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 CHF and chronic kidney disease was on a physician-ordered 1500 ml/day fluid restriction divided between dietary and nursing, with care plan interventions to offer fluids within restriction parameters. Facility policy assigned nursing responsibility for tracking total fluid intake but lacked guidance on actions when restrictions were exceeded. Over several months, MAR review showed the resident repeatedly exceeded the nursing fluid allotment, yet there was no documentation that the physician was notified. The record also lacked documentation of fluids taken with meals, so total 24-hour intake was never determined. The DON confirmed that dietary fluid intake was not recorded, that the resident exceeded allotted nursing fluids on multiple occasions, and that staff did not total all fluids over each 24-hour period.
Surveyors found that medications on two medication carts were not labeled or discarded according to facility policy. On one cart, an RN had an opened single-dose haloperidol vial stored loose with insulin pens, without any resident name or date. On another cart, an LPN had a lispro insulin pen for a resident that was kept beyond the 28-day discard period and a Lantus insulin pen for another resident that was opened but not dated, despite the facility’s requirement to date insulin when first used and discard lispro after 28 days. The DON later confirmed that medications were expected to be labeled, stored, and discarded per policy and manufacturer guidelines.
The facility did not follow its diet extension sheets and approved menus for residents on regular diets, affecting all residents reviewed on this diet. The diet manual required that regular diets provide adequate nutrients through three balanced meals and up to three snacks daily. However, during a lunch meal service, residents on regular diets were served rotini pasta salad using a 3‑oz scoop instead of the 1/2 cup (4 oz) portion specified on the diet extension sheets. In an interview, the NHA acknowledged that meals were expected to be prepared and served according to menus approved by the dietician and physician, but the observed portions did not match those requirements.
Staff failed to follow infection prevention and control policies during wound care, medication storage, and medication administration. A resident with a stage 4 pressure ulcer and MDRO risk had an order and care plan for Enhanced Barrier Precautions, including gown and glove use for wound care, but an RN performed a dressing change without wearing a gown. An LPN stored a personal jacket in a medication cart drawer with medications and, during medication administration for another resident, placed an inhaler and antibiotic eye drops directly on the overbed table without a clean barrier, did not wear gloves to administer the eye drops, and did not wear gloves when applying a lidocaine patch, then returned the medication boxes to the cart drawer.
A resident with GERD and peripheral vascular disease was observed in bed with eight medications left on the overbed table, which the resident stated an LPN had left for self-administration after breakfast. Facility medication administration policy lacked a requirement for staff to remain with residents and observe medication ingestion. Review of the clinical record showed no MD order, care plan, or evaluation authorizing self-administration of medications for this resident, and the administrator confirmed medications should not have been left at the bedside.
A resident with dementia and HTN had an order for daily losartan with instructions to hold the dose for low BP, but nursing staff did not consistently document BP readings with each administration and only a few BP entries coincided with dosing. On several occasions the medication was held for a low pulse, which was not part of the MD’s hold parameters, and on one occasion it was held for a low BP that did meet the ordered criteria. The DON acknowledged she could not verify that BPs were consistently taken before giving the medication and confirmed that BP values should have been documented with each dose to show compliance with the ordered parameters.
Surveyors identified multiple failures to follow facility food safety policies, including undated bulk dressings and bread products, inadequately covered vegetables in the walk-in cooler, dirty equipment and surfaces, and cups and plates stored upright and uncovered. A cook handled carrots from a bulk container without gloves while manipulating the plastic liner, and the kitchen lacked written cleaning protocols or logs. In two kitchenettes and a rehab unit refrigerator, surveyors found spills, food debris, toaster crumb buildup, unlabeled and undated personal food items, missing or broken thermometers, and plates and dome lids stored upright and uncovered. Review of temperature logs showed staff did not consistently check cold food and beverage temperatures at point of service, despite policies requiring cold foods to be maintained at or below 41°F and all refrigerated foods to be covered, labeled, dated, and monitored.
A deficiency was cited when staff failed to implement infection control policies for a resident with a stage 3 sacral pressure ulcer and diabetes. Facility policy required enhanced barrier precautions for residents with wounds under specified conditions, yet there was no door signage indicating the need for PPE, no physician order for enhanced barrier precautions, and no related care plan. A wound consult documented an open, healing stage 3 sacral ulcer, but the DON reported she believed the ulcer had closed and that enhanced barrier precautions were no longer necessary.
The facility’s antibiotic stewardship program allowed interrupted antibiotic therapy for a resident with a confirmed Proteus mirabilis UTI. Policy required using C&S results and clinical status to determine whether to start, continue, modify, or discontinue antibiotics, and cited guidance indicated that lapsed or missed doses early in treatment reduce efficacy and that complicated UTIs should be treated with ciprofloxacin 500 mg BID for 7 days. Instead, the provider ordered ciprofloxacin 250 mg BID for 3 days, which was stopped after a RN reported no UTI symptoms, consistent with the ICP’s description that this provider typically uses 3‑day courses with RN reassessment and discontinuation if asymptomatic. Days later, the resident was found to have suprapubic tenderness and was started on a new 7‑day course of ciprofloxacin 500 mg BID for a complicated UTI, demonstrating that the program permitted lapsed antibiotic dosing.
Surveyors found that the facility failed to follow its own policy for medication storage and beyond-use dating. In a medication room, an open multidose tuberculin vial lacked an open date, expired needles remained in stock, and an open vial of insulin lispro had not been discarded per dating requirements. On a medication cart, an open bottle of LiquaCel and an open Lantus insulin pen were also missing open date labels. Staff, including the NHA and DON, confirmed that these items should be dated when opened and expired medications and supplies should be discarded.
Failure to Monitor and Document Fluid Intake for Resident on Fluid Restriction
Penalty
Summary
The facility failed to adequately monitor and manage fluid intake for a resident on a physician-ordered fluid restriction, resulting in a failure to ensure proper hydration and adherence to the ordered restriction. Facility policy titled "Fluid Restriction" assigned nursing services responsibility for tracking and documenting total volume consumed, but the policy did not provide guidance on what measures staff should take if a resident exceeded ordered fluid restrictions. The resident had diagnoses including acute on chronic diastolic congestive heart failure and hypertensive heart and chronic kidney disease with heart failure, and had an order for a regular/liberalized diet with a 1500 cc fluid restriction, divided as 800 cc from dietary and 700 cc from nursing. The resident’s care plan identified risk for dehydration and nutritional risk, with interventions such as offering small amounts of fluids frequently and enforcing the 1500 ml fluid restriction, but the nurse aide Kardex only noted that the resident was on fluid restrictions without further directions. The dietary tray ticket indicated a 1500 ml per day restriction and a maximum of 240 ml per meal. Review of Medication Administration Records from August through mid-March showed that the resident exceeded the allotted nursing fluid portion on multiple dates across several months. Despite these repeated exceedances, the clinical record contained no documentation that the physician was notified when the resident went over the ordered nursing fluid allowance. Additionally, there was no documentation of fluids consumed from meal trays during this period, so the resident’s total 24-hour fluid intake was not determined. In an interview, the DON confirmed there was no documentation of dietary fluid intake with meals, that nurse aides verbally reported fluids to nurses, that the resident did exceed allotted nursing fluids on some occasions, and that there was no documentation showing all fluids were totaled for each 24-hour period, despite the expectation that staff follow fluid restriction orders and notify the physician when they are exceeded.
Improper Labeling and Expired Insulin and Haloperidol on Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to properly label and discard medications in accordance with its own policies and accepted professional standards. Review of the facility’s “Storage of Medication” policy dated January 2025 and its appendix “Medications with Shortened Expiration Dates” (2007) showed that medications and biologicals must be stored to maintain integrity, insulin vials and pens must be dated when first used, and lispro insulin must be discarded 28 days after opening. During observation of the South Wing B Hall medication cart with a registered nurse, surveyors found an opened 1 ml single-dose vial of haloperidol lying loose in a plastic bin with insulin pens, without a resident name or date on the vial. The nurse confirmed the vial was not labeled or dated and acknowledged it should have been discarded after single use. On the South Wing C Hall medication cart, observed with an LPN, surveyors identified a lispro insulin pen for Resident 74 dated as opened on February 16, 2026, which exceeded the 28-day discard timeframe specified in the facility’s policy. They also found a Lantus insulin pen for Resident 5 that had been opened but was not dated, although the pharmacy label showed it had been dispensed on March 13, 2026. The LPN confirmed that Resident 74’s insulin pen was beyond the 28-day expiration and should have been discarded, and acknowledged that the Lantus pen should have been dated when opened and that she may have been the nurse who opened it without dating it. In a subsequent interview, the DON stated she expected medications to be labeled and stored properly and discarded when expired per policy or manufacturer guidelines.
Failure to Follow Diet Extension Sheets for Regular Diet Menus
Penalty
Summary
The facility failed to follow its diet extension sheets and approved menus to meet the nutritional needs and preferences of residents on regular diets for all 79 residents reviewed. The facility’s diet and nutrition care manual, reviewed February 16, 2026, specified that the regular diet should provide adequate nutrients as recommended by the Dietary Guidelines and National Research Council, using these guidelines to provide three balanced meals and up to three snacks daily. During observation of a lunch meal service on March 17, 2026, residents on regular diets were served rotini pasta salad using a 3‑ounce scoop. Review of the diet extension sheets for that lunch meal showed that residents on regular diets were to receive 1/2 cup (4 ounces) of rotini pasta salad, indicating that the served portion did not match the diet extension sheet. In an interview, the Nursing Home Administrator stated that she would expect resident meals to be prepared and served in accordance with menus approved by the dietician and physician, confirming that the observed practice did not align with facility expectations and written guidance.
Failure to Follow Infection Control and Medication Handling Policies
Penalty
Summary
The deficiency involves failure to implement infection prevention and control policies, including Enhanced Barrier Precautions and medication administration protocols. Resident 92 had a stage 4 pressure ulcer of the right buttock and dementia, with physician orders for enhanced barrier infection precautions and a care plan identifying risk for MDRO colonization/infection due to chronic wounds. The care plan required use of gown and gloves for high-contact activities, including wound care. During an observed dressing change to Resident 92’s sacral pressure ulcer, a registered nurse completed the ordered wound care without wearing a gown at any time, contrary to the resident’s care plan and the facility’s Enhanced Barrier Precautions policy. The Nursing Home Administrator later stated she would expect employees to use appropriate personal protective equipment. Additional deficiencies were identified related to infection control and medication handling on the South Wing C Hall medication cart and during medication administration. An LPN stored a personal jacket in the bottom drawer of the medication cart along with medications and acknowledged that the jacket should not be in the cart; the DON confirmed staff personal items should not be stored in medication carts. In a separate observation of medication administration for another resident, the same LPN placed the resident’s inhaler and antibiotic eye drops, in their boxes, directly on the overbed table without a clean barrier, did not apply gloves before administering antibiotic eye drops, and did not wear gloves when applying a lidocaine patch. After administration, the LPN returned the inhaler and eye drop boxes to the medication cart drawer. The LPN acknowledged she should have used a clean barrier and worn gloves, and the DON confirmed that gloves and a clean barrier were required by facility policy.
Medications Left at Bedside Without Orders or Evaluation for Self-Administration
Penalty
Summary
The facility failed to ensure that medications were administered in accordance with professional standards of practice for one resident. Facility policy on Medication Administration, General Guidelines, dated January 2025, did not contain any expectation that employees administering medications must remain with the resident and observe ingestion. Review of the Pennsylvania Nursing Practice Act, Chapter 21.145, indicated that an LPN administers medications and carries out therapeutic treatments as ordered by an authorized practitioner. For the identified resident, clinical record review showed diagnoses of GERD without esophagitis and peripheral vascular disease. On observation, the resident was seen sitting in bed with eight pills left on the overbed table, including aspirin 81 mg, bupropion ER 150 mg, bupropion ER 300 mg, calcitriol 0.5 mcg, two tablets of vitamin B12 500 mcg, metoprolol 50 mg, and senna 8.5 mg. The resident reported that an LPN had left the medications there for her to take after she finished breakfast. Review of the physician’s orders did not show any order for self-administration of medications, and the care plan did not include a self-administration of medication plan. The clinical record also lacked any evaluation of the resident for self-administration of medications. The Nursing Home Administrator confirmed that the resident should not have had medications left at the bedside.
Failure to Follow Antihypertensive Medication Parameters and Document BPs
Penalty
Summary
The deficiency involves the facility’s failure to ensure that antihypertensive medication was administered in accordance with professional standards and the physician’s ordered parameters for one resident. The resident had diagnoses including dementia and hypertension and a physician’s order for losartan 50 mg by mouth once daily, with instructions to hold the medication for systolic blood pressure less than 100 or blood pressure less than 100/60. Review of the Medication Administration Records from mid-October through early March showed that losartan was documented as administered on most days, but there was no documentation of the resident’s blood pressure with each administration, and blood pressures were only recorded on six occasions that could possibly coincide with the losartan dosing. Review of the vitals documentation revealed no evidence that blood pressures were taken consistently prior to administering a medication with specific blood pressure parameters. Further review of the clinical record progress notes showed that on three dates the losartan was held and coded as “5=Hold See Progress Notes.” On two of those dates, the medication was held due to a pulse of 56, which was not included in the physician’s parameters for holding the medication. On the third date, the medication was held for a blood pressure of 99/54, which met the ordered hold parameters. During an interview, the DON stated she could not confirm that nurses consistently took the resident’s blood pressure before administering losartan and suggested that nurses may have taken blood pressures and written them on report sheets instead of documenting them in the clinical record. She confirmed that there should have been a corresponding documentation field with the medication administration to record the blood pressure and demonstrate that the physician’s ordered parameters were followed.
Food Storage, Sanitation, Labeling, and Temperature Control Deficiencies
Penalty
Summary
The deficiency involves the facility’s failure to store, prepare, distribute, and serve food in accordance with its own policies and professional food safety standards in the main kitchen, two kitchenettes, and a resident unit refrigerator. Policy review showed requirements for stock rotation, dating and labeling of food, maintaining clean and functional refrigeration with thermometers, and ensuring all refrigerated foods are covered, labeled, dated, and monitored. Policies also required that foods brought from outside sources be labeled with resident name and date, stored apart from facility food, and that all refrigeration units have internal thermometers. Another policy required cold foods to be stored and maintained at or below 41°F and that temperatures be checked periodically and at point of service for foods sent to units. During a kitchen tour with the Director of Food Services, surveyors observed multiple violations of these policies. In dry storage, large containers of honey Dijon mustard dressing and ranch dressing were undated. In the walk-in cooler, pans of broccoli were inadequately covered, and a drawer containing ladles had a dark substance along its edge. There was substantial grease residue on the floor near an unused deep fryer. A cook was observed scooping carrots from a large box lined with a plastic bag without wearing gloves, using one hand to hold the scoop and the other to hold and then roll down the plastic bag back into the box; the Director of Food Services confirmed gloves should have been worn. Additional findings included undated hamburger buns and hot dog rolls on a bread rack, food debris on the floor of a dessert refrigerator, and trays of cups and stacks of plates stored upright in the dish room. The Director of Food Services acknowledged these findings and stated she expected evening staff to clean the kitchen daily but had no written cleaning protocols or logs. In the first-floor kitchenette, surveyors found spills inside the reach-in refrigerator door, food debris in the bottom of a side-by-side refrigerator/freezer, light food splatter in the microwave, a dark spill in a dry-goods cabinet, and moderate crumbs in the toaster crumb tray. Plates and dome lids were stored upright and uncovered in preparation for lunch. On the upper-level rehabilitation unit, the unit refrigerator contained a bottle of coffee creamer, a squeeze bottle of butter, and two cans of soda with no names or dates, and there was no thermometer present. In the second-floor kitchenette, there were spills and food debris in the refrigerator, a broken thermometer in the side-by-side refrigerator portion, crumbs in the toaster crumb tray, and plates and dome lids stored upright and uncovered. Review of food temperature logs over several days showed staff did not consistently check cold food or beverage temperatures at point of service. In an interview, the NHA confirmed he expected proper labeling and storage of foods, proper dish storage, adherence to food temperature checks per policy, and glove use during food preparation.
Failure to Implement Enhanced Barrier Precautions for Resident With Stage 3 Pressure Ulcer
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the implementation of enhanced barrier precautions for a resident with a pressure ulcer. Facility policy titled "IC-Enhanced Barrier Precautions," revised April 1, 2024, stated that enhanced barrier precautions apply when a resident is not known to be infected or colonized with any MDRO, has a wound or indwelling medical device, and does not have secretions or excretions that are unable to be covered or contained, and when contact precautions do not otherwise apply. Clinical record review for Resident 5 showed diagnoses including a stage 3 pressure ulcer of the sacral region and diabetes. A wound team consult dated March 2, 2026, documented that the resident had a stage 3 sacral pressure ulcer. On multiple observations of the resident’s room door, surveyors did not see any signage indicating that the resident was on enhanced barrier precautions or that PPE was required when providing care. During observation of the resident’s stage 3 pressure ulcer treatment, the ulcer was noted to be healing but still presented as an open area on the sacrum. Review of the physician’s orders did not show any order for enhanced barrier precautions for this resident, and review of the care plan did not reveal any care plan addressing the need for enhanced barrier precautions. In an interview, the DON stated she believed the resident’s pressure ulcer had closed and that enhanced barrier precautions were no longer needed. The deficiency was cited under 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
Antibiotic Stewardship Program Allowed Lapsed UTI Treatment
Penalty
Summary
The deficiency involves the facility’s antibiotic stewardship program allowing lapsed or interrupted antibiotic therapy for a resident with a confirmed urinary tract infection (UTI). Facility policy on Antibiotic Stewardship requires that when a culture and sensitivity (C&S) is ordered, it will be completed and the lab results and current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued. National Institute of Health resources cited in the report state that lapsed or missed doses, particularly early in treatment, reduce treatment efficacy and allow for development of drug resistance, and FDA recommendations indicate that treatment for Proteus mirabilis complicated UTIs should be 500 mg of ciprofloxacin twice daily for 7 days. Despite these standards, the facility’s practice, as described by the Infection Control Preventionist (ICP), is that residents under this provider’s care are usually treated for only 3 days with antibiotics for a UTI with a positive culture, with discontinuation if a RN assessment finds no symptoms, and possible later restart if symptoms recur at the provider’s next visit. Resident 60 had diagnoses including Parkinson’s disease with dyskinesia and urinary retention, and a UTI confirmed by culture on November 28, 2025, showing >100,000 CFU/ml Proteus mirabilis. On that date, the provider ordered ciprofloxacin 250 mg by mouth twice daily for 3 days, and the resident received doses from the evening of November 28 through the morning of December 1, when the antibiotic was stopped per the initial order after the provider’s designated RN reported the resident had no UTI symptoms. The resident was then seen again on December 3, when suprapubic tenderness was noted on physical assessment, and the provider ordered a new course of ciprofloxacin 500 mg twice daily for 7 days for a complicated UTI. The Nursing Home Administrator stated that antibiotic usage is referred to the provider. The surveyors concluded that this pattern of short-course treatment with potential interruption and later restart, in the context of a confirmed Proteus mirabilis UTI and cited national guidance, demonstrated that the facility’s antibiotic stewardship program allowed for lapsed doses of antibiotic usage.
Failure to Discard Expired Medications and Label Opened Medications
Penalty
Summary
Surveyors identified that the facility did not follow its own medication storage policy regarding expiration dating and labeling of opened medications and supplies. In the 2nd floor medication storage room, an open multidose vial of tuberculin solution was observed without an open date label, despite facility policy requiring certain medications to be dated when opened due to shortened expiration periods. In the same storage room, a box of 25-gauge needles with an expiration date of February 28, 2026, remained present after that date, and an open vial of insulin lispro was labeled with an open date of January 17, 2026, indicating it had not been discarded in accordance with beyond-use dating requirements. On the 2nd floor medication cart, surveyors observed an open bottle of LiquaCel and an open Lantus insulin pen, both lacking open date labels, even though these products require shortened expiration dating once opened. Staff interviews confirmed that tuberculin solution, LiquaCel bottles, insulin pens, and other specified medications and supplies are expected to be labeled with open dates when first used and that expired medications and supplies should be discarded. The Nursing Home Administrator and DON acknowledged that the facility’s expectation is for medications to be labeled with open dates and for expired items to be disposed of, which had not occurred in these instances.
Some of the Latest Corrective Actions taken by Facilities in Pennsylvania
- Educated maintenance staff to ensure no space heaters were used in resident rooms and hallways (K - F0689 - PA)
- Audited affected areas to ensure no space heaters were in use and reported results to the QAPI committee for further action and recommendations (K - F0689 - PA)
Improper Use of Radiant Space Heaters Creating Accident Hazards
Penalty
Summary
The deficiency involved the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision and assistive devices after a loss of heat in one rehabilitation hallway. On the evening of January 31, 2026, the facility responded to the heat loss by placing three radiant space heaters in resident rooms and two radiant space heaters in the affected hallway. During observations on February 3, 2026, surveyors found these radiant space heaters actively in use in resident rooms and in a hallway accessible to residents, positioned so that residents could come into direct contact with hot surfaces and electrical components. Temperature readings taken with the Maintenance Director on February 3, 2026, showed that the heaters in resident rooms reached surface temperatures ranging from 123°F to 153°F, and the heaters in the hallway measured between 136°F and 139°F. The Nursing Home Administrator acknowledged awareness of these temperatures and explained that heaters were placed in certain rooms based on residents’ transfer abilities and cognitive status. The Maintenance Director reported placing orange caution cones around the hallway heaters as a measure to prevent residents from walking into them. Despite this, observation in the hallway showed a resident in a wheelchair independently propelling using handrails and having to maneuver around both hallway heaters to continue ambulating. Review of Minimum Data Set (MDS) assessments revealed that one resident with a heater in the room was independent with transfers and ambulation and had moderate cognitive impairment, another was dependent for transfers and ambulation with moderate cognitive impairment, another was independent with transfers and ambulation with intact cognition, another was dependent for transfers and ambulation with severe cognitive impairment, and another was dependent for transfers and ambulation with a BIMS score indicating near-intact cognition. The Nursing Home Administrator reported that the facility had no policies or procedures providing guidance for the use of radiant space heaters in resident care areas. Interviews with CNAs showed inconsistent understanding of the risks associated with radiant space heaters, including burns, fire, and electrical hazards. These conditions led surveyors to identify an Immediate Jeopardy situation affecting residents on the rehabilitation unit. Immediate Jeopardy began when the facility lost heat in the rehabilitation unit and implemented the use of radiant space heaters in resident rooms and hallways, and continued until the facility removed all space heaters, implemented alternative heating measures, and demonstrated corrective actions were sufficient to remove the Immediate Jeopardy.
Removal Plan
- Remove space heaters from resident rooms and hallways.
- Maintain room temperatures at 71 degrees and above.
- Interview residents in affected rooms to ensure they are warm enough and offer extra blankets.
- Monitor residents.
- Contact vendor to provide PTAC units to provide heat in residents' rooms while awaiting repair of the heat source.
- Remove space heaters from the facility.
- Educate maintenance staff to ensure no space heaters are in use in resident rooms and hallways.
- Complete audits of resident room temperatures and hallway temperatures in the affected area until the heat source is repaired.
- Audit affected areas to ensure no space heaters are in use and report results to the QAPI committee for further action and recommendations.
Improper Storage and Labeling of OTC Medications in Medication Carts and Central Supply
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were properly labeled and securely stored in accordance with facility policy and accepted professional standards. Facility policies required that all medications in carts, medication rooms, or central supply be locked at all times unless in use or under the direct observation of the medication nurse, and that nursing staff check medication labels and expiration dates prior to administration. Policies also required that opened multi-dose containers be dated when opened and that the label of all medications be checked against the physician’s order before removal from the container. Additionally, the facility’s procedure for unavailable medications required staff to obtain OTC medications from central supply when not available in the cart and to notify nurse management if a system-wide issue was identified. Surveyors found that OTC medications in central supply were stored in closed, factory-labeled bottles on open shelves in a room accessed by a keypad lock. The Central Supply Manager stated that staff had access to the room via a code, but she was not aware of all staff who had the code, and reported that therapists and nurse aides, in addition to nursing staff, had collected materials from central supply after hours. This meant that OTC medications were not stored in locked compartments accessible only to authorized personnel, contrary to the facility’s own policy and accepted standards for medication security. On six of ten nursing units (1C, 1D, 3C, 3D, 3F, and 4F), surveyors observed OTC medications stored in open plastic cups with handwritten labels inside medication carts, rather than in their original, labeled bottles. On unit 1C, one cart contained seven cups labeled with drug names such as an eye supplement, guaifenesin ER 600 mg, melatonin 5 mg, cetirizine 10 mg, iron, B12 100, and Fiber Con, but the LPN could not determine doses, manufacture dates, expiration dates, or when the original containers had been opened. Another cart on the same unit contained cups labeled with ASA EC, Mucinex, Ibuprofen 200 mg, and a cup labeled Senna 8.6 that contained a mixture of red, pink, and brown pills, some of which the LPN could not identify. Residents on this unit had physician orders that correlated with the medications stored in these cups. On unit 1D, a medication cart contained seven cups labeled with various supplements and medications, including Oyster Shell D3, Cranberry 450, Vit D 2000 iu, omep 2D, MVI, cetirizine, and vit D3 2000 iu. The LPN on this unit was unable to determine doses, manufacture dates, expiration dates, or when the original containers had been opened, even though residents on the unit had orders corresponding to these medications. On unit 3C, a cart contained cups labeled Vitamin D3 50,000 iu, Docusate, and Vit C 500 mg, and the LPN again could not determine doses, manufacture dates, expiration dates, or when the original containers had been opened, despite residents having corresponding physician orders. On unit 3D, a medication cart contained cups labeled Senna 8.6 mg, Vitamin D3 50,000, Multivitamin, and Fiber-lax, and the LPN could not determine manufacture dates, expiration dates, or when the original containers had been opened, while residents on the unit had orders matching these medications. On unit 3F, one cart contained cups labeled Vit D 2,000 iu and Tylenol 500, and another cup labeled Iron 325 that contained white and black pills, some of which the LPN could not identify or trace back to an original container. A second cart on 3F contained cups labeled Calcium 600+D 10 mcg and Iron 325, with the LPN again unable to determine manufacture dates, expiration dates, or opening dates of the original containers, even though residents had corresponding orders. On unit 4F, one medication cart contained 14 cups labeled with various medications and supplements, including Docusate Sodium, Ibuprofen, Oyster Calcium, Iron, Multi vitamins, Cranberry, Mag Ox, Aspirin, ASA 81, Docusate, Multivit, Therems, Fe sulp, and Oyster Cple. Another cart on the same unit contained two unlabeled cups with pills and ten cups with handwritten labels such as Vit B12, Cranberry, Ibuprofen, Iron, Aspirin, Multivit, Oyster Cal, Thera-M, VitD, and Certizine. The LPN on this unit was unable to determine doses, manufacture dates, expiration dates, or when the original containers had been opened, and could not identify the pills in the two unlabeled cups, even though residents on the unit had physician orders that correlated with the medications in these cups. The DON confirmed that OTC medications were improperly stored and labeled in open, hand-labeled cups in the medication carts. The surveyors determined that this failure to properly store and label medications put residents at risk for medication administration errors and resulted in an Immediate Jeopardy situation at F761-K.
Removal Plan
- Discard and destroy all medications observed in medication cups or unlabeled cups, or any medication that is unable to be identified.
- Replace any discarded medication with an unopened, labeled OTC medication bottle.
- Store OTC medications in the original, labeled bottle in the medication carts and administer to residents following medication administration policies.
- Submit OTC medication orders with the Clinical Supply order and purchase needed OTC medications from a local pharmacy if not sent, backordered, or out of stock.
- Change the Central Supply keylock code and provide it only to central supply staff and RN Supervisors.
- Train all licensed and central supply staff regarding storage of medications, proper distribution of OTC medications, and the medication not available procedure.
- Audit all medication carts to ensure no loose or unlabeled medications are stored in any cart.
Failure to Transcribe Admission Lithium Order and Address Pharmacy Alert Leading to Psychiatric Decompensation
Penalty
Summary
The deficiency involves the facility’s failure to follow nursing standards of practice and accurately transcribe and implement admission medication orders for a newly admitted resident, resulting in the omission of a prescribed psychotropic medication. Pennsylvania Code Title 49 requires RNs to carry out nursing care actions that promote, maintain, and restore well-being and to be fully responsible and accountable for the quality of care delivered. Facility policies required clarification and transcription of newly prescribed medications onto the MAR or into the electronic MAR, implementation of written transfer orders unless unclear or incomplete, and acting upon and documenting pharmacist recommendations. The RN job description required delivery of care using the nursing process while maintaining professional standards. The resident, admitted with schizoaffective disorder bipolar type, Parkinson’s disease, and major depressive disorder, had transfer orders that included lithium carbonate 300 mg extended-release orally with no stop date. On admission, the facility’s physician orders dated the same day did not include the lithium carbonate 300 mg order, and the resident’s MARs for the subsequent period showed no evidence that this medication was ordered or administered. A pharmacy admission medication review identified a potential clinically significant irregularity, noting that the lithium carbonate 150 mg dose fell below the recommended daily dose and was potentially subtherapeutic, but there was no evidence that this review was addressed by facility staff or the physician. Documentation from the resident’s last behavioral health visit prior to admission showed active orders for both lithium carbonate 150 mg daily and 300 mg daily, indicating that the higher dose should have been part of the resident’s regimen. Following admission, the resident’s clinical record documented escalating behavioral and psychiatric symptoms over multiple days, including pacing, wandering, screaming, yelling, loud and unusual religious statements, hitting staff, increased anxiety, arguments with other residents, and repeated administration of anti-anxiety medications. Progress notes described manic behavior, flight of ideas, talking to self and to people not present, delusional thoughts, agitation, disruptive behavior in common areas, lack of sleep, and the need for one-on-one care due to mania. The resident experienced falls and was noted to be confused, disoriented, and in a manic state. Laboratory results showed a lithium level of 0.14 mmol/L, below the referenced normal range of 0.60–1.20 mmol/L, and a neurology progress note stated that the resident’s lithium doses were not correctly dosed and that the resident was showing signs of active psychosis. In interviews, the DON confirmed that the lithium carbonate 300 mg order from the transfer orders was not transcribed into the facility medication record and that the pharmacy admission medication review identifying a potential clinically significant irregularity was not addressed by facility staff or the physician. The resident’s care plans included a plan for risk of adverse effects related to antipsychotic medication, with a goal of no side effects, and a plan for risk of behavioral symptoms related to schizoaffective disorder with an intervention to administer medications per physician order. Despite these care plans, the lithium carbonate 300 mg order was not implemented because it was never transcribed into the electronic medical record or MAR, and the pharmacy’s alert about a potentially subtherapeutic lithium dose was not acted upon. The facility’s failure to accurately transcribe the admission medication orders and to respond to the pharmacist’s identified irregularity created a situation that surveyors determined placed the resident in Immediate Jeopardy of the likelihood of serious bodily injury, harm, or death.
Removal Plan
- All Registered Nurses will receive education regarding the proper process for entering physician orders for new admissions, including thorough review of hospital discharge orders, accurate entry of orders into the electronic health record, and the required process for transcription and clarification to ensure accuracy within the medical record.
- Nursing staff will utilize a standard Medication Transcription/Clarification Tool during the admission process to ensure all medication orders are completely and accurately transcribed.
- Any discrepancies identified will be clarified with the physician prior to implementation, and physicians will be notified promptly of any transcription error or clarification needs.
- Implement a revised admission process requiring use of the Medication Transcription/Clarification Tool to validate that medication orders are accurately entered into the electronic health record and appropriately populate in the electronic medication administration record.
- Director of Nursing or designee will audit admissions to verify accuracy of order transcription and clarification.
- Admission audits will be conducted until sustained compliance is achieved.
- Audit results will be reviewed at the Quality Assurance Performance Improvement meetings and additional corrective action or re-education will be implemented as indicated by audit findings.
Failure to Document and Act on Full Code Status Resulting in No CPR Initiation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s code status was clearly documented and readily available in the clinical record, which delayed the decision to provide life-sustaining measures such as CPR. The American Heart Association (AHA) guidelines and the facility’s own CPR policy both state that CPR should be initiated for an unresponsive individual unless there is a valid DNR order or clear, irreversible signs of death. The facility’s policy further specifies that if a resident’s DNR status is unclear, CPR must be initiated and continued until a DNR or physician’s order not to administer CPR is confirmed. In this case, the resident’s hospital records and the attending physician’s encounter note documented the resident as “Full Code,” indicating the resident wished to receive all possible life-saving interventions. The resident, identified as CL1, had been admitted from the hospital with acute respiratory failure with hypoxia and atrial fibrillation, and the hospital emergency room record and physician encounter note both documented a Full Code status. However, the facility’s physician orders for the resident did not contain any order for code status, and the code status was not displayed where staff expected to find it in the EMR or on the nurse’s sheet. On the night of the incident, the resident was last known to be responsive around 2:30 a.m. when an aide reported the resident rolled over and drank water. The nurse assigned to the resident observed the resident at midnight with a BIPAP mask on and again around 3:30 a.m. sleeping with a nasal cannula, noting the resident had a habit of removing the BIPAP mask. Shortly before 5:00 a.m., an aide called the assigned nurse (Employee E4) to check on the resident. The nurse found the resident lying supine, appearing normally pale, and reported not feeling a pulse at the wrist or neck. Because the code status was not listed on the nurse’s sheet, the nurse and the nursing supervisor (Employee E3) spent approximately 10 minutes looking for the code status in the EMR, during which time an aide remained with the resident. The code status could not initially be found in the computer, and no CPR was started. The supervisor assessed the resident as gray, cool, with no breath sounds, no carotid or radial pulse, eyes closed, mouth open, and mottling on the legs, and later located documentation in the EMR under a miscellaneous section indicating the resident was Full Code. Despite this, CPR was not initiated. The DON confirmed that the resident’s code status should have been reflected in the EMR banner and on physician orders but was not, and also confirmed that staff did not initiate CPR, citing their belief that the resident showed irreversible signs of death. The surveyors concluded that the assessments described by staff did not meet the AHA or facility policy criteria for irreversible signs of death, and that the failure to document and locate the code status and to initiate CPR in accordance with the resident’s Full Code status constituted an Immediate Jeopardy situation.
Removal Plan
- Completed a full house audit of all residents to determine presence of code status and presence of a physician order.
- Reviewed CPR drills.
- Provided licensed staff education on CPR policy and procedures, including general guidelines with focus on assessment of unresponsive residents, when to initiate CPR, and identification of irreversible signs of death.
- Taught licensed staff that code status will be in PCC on the code status banner.
- Educated licensed staff on the Emergency Code documentation form, including the narrative of details during the code.
- Educated licensed staff on compliance with physician orders related to the provision of CPR when indicated.
- Updated licensed staff orientation to include CPR and procedures, Emergency Code Documentation, and compliance with physician order.
- Audited the order listing report and admission/readmission documentation for presence of code status and corresponding order in PCC.
- Audited effectiveness of licensed staff training via questionnaires and on-the-spot interviews.
- Presented and reviewed all ongoing compliance audits at the QAPI meeting.
- Completed a code drill to ensure licensed nurses were prepared to respond to situations that required CPR.
- Scheduled remaining staff to receive the education prior to the start of their next shift.
Failure to Supervise High-Risk Resident Resulting in Elopement and Injury
Penalty
Summary
The facility failed to provide necessary supervision and environmental controls to monitor a resident’s location and prevent an elopement. Facility policy on elopement required staff to monitor residents to prevent unauthorized departures. The resident involved had diagnoses including infection and inflammatory reaction due to an indwelling catheter, abnormalities of gait and mobility, and muscle weakness. An MDS assessment documented memory impairment and a need for partial assistance to walk, and the care plan identified that the resident ambulated with a front-wheeled walker and assistance from one staff member. Despite these identified needs, the resident was last seen by staff at 10:00 a.m. walking in the skilled nursing hallway and was not adequately supervised thereafter. At 11:44 a.m., the resident’s family notified staff that they could not locate the resident when they arrived for a visit. The facility was unaware of the resident’s location or that he had left the skilled nursing area for one hour and 45 minutes. The resident was later found at 12:30 p.m. lying on the concrete floor of a parking garage associated with an independent living apartment area located at the opposite end of a connected building, not part of the skilled nursing units. The resident stated he was cold and was observed with skin tears on the left foot/toes, left leg, and both elbows, dried blood on the back of the head, and a scalp laceration requiring staples. The Administrator reported that they believed the resident exited through unmonitored, unlocked doors leading to the independent living section and then accessed an elevator to the parking garage. There was no evidence that the skilled nursing exit doors were alarmed, locked, or monitored, and residents at risk for elopement had access to this area, resulting in an Immediate Jeopardy situation at F689-J.
Removal Plan
- Resident 1 was assessed by a licensed nurse and sent to the hospital for evaluation.
- All facility residents had a new elopement assessment completed.
- All residents at risk for elopement were communicated to staff and had their care plans/interventions updated.
- All safety devices were checked to ensure they were in place, including electronic devices applied to at risk residents to prevent doors from opening (Wander Guard system).
- An audit was conducted of all skilled nursing community exits.
- A staff member was placed to observe any exits that are not locked at all times until the facility's vendor completes the installation of new locking mechanisms.
- All staff were re-educated on the elopement policy and that staff must monitor the exit doors at all times until the locking mechanisms are installed.
- The Director of Nursing or designee was to initiate weekly audits and report results to the QAPI (Quality Assurance, Performance Improvement) committee.
Resident Left Without Functioning Call Bell After RN Unplugs System
Penalty
Summary
The deficiency involves the facility’s failure to ensure a fully functioning and accessible call bell system for a cognitively intact resident, resulting in the resident being without an active call system in the room and bathroom/bathing area for an extended period. The resident had diagnoses including cancer, malnutrition, and malignant neoplasm of the larynx, and was assessed as cognitively intact with a BIMS score of 15. Facility policy required that call lights be plugged in and functioning at all times and that residents unable to use call lights be checked frequently. Despite this policy, the resident’s call bell was disconnected from the wall and left inaccessible on the floor, leaving the resident unable to summon assistance. According to facility documentation and witness statements, during a night shift an RN attempted to address a problem with the television sound that was controlled through the call system remote. The resident requested that the TV sound be turned off, and when the RN could not silence the sound using the available controls, the RN removed the call system cord from the wall to stop the noise. The RN acknowledged that this action disconnected the call system and that no alternative call method (such as a hand bell or backup cord) was provided to the resident. The resident later reported that the call bell was left on the floor and was not accessible, and that she experienced an episode of emesis and was unable to call for assistance because the call bell had been disconnected. Additional staff statements indicated that other staff were aware the call light was not working and did not ensure that the resident had an alternative means to call for help. A nurse aide reported being told by the RN that the call light was not working and that she did not know how to fix it. Another undated/unsigned witness statement described a staff member seeing the call light going off at 2 a.m., being told by the assigned nurse that the light had been broken that shift and that it was fine with no need to enter the room, and therefore not checking on the resident. Facility documentation also showed a gap in the resident’s MAR documentation between 1:25 a.m. and 4:00 a.m. The Nursing Home Administrator later confirmed that the facility failed to provide a fully functioning call bell system for this resident, which was determined to be an immediate jeopardy situation.
Removal Plan
- Tested Resident R1's call bell to ensure proper functioning and verified the resident had access to a functioning call system positioned appropriately to meet the resident's needs.
- Completed an assessment of Resident R1 to ensure no adverse outcomes occurred as a result of the call bell being unplugged; no injuries found.
- Educated staff from all departments on call bell accessibility and what to do if the call bell stops working.
- Inspected and tested all resident rooms and common areas with call bell access for functionality and accessibility; no issues identified.
- Had an outside vendor examine the nurse call system and test all activation points; all found in good working condition.
- Conducted a root cause analysis regarding the call bell issue and performed an audit of the call bell system in all resident rooms and common areas where residents may initiate a call.
- Implemented a preventative maintenance schedule for ongoing monitoring of the call bell system.
- Re-educated staff on daily visual checks of call bell accessibility and reporting procedures for any identified functionality issues.
- Implemented Maintenance Director/designee audits of call bell functionality and maintained documentation, reviewed results at QAPI, and corrected and reported any deficiencies immediately.
- Updated the TELS maintenance tracking system to include conducting a test of the nurse call system.
- Completed immediate corrective action for Resident R1 and completed facility-wide call bell testing, with ongoing preventative maintenance and monitoring to continue.
Elopement of At-Risk Resident Due to Door Alarm Failure and Inadequate Supervision
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision to prevent the elopement of a resident identified as being at risk for elopement. Facility policy on elopement, revised June 2023, states that residents at risk for elopement will be appropriately monitored to reduce potential injury and defines elopement as a resident leaving the premises without staff knowledge and supervision. Resident 3 had an elopement care plan in place since November 2025, identifying a potential for elopement and associated injury related to exit-seeking behavior and a desire to go home. Interventions included reorientation, encouragement of group activities, provision of diversional activities when exit seeking, redirection from exits, and use of a wander guard device with checks for placement and function each shift. Resident 3’s clinical record showed diagnoses including alcoholic cirrhosis of the liver, hepatic encephalopathy, and GERD. The resident had physician orders for a wander guard device, initially to the right ankle and later changed to the left ankle, with instructions to check placement every shift and function every night shift. An elopement/wander risk evaluation dated November 1, 2025, scored the resident as a moderate elopement risk. The care plan also documented that the resident required direct supervision while outdoors and needed one-person assistance with a walker for ambulation. Despite these identified risks and interventions, camera footage confirmed that Resident 3 exited the main entrance at 5:33 PM on February 4, 2026, without staff awareness. The resident’s absence was not discovered until approximately 8:45 PM, when staff realized the resident could not be located on the unit and within the facility, and the resident had not signed out. Staff interviews and witness statements indicated that the resident was last seen around dinner time and that staff only began searching after a nurse aide noted the resident had been gone for a long time. The receptionist reported not noticing anyone by the door and not seeing the resident exit. The Nursing Home Administrator later stated that the facility determined there was an issue with the wander guard system at the main entrance door, which was alarming only intermittently and had a closing delay that could allow someone to exit without triggering an alarm. Resident 3 was ultimately found by a staff RN in the street approximately 0.3 miles from the facility, after having crossed a heavily trafficked roadway in cold, dark conditions. This failure to provide adequate supervision and maintain effective elopement prevention measures also placed eight additional residents with elopement risk and wander guard orders on unlocked units in an Immediate Jeopardy situation.
Removal Plan
- Resident 3 was returned to the facility with no adverse outcome, a new wander guard was placed on the resident, and an updated elopement evaluation was completed.
- All facility residents with active orders for wander guards had devices checked for function.
- House-wide resident elopement scores were reviewed for accuracy and to ensure care plans were in place as indicated.
- Elopement binders were reviewed and updated to include residents with wander guards.
- The door system was evaluated for function.
- The over-ride button at the receptionist desk was disengaged and disabled until the door and wander guard system is repaired and function validated.
- A service call was placed to the door company and repairs were scheduled.
- A surveillance camera was installed in the lobby to continuously monitor the lobby area.
- Signage was installed on lobby exiting doors to remind visitors and staff to check surroundings when exiting the facility.
- The building entrance door was monitored continuously by the receptionist or designee until repairs were completed and the door and system were fully operational.
- Facility staff were re-educated on the facility elopement policy.
- Reception staff were educated that the over-ride button was disabled and that manual code entry must be used to unlock the door.
- Facility staff were educated to be mindful of who is behind them when exiting and to monitor for residents attempting to exit before the door fully closes.
- The DON or designee will conduct observational audits of door code entry to ensure the door is monitored until fully closed and report results to QAPI.
- The Maintenance Director or designee will conduct door and wander guard function audits once the door is repaired and report results to QAPI.
- Wander guard function audits will be checked daily on the shift and report results to QAPI.
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