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
A resident with multiple medical conditions and advanced pressure ulcers did not consistently receive or have documented wound care as ordered. Several days of wound treatments were not recorded, and there was no documentation of refusals or reasons for missed care. Facility leadership confirmed that wound care coverage was not effectively communicated when the wound nurse was unavailable, leading to lapses in treatment and documentation.
Facility staff did not maintain required minimum staffing levels for NAs and LPNs across multiple shifts, as confirmed by census data, schedules, and staff interviews. There were several days when the number of NAs and LPNs on duty fell below mandated ratios, and no additional higher-level staff were present to compensate for these shortages.
Facility staff did not provide the required minimum of 3.2 hours of direct nursing care per resident per day on 16 out of 21 days, as confirmed by review of schedules and census data and acknowledged by the NHA.
The facility did not maintain its fire alarm system as required, with the fire alarm panel displaying fault and trouble indicators over multiple survey visits. The deficiencies were confirmed by the maintenance supervisor and remained uncorrected due to delays in vendor payment and scheduling.
The facility did not provide documentation for required sprinkler system inspections and allowed sprinkler heads to become covered in dust and corrosion. Staff confirmed missing inspection records and overdue maintenance, and the facility was unable to complete necessary repairs due to a payment hold with the vendor. The deficiencies remained uncorrected during follow-up surveys, resulting in a continuous fire watch.
Surveyors found that the facility did not maintain its fire alarm system in operable condition, with issues such as failed battery load tests, a non-functioning buzzer at the FACP, improperly connected horn strobes, missing required signage at pull stations, and malfunctioning smoke and heat detectors. Facility leadership confirmed these deficiencies were not corrected at the time of review.
A portable fire extinguisher next to a resident room was found to be blocked during an observation, and this was confirmed by facility leadership during the exit interview.
Surveyors identified that the facility did not maintain required inspections or corrective actions for fourteen fire and smoke dampers in the HVAC system, with issues such as non-functioning motors, missing dampers, and inadequate fire wall protection remaining unaddressed at the time of survey.
An electrical panel inside the nurse station supply closet was found to be blocked by a large cart, making it inaccessible in violation of NFPA 70 requirements. This was confirmed by facility leadership during the survey.
Surveyors observed that a courtyard exit egress door was secured with a combination padlock, which did not meet NFPA 101 requirements. The issue was confirmed by facility leadership and had been previously identified earlier in the year.
Failure to Provide and Document Pressure Ulcer Care
Penalty
Summary
A deficiency was identified when a facility failed to ensure that a resident with pressure ulcers was assessed and provided necessary treatment and services consistent with professional standards of practice. The facility's wound care policy required documentation of wound care procedures, including the type of care given, assessment data, and the resident's response. However, review of the Treatment Administration Record (TAR) for a resident with Stage 3 and Stage 4 pressure ulcers revealed multiple dates where wound treatments were not documented as completed, and there was no documentation of refusals or reasons for missed treatments. The resident in question had significant medical conditions, including metabolic acidosis, pulmonary embolism, and hypertension, and was documented as having both Stage 3 and Stage 4 pressure ulcers. Physician orders were in place for specific wound care treatments, and the care plan directed staff to administer treatments as ordered and monitor for effectiveness. Despite these orders, the clinical record showed gaps in the documentation of wound care, with several days lacking evidence that treatments were performed or that the resident refused care. Interviews with facility leadership confirmed that dressing changes were not documented as completed and that there was a lack of effective communication regarding coverage for wound care when the wound nurse was unavailable. The Director of Nursing acknowledged that the wound nurse may have been assigned to other duties, and coverage for daily wound care was not effectively communicated to other staff, resulting in missed or undocumented treatments for the resident's pressure ulcers.
Plan Of Correction
R1 has discharged from this facility. A 7-day look-back audit will be completed on wound dressing documentation to ascertain no other residents were affected. The DON will educate the Wound Nurse and Nursing Staff on the facility wound care policy. The DON/Designee will audit wound dressing documentation weekly for 2 weeks to ensure documentation is completed. Results of these audits will be reviewed in the Quality Improvement Committee for recommendations as needed.
Failure to Meet Minimum Nurse Aide and LPN Staffing Requirements
Penalty
Summary
The facility administrative staff failed to meet required minimum staffing levels for nurse aides (NAs) and licensed practical nurses (LPNs) over a 21-day review period. Specifically, there were multiple days when the number of NAs on duty did not meet the mandated ratios for day, evening, and overnight shifts. For the day shift, the facility did not provide at least one NA per 10 residents on five days. On the evening shift, the required one NA per 11 residents was not met on two days, and for the overnight shift, the one NA per 15 residents requirement was not met on ten days. These shortages were confirmed through a review of census data, nursing time schedules, and staff interviews, with no evidence of additional higher-level staff compensating for the deficiencies. Additionally, the facility did not meet the minimum LPN staffing requirements. On seven days, the day shift did not have at least one LPN per 25 residents, and on two days, the evening shift did not have one LPN per 35 residents. These findings were also confirmed by census data, time schedules, and staff interviews. The Nursing Home Administrator acknowledged the staffing shortages and confirmed that the required staffing levels were not maintained, with no compensatory measures in place.
Plan Of Correction
NHA will educate DON/Scheduler on minimum staffing hours/regulations on new staffing guidelines effective July 1, 2024. Facility has advertised for open CNA positions. Interviews will be conducted as applicants apply. Open interviews have been scheduled for every Thursday in January 2026, 10am to 2pm. Scheduler will meet daily with NHA/DON/Designee to review staffing schedule for a period of 2 weeks to ensure CNA ratios are being met. Scheduler will continue to monitor CNA ratios to ensure the facility has sufficient staffing. Results of these audits will be reviewed in the Quality Improvement Committee for recommendations as needed. NHA will educate DON/Scheduler on minimum staffing hours/regulations on new staffing guidelines effective July 1, 2024. Facility has advertised for open LPN positions. Interviews will be conducted as applicants apply. Open interviews have been scheduled for every Thursday in January 2026, 10am to 2pm. Scheduler will meet daily with NHA/DON/Designee to review staffing schedule for a period of 2 weeks to ensure LPN ratios are being met. Scheduler will continue to monitor LPN ratios to ensure the facility has sufficient staffing. Results of these audits will be reviewed in the Quality Improvement Committee for recommendations as needed.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
Facility administrative staff failed to provide the minimum required 3.2 hours of direct general nursing care per resident per day on 16 out of 21 days, as evidenced by a review of nursing time schedules and census data. On multiple dates, the provided nursing care per patient day (PPD) fell below the regulatory minimum, with values ranging from 2.77 to 3.18 hours for census counts between 153 and 165 residents. This deficiency was confirmed by the Nursing Home Administrator during an interview, acknowledging that the facility did not meet the mandated nursing care hours on the specified days. No specific information about individual residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
NHA will educate DON/Scheduler on minimum staffing hours/regulations on new staffing guidelines effective July 1, 2024. Facility has advertised for open nursing care positions. Interviews will be conducted as applicants apply. Open interviews have been scheduled for every Thursday in January 2026, 10 am to 2 pm. Scheduler will meet daily with NHA/DON/Designee to review staffing schedule for a period of 2 weeks to ensure the facility is providing the minimum general nursing hours to each resident. Scheduler will calculate HPPD throughout the day to ensure the facility has sufficient staff. Results of these audits will be reviewed in the Quality Improvement Committee for recommendations as needed.
Failure to Maintain Fire Alarm System in Accordance with NFPA Standards
Penalty
Summary
The facility failed to maintain its fire alarm system in accordance with NFPA 70 and NFPA 72 requirements. During an observation and interview, the fire alarm panel was found to display a "FAULT RSTRD" message, with both supervisory and system trouble indicator lights illuminated, indicating a malfunction of the system. The maintenance supervisor confirmed these deficiencies at the time of the survey. Subsequent document reviews and interviews during onsite revisit surveys revealed that the deficiencies with the fire alarm panel remained uncorrected over multiple visits. The facility had not completed the necessary inspection or repairs, as a vendor required payment in advance and funding had not been secured. Throughout this period, the facility continued to experience a malfunctioning fire alarm system.
Plan Of Correction
1. Absolute Fire Protection will be contacted to correct the system malfunction and restore the fire alarm panel to "normal" status by 1/30/2026. 2. The Environmental Services Director/designee will perform an audit to ensure that the fire alarm panel reads "normal" status; the audit will be conducted daily for four weeks, weekly for four weeks, and bi-weekly for five weeks. 3. The results of this audit will be reviewed at the facility's next two quarterly Quality Assurance Performance Improvement meetings to ensure compliance.
Failure to Maintain and Document Sprinkler System Inspections and Maintenance
Penalty
Summary
The facility failed to meet sprinkler system requirements for two of three systems, as evidenced by missing documentation for required quarterly inspections and overdue trip tests. Specifically, there was no documentation for the second and third quarter sprinkler inspections, the last full-flow trip test was completed over three years prior, and the last annual partial trip test was completed more than a year ago. Additionally, a quarterly inspection noted that the system compressor had parts on order, and the facility was unable to provide further documentation due to a payment hold with the sprinkler vendor. Interviews with facility staff confirmed the lack of required documentation at the time of the survey. Further deficiencies were observed, including multiple sprinkler heads covered in dust and corrosion in the corridor outside the maintenance office and in the mechanical room inside the laboratory. These conditions were confirmed by staff interviews. During subsequent revisit surveys, it was found that the deficiencies had not been corrected, as the facility was still awaiting vendor approval and funding to schedule the necessary inspections and repairs. As a result, the facility was maintaining a continuous fire watch.
Plan Of Correction
1. Absolute Fire Protection will be contacted to ensure that: a. The fourth quarter sprinkler inspection is completed. b. The three-year, full-flow trip test is completed by April 30th, once the partial trip test verifies that the dry valves are working correctly. c. The annual partial trip test is completed by the designated "substantial compliance" date of 1/30/2026. d. Any needed parts for the system compressor are ordered, received, and installed to ensure the system compressor is operational. 2. The Administrator will assist the Environmental Services Director in ensuring that Absolute Fire Protection is contacted for service and that payment will be secured for any and all necessary parts to ensure the system compressor is operational. 3. The results of these corrective actions will be reviewed at the facility's next two quarterly Quality Assurance Performance Improvement meetings to ensure compliance. K 0353
Failure to Maintain Operable Fire Alarm System Components
Penalty
Summary
The facility failed to maintain fire alarm system components in operable condition, as evidenced by a review of documentation and interviews. The fire alarm report identified several deficiencies, including failed load tests for Altronix BPS batteries in the first floor utility closet and electrical room, a non-functioning piezoelectric buzzer at the fire alarm control panel (FACP), and horn strobes on the fifth floor not being properly tied into the FACP soft key NAC disablements. Additionally, multiple pull stations throughout the building were missing the required 'in case of fire, call 911' signage, with approximately 23 signs absent. Further deficiencies included a smoke detector at the top of the center stairs that failed and was reported as a supervisory issue, and a heat detector in the hall by the boiler that failed and was incorrectly labeled on the FACP. During the exit interview, the administrator and maintenance directors confirmed that these fire alarm deficiencies had not yet been corrected, affecting the entire facility.
Plan Of Correction
EES was scheduled to be on site the week of January 12, 2026, to review and correct all identified fire alarm maintenance items, including panel notifications, documentation, and system reporting. A full inspection report will be retained in the Life Safety binder. The maintenance director will perform weekly audits for 4 weeks and then monthly audits for 2 months to ensure the facility fire alarm system components remain in operable conditions.
Blocked Portable Fire Extinguisher Identified
Penalty
Summary
A deficiency was identified when, during an observation, a portable fire extinguisher located next to room 425 was found to be blocked. This issue was noted on one of the six levels within the facility. The finding was confirmed during an exit interview with the Administrator, Regional, and local Maintenance Director. No additional details regarding residents, staff, or specific patient conditions were provided in the report.
Plan Of Correction
The facility immediately freed the fire extinguisher next to room 425 from blockage. The maintenance director will re-educate all staff on maintaining clear access to all fire extinguishers. The maintenance director or designated designee will perform weekly audits for 4 weeks and then monthly audits for 2 months to ensure the facility is maintaining clear access to all fire extinguishers. Date of completion: 2/16/2026
Failure to Address Fire Damper Deficiencies in HVAC System
Penalty
Summary
The facility failed to maintain required inspections and corrective actions for its Heating, Ventilating, and Air Conditioning (HVAC) equipment, specifically affecting fourteen fire and smoke dampers. During a document review, it was found that a previous fire damper inspection report listed multiple deficiencies, including dampers with no power to the motor, motors that did not actuate and required replacement, missing dampers, dampers located outside of fire walls, dampers that did not fall and required replacement, and missing duct access doors. Additionally, some walls did not extend to the deck or had missing sheetrock, further compromising the integrity of the fire protection system. These deficiencies were confirmed during an exit interview with the Administrator and Maintenance Directors, who acknowledged that the issues identified in the inspection report had not been addressed or corrected at the time of the survey. The lack of corrective action for these deficiencies resulted in the facility not meeting the required standards for HVAC system maintenance and fire safety as outlined by NFPA 101.
Plan Of Correction
NotSpecified The facility reached out to LLS and Reed Electric to correct all identified fire damper deficiencies. Repairs and reinspection are due to be completed the week of January 12th, 2026. Documentation will be retained for life safety review. The maintenance director or designated designee will perform weekly audits for 4 weeks and then monthly for 2 months to ensure fire damper compliance. Date of completion: 2/16/2026
Electrical Panel Blocked by Cart in Nurse Station Supply Closet
Penalty
Summary
During an observation on the second floor of the facility, it was found that an electrical panel located inside the nurse station supply closet was blocked by a large cart. This observation was made on December 22, 2025, at 12:25 p.m. The presence of the cart obstructed access to the electrical panel, which is a violation of NFPA 70 2011 Section 110.26, requiring electrical panels to be accessible. The deficiency was confirmed during an exit conference with the Administrator and Maintenance Director later that day. No information regarding residents or their medical conditions was provided in relation to this deficiency.
Plan Of Correction
The obstructing cart was removed immediately, freeing the 2nd floor electrical panel of blockage. The maintenance director will re-educate all staff on maintaining clear access to all electrical panels. The maintenance director or designated designee will perform weekly audits for 4 weeks and then monthly audits for 2 months to ensure the facility is maintaining clear access to all electrical panels. Date of completion: 2/16/2026
Improper Locking of Courtyard Exit Egress Door
Penalty
Summary
The facility failed to maintain proper exit egress on one of the courtyard exit doors. During an observation on the first floor, surveyors found that the exit gate door leading to the outside courtyard was secured with a combination padlock. This locking arrangement did not comply with NFPA 101 requirements for egress doors, which prohibit locks that require a tool or key from the egress side unless specific special locking arrangements are met. The deficiency was confirmed during an exit interview with the Administrator, Regional, and Local Maintenance Director, who acknowledged that the combination padlock was discovered during the survey. It was also noted that this was the second time within the same calendar year that the issue had been identified by surveyors.
Plan Of Correction
The combo pad lock on the exit gate door was immediately removed. The facility will replace this with a magnetic locking system. Plans for the magnetic locking system will be forwarded to Life Safety Plan Review for approval. The maintenance director will provide education to all staff on proper egress requirements and emergency access. The maintenance director or designated designee will perform weekly audits for 4 weeks and then monthly for 2 months on all egress doors to ensure ongoing compliance. Expected date of completion: 2/18/2026
Some of the Latest Corrective Actions taken by Facilities in Pennsylvania
Policy & Staff Education
- Updated the 1:1 supervision policy to require staff remain with assigned residents until relieved (K - F0689 - PA)
- Educated all staff on the revised 1:1 policy and prohibition on sharing door codes (K - F0689 - PA)
- Trained staff to initiate an immediate search whenever a door alarm sounds (K - F0689 - PA)
- Instructed staff to avoid using fire-alarm doors for routine exits to reduce alarm fatigue (K - F0689 - PA)
- Re-educated licensed nursing staff on the elopement policy and wander-guard system operation and documentation (J - F0689 - PA)
- Educated all staff on alert-bracelet procedures, stronger bands, and related care-plan requirements (J - F0689 - PA)
- Posted reminder signage instructing staff not to share door codes and to monitor exit-seeking residents (J - F0689 - PA)
Security Enhancements & Ongoing Monitoring
- Changed all door and elevator access codes to new combinations (K - F0689 - PA)
- Established quarterly elopement-risk assessments on admission and with significant events (K - F0689 - PA)
- Instituted monthly department-head meetings to review elopement incidents and trends (K - F0689 - PA)
- Changed front-door wander-guard codes and restricted code knowledge to administrative staff (J - F0689 - PA)
- Implemented shift-by-shift door security checks by the Maintenance Director or designee (J - F0689 - PA)
- Started routine elopement drills for staff preparedness (J - F0689 - PA)
- Added weekly transmitter battery-life and placement checks to the wander-guard audit tool (J - F0689 - PA)
- Initiated daily system function checks of the wander-guard alarm system (J - F0689 - PA)
- Created a monitoring log to verify correct alert-bracelet bands and policy compliance (J - F0689 - PA)
- Required receptionists to review the at-risk-resident binder at the start of each shift and document the review (J - F0689 - PA)
- Started weekly audits of alert bracelets, bands, logs, and related care plans with findings reported to QAPI (J - F0689 - PA)
Failure to Properly Disinfect Blood Glucose Meter Between Residents
Penalty
Summary
The facility failed to implement proper infection control procedures regarding the use and disinfection of a multi-use blood glucose meter (BGM) for four residents who required fingerstick blood glucose testing. Facility policy and the manufacturer's instructions required that blood glucose meters intended for reuse be cleaned and disinfected between resident uses with an EPA-registered disinfectant detergent or germicide wipe. However, observations revealed that an LPN used only 70% isopropyl alcohol wipes to clean the blood glucose meter before and after each use, rather than the required EPA-registered germicidal wipes. The medication cart used by the LPN did not contain the appropriate disinfectant wipes as specified by the manufacturer and facility policy. Clinical record reviews showed that the affected residents had diagnoses including diabetes mellitus, viral hepatitis C, and human immunodeficiency virus (HIV), all of which can be transmitted via bodily fluids. Orders for these residents required frequent blood glucose monitoring and insulin administration based on sliding scale protocols. The LPN confirmed that the same blood glucose meter was used for multiple residents, and that only alcohol wipes were used for cleaning between uses, contrary to both policy and manufacturer instructions. Interviews with facility staff, including the DON and Infection Preventionist, confirmed that the expectation was to use EPA-registered germicidal wipes for disinfecting blood glucose meters. The failure to follow these procedures was observed directly by surveyors and acknowledged by staff, resulting in the determination of Immediate Jeopardy due to the increased likelihood of transmitting bloodborne pathogens between residents.
Removal Plan
- LPN 1 was removed from schedule immediately and will not be returning to the facility.
- Director of central supplies ensured that each of the eight medication carts had the disinfecting agents that meet the requirements of the Environmental Protection Agency (EPA) registered cleaning products as noted in the manufacturer's instructions.
- All nurses will be educated on the Obtaining a Fingerstick Glucose Level, policy and procedure. In addition, they will be educated on the necessity of using the approved EPA registered germicidal wipe as required in the manufacturer's instructions and where to obtain them. Education provided by the DON/designee. No licensed nurse will be permitted to begin their shift until they have been educated on the proper use and disinfection of the glucometer.
- Newly hired licensed nurses will be educated at orientation on the Obtaining a Fingerstick Glucose Level, policy and procedure using the approved EPA registered germicidal wipe requirements as noted in the manufacturer's instructions. All agency licensed nurses will be educated before they begin their first shift in the facility.
- Central supply department received education regarding ensuring that the EPA germicidal wipes are in the carts.
- DON/designee will complete random glucometer cleaning and disinfecting observation audits daily for seven days plus weekly for four weeks and monthly for three months ensuring education has been effective.
- DON/designee will be monitoring steps of the action plan for continued compliance.
- Central supply/designee will monitor ensuring the EPA germicidal wipes are in the carts.
- Audits will be brought to QA&A for review and recommendations.
- QAPI committee will determine the need for further audits.
Failure to Provide Adequate Supervision and Elopement Prevention
Penalty
Summary
The facility failed to provide adequate supervision and monitoring to prevent the elopement of a resident who was identified as being at high risk for elopement. The resident, who had diagnoses including dementia, insomnia, wandering, restlessness, and agitation, was assessed as having memory impairment and was able to ambulate independently. The care plan and physician orders required 1:1 supervision and the use of a roam alert bracelet due to the resident's history and ongoing behaviors such as exit-seeking, attempting to use elevators, and previously eloping from another facility. Despite these interventions, there were multiple documented incidents where the resident was found attempting to access elevators, standing by exit points, and even obtaining and hiding door codes, yet the facility did not consistently implement or evaluate the recommended 1:1 supervision in a timely manner. On the day of the incident, the assigned 1:1 staff member left their post and was not replaced, leaving the resident unsupervised in violation of the care plan and physician's order. During this period without supervision, the resident was able to use a previously obtained door code to exit the facility through a stairwell door, as later confirmed by camera footage. The facility also failed to change the door codes after discovering the resident had obtained them, and did not provide required elopement prevention training to the staff assigned to the resident at the time of the incident. Additionally, the facility did not immediately initiate a search when the resident's alert bracelet alarmed, and there was no evidence that staff on the unit had received the necessary training as outlined in the facility's Immediate Jeopardy action plan. Further review revealed that 29 residents on the same unit were assessed as being at risk for elopement, yet there was no documentation that staff had received the required education on elopement prevention prior to their shifts. The facility's failure to provide adequate supervision, implement timely interventions, and ensure staff were properly trained directly resulted in the resident's unwitnessed elopement from the building, which was only discovered after the resident could not be located and was later found offsite by police.
Removal Plan
- Resident 2's room was changed to a secure unit.
- The facility changed all the door and elevator codes.
- The facility updated the 1:1 policy to include that staff is never to walk away from the assigned resident until another staff member takes their place.
- The facility educated all staff regarding the new 1:1 policy and not sharing door codes.
- The facility educated staff that a search should occur immediately if a door alarm is sounding.
- The facility instructed staff not to utilize fire alarm doors for everyday use to decrease alarm fatigue.
- The facility will continue to assess residents' risk of elopement upon admission, quarterly, and with events.
- The Nursing Home Administrator will update the pre-admission review of elopement risk to ensure the facility can safely manage a resident at risk of elopement.
- Monthly department head meetings will be held for the leadership team to discuss elopement events.
- Staff members observed to be giving out door and elevator codes to visitors or residents will receive disciplinary action.
Failure to Supervise Resident with Sexually Inappropriate Behaviors Creates Immediate Jeopardy
Penalty
Summary
The facility failed to provide necessary supervision for a resident with a known history of sexually inappropriate behaviors, resulting in an immediate jeopardy situation for multiple residents. The resident in question had severe cognitive impairment, a history of sexual offenses, and was identified as a registered sexual offender. Despite these known risks, the care plan interventions designed to monitor and manage the resident's behaviors were not implemented or documented as completed. Staff interviews and clinical record reviews revealed that the resident frequently wandered into other residents' rooms, engaged in inappropriate touching, and was not consistently monitored as required by the care plan. Multiple incidents were reported where the resident was observed engaging in sexually inappropriate behaviors with other residents, many of whom were cognitively impaired or physically unable to defend themselves. Staff and resident interviews indicated that these behaviors were ongoing and widely known among staff, yet there was a lack of formal reporting and documentation. Staff described instances of the resident touching, kissing, and following female residents, with some staff expressing discomfort and concern over the lack of action taken by facility management. In several cases, staff reported being discouraged from filing incident reports or were told by management that such behaviors were permissible among older adults. The facility's failure to follow its own policies for behavior management and resident supervision, as well as the lack of consistent documentation and reporting, allowed the resident's inappropriate behaviors to continue unchecked. This resulted in direct harm and distress to at least five residents, including incidents where residents were found in vulnerable positions and unable to recall or defend against the inappropriate actions. The deficiency was further compounded by the lack of timely intervention, inadequate monitoring, and insufficient staff education on handling residents with sexually aggressive behaviors.
Removal Plan
- Resident R1 is placed on 1:1 supervision and continues to remain on 1:1 supervision.
- Resident R1 care plan will be updated to individualized interventions regarding supervision based on his sex offender status.
- Resident R1 behavior is monitored by the 1:1 supervisor.
- Facility will identify and address any allegations of inappropriate touching/behaviors via facility policy and investigative process.
- Follow-up and follow-through of interventions will be monitored by the Director of Nursing and Nursing Home Administrator.
- Any affected residents identified, reporting will be completed, notifications will be made, and support will be offered to residents and family.
- Staff and consultants' failure to report any allegations timely will be addressed through the disciplinary process up to and including termination of employment or contracted services.
- An audit on all female residents will be completed by the Director of Nursing, or designee, to identify any documented inappropriate touching or sexually inappropriate behaviors.
- If any are found, facility policy and protocol of investigation, notification, and reporting will be followed.
- Current female residents who are cognitively intact are being interviewed five days per week.
- Current female residents who are cognitively impaired are having a complete skin assessment five days per week.
- With resident remaining on 1:1 supervision, female residents are being kept safe from Resident R1 inappropriate touching/sexual behaviors.
- Education was completed with all staff on Abuse/Neglect, Reporting of Incident and Accidents, and providing direct supervision with Resident R1 by the Director of Nursing.
- Education of all new hires will include supervision of handling residents with history of sexual aggression and behaviors. This will be updated into the new hire packet.
- Mandatory education will be sent to all staff to inform staff of updates to Resident R1 care plan interventions to successfully redirect sexual aggression and behaviors.
- Resident R1 will remain on 1:1.
- Resident R1 is being followed by facility contracted psychiatric provider in conjunction with the facility medical director.
- Referrals are being made to alternate care facilities that can better meet Resident R1's needs.
- While Resident R1 remains in the facility, audits will be completed on female residents who are cognitively intact daily for two weeks, weekly for two weeks and then monthly for two months to ensure residents safety.
- While Resident R1 remains in the facility, audits will be completed on female residents who are cognitively impaired daily for two weeks, weekly for two weeks and then monthly for two months to ensure residents safety.
- An Ad Hoc Quality Assurance and Process Improvement Meeting was held by the Administrator or designee to address supervision of handling residents with sexual aggression and behaviors, including adding of this education to new hire orientation.
- This plan of correction will be monitored through facility Quality Assurance and Process Improvement meeting until such time consistent substantial compliance has been met.
Failure to Document and Administer Crushed Medications Results in Significant Medication Error
Penalty
Summary
The facility failed to accurately document and follow physician orders regarding the administration of crushed medications for a significant number of residents. Specifically, 29 out of 33 residents who required their medications to be crushed did not have this need properly documented in their care plans or physician orders. This lack of documentation and communication led to staff uncertainty about which residents required crushed medications, as confirmed by interviews with staff members who assumed others would know or relied on incomplete information. One resident with a diagnosis of dementia, chronic obstructive pulmonary disease (COPD), and dysphagia had a physician's order for medications to be given crushed in pudding or applesauce. However, the resident's care plan did not include specific interventions for dysphagia or the need for crushed medications. On the day of the incident, the resident requested to take medications whole, and an LPN provided the medications uncrushed, contrary to the physician's order. Shortly after, the resident began coughing, experienced respiratory distress, and ultimately became unresponsive. Staff attempted various emergency interventions, including the Heimlich maneuver, suctioning, and oxygen administration, but were delayed in providing high-flow oxygen due to the unavailability of an oxygen key. A finger sweep revealed whole pills in the resident's mouth/throat, and the resident was pronounced deceased after these efforts were unsuccessful. Interviews with staff confirmed that the need for crushed medications was not consistently communicated or documented, and that staff were not always aware of the correct medication administration method for each resident. The facility's failure to ensure accurate documentation and adherence to physician orders for medication administration resulted in a significant medication error and an immediate jeopardy situation for one resident, with widespread deficiencies identified for many others.
Removal Plan
- Facility had speech therapist complete a whole house audit to validate medication delivery method (crushed vs whole). All discrepancies were immediately addressed.
- An order will be obtained by physician for all current residents requiring crushed meds and all care plans will be updated to reflect the orders.
- Education will be provided to all licensed staff on proper medication administration, following physician orders and the steps to take for resident refusals.
- For agency staff a binder will be created containing the education on proper medication administration, following physician orders and the steps to take for resident refusals. Agency staff will be educated prior to the start of their shift.
- LPN identified with deficient practice will receive 1:1 education and disciplinary process will be followed.
- Director of Nursing, or designee, will audit 10 residents a day, 5 days a week for 4 weeks. The audit is to validate the nurse followed physician orders for medication administration.
- An ad hoc QAPI will be held to discuss deficient practice and immediate Plan of Correction with the Interdisciplinary Team.
Failure to Prevent Elopement Due to Inadequate Supervision and Lapses in Elopement Protocol
Penalty
Summary
The facility failed to provide adequate supervision and accident hazard prevention for two residents identified as high risk for wandering, resulting in both residents eloping from the facility. For one resident with diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, the initial admission assessment identified a high risk for wandering, but there was no documented evidence that elopement or wandering interventions were developed or implemented after this determination. The resident was able to exit the building unsupervised, with staff only becoming aware after being notified by the resident's family. Staff interviews and witness statements confirmed that the resident was found outside the facility, and it was later discovered that a wander guard device had not been placed on the resident at admission, despite the high-risk assessment. Another resident, with diagnoses of high blood pressure, anxiety, and depression, also demonstrated exit-seeking behavior and was identified as an elopement risk. The care plan included interventions such as issuing a wandering device and frequent monitoring, but the resident was able to leave the building and was found outside in the parking lot by staff. Documentation revealed that the resident had previously cut off a wander guard device, and at the time of the elopement, the device was not found on the resident. Staff statements indicated confusion about the monitoring of the front entrance, and the door was found to be unlocked and unattended at the time of the incident. The facility's failure to implement and maintain effective elopement prevention measures, including the timely application of electronic monitoring devices and adequate supervision, directly resulted in both residents leaving the premises without staff knowledge. The lack of consistent communication, incomplete documentation, and lapses in monitoring procedures contributed to the residents' ability to elope, creating an immediate jeopardy situation as determined by the surveyors.
Removal Plan
- The facility Administrator, and or designee, will review current elopement policy for accuracy and update as needed.
- All residents will be evaluated for risk of elopement by the facility Director of Nursing, or designee.
- Any new identified residents as at risk of elopement will receive orders from physician for use of wanderguard bracelet and care plan will be updated accordingly by facility Director of Nursing, or designee.
- An audit of all residents identified as at risk for elopement will have their care plan reviewed to ensure resident centered interventions are in place, completed by facility Director of Nursing, or designee.
- All staff, both facility and agency, will be educated by the facility Director of Nursing, or designee, regarding elopement policy, identifying residents at risk, and implementing interventions.
- The facility Administrator and Director of Nursing will complete a root cause analysis as to what system failed allowing this elopement to occur.
- Facility Administrator and Director of Nursing will review the procedure on the front door monitoring, this to include functionality of wanderguard system, as well as the schedule of personnel monitoring front entrance.
- The front door wanderguard codes have been changed and code knowledge limited to administrative staff.
- Facility door will be secured and code use will be required for entry or exit. Compliance will be monitored through audits.
- Audits will consist of door security assessment by facility Administrator, or designee, audit of resident risk assessments will be completed by the facility Director of Nursing, or designee, and an audit of all resident care plans who were identified at risk of elopement will be completed by the Director of Nursing, or designee.
- Results will be reviewed at QAPI (Quality Assurance and Performance Improvement Committee) to be completed by NHA.
Failure to Timely Report and Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to identify and timely report criminal allegations of abuse and neglect involving an LPN to local law enforcement and required agencies. Multiple staff members, including housekeepers and nurse aides, reported concerns that the LPN was administering medications such as melatonin and Tylenol to residents without proper orders, resulting in residents appearing sedated, lethargic, and unable to eat or remain awake during the day. Staff also noted an increase in resident deaths on the memory impaired unit during shifts when the LPN was working. These concerns were documented in witness statements and interviews, with specific observations of residents' abnormal behavior and changes in condition, such as hypothermia and excessive sleepiness. Despite these serious allegations and observations, the facility did not promptly initiate an investigation or report the incidents to the Area Agency on Aging, the Department of Health, or local law enforcement as required by state law and facility policy. The Director of Nursing and Nursing Home Administrator were made aware of the allegations but delayed reporting for ten days, only notifying authorities after being prompted during the survey process. The DON dismissed the initial reports as hearsay and gossip, contributing to the delay in addressing the allegations. The failure to act on staff reports and to follow mandated reporting procedures resulted in an immediate jeopardy situation, as the facility did not ensure the protection of residents from potential abuse or neglect. The deficiency was identified through review of facility documentation, staff interviews, and examination of resident records, which confirmed that the facility did not comply with legal and policy requirements for timely reporting and investigation of suspected abuse and neglect.
Removal Plan
- Review current residents' medical records for signs of abuse/neglect by the DON and/or designee. Interview all interviewable residents for any signs and/or symptoms of abuse and/or neglect. If any allegations of abuse/neglect are found, follow abuse policy, and begin investigation and reporting immediately.
- Interview staff for review of abuse/neglect allegations that have not been reported to the DON and/or designee. If any allegations are identified, begin investigation and reporting immediately.
- Update review of Electronic event report for neglect allegation by the DON/designee to accurately reflect concern for Nurse giving Tylenol and Melatonin to all residents on the memory unit whether there is an order or not thus causing potential harm.
- Review Abuse/Neglect Policy, Incidents and Accidents Policy, and reporting criteria by NHA and/or designee and update if needed.
- Educate all house staff and agency staff on the abuse/neglect policy and reporting abuse by the DON and/or designee prior to their next shift worked.
- Audit all residents who have had an allegation of abuse/neglect in the last 30 days by the DON and/or designee to ensure that it was reported appropriately and timely.
- Review all audits and policy changes related to IJ 609 at an Ad hoc Quality meeting.
Failure to Supervise and Protect Resident with Suicidal Ideation
Penalty
Summary
The facility failed to keep a resident with known suicidal ideation and a history of suicide attempt free from hazards and did not provide the necessary monitoring and supervision as required by facility policy and physician orders. The resident, who had diagnoses of depression and adjustment disorder, was found on multiple occasions with a cord wrapped around their neck and expressing suicidal ideation. Despite these incidents, there was no evidence that the required 1:1 supervision or every 15-minute checks were implemented or documented as ordered by the physician and outlined in facility policy. Facility policy required that any suicide threats be taken seriously, with immediate reporting to the nurse supervisor or charge nurse, and that a staff member remain with the resident until further assessment. The policy also required removal or securing of items that could be used for self-harm, such as cords and plastic liners. However, observations revealed that cords in the resident's room, including bed control cords, call bell cords, and telephone cords, were not secured and remained accessible. Additionally, the resident's roommate also had unsecured cords in the shared room. Interviews with staff confirmed that after the resident was found with a cord around their neck and expressing suicidal ideation, appropriate assessments and monitoring were not performed. Staff were unclear about documentation procedures and did not consistently implement or record the required supervision. The DON and NHA acknowledged the lack of evidence for required monitoring and supervision, and staff interviews further confirmed that facility policies were not followed in response to the resident's suicidal behavior.
Removal Plan
- Resident R96 will be provided with a safe environment by securing bed control cord, call bell cord, and telephone cord so cords are not accessible to resident to harm self. Roommate's cords have also been secured. The room has also been checked for any other hazardous items to ensure a safe environment.
- Physician orders for monitoring resident BP will be completed by nursing staff every 15 minutes to ensure resident safety.
- Residents will be evaluated by psychiatric services for safety.
- Care plan will be reviewed and updated.
- The Director of Nursing or designee will complete a house audit of all residents for suicidal ideations. A resident questionnaire on suicidal ideation will be used for all residents with a BIMS of 9 or above. Residents with a BIMS of 8 or below, a resident skin check and review of risk management to determine resident's safety.
- Care plans will be updated to reflect the residents' current condition by Licensed Practical Nurse Assessment Coordinator (LNAC) or designee.
- A house audit of environment will be completed by Environmental Services Supervisor or designee to validate no hazards are identified for residents with suicidal ideations.
- The NHA, DON and Regional Clinical Consultant will review and update the facility policy and procedures for Suicidal Threats and Supervision of Residents with suicidal ideations.
- All staff will be re-educated on the facility policy and procedures for Suicidal Threats, Care Plans and Supervision of residents identified with suicidal ideations.
- All incidents and accidents will be reviewed and results reported to the Quality Assurance and Process Improvement Committee for review and frequency of audits.
Failure to Prevent Elopement and Ensure Adequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and implement safety interventions to prevent elopement for a resident with severe cognitive impairment and a history of wandering and exit-seeking behaviors. The resident, who had diagnoses including vascular dementia and required assistance with activities of daily living, was identified as being at risk for elopement and had a care plan in place that included the use of a wander guard bracelet and regular checks. Despite these interventions, the resident was able to exit the building unsupervised and was later found outside by a staff member. Multiple door alarms were activated during the evening of the incident, but staff responses were inconsistent and ineffective. Staff were unable to interpret alarm panels due to the lack of posted zone identifiers, and alarms were repeatedly silenced without confirming the safety of all residents. No immediate headcount or licensed nurse assessment was completed, and the facility's Code Green procedure was not initiated. Communication among staff was poor, with conflicting accounts of the event and a lack of clarity regarding which resident was missing and which door had been used for the exit. The incident was not reported to administration or investigated until approximately 30 hours after it occurred. During this time, no new interventions were implemented to ensure the safety of other residents at risk for elopement. The facility's failure to respond effectively to multiple alarms, identify the missing resident in a timely manner, and follow established elopement protocols resulted in a breakdown of supervision and safety systems for residents identified as being at risk for elopement.
Removal Plan
- Complete a skin assessment on the resident.
- Ensure the resident's wander-guard bracelet is intact and functional.
- Initiate fifteen-minute safety checks.
- Update the resident's care plan to reflect current interventions.
- Review and revise the facility's elopement policy and door alarm protocol.
- Educate all staff on elopement prevention, wandering, resident safety, and identification of alarm zones.
- Check all wander-guard door boxes and door alarms for proper functioning.
- Check all residents with wander-guard bracelets for proper device placement and functionality.
- Complete audits to ensure no other residents are affected by alarm or supervision concerns.
- Complete new elopement risk assessments for all residents.
- Review and update elopement binders and resident care plans.
- Initiate door checks on each shift to be completed by the Maintenance Director or designee.
- Conduct elopement drills by the Maintenance Director or designee.
- Review results of education, audits, and drills at the next QAPI meeting for continued monitoring.
Failure to Prevent Elopement Due to Inadequate Supervision and Non-Functioning Wander Guard
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision and interventions to prevent elopement for a resident identified as being at risk. Facility policies required that an elopement risk observation be completed by a licensed nurse upon admission, re-admission, or significant change in status, and that interventions such as a Wander Guard device be implemented as needed. For one resident with dementia and a history of wandering, the care plan and physician orders specified the use of a Wander Guard, with function and placement to be checked every shift. However, documentation and interviews revealed that the resident was able to leave the facility unsupervised, and the Wander Guard system did not alarm as intended. On the day of the incident, the resident accessed the elevator, exited the building, and was later returned by EMS. Staff failed to recognize the event as an elopement, did not notify administrative staff until the following day, and did not perform a physical assessment or notify the resident's family upon return. The Wander Guard device was found to have a low battery, and system reports confirmed that the device's battery status had been low on the day of the elopement. Despite this, staff had charted that the Wander Guard was functioning for all shifts, and no immediate action was taken to check or replace the device after the resident was returned. Interviews with nursing staff and the administrator confirmed that the alarm system was not functioning properly prior to the elopement and that staff did not follow policy in responding to the incident. The administrator acknowledged that the Wander Guard should have been checked and replaced after the resident's return, and that no new interventions were implemented until the following day. The failure to ensure the proper functioning of the Wander Guard system and to respond appropriately to the elopement placed the resident in immediate jeopardy.
Removal Plan
- Resident 3's wander guard transmitter was replaced with a new transmitter and checked for function.
- A facility wide sweep was conducted on all in house wander guard transmitters to ensure proper function and battery life.
- Any transmitters with a low battery life or improper function were replaced.
- Disciplinary action was enforced with the staff member who failed to respond to the incident in a timely and appropriate manner.
- All licensed nursing staff were re-educated on the elopement policy and procedure.
- All licensed nursing staff were also re-educated on the wander guard system function and documentation.
- All new staff and agency staff will receive the education.
- The Director of Nursing or designee added checking the transmitter battery life to the weekly audit tool and the weekly audit tool would include wander guard placement and battery status.
- Any transmitters with a low battery status would be replaced at the time of discovery.
- The wander guard system check was completed daily and will continue to be checked for function daily.
- System check audits would be completed by the Building Services Director or designee daily for three months and transmitter audits would be completed weekly for four months, and then monthly for three months.
- Upon admission, all residents would receive an elopement assessment and the assessments would determine interventions as needed.
- Updates would be added to the resident care plan and discussed with the interdisciplinary team.
- Audit results would be reported to the Quality Assurance Performance Improvement committee to identify trends, further opportunities for quality improvement, and needs for additional education/re-education.
Failure to Notify Provider and Assess Capacity During AMA Discharge
Penalty
Summary
The facility failed to ensure timely notification of a provider when a resident left the facility against medical advice (AMA), and did not confirm the resident's capacity to make such a decision. The facility's policy required prompt notification of the resident's physician or provider if a resident or representative requested discharge AMA. However, documentation showed that the provider was not notified until two days after the resident had left the facility. There was also no evidence that a capacity evaluation was performed prior to the resident's discharge, despite the resident having a history of altered mental status, cognitive deficits, and a recent stroke. The resident in question had multiple diagnoses, including problems related to living alone, altered mental status, muscle weakness, cognitive communication deficit, metabolic encephalopathy, and a below-the-knee amputation. The care plan indicated performance deficits in activities of daily living, limited mobility, impaired cognitive function, and short-term memory loss. The resident's physician had documented that decision-making capacity needed to be re-evaluated before discharge, as the resident seemed unable to understand the potential problems after leaving the facility, such as not having a home or transportation. Despite this, there was no documentation of a capacity assessment being completed, and staff allowed the resident to sign out AMA without confirming capacity or ensuring a safe discharge plan. Staff interviews confirmed that no capacity evaluation was performed, and the provider was not notified at the time of discharge. The resident left the facility in a wheelchair, without medications, a confirmed destination, or social support. Facility documentation showed that the AMA discharge form was signed by the resident and nursing supervisors, but there was no evidence of timely provider notification or interventions to ensure the resident's safety. This series of actions and omissions resulted in an Immediate Jeopardy situation.
Removal Plan
- The facility policy, Discharging a Resident Without a Physician's Approval, was updated and compliance with the updated policy will be implemented. The updates included that when a resident desires to leave AMA, staff will reference the resident's capacity in the medical record for consideration with management of the discharge and any AMA discharge will now require an incident report that will prompt staff to contact the provider.
- Physicians will be notified of AMA discharges immediately. The incident reports are audited by the risk management nurse. Compliance with the policy will be audited through High Risk Event and Quality Assurance and Performance Improvement (QAPI) meetings.
- Nursing staff onsite were re-educated on the updated policy, and notification to the Pennsylvania Department of Health and the local Area Agency on Aging at the time of an AMA discharge. The remainder of nursing staff will be educated.
- A new physician's order set was implemented to clearly communicate to the interdisciplinary team when a resident lacks capacity, has capacity, or if capacity is to be determined. Resident capacity will be documented with the order set. Nursing supervisors will audit new admissions for implementation of the order set.
- The interdisciplinary team will be educated on the new order set, and to document resident capacity based only on physician documentation. Compliance will be reviewed at QAPI meetings.
Failure to Prevent Elopement Due to Inadequate Supervision and Policy Noncompliance
Penalty
Summary
The facility failed to provide adequate supervision and monitoring to prevent an elopement for a resident identified as being at risk. The resident, who had diagnoses including vascular dementia, syncope, and cerebral infarction, was independently ambulatory and had documented memory impairment. Despite being assessed as a wanderer at risk for elopement, the resident was able to repeatedly remove his alert bracelet, which was intended to prevent unauthorized exits. Facility policy required that residents capable of removing their alert bracelets be issued a stronger, tamper-resistant band and, if still able to remove it, be placed on one-to-one observation. However, after the resident removed his alert bracelet on multiple occasions, there was no documented evidence that a stronger band was provided or that one-to-one observation was implemented as required by policy. Additionally, there was no documentation that the resident's care plan was updated to include interventions addressing his elopement risk, wandering behavior, or alert bracelet use. On one occasion, the resident was found off the unit and returned, but later the same day, he was able to leave the facility undetected and was found by police walking along a road a mile away. Staff interviews confirmed the lack of appropriate interventions and care plan updates, and the failure to follow facility policy led to an Immediate Jeopardy situation.
Removal Plan
- Resident 1's room was changed to a secure unit, and a new alert bracelet was placed on the resident. The resident's care plan was updated to include risk for elopement. Resident 1 was placed on 1:1 observation.
- The facility conducted an immediate audit of all residents with alert bracelets to ensure they were intact and with the appropriate band.
- The facility conducted an audit to ensure all residents with an alert bracelet had an appropriate care plan in place.
- The facility created a log to monitor each alert bracelet and band to ensure the correct band is in place, and that the policy regarding stronger bands is being followed.
- The receptionists will review the binder of at risk residents at the start of their shifts for changes and initial a log.
- The facility will update the template for 1:1 orders in the electronic health record.
- The facility educated all staff in the facility on the facility's procedure for alert bracelets, stronger bands, and resident care plans. All staff that were available were immediately educated. Other staff will be re-educated prior to the start of their next shift.
- Weekly audits of alert bracelets, bands, logs, and care plans will be completed and the results discussed at QAPI (Quality assurance, performance improvement) committee.
- Signs are posted with instructions to not share door codes and to be aware of residents who may try to exit.
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