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
The facility failed to prevent ongoing intrusions into residents' rooms by other residents with cognitive impairments, resulting in repeated complaints about privacy violations, rummaging of personal belongings, and consumption of food. Despite these concerns being raised in council meetings and interviews, the issue persisted without documented resolution, impacting residents' dignity and quality of life.
The facility did not maintain an adequate supply of clean linens for resident care in two care units, as evidenced by resident concerns, staff reports of frequent shortages, and observations of insufficient linens on carts and in storage. The issue was compounded by delays in linen delivery and problems with linens not being returned from laundering.
The facility did not consistently provide evening snacks to residents, resulting in meal intervals exceeding 14 hours in several nursing unit areas. Multiple residents reported that snacks were not regularly offered, and the NHA could not provide documentation to show that evening snacks were consistently available, despite facility policy requiring them.
The facility did not maintain an effective pest control program, resulting in ongoing issues with small black flies, gnats, and ants in resident rooms and common areas. Multiple residents reported persistent pest sightings, and surveyors observed flying insects in hallways, resident rooms, and near food service areas. Pest control services were performed but lacked detailed documentation and follow-up, and the facility could not provide evidence of consistent efforts to resolve the issue.
A resident with chronic kidney disease, anxiety disorder, and moderate cognitive impairment was manually transferred to bed by two staff without the use of the ordered standing lift, causing significant distress and resulting in the resident biting a nurse aide. The care plan at the time did not address the resident's anxiety regarding transfers or provide alternative interventions, leading to a failure in implementing a comprehensive, person-centered care plan.
Surveyors identified that two residents were exposed to accident hazards due to unsecured medications left accessible in a resident's room and a cognitively impaired resident gaining unauthorized access to a restricted area behind the front desk. The facility did not follow its own policies for medication security or implement effective supervision to prevent these incidents.
Surveyors found that two residents receiving oxygen therapy did not have their equipment maintained or labeled according to physician orders and facility policy. Observations revealed humidification bottles and tubing were not dated, bottles were stored on the floor, and in one case, the bottle could not be secured due to broken straps. Staff interviews confirmed these deficiencies, and the administrator acknowledged the improper storage and lack of dating.
A resident with severe cognitive impairment and multiple pain management orders received PRN opioid medication without documented attempts at non-pharmacological interventions or assessment of pain level, contrary to facility policy. Staff administered morphine on several occasions without determining if a non-opioid medication was appropriate, and physician orders lacked clear guidance on pain intensity for medication selection.
A resident's personal belongings were not properly documented upon admission and discharge, as required. The inventory list lacked signatures from the resident or responsible party, and there was no record confirming the return of the resident's possessions at discharge. The DON confirmed that no further documentation was available to verify the release of these items.
Surveyors found that the facility did not maintain documented job descriptions in the personnel files of a nurse aide, an activities aide, and a dietary aide, as required by policy. This was confirmed by the administrator during the review.
Failure to Prevent Resident Room Intrusions and Protect Resident Rights
Penalty
Summary
Julia Ribaudo Extended Care Facility was found noncompliant with federal and state regulations regarding resident rights and the promotion of a dignified environment. Surveyors identified that the facility failed to ensure residents' personal spaces were protected from intrusions by other residents. Multiple residents reported ongoing issues with other residents, particularly those with severe cognitive impairments, wandering into their rooms uninvited, rummaging through personal belongings, and consuming their food. These incidents were documented through clinical record reviews, resident council meeting minutes, and direct resident interviews. Specific examples included one resident with severe cognitive impairment repeatedly entering the rooms of other residents, sitting on their beds, and taking their snacks. Residents affected by these intrusions expressed frustration, anger, and the need to hide their belongings or call for staff assistance to remove the wandering resident. The issue was persistent, as evidenced by repeated mentions in resident council meeting minutes over several months, with no clear documentation of resolution or effective intervention by the facility. Interviews with the Nursing Home Administrator and Director of Nursing confirmed that resident wandering and room intrusions had been a recurring concern raised by residents. Despite some reports of improvement, the problem remained unresolved for several residents, as indicated by their continued complaints during group interviews and council meetings. The facility's failure to address these concerns and protect residents' rights to privacy and dignity led to the cited deficiency.
Plan Of Correction
Preparation, submission, and implementation of the Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our Plan of Correction is prepared and executed as a means to continuously improve the quality of care and to comply with state and federal regulatory requirements. The facility is unable to retroactively correct Resident 3 and Resident 29's personal space being impeded on by wandering residents 16 and 19. All residents who voiced concerns during the resident council meeting were offered interventions that will deter wandering residents from entering their rooms. To identify like residents that could be affected by wandering residents, the DON/designee will interview all current alert and oriented residents with BIMS of 12 and greater. To prevent reoccurrence, the NHA/designee will educate the IDT team completing concierge rounds to follow up with the identified alert and oriented residents to monitor any further concerns or resolution. To prevent reoccurrence, nursing staff re-educated on the redirection of wandering residents to prevent the wandering of residents into peers' rooms. To monitor and maintain compliance, the DON/designee will interview 6 random alert and oriented residents with BIMS of 12 and greater to monitor resolution of wandering residents weekly x4 and then monthly x2. Results will be reviewed at QAPI. The team completing concierge rounds will follow up with the identified alert and oriented residents to monitor any further concerns or resolution. To prevent reoccurrence, nursing staff re-educated on the redirection of wandering residents to prevent the wandering of residents into peers' rooms. To monitor and maintain compliance, the DON/designee will interview 6 random alert and oriented residents with BIMS of 12 and greater to monitor resolution of wandering residents weekly x4 and then monthly x2. Results will be reviewed at QAPI.
Failure to Maintain Adequate Supply of Clean Linens
Penalty
Summary
The facility failed to maintain an adequate supply of clean linens to meet the needs of residents in two of four resident care units, specifically in the E Hallway and A Hallway. Resident council meeting minutes documented concerns from residents about linen availability, and the Nursing Home Administrator acknowledged that nurse aides were discarding washcloths and that additional linen had been ordered. Observations over several days revealed that linen carts in these hallways frequently contained only a minimal number of washcloths and bath towels, with some instances where no washcloths were available for resident care. Staff interviews confirmed ongoing difficulties in obtaining clean linens, with reports that clean linens were not delivered to the floors until after 9:00 AM, despite care being provided earlier, resulting in shortages. Further observations showed that the facility laundry room had no additional linens available for staff use at the time, and the linen closet outside the E Hallway had a limited supply. The Nursing Home Administrator also reported issues with linens being sent out for laundering and not returned, and was unable to confirm that the facility maintained an adequate number of linens to meet residents' daily needs.
Plan Of Correction
The facility is unable to retroactively correct the available linen supply on E Hallway and A Hallway linen cart. This has the potential to affect all residents. The NHA/designee completed an audit of all linen carts and rooms to ensure there was available linen. To prevent reoccurrence, the NHA/designee will educate housekeeping/laundry aides and CNAs on facility linen laundering processes and the location of clean linen should the linen cart need to be restocked. To monitor and maintain compliance, the NHA/designee will ensure an adequate supply of linens is available in linen carts and supply closets weekly x 4 and monthly x 2. Results will be reviewed at QAPI.
Failure to Consistently Provide Required Evening Snacks
Penalty
Summary
The facility failed to consistently provide evening snacks to residents, as required by federal regulations and its own policy. Scheduled mealtimes in multiple nursing unit areas resulted in more than 14 hours elapsing between the evening meal and breakfast the following day. Specifically, the intervals ranged from 14 hours and 15 minutes to 14 hours and 30 minutes, exceeding the 14-hour maximum unless a nourishing snack is provided at bedtime or a resident group agrees to a longer interval. During a resident council interview, four out of eight residents reported that snacks were not consistently offered in the evenings. One resident stated that snacks were only occasionally offered, while three others indicated they were not offered snacks at all. These resident accounts were corroborated by the lack of documentation showing that snacks were consistently provided during the evening hours. The Nursing Home Administrator confirmed that it is the facility's policy to offer nourishing snacks in the evening but was unable to provide evidence that this was being done consistently. The deficiency was identified through a combination of policy review, scheduled mealtime analysis, and resident and staff interviews.
Plan Of Correction
Resident#28, #32, #69, and 90 are currently being offered HS snacks. To identify like residents that have the potential to be affected, an audit was completed of current residents to ensure that snacks are being offered. To prevent this from recurring, the DON/designee will educate the nursing staff on offering HS snacks to the residents. To monitor and maintain ongoing compliance, the DON/designee will audit 5 residents weekly for 4 weeks, then monthly for 2 months, to ensure that snacks are being offered by the nursing staff. Results will be reported to QAPI for recommendations and follow-up.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as required, resulting in ongoing issues with small black flies, gnats, and ants in resident rooms and common areas across two nursing units and a resident dining/lounge area. Multiple residents reported persistent sightings of these pests, and direct observations by surveyors confirmed the presence of flying insects in hallways, resident rooms, and near food service areas such as the pantry and around the garbage can and ice machine. Resident council meeting minutes and interviews further documented that these pest issues had been ongoing for several months, despite the facility being informed by residents. A review of the facility's pest control policy and contract revealed that while routine pest control services were in place, the contract specifically excluded certain pests such as gnats and other free-flying insects. Pest control invoices showed treatments were performed, but lacked detailed descriptions of services, follow-up actions, or outcomes. The facility was unable to provide documentation of consistent follow-up or contractor recommendations to resolve the persistent pest issues. The Nursing Home Administrator acknowledged the ongoing pest problems despite treatments.
Plan Of Correction
The facility cannot go back and retro-correct the pest control concern. Pest control strips were added to the community to decrease pest concerns. NHA has pest control services on a weekly/as needed schedule to tour the facility to ensure that pest control techniques are effective. This has the ability to affect all residents. To prevent this from recurring, NHA/designee will educate staff on the Pest Control Policy. NHA has pest control services on a weekly/as needed schedule to tour the facility to ensure that pest control techniques are effective. To monitor and maintain ongoing compliance, NHA/designee will complete weekly rounds with the pest control technician weekly x 4, then monthly x 2, to ensure that pest control techniques are effective. NHA/designee will interview 5 alert and oriented residents to verify that the techniques are effective. Results will be reported to QAPI for recommendations and follow-up.
Failure to Develop and Implement Comprehensive Care Plan for Safe Transfers
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed the individualized needs and interventions for safe transfers for one resident. The resident, who was admitted with chronic kidney disease and an anxiety disorder, had a physician's order requiring the assistance of two staff members for transfers using a standing lift. Despite this order, there was an incident where two staff members manually transferred the resident to bed without the use of the standing lift, which was not in accordance with the care plan or physician's order. The resident, who was moderately cognitively impaired, experienced significant distress during the manual transfer and bit a nurse aide as a result. The incident was documented in a progress note, and the resident later explained that she was upset and frightened by the way she was transferred, as it deviated from the usual method involving the standing lift. Staff interviews confirmed that the manual transfer occurred and that the resident became anxious during the process. At the time of the incident, the resident's care plan did not identify her anxiety regarding transfers nor did it include the option for a manual two-person assist. The care plan was only updated after surveyor inquiries to reflect the resident's anxiety and to specify the appropriate transfer methods. Prior to this update, staff were expected to follow the physician's orders and the individualized plan of care, but the plan did not adequately address the resident's specific needs related to transfers.
Plan Of Correction
Resident 22's Transfer Care Plan was updated with individualized needs on. To identify like residents, a facility audit was completed by the DON/designee to identify any residents using a stand lift that have associated anxiety or behaviors. Care plans were updated to reflect individualized preferences for alternative safe transfers, other than facility policy to utilize Hoyer lift. To prevent reoccurrence, the DON/designee will educate licensed nursing on updating resident care plans with individualized preferences as they occur. To monitor and maintain compliance, the DON/designee will audit residents with new orders for stand lift/Hoyer lift, with associated anxiety or behaviors requiring individualized needs related to transfers, and update care plans as needed weekly x 4 and monthly x 2. Results will be reviewed at QAPI.
Failure to Secure Medications and Prevent Unauthorized Access
Penalty
Summary
The facility failed to implement adequate safety measures to prevent accidents for two residents. For one resident with chronic obstructive pulmonary disease (COPD), surveyors observed a bottle of Pepto Bismol and two prescription inhalers stored in an unlocked bedside table drawer and on the bed. The resident stated that her nephew brought her the Pepto Bismol and that a nurse had given her the inhalers, which she kept accessible in case she became short of breath. The resident's clinical record indicated she did not wish to self-administer medications, and the facility's policy required that self-administration be assessed, documented, and that medications be stored in a locked compartment if permitted. However, the medications were not secured, and the resident's drawer did not lock, making them accessible to others. For another resident with Parkinson's disease and moderate cognitive impairment, the care plan noted issues with noncompliance, including attempts to access restricted areas. Despite interventions such as a gate and education, the resident was observed behind the front desk, where he activated the door mechanism to allow entry to the survey team. The resident acknowledged he was not permitted in that area and asked the surveyors not to report his actions. The Nursing Home Administrator confirmed that adequate safety measures were not in place to prevent the resident from accessing the restricted area. These findings demonstrate that the facility did not maintain a resident environment free of accident hazards and did not provide adequate supervision or assistance devices to prevent accidents, as required by facility policy and federal regulations. The deficiencies were identified through observations, record reviews, and interviews with residents and staff.
Plan Of Correction
Resident 62's POC was reviewed, CRNP was notified of Pepto Bismol at bedside. New orders received for Pepto Bismol and self-administration assessment completed. Trellegy inhaler removed from resident room and explained that there was no current order without incident. Resident 62 has an order in place from 10/10/2024 that she may keep her Combivent inhaler at bedside and self-administer. Resident instructed to keep medications in locked bedside table. Initial audit performed to ensure that no other residents had medications at bedside and if so, medications were removed and if indicated, self-assessment were completed. Resident 63 was immediately educated on facility policy for visitor entry. Facility staff immediately educated on visitor entry policy and keeping the entry behind the desk restricted if staff not present. Maintenance director applied plastic casing with lock over unlocking mechanism. To identify like residents that could be affected, the resident's DON/designee will interview residents with a BIMS of 12 or higher to ask if they would like to self-administer and if they request, a self-administration assessment will be completed. All residents assessed and determined to self-administer will be educated on keeping medications locked at bedside. To identify like residents that could be affected, all residents that are alert and oriented with a BIMS of 12 and above that are independently mobile were educated on the visitor entry policy. To prevent reoccurrence, DON/designee will educate licensed nurses on the self-administration policy. To prevent reoccurrence, DON/designee will educate all facility staff; all staff were educated on visitor entry policy and keeping the entry behind the desk restricted if staff not present. To identify like residents that could be affected, the resident's DON/designee will interview residents with a BIMS of 12 or higher to ask if they would like to self-administer and if they request, a self-administration assessment will be completed. All residents assessed and determined to self-administer will be educated on keeping medications locked at bedside. To identify like residents that could be affected, all residents that are alert and oriented with a BIMS of 12 and above that are independently mobile were educated on the visitor entry policy. To prevent reoccurrence, DON/designee will educate licensed nurses on the self-administration policy. To prevent reoccurrence, DON/designee will educate all facility staff; all staff were educated on visitor entry policy and keeping the entry behind the desk restricted if staff not present. To monitor and maintain compliance, DON/designee will audit all new residents with a BIMS of 12 or higher for self-administration preferences and self-administration assessments weekly for 4 weeks and monthly for 2 months. To monitor and maintain compliance, DON/designee will audit that medications are not left out and available for other residents to get. To monitor and maintain compliance, DON/designee will audit front desk to ensure resident access behind the desk is restricted if an employee is not present behind the desk and that access to the entry mechanism is not accessible if staff is not present behind the desk weekly for 4 weeks and monthly for 2 months. Results will be reviewed at QAPI.
Failure to Maintain and Label Oxygen Therapy Equipment per Policy
Penalty
Summary
Surveyors identified that the facility failed to ensure oxygen therapy was administered and maintained according to physician orders and facility policy for two residents. The facility's policy required licensed clinicians to administer oxygen as ordered, change humidifier bottles when empty, and date equipment. For one resident with chronic obstructive pulmonary disease (COPD), observations revealed the oxygen humidification bottle was stored directly on the floor, was empty, and neither the bottle nor the tubing was dated. These issues persisted over two consecutive days, and a registered nurse confirmed the deficiencies during an interview. For another resident, also with COPD, staff were ordered to administer oxygen with humidification as needed, clean the concentrator, and change tubing weekly. Observations showed the nasal cannula and tubing were left across the bed with the cannula on the floor, and the humidification bottle was also on the floor with broken attachment straps, preventing it from being secured to the concentrator. The bottle was not dated, and these conditions were confirmed by a staff member during an interview. The Nursing Home Administrator acknowledged that humidification bottles should not be stored on the ground and should be dated when changed. The findings were based on clinical record reviews, facility policy, direct observations, and staff interviews, and demonstrated a failure to follow established protocols for oxygen therapy equipment maintenance and infection control.
Plan Of Correction
Resident #3 concentrator fixed, and humidifier bottle and tubing replaced. Resident #62 concentrator fixed, oxygen bag replaced and dated per policy, humidifier bottle and oxygen tubing replaced. To identify like residents that have the potential to be affected, DON/designee audited residents receiving oxygen therapy to ensure concentrator working properly, humidification bottle not on floor, and documentation present in the electronic clinical record. To prevent this from recurring, licensed staff will be educated on the oxygen administration policy by the DON/designee. To monitor and maintain ongoing compliance, DON/designee will audit 5 residents weekly x4 then monthly x2 to ensure concentrator working properly, humidification bottle changed, tubing changed, and documented in the electronic record. Result to QAPI for recommendation and follow-up.
Failure to Attempt Non-Pharmacological Pain Interventions Before Administering Opioids
Penalty
Summary
The facility failed to follow its own pain management policy by not attempting non-pharmacological interventions before administering a narcotic pain medication on an as-needed basis to a resident. The policy required that non-pharmacological interventions be tried prior to giving PRN pain medication, and if these interventions failed, medication would be administered according to the resident's pain intensity rating. However, documentation showed that staff did not attempt these interventions or assess the resident's pain level before administering opioid medication. The resident involved had a history of major depressive disorder and unspecified dementia with agitation, and was severely cognitively impaired, as indicated by the absence of a BIMS score on the MDS assessment. The resident had multiple physician orders for pain management, including acetaminophen for mild pain and morphine sulfate for pain or shortness of breath, but the orders for morphine did not specify a pain level or scale, making it unclear when to use each medication as per facility policy. Review of the electronic Medication Administration Record revealed that the resident received PRN morphine sulfate on multiple occasions without any documented attempts at non-pharmacological interventions and without assessment of pain level to determine if a non-opioid medication would have been appropriate. This was confirmed during an interview with the Nursing Home Administrator, who reviewed the findings related to the failure of licensed nursing staff to follow the required pain management procedures.
Plan Of Correction
Resident #19 Morphine order clarified to indicate levels of pain. Cannot go back and retro-correct non-pharmacology interventions for resident #19. To identify like residents that have the potential to be affected, DON/designee audited all residents with PRN pain medication to ensure that residents' pain levels are clarified in the physician order and non-pharmacological interventions are being offered prior to administration of the medication. To prevent this from recurring, licensed staff will be educated on pain management by the DON/designee. To monitor and maintain ongoing compliance, DON/designee to audit 5 residents x4 weeks then monthly x 2 months to ensure that pain levels are completed and non-pharmacological interventions offered prior to administration of the medication. Results to QAPI for recommendations and follow-up.
Failure to Document and Return Resident's Personal Belongings at Discharge
Penalty
Summary
The facility failed to maintain a complete and accurate record of a resident's personal possessions upon both admission and discharge. Specifically, for one resident, the inventory list documenting personal belongings at admission and discharge did not include a signature from either the resident or a responsible party. Additionally, there was no documentation in the resident's discharge information indicating that the belongings were returned to the resident upon discharge. An electronic observation detail report showed that the resident arrived with four belongings, but the facility was unable to provide further documentation confirming the release of these items at discharge. During an interview, the Director of Nursing confirmed that no additional records could be produced to verify the return of the resident's possessions.
Plan Of Correction
Resident #94 received all of his personal belongings upon discharge. To identify like residents that have the potential to be affected, the DON/designee completed a 2-week audit of new admissions to ensure that personal inventory sheets were completed upon admission and discharge of the residents. To prevent this from recurring, the DON/designee educated the nursing staff on the completion of the personal inventory sheet upon admission and discharge of the resident. To monitor and maintain ongoing compliance, the DON/designee will audit personal inventory sheets of new admissions and discharges weekly for 4 weeks, then monthly for 2 months, to ensure they are being completed and signed per the policy. Results will be reported to QAPI for recommendations and follow-up.
Missing Job Descriptions in Employee Personnel Files
Penalty
Summary
The facility failed to ensure that the personnel records for three employees, specifically a nurse aide, an activities aide, and a dietary aide, contained documented evidence of their job descriptions. Review of the personnel files for these employees, all hired in 2025, revealed that none included a written job description outlining the duties, responsibilities, and qualifications for their respective roles. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the facility could not produce the required documentation for these employees.
Plan Of Correction
Employee #5, #7, and #8 have signed job descriptions. To identify like individuals that have the potential to be affected, NHA/designee will audit new hires in the last 14 days to ensure job descriptions are signed by the employee. To prevent this from recurring, Human Resources will be educated by NHA/designee on personnel policies and procedures. To monitor and maintain ongoing compliance, NHA/designee will audit new personnel files weekly for the first four weeks, then monthly for two months, to ensure personnel files contain the signed job description. Results will be reported to QAPI for recommendations and follow-up.
Some of the Latest Corrective Actions taken by Facilities in Pennsylvania
Policy & System Changes
- Reviewed and revised the facility elopement policy to strengthen prevention measures (J - F0689 - PA)
- Updated resident‐escort procedures and created an office-to-facility return protocol to ensure residents are not left unattended after appointments (K - F0689 - PA)
- Implemented a staffing ratio of one staff member for every eight resident smokers to provide adequate supervision during smoking times (J - F0689 - PA)
- Placed lists of residents at risk for elopement at each nursing station to keep staff continuously aware of high-risk individuals (J - F0689 - PA)
- Installed elopement binders with resident photos at all nurses’ stations and reception areas for rapid identification of at-risk residents (J - F0689 - PA) (J - F0689 - PA)
- Added a protective cover over the exit-door release button to limit unauthorized resident egress (J - F0689 - PA)
- Established daily door-alarm functionality audits by maintenance to ensure exit alarms remain operable (J - F0689 - PA)
- Instituted validation checks of resident returns from off-site appointments before closing transportation logs (K - F0689 - PA)
- Started head counts of all residents each shift against census to detect missing residents promptly (J - F0689 - PA)
- Integrated elopement-risk screening into admission, quarterly reviews, and daily stand-up audits to keep care plans and interventions current (J - F0689 - PA) (J - F0689 - PA)
Staff Education & Drills
- Trained staff on escort requirements for off-site appointments to prevent unsupervised outings (K - F0689 - PA)
- Educated all staff, including agency personnel, on revised elopement policies, documentation of exit-seeking behaviors, reporting protocols, and intervention implementation (J - F0689 - PA)
- Provided comprehensive training on dementia behaviors, elopement-risk mitigation, alarm response, resident re-orientation, lobby monitoring, code 10 procedures, and safety checks (J - F0689 - PA)
- Educated staff on the facility’s smoking prohibition and supervision requirements to reduce unsupervised exits for smoking (J - F0689 - PA)
- Incorporated elopement-risk, missing-person, and visitor-badge procedures into new-employee orientation to sustain competence in future staff cohorts (J - F0689 - PA)
- Conducted elopement drills every shift and instituted monthly drills on all shifts to reinforce rapid response skills (K - F0689 - PA) (J - F0689 - PA)
- Educated reception and security staff on enforcing visitor-badge return prior to door release to control building egress (J - F0689 - PA)
- Held interdisciplinary huddles to review residents with frequent leave-of-absence orders and early signs of elopement risk to enhance proactive monitoring (J - F0689 - PA)
Failure to Educate Staff on Safe Food Heating Results in Resident Burn
Penalty
Summary
The facility failed to ensure that direct care staff were educated on the safe process for heating and reheating food, as required by facility policy. The policy specified that food and beverages must be heated, stirred, temperature-checked, stirred again, and re-checked before being served to residents, with temperatures maintained between 140°F and 165°F to minimize the risk of burns. However, a licensed nurse who had not received this education prepared instant ramen soup for a resident and did not check the temperature before serving it. The resident involved had diagnoses of diabetes and peripheral vascular disease, was cognitively intact, and required set-up assistance with feeding. After the soup was served, the resident spilled it on their chest, resulting in a second-degree burn. Observations and clinical documentation confirmed the presence of a significant burn area on the resident's chest and abdomen, and the resident reported pain following the incident. Progress notes and wound care consults documented the extent and treatment of the burn. Interviews and facility documentation revealed that the nurse did not follow the required procedure for checking food temperature, and there was no evidence of temperature documentation for the soup. The Nursing Home Administrator confirmed that the staff member had not been trained on the safe food heating policy, and further acknowledged that all direct care staff, including nurses and nursing assistants, had not received this education. This lack of staff education and failure to follow policy led to an Immediate Jeopardy situation when the resident sustained a burn from overheated food.
Removal Plan
- Education was provided to the staff
- A whole house audit was conducted to check all microwaves in the facility had thermometers attached to it
- All residents were assessed to ensure no other residents received a burn from re-heated food items
- Process signage for re-heating food in the microwave were attached to the microwaves
- House-wide education developed and implemented for all facility staff on re-heating process, education was implemented and presented during the new hire and agency orientation
- Dietary performed audits to ensure thermometers are present and functioning on all microwaves in resident areas
- Audits were completed and ongoing
- The outcome of audits will be reviewed at the QA meeting
Failure to Supervise Severely Cognitively Impaired Resident During Offsite Appointment
Penalty
Summary
The facility failed to provide adequate supervision to prevent elopement for a resident with severe cognitive impairment, resulting in an immediate jeopardy situation for multiple residents. Specifically, a resident with a BIMS score of 6, indicating severe cognitive impairment, was allowed to leave the facility unaccompanied for a medical appointment, despite facility policy requiring an escort for residents with a BIMS score lower than 13. The resident was not identified as at risk for elopement in the care plan, and the physician's order permitted the resident to leave unaccompanied when arranged by the facility. During the appointment, the resident was left unsupervised in the lobby, was not picked up as planned, and subsequently left the premises independently by calling a ride service and returning to his home. Review of facility records revealed that several other residents with severe cognitive impairment also had orders allowing them to leave the facility unaccompanied, contrary to the established escort protocol. Staff interviews confirmed that residents with severe cognitive impairment should not be permitted to leave unaccompanied, and that new residents should not have such orders until evaluated by a provider. Despite these protocols, the facility failed to ensure that care plans and physician orders were consistent with the residents' cognitive status and supervision needs. The incident was further compounded by the lack of elopement-related goals and interventions in the affected resident's care plan, and the absence of appropriate supervision during the transfer process. The resident was reported missing after the appointment, prompting a police search and notification of emergency services. The resident was eventually located at his home, having left the appointment site without facility staff knowledge or supervision. This failure to provide adequate supervision and to follow established protocols resulted in an immediate jeopardy situation for all residents with similar cognitive impairments.
Removal Plan
- Complete AMA discharge at residence.
- Call emergency services for hospital transfer for PICC removal.
- Notify Adult Protective Services.
- Notify Ombudsman.
- Review escort protocol.
- Educate staff on sending residents to appointments with escorts.
- Update elopement book.
- Conduct wellness check on resident.
- Conduct elopement drills every shift.
- Validate appointment returns.
- Develop protocol for offices to call building or driver for return and not put residents in the lobby.
- Review upcoming appointments and determine if escorts are needed in morning meeting.
- Update care plans.
Failure to Ensure Nursing Staff Competency with Insulin Pump Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies and skill sets to care for a resident using an insulin pump, resulting in immediate jeopardy to the resident's health and safety. The Director of Nursing confirmed that there was no policy in place for insulin pumps, and the facility's policy on competent nursing staff was not followed in this case. Clinical record review showed that a resident with multiple diagnoses, including diabetes, was admitted with an insulin pump, but the nursing admission evaluation did not document the presence of the pump, and the care plan did not address its management. Multiple interviews with RNs and LPNs revealed that none of the nursing staff, including agency staff, had received education or training on insulin pumps. Staff members were unfamiliar with the device, its maintenance, and its operation, with some only having personal knowledge from outside the facility. One LPN, who was working her first shift at the facility, transcribed hospital discharge orders incorrectly, entering the wrong insulin type and route of administration due to lack of training and orientation. This error led to the administration of insulin subcutaneously instead of refilling the pump, resulting in the resident experiencing hypoglycemia and requiring hospital transfer for an accidental insulin overdose. The employee file for the LPN who made the error did not contain evidence of facility orientation or training on the admission process, order transcription, or insulin pump management. The Director of Nursing and Nursing Home Administrator confirmed that staff were not trained on insulin pumps or related processes, and that this lack of training and competency directly resulted in a negative outcome for the resident.
Removal Plan
- Audit residents to identify specialty equipment. If specialty equipment is identified, obtain physician orders. Update care plans to include specialty equipment if applicable.
- Audit admission assessments for residents for special equipment specifically insulin pumps and/or continuous glucose monitors.
- Audit physician orders from discharge paperwork for residents for accuracy.
- Conduct pre-admission resident screening to identify any special equipment. Communicate special equipment needs to the nursing team prior to resident admission. Educate Admissions Director on this process.
- Educate licensed nursing staff (including agency) on conducting pre-admission resident screening to identify any special equipment and communicating special equipment needs to the nursing team prior to resident admission.
- Educate licensed nursing staff (including agency) on assessing residents upon admission for special equipment including insulin pumps/continuous glucose monitors.
- Educate licensed nursing staff (including agency) on obtaining physician orders for specialty equipment.
- Educate licensed nursing staff (including agency) on accurate order transcription and admission red lining processes.
- Educate licensed nursing staff (including agency) on care plan updates on specialty equipment.
- Educate licensed nursing staff (including agency) on updated processes.
- Update and review facility policy on medication administration to include specialty equipment, obtaining physician orders, and updating care plans.
- Conduct audits of new resident admission assessments to ensure assessments, redlining, and orders are completed and accurate.
- Submit findings of audits through facility Quality Assurance and Performance Improvement program.
Failure to Prevent Elopement and Identify At-Risk Residents
Penalty
Summary
The facility failed to provide adequate supervision and monitoring to prevent accidents, specifically elopement, for two residents. One resident, who was assessed as being at risk for elopement due to cognitive impairment, poor decision-making skills, and exit-seeking behavior, was able to leave the facility unsupervised. This resident exited the building when a CNA was assisting other residents to a smoking area, and the door was opened using a code that temporarily disabled the Wanderguard alarm system. The resident was not identified as a smoker and was not being directly supervised at the time, allowing him to leave unnoticed until another resident alerted staff. Another resident, also with cognitive impairment and a history of exit-seeking behavior, was not properly identified as an elopement risk. Although this resident had previously been assessed as at risk and had a Wanderguard device ordered, the device was discontinued after one week without documented evidence of ongoing risk assessment or justification. Staff interviews revealed that this resident had managed to exit the building with visitors and had to be redirected frequently due to continued exit-seeking behaviors. However, the resident was not included in the facility's elopement risk binder, and key staff, including the NHA, were unaware of her risk status or previous incidents. Observations and staff interviews indicated a lack of consistent documentation and communication regarding which residents were at risk for elopement and who required supervision during high-risk activities such as smoking breaks. Staff relied on informal knowledge rather than documented lists, and there was insufficient supervision during these times. The facility's failure to identify and supervise residents at risk for elopement resulted in one resident leaving the premises without staff knowledge and another resident's risk not being properly managed or communicated.
Removal Plan
- The facility reviewed and revised the elopement policy.
- The Director of Nursing or designee will complete assessments on all residents to identify their risk for elopement, and care plans will be updated to reflect the residents' current condition, risk for elopement and resident centered interventions.
- A list of residents at risk for elopement will be placed at each nursing station to inform staff of residents at risk.
- The Nursing Home Administrator or Designee will educate all staff, including agency staff, on elopement policies and procedures, documenting residents with exit seeking behaviors, reporting exit seeking behaviors to administration and implementing proper interventions for these residents prior to staff's next scheduled shift.
- The facility will allocate additional staff members to supervise smokers to ensure appropriate supervision is available to meet residents.
- The facility will have one staff member for every eight residents who smoke.
- The Facility will complete a head count of all residents each shift to ensure residents are safe and provided adequate supervision.
- The Director of Nursing of Designee will review progress notes daily to identify any residents with new exit seeking behaviors to ensure appropriate interventions are in place.
- The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for frequency of audits.
Failure to Prevent Elopement Due to Inadequate Supervision and Care Planning
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident who was identified as being at risk for wandering and exit-seeking behaviors. The resident had a history of cognitive impairment, poor decision-making skills, and demonstrated wandering and exit-seeking behaviors, as documented in an Elopement Risk Assessment. Despite these findings, the resident's care plan did not include any interventions to address elopement risk, and there were no physician orders for elopement prevention measures. On the day of the incident, the resident was last seen by staff in a recliner in the community room and later in another resident's room before being returned to his own room around 7:30 p.m. The resident was left unsupervised, and staff failed to monitor the front door, which allowed the resident to exit the facility without detection. The absence of supervision at the front desk was confirmed by video footage, contradicting an initial staff statement. The facility did not document the resident's wandering behaviors in the progress notes, and there was no immediate notification to local authorities by the facility when the resident was discovered missing. The resident was found by police in a nearby residential area without shoes and with no memory of how he arrived there. The police were alerted by a passer-by, not the facility, and the resident was subsequently taken to the emergency department for evaluation. The incident revealed gaps in supervision, documentation, and adherence to elopement prevention protocols, resulting in an immediate jeopardy situation for the resident.
Removal Plan
- Complete a root cause analysis to validate the cause of the resident elopement.
- Complete a head count to ensure all residents are accounted for.
- Reassess the resident upon return from the hospital and implement frequent checks.
- Audit all elopement books to ensure accuracy.
- Review and assess all residents for elopement risk, wandering, and update care plans and orders to include appropriate interventions.
- Assess all residents in house for elopement risk by the Director of Nursing or designee.
- Review and update care plans for residents identified with elopement risks with interventions to prevent elopement by the Director of Nursing or designee.
- Add all residents identified to be elopement risk to Elopement Binder per protocol.
- Conduct a house audit on all doors and exit points to ensure that facility is secure and alarms are functional by Maintenance.
- Conduct education to all facility staff regarding dementia/behavior in LTC residents, elopement risk and mitigation, and elopement policy and procedures to include keeping doors secure.
- Educate all staff on elopement interventions such as responding to alarms, reorienting wandering patients, encouraging activities, monitoring the front lobby and sign in sheet, code 10, and safety checks.
- Educate staff that all residents assessed as an elopement risk will have their picture and face sheet in the elopement book.
- Place elopement books with identified resident photos on all nurses' stations in addition to the current one at the receptionist's desk by the Administrator or designee.
- Screen newly admitted residents for elopement risk on admission, quarterly and as needed, and update care plans appropriately.
- Place new admissions and any resident assessed as an elopement risk in the elopement book that includes photograph and face sheets. Book is available for staff to review and monitor at all times.
- Investigate all incidents, perform root cause analysis and follow up with appropriate interventions by the DON or designee.
- Review elopement interventions and update as required by the QAPI team.
- Ensure the front door is monitored 24 hours 7 days a week by the RN supervisor until the wander guard system is installed.
- Review the lobby monitoring sign in sheet regularly.
- Audit door alarms daily by maintenance.
- Conduct elopement drills monthly on all shifts.
- Monitor the plan of correction by QAPI including all door audits, elopement book, elopement drills and all new admissions will be audited for elopement risk.
- Monitor the plan of correction at the Quality Assurance and Process Improvement meeting until consistent substantial compliance has been met.
Failure to Prevent Elopement and Ensure Smoking Safety
Penalty
Summary
The facility failed to implement sufficient monitoring interventions and supervision to prevent an elopement incident involving a resident. The resident, who had a history of traumatic subdural hemorrhage, mild cognitive impairment, COPD, type 2 diabetes, repeated falls, anxiety, depression, and nicotine dependence, was able to exit the facility without staff awareness. The resident left the premises by unlocking the door and leaving the property to purchase cigarettes, despite the facility's status as a tobacco-free, non-smoking environment. Staff interviews and documentation confirmed that the resident was able to access the door release button and leave the facility unsupervised. Prior to the elopement, there was no evidence that the facility had conducted a safe smoking assessment or implemented any safety interventions related to the resident's smoking habits. Progress notes indicated that the resident had previously been caught smoking inside the facility and had expressed frustration about not being able to smoke, but no additional safety measures or care plan updates were documented. The resident's care plan and progress notes lacked any interventions or updates addressing elopement risk or smoking safety from the time of the incident until the investigation several days later. Staff interviews revealed that the resident's cigarettes and lighter were kept in a locked medication cart, and when the resident requested a cigarette, staff would provide them and allow the resident to smoke on the porch. However, there was no supervision or monitoring in place to prevent the resident from leaving the property. The facility was unable to provide a smoking policy when requested, and there was no documentation of the elopement in the progress notes until the investigation began. At the time of the investigation, no elopement prevention interventions had been implemented for the resident.
Removal Plan
- Resident will have a smoking assessment completed. Resident will have supervised smoking three times per day until discharged to a smoking facility, or until discharged to his residence.
- All residents will be assessed for elopement risk by the director of nursing or designee.
- All care plans for residents identified with elopement risks will be reviewed and updated if needed with interventions to prevent elopement by the Director of Nursing or designee.
- A facility care feed message will be sent to families reminding them that the facility is a non-smoking facility and resident smoking is prohibited.
- Education will be completed by all staff on elopement risks, assessments, and supervision of residents by the director of nursing or designee.
- Education will be provided to all staff on facility smoking policy. Facility is a non-smoking facility for residents.
- Elopement books with identified resident photos will be placed on all nurses stations in addition to the current one at the receptionist's desk by the Administrator or designee.
- A protective device will be placed over the exit door button to prevent residents from access.
- Audits will be implemented to ensure residents are adhering to the facility smoking policy by the Director of nursing or designee.
- New admissions will be audited for elopement and smoking risks at morning stand up meeting by the director of nursing or designee to ensure appropriate interventions are in place as needed.
- An Ad Hoc Quality Assurance and Process Improvement Meeting will be held by the Administrator or designee.
- This part of correction will be monitored at the Quality Assurance and Process Improvement meeting until such time consistent substantial compliance has been met.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Protocol Lapses
Penalty
Summary
A deficiency occurred when a resident with a history of repeated falls, difficulty walking, pelvic fracture, and cognitive impairment was able to leave the facility without a physician's order for a leave of absence (LOA) and without staff supervision. The resident, who required one-person assistance for ambulation and had a moderately impaired cognitive status as indicated by a BIMS score of 10, exited the third floor via elevator and walked out the front entrance using a walker. The resident was not identified as having an LOA order in the clinical records, and there was no documentation of staff being notified or a sign-out process being followed. Facility policy required that residents at risk for wandering or elopement have care plans with specific interventions and that staff intervene if a resident attempts to leave. However, the receptionist on duty did not recognize the resident as a facility resident, mistaking her for a visitor due to her appearance. The receptionist was distracted by personal computer use and failed to follow the protocol of ensuring all residents and visitors sign out and wear visitor badges. Surveillance footage confirmed that the receptionist opened the door for the resident, who then left the premises unchallenged. Staff interviews revealed that the assigned nursing assistant was aware the resident wanted to walk but did not clarify the resident's intentions or monitor her whereabouts. The resident was later found approximately 1.2 miles away in a busy area after being missing for about two hours. The failure to provide adequate supervision and to follow established LOA and visitation protocols resulted in the resident leaving the facility unsupervised, placing her at high risk for injury.
Removal Plan
- Resident was assisted back to the Center and assessed by RN Supervisor for injuries.
- The Center completed a headcount of all residents and compared it to the midnight census to ensure all residents were accounted for.
- The Nursing Administration held huddles with staff to discuss residents who go on frequent LOAs and signs and symptoms that may indicate risk for leaving the Center without staff notification.
- Shift RN Supervisor provided immediate education to receptionist on duty.
- RN Supervisors were educated on the completion of headcount of all residents compared to midnight census and the immediate reporting of any discrepancy to the Director of Nursing/designee.
- Staff were educated on signs and symptoms that may indicate a risk of elopement.
- Reception/security staff were educated on the process of each visitor receiving a badge that must be returned prior to door being opened and visitor leaving the premise.
- Staff educated on elopement/missing person policy and procedure including code yellow announcement to notify staff in Center, search both on the premises and the surrounding areas, notification processes including local police department.
- Staff educated on elopement drills including how often and expected response.
- All the training above will be added to our general orientation schedule for all new future employees.
- Residents with a current unsupervised LOA order were re-educated on the LOA policy/agreement and understood the sign out process with both the nursing staff on the unit.
- Auditing census compared to headcount every 4 hours for 3 days then every shift for 14 days then daily. All variances will be reported to the QAPI Committee monthly.
- Random audit of five visitors to ensure compliance with the visitor pass system two times daily for 14 days then daily for two months. All variances will be reported to the QAPI Committee monthly.
- Daily audit of LOA log to ensure reception/security staff are checking for clearance to leave the Center. The audit will be completed daily for three weeks with all variances reported during the clinical meeting.
- The QAPI Committee will make recommendations to ensure continued compliance. Upon sustained compliance, the QAPI Committee will recommend the reduction or resolution of the audits and the reception/security staff.
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