
- Conduct room temperature audits in every resident room every two hours until all resident rooms are at 71°F or higher, then once every four hours daily for seven days, weekly for three weeks, then monthly for three months.
- Include in temperature audits ensuring windows are closed and residents are offered plastic covering for windows.
- Evaluate all residents for signs and symptoms of hypothermia, including residents unable to independently express needs and residents with a temperature over the last three days and/or during whole house audit of 97.6°F or lower.
- Address any identified concerns immediately with individualized interventions and place orders for ongoing monitoring as needed.
- Document resident temperatures in the weights/vitals section of the electronic medical record and document hypothermia evaluation in progress notes.
- Conduct an audit of resident observations for cold intolerance, distress, or changes in condition related to temperature in every resident room every shift daily for seven days, weekly for three weeks, then monthly for three months.
- Ask interviewable residents about comfort level and offer interventions as needed.
- Evaluate non-interviewable residents for observable signs of discomfort related to temperature.
- Educate nursing staff (including agency) on signs and symptoms of hypothermia, risk factors, interventions to prevent hypothermia, comfort measures, and appropriate response when signs/symptoms are identified.
- Educate nursing assistants on non-clinical signs and symptoms of hypothermia and to alert a nurse if observed.
- Complete staff education; staff educated by phone/email to sign education prior to next working shift; reinforce education as needed.
- Provide additional blankets, layering, and environmental adjustments as needed.
- Offer room relocation as appropriate to maintain resident comfort.
- Implement a plan to utilize outside resources as necessary to maintain safe air temperatures during future weather events or mechanical issues, including an updated rental company in place.
- Review relevant policies and procedures related to environmental safety, resident monitoring, and emergency response.
- Update policies as indicated based on audit findings and QAPI review.
- Report audit findings, trends, and corrective actions to the QAPI committee; QAPI to evaluate effectiveness and recommend changes as needed.
- Apply plastic coverings to every resident room and hallway window in resident care areas to prevent drafts.
- Clarify/register controls after identifying some knobs on registers were turned off to prevent inadvertent turning off of heat.
- Have heating vendor send a technician back to ensure correct functionality and further explore the system for any additional needed corrections and complete repairs as soon as possible pending parts/resources.
- Install rental one-ton heating units and rent for at least one week.
- Order and install additional rental heating units.
- For rooms reading under 71°F with a laser thermometer, re-check using a room air thermometer and verify temperatures above 71°F.
- Order air thermometers for each room.
Unsanitary Kitchen Conditions and Unaddressed Cockroach Infestation
Penalty
Summary
The deficiency involves the facility’s failure to maintain the kitchen in a sanitary condition and free of pest infestation while preparing, storing, and serving food for all residents. During a kitchen tour, surveyors observed debris and rodent droppings on the dishwashing area floor and along the perimeter floors throughout the kitchen. Under the dishwasher, the floor was soiled and contained used latex gloves, garbage, bottle caps, a fork, and rodent droppings. These conditions were present in active food service and dishwashing areas where food, utensils, and food-contact surfaces are handled. In the food preparation and tray line service area, surveyors observed seven sticky traps placed on the floor. One trap under the left side of the food preparation area contained five cockroaches, three of which were alive and moving. Another trap on the right side of the kitchen contained five cockroaches, with two alive and moving, and a third trap contained four cockroaches, two of which were alive and moving. These observations showed live and dead cockroaches present in food preparation and storage areas. The report notes that cockroaches are known vectors for disease-causing organisms such as Salmonella, E. coli, and Staphylococcus, and that their presence in these areas created a high risk of contamination of food, utensils, and food-contact surfaces with disease-causing organisms, placing all 135 residents in a situation of Immediate Jeopardy to their health and safety. Interviews and record reviews showed that the facility had an ongoing pest control contract but did not ensure that cockroach activity in or near the kitchen was specifically addressed. The Director of Dietary Services stated that the outside pest control company had been treating the kitchen for rodents since December 2025, but the area was not being treated to prevent cockroaches. A dietary worker reported not seeing many cockroaches recently but acknowledged having seen them in the past. The Nursing Home Administrator confirmed that pest control services were requested in December 2025 in response to a rodent infestation and that remediation services twice weekly were recommended. Pest control inspection reports documented that on January 5, 2026, the pest management provider identified cockroaches at a coffee station located about 50 feet from the kitchen entrance and identified a potential rodent entry point in the dishwasher room, but there was no documentation that cockroach-specific treatment was initiated. The pest control provider confirmed observing German cockroach activity at the coffee station and stated that routine services consisted of perimeter spraying, with no targeted cockroach treatment areas identified. The facility did not provide documented evidence that staff were monitoring for cockroaches in the kitchen or that increased sanitation measures or environmental controls were implemented to ensure food was stored, prepared, distributed, and served under sanitary conditions and free of pest infestation.
Removal Plan
- Dispose of exposed food items
- Cease food preparation
- Transition dietary services to an outside vendor until pest mitigation was completed
- Activate pest control services for immediate treatment of source areas, including clean-out treatment, aerosol application, and gel treatments
- Place the kitchen under continuous monitoring by the Director of Dietary Services and the Nursing Home Administrator
- Schedule audits for each meal
- Conduct a comprehensive inspection of the kitchen by a licensed pest control inspector
- Implement aerosol treatment for immediate control and gel application for prevention
- Educate dietary staff on the facility's Pest Control and Kitchen Sanitation Policies and Protocols
- Review all residents for signs and symptoms of foodborne illness
- Initiate audits of pest control logs and environmental monitoring
- Implement inspection and monitoring by the pest control provider
Systemic Failure in Abuse/Neglect Training, Screening, and Licensing Leading to Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to implement its own policies and procedures to prevent abuse, neglect, and mistreatment, specifically through required screening and training of staff. The facility’s written Abuse, Neglect, & Mistreatment policy stated that all potential employees would be screened for a history of abuse, neglect, or mistreatment through inquiries to state licensing authorities or nurse aide registries and criminal background checks, and that abuse, neglect, and misappropriation education would be completed upon hire and at least annually for all employees. Despite this, review of employee files showed that one LPN had no documentation of a pre-employment background check, and an out-of-state scheduler had only a state background check with no evidence of the required FBI background check. Further review revealed that 26 facility employees had no pre-employment background check documented in their files until checks were completed later. The facility also failed to ensure that staff held current, valid licenses and that these were verified prior to and during employment. File reviews showed that multiple staff members, including two NAs, two RNs, and the DON, had expired licenses or no license on file. Additional audits identified two NAs who had been working with expired licenses. The NHA acknowledged not knowing the process for checking expired licenses. These lapses occurred despite the policy requirement that screening include inquiries into state licensing authorities and nurse aide registries to identify any disciplinary actions. In addition, the facility did not provide required annual abuse and neglect prevention training to its staff. Review of training records and staff files showed that five of seven staff members later identified as alleged perpetrators in a reported neglect incident had no documentation of annual abuse and neglect education for the current year. A broader review confirmed that none of the 90 current facility employees had documentation of annual abuse and neglect training for a 12‑month period. The Human Resources Director stated that no annual education had been completed from January through the date she started working at the facility, and the list of 2025 education topics did not include abuse and neglect. Staff interviews corroborated that while some employees had recently received abuse and neglect education, several indicated it had been a long time since they received such training at this facility or that they received it only at other jobs. These combined failures in training, background checks, and license verification resulted in an Immediate Jeopardy determination for all residents. The neglect incident that triggered identification of alleged perpetrators involved 12 residents on the second floor who did not receive any morning care because no staff were assigned to rooms 209-A through 217-B. A NA reported that these residents had not received morning care, and surveyors informed the NHA and DON twice during the same day that the 12 residents still had not received any morning care. The NHA confirmed that seven staff members, including NAs, an LPN, RNs, the DON, and the NHA, were identified as alleged perpetrators of neglect related to this incident. The facility’s own policy defined neglect as failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress, including when staff are aware or should be aware of residents’ care needs but do not meet them due to factors such as lack of training, insufficient staffing, lack of supplies, or lack of knowledge of resident needs. The survey findings linked the lack of required abuse/neglect training, incomplete background checks, and unverified or expired licenses to this neglect event and the resulting Immediate Jeopardy for all residents. Surveyors confirmed through interviews with successive NHAs that the facility failed to ensure annual abuse and neglect prevention training for the majority of staff, failed to complete required pre-employment criminal background checks for multiple employees, failed to conduct an FBI background check for an out-of-state employee, and failed to verify current, valid licenses and any disciplinary actions prior to employment for several staff members. These findings were cited under Pennsylvania regulatory provisions related to the responsibility of the licensee, management, and personnel policies and procedures. The Immediate Jeopardy was based on these systemic failures in screening, training, and oversight, combined with the documented incident in which 12 residents did not receive morning care due to lack of staff assignment.
Removal Plan
- Facility has reviewed current policy on abuse and neglect.
- All current facility staff including agency will receive training on current facility policy for abuse and neglect.
- Those who do not complete education will not be permitted to work until education is completed.
- All current facility employee files, including agency, will be reviewed to ensure that they have education on facility policy for abuse and neglect, a current and active license on file, and a background check present in their file.
- Missing items that are identified in audit will be immediately corrected.
- Facility will audit all new hire and all new agency staff files to ensure that files contain evidence of abuse education, a current and active license, and a background check.
- Results of the audit will be reported to the Ad Hoc Quality Assurance Performance Improvement Committee.
Failure to Protect Resident From Sexual Abuse and Delay in Investigation and Care Plan Updates
Penalty
Summary
The facility failed to protect a resident from sexual abuse and to ensure residents were free from such abuse, resulting in an Immediate Jeopardy situation. Facility policy defined sexual abuse as non-consensual sexual contact of any type and required implementation of an abuse prohibition program, including investigation of incidents and protection of residents during investigations, with social services assigned to monitor the resident’s feelings and involvement. The resident involved had diagnoses including muscle weakness, was interviewable without cognitive impairment per the MDS, and was dependent on staff for ADLs, including personal hygiene. According to facility documentation, the resident reported that during evening incontinence care, a nurse aide cleaned her perineal area in a circular motion while asking, “Do you like that?” twice and flicking his tongue at her. The resident described that the aide folded and balled up multiple cleansing wipes and rubbed her vagina in an area she described as “the man in the boat,” in a circular motion, while repeatedly asking if she liked it and maintaining a fixed stare with continual tongue flicking. The resident stated she yelled at the aide twice not to say anything like that to her again, felt horrified, scared, singled out, and tearful, and reported that she had not previously observed any similar tongue or mouth behavior from the aide. Clinical records confirmed that the aide provided ADL care to the resident on the date of the alleged incident. The facility’s investigative and protective actions were delayed and incomplete in the period immediately following the allegation. The resident reported she was not informed of any new interventions, options for interventions, or care plan updates until seven days after the initial allegation and was not aware of any measures implemented to protect her following the allegation. Documentation showed that the resident was provided victim’s rights information by police several days after the incident, and there was no evidence that her care plan was updated to address interventions to manage potential trauma until more than a week after the allegation. Additionally, although the facility interviewed residents and conducted physical assessments on residents on the unit where the resident lived, there was no evidence that residents or staff on another unit where the aide had also worked were interviewed or assessed as part of a thorough investigation until more than a week after the alleged incident, as confirmed by the Administrator.
Removal Plan
- Resident 1 was assessed and offered emotional support.
- Resident 1's plan of care was updated.
- Resident 1 will be followed by social services for emotional support and to determine indicators of post-traumatic stress disorder.
- The facility conducted interviews with staff and residents to identify any additional residents who may have been impacted.
- The police, Area Agency on Aging, and Pennsylvania Department of Aging were notified of the allegation of sexual abuse.
- The Administrator or designee re-educated the management team on conducting a thorough investigation.
- Staff were re-educated on reporting allegations of abuse or concerns about any staff member.
- All staff will be re-educated.
- Family members of non-interviewable residents will be contacted to identify any potential concerns of sexual misconduct.
- Identified concerns will initiate an immediate thorough investigation.
- Education on what constitutes a thorough investigation included ensuring the alleged perpetrator is suspended and residents are safe, obtaining statements from all staff who may have witnessed anything related to the incident, identifying all assignments or units where the perpetrator may have worked and interviewing all applicable residents, and reviewing the Abuse Critical Element Pathway throughout the investigation.
- The Director of Nursing or designee will conduct interviews with sampled residents and family members to identify any potential allegations of sexual misconduct.
- Any identified concerns from resident or family interviews will result in an immediate thorough investigation.
- The Market Operations Advisor educated the Clinical Lead on expectations for review of completed audits.
- The Director of Nursing or designee will conduct interviews of sampled staff members to identify any potential allegations of sexual misconduct.
- Any identified concerns from staff interviews will result in an immediate thorough investigation.
- The alleged perpetrator was suspended and will remain suspended until the investigation is completed.
- The facility will follow appropriate protocol per policy and legal requirements.
- If the alleged perpetrator returns to work, he will be re-educated on the abuse policy and have random observations of resident care.
- The results of the audits will be presented at the QAPI meetings for review.
Failure to Secure Windows and Address Suicide Risk Leading to Resident Jumping from Second-Floor Window
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment as free of accident hazards as possible and to provide adequate supervision and environmental safety for a resident with significant mental health needs. The resident was admitted with anxiety, major depressive disorder, a documented history of suicide attempts, and prior inpatient psychiatric hospitalizations. The admission MDS showed the resident was cognitively intact, and the PASRR identified a Level II status for serious mental illness. Clinical notes over the ensuing weeks documented persistent and worsening depression, anxiety, pacing, restlessness, and episodes of self-harm behavior such as repeatedly striking his head against the wall. Psychology and psychiatric notes described high anxiety, guarded behavior, feelings of being trapped, visual hallucinations, and major depressive disorder with psychotic disturbance. The resident and spouse, who shared the same room, were known to have had numerous attempted joint suicides with psychiatric hospitalizations. Despite this history and ongoing symptoms, the resident’s care plan for depression and anxiety, initiated shortly after admission, did not include the resident’s documented history of suicide attempts until after the incident. Staff notes repeatedly described escalating anxiety, restlessness, frequent pacing in the room and hallways, and staff difficulty redirecting the resident. Staff and psychiatric providers reported frequent falls likely related to increased restlessness and worsening mood disturbances. The resident expressed a desire to go home, reported feeling dizzy and trapped, and was described as extremely anxious, with his wife identified as a trigger for his distress. Although separation from his wife and psychiatric follow-up were discussed, there is no indication in the report that increased supervision or specific suicide-risk precautions were implemented before the event. On the day of the incident, the RN supervisor assessed the resident for vomiting and difficulty urinating, noted no abdominal distension, and then left the room after the resident became verbally abusive, laid himself on the floor, and then returned to bed independently. Approximately 15 minutes later, the resident’s wife alerted staff that he had jumped out of the second-floor window. The resident had been alone in the room with his wife at the time. Facility investigation and interviews revealed that the window from which the resident exited could be opened fully without restriction, and the screen had been knocked out. The Maintenance Director stated that windows were not routinely inspected and had last been checked a year prior. Observations showed that while some windows in the facility had rubber stoppers limiting opening to a few inches, other windows, including the one in this resident’s room, did not have such devices. The facility’s investigative documentation initially claimed the resident had removed safety screws, but interviews and observations established that no such screws were in place on that window prior to the incident, and that screws were first installed after the event. Additional observations found other windows in resident-accessible areas that could open widely without restriction, demonstrating a broader failure to ensure window security and environmental safety.
Removal Plan
- Resident 1 was transported from the facility to the hospital emergency room and admitted; a safety device was placed in all windows in the facility that would not allow them to open past 4 inches.
- An audit was completed of all windows in residents' rooms and common areas to ensure that window safety devices are in place.
- Residents with a history of suicide attempts will be reviewed to ensure they have psychiatric services in place, psych medications are reviewed, care plans are updated if needed, and a suicide risk assessment is completed; if they trigger for suicide risk, appropriate actions will be taken per the facility Suicide Threats policy.
- Newly admitted residents will have their antidepressant medications reviewed and compared to their hospital discharge instructions to ensure that they are ordered correctly.
- Maintenance will ensure that all windows have been addressed so that they cannot open past 4 inches.
- Maintenance or a designee will perform random window safety audits.
- The DON/designee will audit all new admissions during morning meetings to check for a diagnosis or history of suicide attempts and ensure clinical recommendations are implemented if positive for suicidal ideations.
- The DON/designee will compare hospital discharge summaries for antidepressant medication orders to ensure they match the physician's orders.
- Results of audits will be presented to risk meetings and to the QAPI/QUAPI committee for further review and recommendations.
- All facility staff will be educated on suicide prevention, suicide threats, the six steps to identifying and addressing behavioral symptoms, and window safety.
- Maintenance or the designee will continue to monitor safety window checks.
- The DON/designee will continue to audit all new admissions during morning meetings for suicide-attempt history/diagnosis and implementation of clinical recommendations.
- The DON/designee will continue to compare hospital discharge summaries for antidepressant medication orders to ensure they match the physician's orders.
Failure to Reassign Staff After NA No-Show Leaves Entire Hall Without ADL Care
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs on the West Hall (rooms 209-A through 217-B), resulting in 12 residents not receiving required ADL care for an entire morning and into the afternoon. On the day of the survey, only two NAs were present on the second floor because the NA assigned to the West Hall did not report for work, and the assignment was not reallocated to other staff. Staff reported that management, including the administrator, DON, and supervisor, had been informed of the staffing shortage. Despite this, no NA coverage was arranged for the affected section, and nurses on the unit did not consistently assume ADL care responsibilities for the unassigned residents. Surveyors observed that all 12 residents in rooms 209-A through 217-B remained in bed around midday with disheveled appearances and still in nightgowns. Multiple residents reported that no one had come in to clean them, change their briefs, assist them out of bed, or provide incontinence care since the overnight shift. One resident stated that only a nurse had come in to administer medications and that they had to seek out someone to request to see the nurse practitioner. Several residents with conditions such as diabetes, hemiplegia, cerebral infarction, heart failure, paraplegia, COPD, and other chronic illnesses reported being soiled with diarrhea or urine since early morning, with no brief changes or application of protective creams, and no assistance with bathing, showering, dressing, or repositioning. Interviews with staff confirmed that no morning care, incontinence care, repositioning, or assistance out of bed had been provided to the residents in the unstaffed section. An LPN stated that when informed there was no third NA, the supervisor said nurses would need to help, but the LPN reported she could not assist with care and that no care had been done since the overnight shift. An RN on the unit stated that she had offered to help but that the LPN refused, and that residents had been left without care. NAs and nursing staff consistently acknowledged that the entire section had no NA coverage, that residents did not receive basic ADL services, and that this constituted neglect. At one point, surveyors observed the RN, LPN, and NA at the nurse’s station talking while residents in the affected section remained without care. The NHA and DON later confirmed that the facility failed to have sufficient nursing staff to provide nursing-related services necessary to attain or maintain residents’ highest practicable well-being, creating an Immediate Jeopardy situation for all 12 residents on the West Hall. The facility’s own Resident Rights policy stated that residents have the right to reside and receive services in a safe, clean, comfortable, and homelike environment, including treatment and support for daily living. The Facility Assessment Tool indicated that the facility was to identify specific staffing needs, including nights, holidays, and weekends, and to implement a proactive and systematic approach to staffing, including cross-training and use of on-call and agency staff. Despite these policies and tools, the facility did not ensure that all residents were assigned to working staff when the scheduled NA failed to report, and did not implement effective contingency measures to cover the West Hall. This failure to follow its own staffing and resident care expectations directly led to the lack of ADL and incontinence care, lack of repositioning, and lack of assistance out of bed for the 12 residents in rooms 209-A through 217-B on the day of the survey. The surveyors determined that this failure to provide sufficient nursing staff and to ensure that residents received necessary care created an Immediate Jeopardy situation by potentially putting residents at risk of harm or injury. The NHA and DON acknowledged that the facility failed to have sufficient nursing staff to provide nursing-related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for the 12 affected residents on the West Hall.
Removal Plan
- Facility DON, NHA, Scheduler, and Designee will review current staffing sheets to ensure that adequate staff are present to meet the residents' needs.
- Facility will prepare and review the current emergency staffing policy and procedures to determine appropriate actions in case of emergency staffing needs.
- Facility will review all agency staffing contracts and obtain additional agency staffing contracts as a back-up to current existing agency contracts.
- NHA, DON, Scheduler or Designee will be educated on how to staff the facility to meet the needs of the facility residents.
- Facility NHA, DON, Scheduler or Designee will review the current schedule to ensure adequate staff are scheduled to ensure adequate care is provided and neglect is avoided.
- Facility nursing staff, including agency, will be educated on meeting staffing needs for each nursing unit and sign the education prior to their next working shift.
- The facility will re-align nurse aide assignments to ensure that all residents are taken care of when a shortage is identified.
- The facility will maintain the projected weekend ratios.
- The facility will hold admissions to ensure that adequate staffing is maintained for the current census.
- The facility will maintain the following staffing pattern to meet the needs of the residents: First floor - First shift = 2 nurses/4 nurse aides; First floor - Second shift = 2 nurses/3 nurse aides; First floor - Third shift = 1 nurse/3 nurse aides; Second floor - First shift = 2 nurses/3 nurse aides; Second floor - Second shift = 2 nurses/3 nurse aides; Second floor - Third shift = 1 nurse/2 nurse aides; One RN Supervisor for each shift.
- Facility DON/Designee will perform audits to ensure that the facility staffing meets the care needs for the residents to ensure that no abuse or neglect is identified.
- Results of the audit will be reported to an Ad Hoc Quality Assurance Performance Improvement (QAPI) Committee.
Failure to Reassign Staff Leads to Widespread Resident Neglect on One Hall
Penalty
Summary
The deficiency involves the facility’s failure to protect 12 residents from neglect when an entire hall (rooms 209-A through 217-B) was left without a nursing assistant (NA) for the day shift, and no reassignment of staff was made to cover those residents. During a tour of the second floor, an NA reported that only two NAs were on the floor because the third did not show up, and that residents down one hall had not been “touched” since the overnight shift. Review of the daily assignment sheets confirmed that the West assignment (rooms 209-A through 217-B) was assigned to an NA who failed to report to work and that this assignment was not reassigned to another staff member. A licensed practical nurse (LPN) stated that when she learned there was no third NA, she informed the supervisor and was told nurses would need to help the NAs, but she said she could not help due to difficulty walking and confirmed that no care had been provided since the overnight shift. Subsequent observations and resident interviews showed that all 12 residents in rooms 209-A through 217-B, who required assistance with activities of daily living, remained in bed in disheveled condition and had not received morning care, incontinence care, repositioning, or assistance getting out of bed. Multiple residents reported that no one had come in to clean them, change their briefs, or help them get up, despite some having conditions such as diabetes, hemiplegia, paraplegia, heart failure, Parkinson’s disease, osteomyelitis, peripheral vascular disease, COPD, depression, and difficulty walking. Several residents specifically stated that their briefs had not been changed since the previous night, that they had experienced diarrhea and remained soiled, and that they usually received skin cream but had not received it that day. One resident reported having to seek out staff to request to see the nurse practitioner because no one had checked on them. Staff interviews corroborated that residents in the affected section did not receive care. An RN stated she offered to help but that the LPN refused, saying she did not want to help with care and was functioning as a cart nurse. The LPN acknowledged that no care, including incontinence care and repositioning, had been provided to the residents in that section and that the whole section had been without an NA all day. NAs confirmed that no morning care, baths, showers, dressing, getting residents out of bed, teeth brushing, or incontinence care had been done for that section. A supervising RN reported being aware that one NA did not show up, notifying the DON and scheduler, and informing nurses that they would have to assist, but stated that the two NAs did not help by splitting the floor into two sections instead of three, resulting in residents not receiving care. The administrator and DON confirmed that the facility failed to ensure residents were free from neglect and failed to timely and effectively manage 12 allegations of neglect, creating an Immediate Jeopardy situation for all 12 residents. The facility’s own abuse, neglect, and mistreatment policy stated that the facility prohibits neglect and is responsible for providing a safe environment, preventing and reporting suspected or alleged neglect, and ensuring that incidents are investigated by the administrator and DON. Neglect was defined in the policy as failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. Despite this policy, the facility did not ensure that all residents were assigned to working staff when the scheduled NA failed to report, and did not ensure that nurses and NAs provided necessary care to the residents in the unstaffed section. The State Agency notified the nursing home administrator and DON twice on the same day about the 12 allegations of neglect and the ongoing lack of care in the affected section before Immediate Jeopardy was called due to resident neglect of the 12 residents.
Removal Plan
- All residents will be assessed and a full body head to toe skin check will be performed for any indications of skin concerns; any identified concerns will be immediately addressed; findings will be documented in resident medical records and attending physician and responsible parties will be notified of adverse findings.
- Facility Medical Director, attending physician for resident (if different from Medical Director), and responsible party for resident will be notified of the neglect that was identified, as well as any potential indications of skin concerns or ill effects secondary to alleged neglect.
- Report will be called into Adult Protective Services.
- Department of Health event report will be completed and applicable PB22's.
- Resident care plans will be updated as applicable to reflect changes as identified.
- Facility NHA, DON, Scheduler and/or Designee will review the current schedule and ensure adequate staff are scheduled to ensure that care is provided to avoid neglect.
- All current nursing staff, including agency, will be educated on facility policy for abuse and neglect and sign the education prior to their next working shift.
- DON/Designee will conduct audits for resident care needs to ensure that no abuse or neglect is identified.
- Results of the audit will be reported to Ad Hoc Quality Assurance Performance Improvement (QAPI) committee.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse and Inadequate Investigation
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from sexual abuse by another resident and to follow its own abuse and sexual abuse investigation policies. Resident 1, who had dementia and a BIMS score of 7 indicating severe cognitive impairment and impaired judgment and decision-making capacity, shared a bathroom with Resident 2, who had intact cognition with a BIMS score of 14. On one evening, a nurse aide (Employee 1) observed Resident 1 in the shared bathroom unlocking and slightly opening the door to Resident 2’s room, which was described as a habitual signal that she was finished using the bathroom. Resident 2 opened his door, leaned toward Resident 1, and kissed her on the lips. Employee 1 immediately removed Resident 1 from the bathroom and notified the RN Supervisor. The facility’s investigation documented this event and noted that Resident 2 later stated, “She is my friend. Who cares if we kissed.” Following this initial incident, staff reported ongoing concerning behaviors by Resident 2 toward Resident 1. Employee 1 stated that she and another nurse aide frequently remained in Resident 1’s room to ensure her safety because Resident 2 continued to sit outside Resident 1’s room and stare at her in common areas. Facility documentation showed that the inside door to Resident 2’s side of the shared bathroom was locked and a bedside commode was provided to limit his access to the shared bathroom, and that the facility attempted to relocate Resident 2 but he declined. The Nursing Home Administrator acknowledged that Resident 1 was not relocated after the first incident due to concern that a move would increase her confusion, and Resident 1 was not offered a room change despite her cognitive impairment. Progress notes documented that Resident 2 exited Resident 1’s room after a visit with her and her family and that he later argued with staff, felt he was being watched, and could not be redirected. Social Services met with Resident 2 and documented that he reflected on past interactions with Resident 1 and was instructed not to enter her room or allow her into his room. A subsequent, more serious incident occurred when Employee 3 and Employee 4, both nurse aides, were conducting rounds after midnight and found Resident 1 missing from her bed, with her wheelchair empty and next to the bed. They found the shared bathroom door locked from the inside and, due to the known prior history between the residents, proceeded to Resident 2’s room. There, they observed Resident 1 lying naked in Resident 2’s bed while Resident 2 was touching her vaginal area, with her legs open. Employee 3 later clarified in interview that she observed Resident 2’s fingers inside Resident 1’s vagina and that she yelled for the supervisor, at which point Resident 1 went to the bathroom, dressed, and wiped herself. Both aides documented that Resident 1 complained of vaginal pain and was observed checking herself in the bathroom. The facility’s investigative documentation recorded that both residents stated they had been talking, that the facility determined there was no evidence of penetration, and that no further assessment was completed at that time. The Nursing Home Administrator stated Resident 1 was not sent to the emergency department for evaluation despite facility policy indicating the need for evaluation following suspected sexual abuse. Despite these events and the facility’s own policy defining sexual abuse as non-consensual sexual conduct and requiring investigation and protection when a resident may lack capacity to consent, the facility did not fully investigate or rule out sexual abuse and did not implement timely and effective interventions to prevent further contact between the two residents. Employee 3 reported that staff were aware of multiple prior incidents, including Resident 2 being found in the bathroom with Resident 1 on multiple occasions and an additional incident where Resident 2 was found caressing Resident 1’s breast. Employee 1 reported that even after the January 11 incident, the two residents were still found unattended together multiple times, and at the time of her interview, they were alone together in the chapel, which the surveyor confirmed. Resident 2 acknowledged spending time alone with Resident 1 and described her as infatuated, while recognizing her dementia diagnosis. Resident 1’s care plan did not include 15-minute safety checks until days after the sexual abuse incident, and the safety check documentation for both residents was incomplete or delayed, with later-added entries and signatures that conflicted with the original records. The Director of Nursing could not explain why incomplete safety check records were later supplemented. Staff reported observable changes in Resident 1’s behavior after the incident, including staying awake later than usual and appearing fearful when using the bathroom, frequently looking toward the doorway previously used by Resident 2. These failures led surveyors to determine that the facility did not ensure Resident 1 was free from sexual abuse by Resident 2 and did not follow its abuse policies, resulting in Immediate Jeopardy to residents’ health and safety.
Removal Plan
- Provide staff education on facility abuse policies, including allegations of sexual abuse.
- Provide education to nurse aides and licensed nurses on documenting resident behaviors.
- Monitor documentation of resident behaviors and update resident care plans as needed.
- Continue education prior to each licensed staff member’s next shift.
- Immediately place the perpetrator and victim on 1:1 supervision in the event of sexual abuse.
Failure to Prevent Resident-to-Resident Sexual Abuse by Known Sexually Disinhibited Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from resident-to-resident sexual abuse despite having policies defining abuse, neglect, and sexual abuse as non-consensual sexual contact of any type with a resident. The facility’s own policy states that abuse includes the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and that neglect is the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility had residents with known psychiatric and behavioral conditions, including one resident with a history of sexually inappropriate behavior, but did not have an adequate care plan in place addressing sexual expression and safety until after an incident occurred. One resident (R1) had diagnoses including parkinsonism, bipolar disorder, and anxiety disorder, and a BIMS score of 15, indicating cognitive intactness. Another resident (R2) had schizoaffective disorder, anxiety, and depression, and a BIMS score of 6, indicating severe cognitive impairment. R2’s care plan identified risk for attention-seeking/manipulative behavior related to psychiatric disease. On a documented date, staff reported that R1 was observed in the dining room alone with R2, acting inappropriately and exposing himself. The residents were separated, and the note stated that the other resident appeared to be consenting, but R2’s low BIMS score and psychiatric diagnoses were known to the facility. The clinical record showed that R1 had exhibited sexually inappropriate behavior on multiple prior dates (7/21/25, 7/23/25, 8/16/25, and 1/3/26). A psychiatric evaluation note for R1 documented that he had been exhibiting inappropriate sexual behaviors with female residents and that staff had observed these behaviors. Staff interviews revealed that some employees had witnessed the incident between R1 and R2 and that at least two staff members had heard rumors or observed changes in R1’s behavior, including sexual behaviors, beginning around the summer of 2025. Despite this history and staff awareness, R1’s care plan addressing sexual expression and protection from unconsented sexual expression was not initiated until after the incident with R2, and the facility failed to prevent R1, a resident with known sexually inappropriate behavior, from having sexual contact with a resident who was not capable of consent, resulting in an Immediate Jeopardy situation.
Removal Plan
- Place Resident R1 on 1:1 supervision and maintain 1:1 supervision.
- Ensure Resident R2 remains safe from resident-initiated sexual abuse by providing 1:1 supervision to Resident R1.
- Update Resident R1's care plan to reflect 1:1 supervision.
- Interview current female residents who are cognitively intact to identify any other residents potentially affected.
- Complete skin assessments for current female residents who are cognitively impaired to identify any other residents potentially affected.
- Provide education to all staff on Abuse/Neglect and Reporting of Incident and Accidents by the Director of Nursing or designee.
- Complete audits for new admissions and current residents for sexual behaviors to ensure resident safety.
- Hold an Ad Hoc Quality Assurance and Process Improvement (QAPI) meeting.
- Monitor the plan of correction at QAPI meetings until consistent substantial compliance is met.
Failure to Provide Appropriate Mental Health Services and Monitoring for Resident With Self-Harm History
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with a history of self-harm and significant mental health diagnoses received appropriate treatment and services to address assessed psychosocial problems. The resident was re-admitted with diagnoses including toxic effects of glycols from suspected antifreeze ingestion, Parkinson’s disease, and depression. The resident’s care plan, updated on 10/30/25, identified a potential risk for ideations of self-harm related to PTSD, glycol toxicity, and hallucinations. Physician orders from 10/25/25 through 12/3/25 included psychiatry/psychology consultation and medications for insomnia, anxiety, depression, and overdose reversal, and progress notes documented a recent voluntary psychiatric hospitalization for Seroquel overdose and a history of possible self-harm attempts, which the resident denied. Despite these identified risks and orders, the clinical record showed inconsistent behavior monitoring and a lack of documented behavioral health interventions to address the resident’s prior suicidal attempts or ideations. Behavior charting for October 2025 showed that 3 of 6 shifts lacked documented behavior monitoring, November 2025 had 24 of 90 shifts without documentation, and December 2025 had 26 of 61 shifts without documentation. The surveyor’s review of the medical records further noted a consistent lack of behavioral health interventions directed at the resident’s history of self-harm and suicidal ideation, even though the resident had a documented history of ethylene glycol toxicity, cocaine use, and Seroquel overdose, as well as recent psychiatric hospitalization. The deficiency also includes the facility’s lack of an effective system to identify and manage residents with prior self-harm attempts. On 12/21/25, the resident was noted to have altered mental status and was transferred to the emergency room. On 12/22/25, the hospital notified the facility of a possible antifreeze ingestion and requested a search of the resident’s room, where staff found a gallon of Peak 50/50 Prediluted Antifreeze. During interviews, the NHA and DON stated they were unaware of the resident’s history of self-harm and acknowledged that the facility did not have a procedure to ensure residents with prior self-harm attempts were referred to mental health services. Surveyors determined that this failure resulted in actual harm to the resident, required hospitalization for antifreeze ingestion, and that there was no system in place to ensure other residents with similar needs were receiving appropriate mental health services, constituting an Immediate Jeopardy situation.
Removal Plan
- Complete an initial audit of current and new admissions to identify any resident with a diagnosis of suicide attempt or suicidal ideation and update care plans with interventions.
- Educate the admission director and clinical liaison to attempt to identify potential needs related to suicide attempts or suicide ideations prior to admission.
- DON or designee will educate staff regarding any new admission with a history of past self-harm attempts on plan of care needs.
- DON or designee will complete a weekly audit on new admissions to determine whether any resident with a history of suicide attempt or suicidal ideation is placed on psych services, has a care plan initiated, and has interventions added to the Kardex.
- Report audit results to the Quality Assurance Performance Improvement Committee.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to initiate CPR for a resident who was a documented full code. The resident, identified as CR1, had diagnoses including chronic kidney disease, adult failure to thrive, and hypertension, and had a physician’s order indicating full code status current through the time of the incident. The resident’s advance directive form showed no advance directives, no living will, and no Power of Attorney, and there was no documentation that the resident had opted out of resuscitative efforts. The resident’s care plan, although current, did not include goals, plans, or interventions related to the resident’s full code status. On the morning of the incident, an LPN (E3) documented that at approximately 7:45 a.m. the resident was found lying in bed on her right side, not responding to her name, with eyes open and skin pale and cool. The call bell was within reach, and the RN supervisor and physician were notified of a change in condition. In a written statement, the LPN reported that CPR was not started because the nurse believed the resident showed signs of irreversible death. There is no indication in the clinical record that the resident’s code status was unclear or that any conclusive signs of irreversible death, such as rigor mortis or other criteria described in the facility’s CPR policy and AHA guidelines, were present or documented at that time. An RN (E4) later documented, in a late entry, that she was informed that the resident ceased to breathe at 7:56 a.m. and that the physician was notified and the resident pronounced deceased. In her statement, the RN reported that when she assessed the resident after being alerted by the LPN that there was no pulse, the resident’s eyes were open, the resident was pale and cool, and there was mottling of the extremities. The RN described these findings, along with the absence of pulse and respirations, as “obvious signs of death” and concluded that the resident had signs of irreversible death and that CPR would not have helped. The clinical record review confirmed that CPR was not administered despite the existing full code order, and staff interviews with other LPNs and RNs indicated that their understanding of procedure was to check code status and initiate CPR for full code residents found pulseless or without respirations. Surveyors determined that the facility failed to ensure consistent care by not initiating CPR for this unresponsive, pulseless full code resident, resulting in an immediate jeopardy situation.
Removal Plan
- Resident R1 no longer resides in facility.
- All professional nursing staff (LPN/RN) will be re-educated on the CPR procedure.
- Agency staff will be educated on the CPR procedure prior to the start of their next shift.
- All professional nursing staff (LPN/RN) will be re-educated on the definition of irreversible death and that it must be documented in the clinical record.
- Agency staff will be educated on the definition of irreversible death and documentation requirements prior to the start of their next shift.
- Whole-house audit will be conducted by the DON/designee to ensure that every resident has a completed POLST order form, the code status order in EHR, and the care plan updated accordingly.
- Policies related to CPR have been reviewed by NHA and DON and updated to include signs of irreversible death.
- Facility will review the incident in QAPI (Quality Assurance/Process Improvement) meeting.
- New admissions will be audited by DON/designee to ensure that the POLST is located in the resident chart and the DNR or Full Code status is in EHR.
- Findings of audits will be submitted through the facility QAPI program.
- All new hires will be educated on CPR procedures and signs of irreversible death.
Resident’s Hair Cut and Shaved Against Expressed Refusal, Constituting Abuse
Penalty
Summary
The facility failed to protect a resident from physical and mental abuse when staff cut and shaved the resident’s hair against her expressed wishes. Facility policies on Abuse Prohibition and Treatment: Considerate and Respectful required that residents be free from abuse, mistreatment, and neglect, and that grooming respect resident preferences for hairstyle and length. The resident had chronic pain syndrome, major depressive disorder, and anxiety, and her MDS showed she was alert, oriented, reported feeling down or hopeless several days per week, and was dependent on staff for personal hygiene. Her care plan documented that she often refused care due to personal preference and that staff were to postpone activities if she refused. On the date of the incident, the resident reported that staff told her not to talk to anyone about certain things and that staff shaved her head using an electric razor after she said no. She stated she previously had a ponytail and that staff shaved her hair like she was a prisoner, without trying any other options. She reported that after staff shaved her head, they took her to the shower. Observation showed her hair was visibly short and uneven, with varying lengths from close to the scalp to about a half inch, and she was seen rubbing her hand over her hair and moving her head during the interview. Staff interviews confirmed that the DON instructed staff to cut the resident’s hair and that scissors and an electric razor were used. The DON acknowledged that the resident “freaked out,” said she did not want her ponytail cut, and objected to the hair being cut, and that no other options were discussed or attempted. A nurse aide stated that the resident screamed no until after her hair was cut, then became silent. The resident’s roommate reported that after staff cut the resident’s hair, the resident was in the room crying. There was no documentation that the resident had tangled hair, a medical need, or any other condition requiring her hair to be cut, no evidence that alternatives such as consultation with a hairdresser or a scheduled haircut were offered, and no documentation that staff acknowledged or honored the resident’s refusal.
Removal Plan
- Resident 1 was seen by social services, psychiatry, and the physician.
- The facility will conduct a full abuse investigation.
- The facility will report the allegation to the Department of Health, Pennsylvania Department of Aging, the local Police Department, and the Area Agency on Aging.
- Psychiatry/psychology services will continue to follow Resident 1 routinely.
- All residents will be assessed for injuries or trauma, with follow-up if needed. If any allegations are brought forward, they will be reported to the abuse coordinator, the resident will be removed from the situation, and staff will be placed on leave if identified as the perpetrator.
- The Administrator will re-review the abuse policy.
- The facility will educate all staff on abuse protocols, resident rights, and refusal of care. Staff members will be given a quiz with the education.
- The facility suspended all involved staff members.
- Weekly audits and then monthly audits will be conducted of any potential abuse allegations and the results discussed at the QAPI committee.
Failure to Initiate CPR for Full Code Resident and Inadequate Staff Adherence to CPR Policy
Penalty
Summary
The deficiency involves the facility’s failure to initiate cardiopulmonary resuscitation (CPR) in accordance with a resident’s advance directives, physician orders, facility policy, and American Heart Association (AHA) guidelines. The facility’s CPR policy required that when an individual is found unresponsive and not breathing normally, licensed or certified staff must initiate CPR unless there is a known Do Not Resuscitate (DNR) order specifically prohibiting CPR or obvious signs of irreversible death, such as rigor mortis. The policy also stated that if a resident’s DNR status is unclear, CPR must be started and continued until a DNR or physician order to withhold CPR is confirmed. AHA guidelines referenced in the policy distinguish presumptive signs of death (such as unresponsiveness, absence of respirations and pulse, fixed and dilated pupils, cool skin, and cyanosis) from conclusive, irreversible signs of death (such as livor mortis, decomposition, decapitation, and rigor mortis). Resident CR1 was admitted with diagnoses including chronic obstructive pulmonary disease, hyperlipidemia, and hypertension. A face sheet from the referring facility, scanned into the electronic medical record prior to admission, documented the resident’s code status as Full Code, indicating a preference to receive CPR in the event of cardiac or respiratory arrest. A nursing note at admission documented baseline confusion, oxygen therapy, and dyspnea, and also noted that attempts to complete admission documentation were unsuccessful because family could not be reached to confirm code status and obtain the resident’s CPAP machine. Despite the presence of the referring facility’s face sheet indicating Full Code status, the resident’s code status was not documented in the facility’s system at the time of the incident. At approximately 2:30 AM, two nurse aides entered the resident’s room and found the resident unresponsive. One aide, who was not CPR/AED certified, did not initiate CPR and instead summoned a registered nurse (RN). The RN’s progress note documented that the resident was unresponsive to verbal commands and sternal rub, had no apical pulse, no obtainable blood pressure or oxygen saturation, one observed respiration, fixed and dilated pupils, and warm, dry skin. The RN did not initiate CPR and directed one aide to check the resident’s code status in the electronic record; the aide reported that no code status was documented. The RN then directed staff to call the RN supervisor. When the RN supervisor arrived, she documented that the resident was unresponsive, pale, with no blood pressure, no pulse oximetry reading, no apical or carotid pulse, no respirations, and no response to sternal rub, and that no DNR or POLST was located in the chart or electronic system. The physician was contacted regarding the resident’s death, and no CPR was initiated at any point, despite the absence of documented irreversible signs of death and the lack of any DNR order. Witness statements provided by staff were consistent in describing the resident as unresponsive with absent vital signs and fixed, dilated pupils, and confirmed that neither the RN nor the RN supervisor initiated CPR. The facility was unable to provide justification for the failure of these licensed nurses to initiate CPR for a resident who did not exhibit documented irreversible signs of death and who was later identified in the closed record as Full Code. Additionally, interviews with multiple LPNs revealed they were unaware of the facility’s policy provisions regarding a designated CPR team and could not identify signs of irreversible death, indicating that staff had not effectively received or understood the CPR policy requirements. Review of other residents’ records showed that 47 additional residents had current physician orders to receive CPR, and the facility’s failures placed these residents, along with Resident CR1, in Immediate Jeopardy to their health and safety.
Removal Plan
- Employee 1 (RN) and Employee 4 (Agency RN Supervisor) were educated on the Emergency Procedure - Cardiopulmonary Resuscitation policy and the need to initiate CPR immediately in accordance with resident wishes and were immediately suspended.
- The facility educated licensed clinical staff on revisions of the CPR policy, including how to respond when someone is unresponsive and when not to initiate CPR (obvious signs of irreversible death) and that if no code status is documented the resident is treated as full code.
- The facility used the payroll system to send the updated CPR policy to staff for electronic review and acknowledgment.
- Nursing education on the updated CPR policy and irreversible signs of death will continue to be completed with licensed staff prior to their next shift starting, beginning with 11pm to 7am shift staff.
- Licensed staff education will be completed regarding the need to initiate CPR immediately in accordance with resident wishes and where to locate code status for each resident in Point Click Care (PCC), on the resident face sheet, and in the orders.
- The facility will ensure each licensed staff member is educated on irreversible signs of death so staff know when it is acceptable not to initiate CPR.
- Education will continue prior to each licensed staff member's next shift.
- Residents’ code statuses were confirmed as reflected in PCC on the resident’s face sheet and in the resident’s orders.
- The Director of Nursing (DON) or designee will audit EMR code status to validate consistency of records for staff reference.
- The DON or designee will audit CPR certification for licensed facility staff.
- The facility conducted a CPR class for employees who were unable to produce up-to-date CPR certification information.
Unsecured Water Beads on Dementia Unit Lead to Resident Ingestion and ICU Transfer
Penalty
Summary
The deficiency involved the facility’s failure to keep water-absorbing beads, an identified choking and obstruction hazard, securely stored on a dementia unit where residents wander. Facility policy required that items needing close supervision be stored in locked cabinets or other secure areas, with cabinets locked when not in active use. Manufacturer instructions and a U.S. Consumer Product Safety Division warning specified that water beads can expand significantly when ingested and pose a serious medical emergency, including life-threatening intestinal blockages or choking. Despite these known hazards and policies, the water beads used for activities were kept in a cabinet in the north lounge activity/dining room on the dementia unit and were not secured. Resident 1, who had dementia, cognitive impairment, dysphagia, and a care plan indicating wandering behavior and the need for a secure environment, was independently mobile on the unit. On the night of the incident, a nurse aide observed the resident in bed at approximately 2:15 a.m. with nothing unusual noted. During 5:00 a.m. rounds, two nurse aides entered the resident’s room and found the resident in bed with the floor covered in water beads. The resident was coughing and spitting water beads out of his mouth. One aide went to get the LPN, and neither aide reported seeing the resident access any items. At about the same time, one of the nurse aides noticed that the north lounge activity room door was open, the light was on, and the cabinet where the water beads were kept was open. When the LPN arrived to assess the resident, she observed the resident coughing up water beads and mucus, with stable vital signs but bilateral rattling lung sounds, and notified the RN. The RN’s assessment documented that the resident was awake, alert with confusion, spitting up water beads, with even, unlabored respirations, cough, and diminished lung sounds with congestion. The DON later confirmed that the water beads had been unsecured in the north lounge activity/dining room on the dementia unit and that it was unknown how many beads the resident had ingested. The resident was transferred to the hospital and admitted to the intensive care unit.
Removal Plan
- Removed the water beads from the facility.
- Identified residents that have the potential to be affected.
- Completed a house review of rooms and lounges for any foreign objects and any other items that would pose a similar issue.
- Provided education to nursing and activities staff on removing items that would pose a potential risk for residents to ingest.
- Locked and secured all activity cabinets.
- Educated newly hired staff on removing items that would pose a potential risk for residents to ingest.
- Will monitor and maintain ongoing compliance.
- Director of Nursing or designee will complete observation audits to ensure items that have potential to be ingested are removed and activity cabinets are locked.
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