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 nurse administered another resident's medications to a cognitively intact resident with multiple chronic conditions after only verbally confirming the last name, without using other required identification methods. The resident developed symptoms including nausea, vomiting, and near syncope, requiring hospital admission for observation and treatment of medication side effects.
A resident with cognitive impairment and a mechanical soft diet began choking during a meal. Instead of immediately performing the Heimlich maneuver, staff moved the resident to his room and bed, delaying emergency intervention by about ten minutes. Multiple staff were present but did not initiate abdominal thrusts until the resident's condition had deteriorated, resulting in the resident's death.
A resident with a mechanical soft diet and specific speech therapy recommendations for bite-size food was given a large portion of food that was not cut as required. Despite staff cues, the resident consumed the entire piece, resulting in choking and death. The lack of communication and adherence to dietary instructions placed other residents with similar needs at high risk.
A deficiency occurred when a hazardous sanitizing chemical was mistakenly served as a beverage to ten residents after a cook, lacking documented training, used a drink pitcher to mix the chemical and left it unlabeled in the kitchen. The solution was then served by another staff member, who assumed it was pink lemonade. Several residents with chronic illnesses and cognitive impairment were affected, and required monitoring and assessment were not documented as completed. Staff interviews and personnel file reviews revealed a lack of formal training and orientation regarding chemical safety and labeling procedures.
A resident with a history of falls, cervical fracture, and on anticoagulation experienced multiple falls, including an unwitnessed fall with possible head impact. Despite physician orders for 15-minute safety checks and neurological assessments, these were not consistently performed or communicated to staff. The resident was not promptly evaluated or transferred for diagnostic imaging, and was later found unresponsive with a large subdural hematoma, resulting in death. The facility failed to provide care in accordance with professional standards, including post-fall monitoring and timely assessment.
Surveyors identified multiple sanitation failures in the dietary department, including improper use of the three-compartment sink, lack of sanitizer test strips, dirty kitchen and storage areas, and widespread issues with unlabeled and undated food items. Additional deficiencies were found in resident dining and pantry areas, with dirty equipment, food debris, and improper storage of cleaning chemicals. Facility leadership confirmed these conditions as food safety and sanitation issues.
Surveyors found that the facility did not maintain a clean and sanitary environment in one care unit, with soiled floors, dirty equipment, and a resident left in a soiled condition for over fifteen minutes after a bowel incontinence episode. Staff shortages contributed to delays in care, and multiple rooms were observed with visible dirt and stains.
Facility administration failed to ensure resident safety when the dietary department served a hazardous cleaning chemical during meal service, resulting in ten residents ingesting the substance and placing all residents in the affected wing at risk. Staff interviews revealed that dietary personnel had not received effective training or competency evaluation on safe handling, storage, and labeling of hazardous chemicals, and administrative oversight was lacking in monitoring departmental operations and implementing facility policies.
The facility did not provide the required minimum number of LPNs on several day and night shifts, as shown by a review of staffing schedules and census data. The Nursing Home Administrator confirmed that LPN staffing levels fell below regulatory requirements on these occasions.
The facility did not return personal funds to the responsible parties of two residents within the required 30-day period after the residents' deaths. One resident's family had not received a $385 refund despite repeated inquiries, and another resident's $2,530 refund could not be verified as returned, with no supporting documentation provided. Staff confirmed both cases of delayed fund return.
Significant Medication Error Resulting in Hospitalization
Penalty
Summary
A significant medication error occurred when a licensed nurse administered another resident's medications to a resident with diagnoses including diabetes, hypertension, prostate cancer, and congestive heart failure. The nurse, who was not the resident's regular caregiver, entered the room where multiple residents were present. Upon calling out the resident's last name, the resident responded, and the nurse proceeded to give the medications without further verification. The medications administered included several drugs not prescribed to the resident, such as Bisacodyl, Chlorpromazine, Diltiazem, Duloxetine, Loratadine, Oxybutynin, Pantoprazole, Senna Plus, Tramadol, and Vraylar. Following the administration, the resident initially denied any immediate ill effects but was later reported by family to be pale, nauseated, and had vomited. The resident's vital signs were assessed, and after further symptoms developed, the physician was notified and ordered the resident to be transferred to the hospital. Hospital records indicated the resident was admitted for observation due to medication side effects, including near syncope, nausea, vomiting, and transient bradycardia, likely related to the medications received in error. The facility's policy required verification of resident identity using multiple methods, such as checking identification bands, reviewing photographs, and confirming with other staff if necessary. However, these procedures were not fully followed during the medication pass, leading to the error. The incident was documented in nursing progress notes and confirmed through staff statements and facility investigation records.
Delayed Emergency Response to Choking Incident
Penalty
Summary
A deficiency occurred when staff failed to provide timely emergency care to a resident experiencing a choking incident. The resident, who had a history of cognitive impairment, decreased safety awareness, and was on a mechanical soft diet with thin liquids, began choking during a meal. Staff observed the resident struggling to breathe and expressing an inability to cough, but instead of immediately initiating emergency measures such as the Heimlich maneuver, they moved the resident from the dining room to his room, a distance of approximately 138 feet, and transferred him to bed before attempting further interventions. During this period, staff encouraged the resident to cough and attempted oral suctioning, but did not perform the Heimlich maneuver until approximately ten minutes after the onset of the choking episode. Multiple staff members, including nursing, therapy, and aide personnel, were present and involved in the response, but there was a delay in recognizing the need for and initiating abdominal thrusts. Witness statements and progress notes confirm that the Heimlich maneuver was not started until the resident was already in his room and in bed, despite clear signs of airway obstruction and the resident's inability to clear the blockage himself. The delay in providing appropriate emergency intervention resulted in the resident losing consciousness and ultimately being pronounced dead. The facility's failure to follow established emergency procedures for choking, as outlined in their own policy and professional standards of practice, directly contributed to the adverse outcome for the resident. The deficiency was identified as an Immediate Jeopardy situation due to the delay in emergency response and the resulting death.
Plan Of Correction
We were unable to correct deficiency F0684 related to Resident 1 as the resident expired in the facility. All nursing staff were educated on the revised choking policy and signs and symptoms to look for when choking. Employee 2 received one-on-one education by Anthony Clark, Director of Nursing, on October 10, 2025, regarding CPR training and emphasis placed on choking resident and employee 2 demonstrated proper technique for the Heimlich maneuver. Employee 2 was placed on a Performance Improvement Plan to demonstrate full knowledge, demonstration of proper Heimlich technique, and adherence to emergency choking protocol. Dysphagia/Choking Procedure in-service was provided to the staff by Anthony Clark, Director of Nursing, and Talayne Gates, SLP, on Tuesday, October 14th at 7am, 1pm, and 3pm, and will be held also on Thursday, October 16th at 7am, 1pm, and 3pm for licensed staff and nursing assistants. DON reviewed the emergency response for a choking resident's times one week. The results of this audit will be reported at the October 23rd QAPI meeting and determined if further staff audits are needed. The facility will begin conducting quarterly mock drills of emergency events, including choking drill, code drill, elopement drill, and active shooter drill, beginning in January 2026. The results will be reviewed at the quarterly QAPI meetings. The QAPI committee will determine if more frequent mock drills for emergency events need to be held.
Removal Plan
- Choking policy was reviewed and updated to American Heart Association Standards.
- All nursing staff will be educated by the Assistant Director of Nursing on the revised choking policy.
- All other nursing staff will be educated by the Registered Nurse Supervisor prior to the start of their shift.
- This will include all full-time, part-time, and prn nursing staff.
- The Assistant Director of Nursing will educate all nursing staff on the signs to look for when someone is choking.
- The Rehab Manager audited all residents on current caseload to ensure current Speech Therapy diet recommendations were being followed.
- The Rehab Manager will audit all residents who have had current Speech Therapy diet recommendations to ensure their current diet order reflects Speech Therapy recommendations.
Failure to Follow Dietary Recommendations Results in Choking Incident
Penalty
Summary
The facility failed to ensure that a resident with specific dietary needs received adequate supervision and assistance to prevent accidents, resulting in a choking incident. The resident had a history of unspecified protein-calorie malnutrition, dehydration, and generalized muscle weakness, and was on a mechanical soft diet with thin consistency. Speech therapy recommendations specified that the resident's food should be cut into bite-size pieces and that small bites or sips should be facilitated during meals. However, these recommendations were not communicated on the resident's meal tray ticket, nor were they consistently followed by staff. On the day of the incident, an occupational therapist handed the resident half of a beef enchilada, approximately 2.5 inches in size, which was not cut into bite-size pieces as required. Despite verbal and visual cues to take small bites, the resident placed the entire portion in his mouth, leading to choking and labored breathing. Staff present attempted to assist the resident, but the food size and lack of adherence to the recommended feeding techniques contributed to the choking event. The speech therapist later confirmed that staff should have cut the food into smaller portions and that such instructions should have been clearly communicated and followed. Further review revealed that other residents with similar dietary needs had varying instructions on their meal tray tickets, such as "cut up meats" or "cut food into bite size pieces," but the process for ensuring these directions were consistently applied was lacking. The nursing home administrator acknowledged that speech therapy recommendations should be properly communicated and documented on meal tray tickets, and that staff should follow these recommendations. The failure to communicate and implement individualized dietary precautions resulted in a choking incident and subsequent death, placing additional residents at high risk for similar events.
Plan Of Correction
We were unable to correct deficiency F0689 related to Resident 1 as resident expired in the facility. Residents 6-14 were screened by Speech Therapy for appropriate diet and checked to see if at risk for choking or require any new safety measures. Director of Rehab audited all current residents that have had a speech therapy diet recommendation to ensure their current diet order reflects speech therapy recommendations. Director of Rehab educated all therapy staff on the new procedure of diet recommendations to be written on the speech therapy recommendation form and physician order as well as provided to nursing. Speech Therapy was also educated to give the speech therapy recommendation form to Dietary. Speech Therapists were instructed if trialing any changes to the diet, the therapist must stay with the resident until the trial item is completed. The Director of Rehab is conducting an ongoing audit for any new speech therapy recommendations to ensure they match the diet order. All nursing staff was educated prior to the start of their shift on the new choking policy and signs and symptoms to look for with a choking resident. Education was given to all nursing staff prior to the start of their shift on diet and diet textures. Dietary Manager educated all dietary staff prior to the start of their shift on diet and diet textures and cutting up food as indicated on the meal ticket. Dysphagia/Choking Procedure in-service was provided to the staff by Anthony Clark, Director of Nursing, and Talayne Gates, SLP, on Tuesday, October 14th at 7am, 1pm, and 3pm, and will be provided on Thursday, October 16th at 7am, 1pm, and 3pm to licensed staff and nursing assistants. The Director of Nursing and Assistant Dietary Manager are conducting audits of all new dietary orders or changes and recommendations for meal ticket accuracy through October 31, 2025. The Dietary Manager audited all meals during tray line service to ensure meal ticket matches diet order and visually observe meal served is accurate through 10/10/25. Beginning 10/13/25, the Dietary Manager will audit 3 meals per week during tray line to ensure meal ticket matches diet order and visually observe meal served is accurate through October 31, 2025. Direct in-service training on F0689, Accidents and Incidents, for all licensed staff and nursing assistants will be provided by Sophie Campbell, MSN, RN, CRRN, RAC-CT, CNDLTC. Sophie Campbell is the Executive Director of the Pennsylvania Association of Directors of Nursing Administration and is an approved directed in-service provider on the list from the Department of Health. The in-service will be held on Wednesday, October 29th at 7am, 1pm, and 3pm. This in-service will be recorded for staff that is unable to attend. Licensed staff unable to attend the in-service will be required to watch the recorded in-service prior to the start of their next shift. All ongoing audits will be reviewed at the monthly QAPI to determine if further auditing is needed. <End of formatted text>
Removal Plan
- Choking policy was reviewed and updated to American Heart Association Standards.
- All nursing staff currently working in the building will be educated by Employee 6 (Assistant DON) on the revised choking policy.
- All other nursing staff will be educated by the Registered Nurse (RN) Supervisor prior to the start of their shift. This will include all full time, part-time and nursing staff.
- Employee 6 will educate all nursing staff currently working on the signs to look for when someone is choking.
- All other nursing staff will be educated by the RN Supervisor prior to the start of their shift. This will include all full time, part-time and nursing staff.
- Employee 7 audited all residents on current caseload to ensure current speech therapy diet recommendations were being followed.
- Employee 7 will audit all residents who have had current speech therapy diet recommendations to ensure their current diet order reflects speech therapy recommendations.
- Employee 7 will educate speech therapists on new procedure to write recommendations on speech therapy recommendation form and physician orders.
- Employee 7 will educate Employee 1 on following dietary orders.
- Employee 12 (Dietary Manager) will educate dietary staff currently working on diet and diet textures.
- All other dietary staff members will be educated by Employee 12 prior to the start of their shift. This will include all full time, part-time, and as needed staff.
- All nursing staff currently working in the building will be educated by Employee 6 on diets and diet textures and to read and follow meal tickets.
- RN Supervisor will educate all nursing staff currently working on diets and diet textures and to read and follow meal ticket directions.
- Employee 12 (Dietary Manager) audited evening meal service tray line to ensure meal tickets matched diet order and visually observed meal service was accurate.
- All meals will be audited during tray line to ensure meal ticket matches diet order and visually observe meal served is accurate.
Improper Chemical Labeling and Storage Leads to Residents Being Served Sanitizer
Penalty
Summary
A deficiency occurred when the facility failed to implement safe and sanitary food handling practices in the kitchen, specifically by not ensuring that hazardous chemical cleaning and sanitizing solutions were properly labeled, stored, and used according to manufacturer instructions and facility policy. A cook, who had not received any documented orientation or training, used a clear plastic drink pitcher to mix a red sanitizing chemical solution due to a lack of available sanitation buckets. After cleaning, the cook left the pitcher containing the chemical in the sink, and it was later mistaken for pink lemonade by another staff member, who then served it to residents on the East unit. Ten residents were served the chemical solution, and the facility could not determine how much was consumed by each individual. The affected residents included individuals with chronic kidney disease, dementia, cerebral infarction, COPD, and cerebral palsy, with varying levels of cognitive impairment. One resident experienced vomiting after lunch, and all affected residents were assessed for symptoms, with physicians and poison control notified. However, clinical record reviews revealed that the ordered monitoring, fluid administration, and oral assessments were not documented as completed at the time of the incident for any of the residents involved. Interviews with dietary staff and review of personnel files showed that most kitchen staff were newly hired and had not received formal education or training regarding their job responsibilities, chemical safety, or labeling procedures. The contracted dietary company did not provide written job descriptions or documented orientation for the staff. The lack of proper labeling, storage, and staff training directly led to the accidental serving of a hazardous chemical to residents, resulting in Immediate Jeopardy to resident health and safety.
Plan Of Correction
Investigation was completed on 9/22/2025. Root cause determined to be isolated staff member improperly using a drink pitcher to store a cleaning sanitizer. Medical team made aware. Poison Control Center consulted. East Unit residents were assessed, and additional orders were implemented for the 10 residents found to have ingested some of the diluted sanitizer. These orders included vital sign monitoring, additional fluids, and oral assessments. Resident Representatives notified. Completed on 9/22/2025. DON/designee to complete follow-up clinical needs determined by post-incident evaluations of affected residents. Completed on 9/23/2025. The chemicals in the kitchen were reviewed for proper storage and labeling; sanitizing solutions were secured. Dietary staff are to store drink pitchers on the shelf under the beverage preparation station. Open chemicals that are in current use are to be stored under the 3-compartment sink. All other chemicals are to be stored in a remote storage area. Dietary staff are to complete pH testing on diluted 3-compartment sink chemicals and keep a log. Chemicals are only to be used for intended purposes and in labeled containers. Completed on 10/3/2025. DON/designee to complete chemical safety education for nursing staff for specifics on chemical storage and container labeling. Date of completion 10/3/2025. Dietary policies for labeling and storing of chemicals were reviewed and updated. Dietary Manager/designee to complete chemical safety training for dietary staff to include Food and Chemical Storage (NO chemicals can be in food storage containers), Sanitation Bucket Use, Labeling and Dating, Hazardous Chemicals, Food Storage, SDS, and Hazard Communications. Chemicals that are in current use are to be stored under the 3-compartment sink. All other chemicals are to be stored in a remote storage area. Dietary staff are to complete pH testing on diluted 3-compartment sink chemicals and keep a log. Chemicals are only to be used for intended purposes and in labeled containers. Completed on 10/3/2025. DON/designee to complete chemical safety education for nursing staff for specifics on chemical storage and container labeling. Date of completion 10/3/2025. Dietary policies for labeling and storing of chemicals were reviewed and updated. Dietary Manager/designee to complete chemical safety training for dietary staff to include Food and Chemical Storage (NO chemicals can be in food storage containers), Sanitation Bucket Use, Labeling and Dating, Hazardous Chemicals, Food Storage, SDS, and Hazard Communications. Chemicals that are in current use are to be stored under the 3-compartment sink. All other chemicals are to be stored in a remote storage area. Dietary staff are to complete pH testing on diluted 3-compartment sink chemicals and keep a log. Chemicals are only to be used for intended purposes and in labeled containers. Completed on 10/3/2025. DON/designee to complete chemical safety education for nursing staff for specifics on chemical storage and container labeling. Date of completion 10/3/2025. Dietary policies for labeling and storing of chemicals were reviewed and updated. Dietary Manager/designee to complete chemical safety training for dietary staff to include Food and Chemical Storage (NO chemicals can be in food storage containers), Sanitation Bucket Use, Labeling and Dating, Hazardous Chemicals, Food Storage, SDS, and Hazard Communications. Dietary Manager/designee to complete post-education audits to ensure compliance with remediation. Audits to be completed 5 times weekly for 4 weeks. Audit findings to be reviewed at the facility QAPI. Audits initiated on 10/3/2025 and continue. DON/designee to complete post-education audits to ensure compliance with remediation. Audits to be completed 5 times weekly for 4 weeks. Audit findings to be reviewed at the facility QAPI. Audits initiated on 10/3/2025 and continue.
Removal Plan
- A root-cause analysis determined that a staff member had improperly used a drink pitcher to mix and store a sanitizing chemical in the kitchen.
- All residents on the East Unit were reassessed for injury or adverse effects, and physician orders were implemented for care and monitoring.
- All chemicals in the kitchen were reviewed for proper labeling and storage.
- Education was provided to all dietary and nursing staff regarding chemical safety, labeling, and segregation of food and cleaning supplies.
- All chemicals not in active use were removed from the kitchen area and placed in a secure, designated chemical-storage area.
- Facility dietary policies regarding chemical labeling, storage, and use were reviewed and revised.
- Post-education audits were initiated to verify continued staff compliance with labeling and storage procedures.
Failure to Provide Post-Fall Monitoring and Timely Assessment for Anticoagulated Resident
Penalty
Summary
A resident with a history of falls, cervical fracture, and on anticoagulation therapy was admitted to the facility and identified as a high fall risk. The care plan included interventions such as keeping the call bell within reach, ensuring non-skid footwear, and encouraging the resident to request assistance for mobility. Despite these interventions, the resident experienced multiple falls during their stay, including unwitnessed incidents and falls resulting in injury. After each fall, documentation shows that only minor or previously implemented interventions were added, and there was no evidence of significant revision to the care plan to address the ongoing pattern of falls. Following an unwitnessed fall with possible head impact, the resident, who was on anticoagulation therapy, was not transferred for immediate medical evaluation or diagnostic imaging as recommended by professional standards and facility policy. Although a physician ordered 15-minute safety checks and neurological assessments after the fall, documentation revealed that these were not consistently performed or communicated to all staff. The neurological assessment flow sheet showed gaps in monitoring, and the facility could not provide evidence that the required 15-minute safety checks were completed. The DON confirmed that staff were unaware of the order for increased monitoring due to a lack of communication. Subsequently, the resident was found unresponsive approximately 13 hours after the fall, with no documented neurological assessments in the five hours prior. Emergency services were called, and the resident was transferred to the hospital, where diagnostic imaging revealed a large subdural hematoma and multiple areas of brain bleeding. The resident was pronounced deceased following further evaluation. The facility failed to ensure that treatment and care were provided in accordance with professional standards of practice, including prompt evaluation and monitoring after a fall in an anticoagulated resident, as well as proper implementation and documentation of physician-ordered interventions.
Plan Of Correction
1. Unable to retro correct deficient practice for Resident CR1. 2. Facility will review residents on anticoagulation therapy who have had a fall in the past 48 hours. Physician will be contacted with post fall assessment findings including neurological evaluation to determine whether residents need to be transferred to the hospital for evaluation. 3. Nursing Educator/ designee will provide education to licensed staff facility on post fall protocols including MD notification to include anticoagulant use and neurological evaluation. 4. Director of Nursing / designee to complete audits on 5 falls weekly to ensure that interventions are initiated to address risk for falls and interventions to prevent reoccurrence. Audits will also include neurological evaluations on unwitnessed falls and q 15-minute checks if applicable, and MD notification if the resident is on anticoagulation therapy. Audits will continue x 8 weeks and findings will be reviewed by the facility QAPI committee. F 0684
Widespread Food Service Sanitation Failures in Dietary and Resident Areas
Penalty
Summary
The facility failed to maintain food service sanitation practices in accordance with professional standards for safe preparation, handling, and service of food. During a tour of the kitchen, surveyors observed multiple sanitation concerns, including improper use and maintenance of the three-compartment sink system. All three sink compartments contained food debris, and no sanitizer test strips were available to verify sanitizer concentration. The surrounding area was dirty, with paper debris, liquid stains, and a sticky residue on the floor. A mop bucket filled with dirty water and cleaning equipment was stored adjacent to the sink, creating a risk of contamination. The Corporate Dietary Manager confirmed that sanitizer test strips could not be located and that there was no documentation verifying that sanitizer concentrations were checked as required by facility policy. He also stated that most dietary staff were recently hired and had not been trained on proper three-compartment sink use. Additional environmental observations revealed widespread sanitation issues throughout the kitchen, maintenance, storage, and service areas. Unlabeled drink pitchers were stored upside-down on a dirty windowsill, and an unlabeled bucket containing a rag in chemical solution was stored next to food items. The kitchen maintenance room contained unidentified machines, an open bottle of degreaser, and electrical extension cords strewn across the machines and floor. A metal cart was visibly soiled, and the floor had visible dirt, paper, and a black sticky substance. In the storage room, uncovered shelving held pans and utensils with standing water and water stains, and the area was cluttered with dust, dirt, cobwebs, and open containers of paper dining products. The kitchen's meal tray delivery cart and open food carts in resident hallways had visible food and liquid stains. Further deficiencies were noted in the Pavilion resident dining area and pantry. Clean coffee cups had a white film inside, and there were open, undated, and unlabeled food items in both the refrigerator and freezer. The refrigerator and pantry areas were dirty, with food debris, paper waste, and dirt accumulation. Dirty dishes, a microwave with dried food residue, and sticky countertops were observed. The cabinet under the sink contained dirty trays and an unlocked bag of dishwasher pods. The Corporate Dietary Manager confirmed that dietary staff were responsible for cleaning and maintaining these areas, and the Nursing Home Administrator acknowledged that the observed conditions constituted food safety and sanitation issues.
Plan Of Correction
1. Three compartment sinks were emptied, cleaned, and sanitizer test strips were obtained. Area around the 3-compartment sink was cleaned, and the dirty mop bucket was emptied and cleaned. Cleaning equipment stored by the 3-compartment sink was moved to avoid possible contamination of food-contact areas. Log obtained for documentation of sanitizer concentrations. Unlabeled drink pitchers were removed from the window sill and cleaned. The window sill was cleaned of dirt and lint. The cleaning bucket was moved away from the spice shelf with cooking products. The kitchen maintenance room was checked for contamination and hazards, and all equipment and cleaning products were removed and/or relocated. The floor of the maintenance storage room was cleaned, and detergent was stored. The 3-tier metal shelving unit in the storage room was cleaned. The floor of the storage room was cleaned of dirt and debris. All meal delivery carts have been cleaned. Kitchen refrigerator fans have been cleaned, as well as the ceiling. Unlabeled and use-by date deli meat has been discarded. Coffee cups with white film in Pavillon dining room have been discarded, as well as an open cereal bag in a box. Metal banquet pans have been cleaned. The refrigerator has been cleaned, and outdated sandwiches and unmarked peaches have been discarded. Resident Pavillon pantry has been cleaned; all outdated, outdated, or opened food items have been discarded. Dirty dishes have been removed for cleaning. The refrigerator and freezer have been cleaned. 2. Corporate Dietary Service manager will complete a detailed and thorough audit of the main kitchen, maintenance storage area, food storage area, walk-in refrigerator and freezer areas, as well as all pantries on nursing units, and ensure areas are compliant. 3. Dietary Manager/designee will educate dietary staff on regulation requirements for food procurement, storage, preparation, serving, and maintaining a sanitary environment. 4. Corporate Dietary Service manager or designee will complete visual inspections and audits of kitchen areas as well as pantries twice a week for eight weeks. Results of audits will be reviewed by the QAPI committee.
Failure to Maintain Clean and Sanitary Resident Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean and sanitary environment in the West Resident Unit. In Room W-16, a large amount of a white substance from an incontinent brief was found strewn under and around a bed, with the floor showing liquid stains, visible dirt, and paper debris. A fall mat was propped against the bathroom door frame and was visibly soiled with dark liquid stains and dirt. Additional rooms, W-9 and W-11, were also noted to have dried liquid stains and dirt on the floors. A resident was observed seated in a wheelchair outside her room with a brown liquid substance on her clothing, wheelchair seat, and tires. Multiple large puddles of the same brown liquid were present under the wheelchair and extended along the floor. The resident reported having a bowel incontinence episode, activating her call bell, and waiting more than fifteen minutes for assistance. Staff interviews revealed that the nurse aide assigned to the resident had to leave due to an emergency, and other aides were occupied with their assigned tasks. The DON confirmed that all resident care and common areas are required to be kept clean and sanitary.
Plan Of Correction
1. Rooms W 8, 9, 11, & 16 including floors and any fall mats, were deep cleaned. Incontinence care was provided to Resident # 12 on 10/4/25. Resident # 12 w/c seat and wheels were cleaned. 2. EVS supervisor to complete an initial audit of all resident rooms, fall mats, and wheelchairs to ensure cleanliness. Any items identified as not clean will be cleaned. 3. EVS supervisor with provide education to housekeeping staff on room cleanliness standards. 4. EVS Supervisor or designee will complete room audits 3 x week for cleanliness of flooring, fall mats and chairs. Audits will be completed 3 x week x 4 weeks, then weekly x 4 weeks. Results of audits will be reviewed at facility QAPI committee.
Immediate Jeopardy: Hazardous Chemical Served to Residents Due to Administrative Oversight
Penalty
Summary
The facility's administration failed to effectively use its resources to promote resident safety and maintain the highest practicable physical and mental well-being of residents. Specifically, the administration did not ensure resident safety when the dietary department served a hazardous cleaning chemical to residents during meal service. As a result, ten out of fifty-seven residents ingested the chemical, placing all residents in the East Wing at risk of consuming a hazardous substance and resulting in an immediate jeopardy to resident health and safety. A review of the job descriptions for the Nursing Home Administrator (NHA) and Director of Nursing (DON) revealed that their responsibilities include overseeing the safety and cleanliness of the facility, ensuring hazardous conditions are addressed, and monitoring departmental operations. The facility failed to carry out these administrative responsibilities, as evidenced by the lack of effective oversight in the safe handling, storage, and labeling of hazardous chemicals within the dietary department. Interviews with staff confirmed that dietary personnel had not received effective training or competency evaluation regarding the safe handling, storage, and labeling of hazardous chemicals in accordance with facility policy and procedure. This lack of oversight and resource utilization by the Administrator and DON contributed to the immediate jeopardy situation, as they did not monitor departmental operations, identify systemic risks, or ensure the implementation of facility policies to maintain resident safety.
Plan Of Correction
Unable to retro correct deficient practice. 2. NHA/ designee will direct and lead and direct the overall operations of the facility and ensure that the Corporate Dietary Service manager provided education to all dietary staff on proper use and storage of kitchen chemicals. NHA will ensure that Corporate Dietary Service manager/ designee is present in the facility to inspect, direct and oversee the dietary personnel to ensure regulatory compliance. In the absence of the NHA, DON will assume these responsibilities. 3. Regional Director of Operations/ designee will provide education to the NHA and DON on Administrative Duties and responsibilities. 4. Regional Director of Operations/designee will follow-up weekly by reviewing audits to ensure the NHA and DON are providing effective and efficient administrative oversight. Audit findings will be reviewed at facility QAPI meeting.
Failure to Meet Minimum LPN Staffing Requirements
Penalty
Summary
The facility failed to meet the required minimum staffing levels for licensed practical nurses (LPNs) as mandated by regulation. Specifically, on two days during the reviewed period, the facility did not provide at least one LPN per 25 residents on the day shift, and on two separate days, did not provide at least one LPN per 40 residents on the night shift. This was determined through a review of the facility's census data and nursing time schedules, which showed that the actual LPN hours worked were less than the required hours for the number of residents present. The Nursing Home Administrator confirmed during an interview that the minimum LPN staffing requirements were not met on these days. No information was provided regarding the specific residents affected, their medical history, or their condition at the time of the deficiency.
Plan Of Correction
Date of POC Updated to reflect reason for previous rejection: 1. The facility cannot correct that the LPN staffing ratio was not met on one LPN per 25 residents on the morning shift on two of five days (9/27/25 and 9/28/25) and one LPN per 40 residents on the night shift on two of five days (9/25/25, and 9/30/25). There were no adverse effects to residents on the identified dates. 2. The facility will ensure that staffing ratios are met every shift. 3. A Daily staffing meeting with scheduler will be held by administration to monitor staffing ratios. Staffing ratios will be reviewed at Standup and Stand down. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects not to meet staffing ratios on a shift, nursing administration/designee will be responsible to call off duty personnel or call extra support staff. --- Date of POC Updated to reflect reason for previous rejection: 1. The facility cannot correct that the LPN staffing ratio was not met on one LPN per 25 residents on the morning shift on two of five days (9/27/25 and 9/28/25) and one LPN per 40 residents on the night shift on two of five days (9/25/25, and 9/30/25). There were no adverse effects to residents on the identified dates. 2. The facility will ensure that staffing ratios are met every shift. 3. A Daily staffing meeting with scheduler will be held by administration to monitor staffing ratios. Staffing ratios will be reviewed at Standup and Stand down. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects not to meet staffing ratios on a shift, nursing administration/designee will be responsible to call off duty personnel or call extra support staff. 4. The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for three months to ensure staffing ratios are met. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.
Failure to Timely Return Resident Personal Funds After Discharge or Death
Penalty
Summary
The facility failed to comply with federal and state regulations regarding the timely return of resident personal funds following discharge or death. Specifically, for two residents, the facility did not return the funds within the required 30-day period. One resident, who had diagnoses including cancer, high blood pressure, and diabetes, was admitted and subsequently passed away. Despite multiple inquiries from the family, the responsible party had not received the refund of $385.00 as of several months after the resident's death. The business office confirmed that billing is managed by a third-party company and acknowledged the delay in refunding the personal funds. A second resident, with medical conditions including diabetes, cerebral infarction, and high blood pressure, also passed away while at the facility. The responsible party for this resident was due a refund of $2,530.00. Although the business office stated that the refund was processed by the third-party company, the facility was unable to provide documentation, such as a copy of the check or a bank statement, to confirm that the funds were actually returned. Staff interviews confirmed that the personal funds for both residents were not refunded to the families within the required timeframe.
Plan Of Correction
The facility cannot correct the past. Resident refunds for R1 who expired 5/5/25 and R2 who expired 5/21/25. The facility will ensure all resident funds for residents who expired/discharged are refunded within the 30-day requirement. Business Office Manager and Wellsky Representative will be re-educated by the Administrator on ensuring resident funds are refunded within 30 days of discharge/expiration. Daily Business Office Meetings will be held by administration to review discharges and confirm if refund has been processed by the facility and Wellsky. The Nursing Home Administrator/designee will audit resident fund accounts for discharges daily for one month, then monthly for 3 months to ensure requirements are being met. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.
Some of the Latest Corrective Actions taken by Facilities in Pennsylvania
Policy & System Changes
- Reviewed and revised the facility elopement policy to strengthen prevention measures (J - F0689 - PA)
- Updated resident‐escort procedures and created an office-to-facility return protocol to ensure residents are not left unattended after appointments (K - F0689 - PA)
- Implemented a staffing ratio of one staff member for every eight resident smokers to provide adequate supervision during smoking times (J - F0689 - PA)
- Placed lists of residents at risk for elopement at each nursing station to keep staff continuously aware of high-risk individuals (J - F0689 - PA)
- Installed elopement binders with resident photos at all nurses’ stations and reception areas for rapid identification of at-risk residents (J - F0689 - PA) (J - F0689 - PA)
- Added a protective cover over the exit-door release button to limit unauthorized resident egress (J - F0689 - PA)
- Established daily door-alarm functionality audits by maintenance to ensure exit alarms remain operable (J - F0689 - PA)
- Instituted validation checks of resident returns from off-site appointments before closing transportation logs (K - F0689 - PA)
- Started head counts of all residents each shift against census to detect missing residents promptly (J - F0689 - PA)
- Integrated elopement-risk screening into admission, quarterly reviews, and daily stand-up audits to keep care plans and interventions current (J - F0689 - PA) (J - F0689 - PA)
Staff Education & Drills
- Trained staff on escort requirements for off-site appointments to prevent unsupervised outings (K - F0689 - PA)
- Educated all staff, including agency personnel, on revised elopement policies, documentation of exit-seeking behaviors, reporting protocols, and intervention implementation (J - F0689 - PA)
- Provided comprehensive training on dementia behaviors, elopement-risk mitigation, alarm response, resident re-orientation, lobby monitoring, code 10 procedures, and safety checks (J - F0689 - PA)
- Educated staff on the facility’s smoking prohibition and supervision requirements to reduce unsupervised exits for smoking (J - F0689 - PA)
- Incorporated elopement-risk, missing-person, and visitor-badge procedures into new-employee orientation to sustain competence in future staff cohorts (J - F0689 - PA)
- Conducted elopement drills every shift and instituted monthly drills on all shifts to reinforce rapid response skills (K - F0689 - PA) (J - F0689 - PA)
- Educated reception and security staff on enforcing visitor-badge return prior to door release to control building egress (J - F0689 - PA)
- Held interdisciplinary huddles to review residents with frequent leave-of-absence orders and early signs of elopement risk to enhance proactive monitoring (J - F0689 - PA)
Failure to Educate Staff on Safe Food Heating Results in Resident Burn
Penalty
Summary
The facility failed to ensure that direct care staff were educated on the safe process for heating and reheating food, as required by facility policy. The policy specified that food and beverages must be heated, stirred, temperature-checked, stirred again, and re-checked before being served to residents, with temperatures maintained between 140°F and 165°F to minimize the risk of burns. However, a licensed nurse who had not received this education prepared instant ramen soup for a resident and did not check the temperature before serving it. The resident involved had diagnoses of diabetes and peripheral vascular disease, was cognitively intact, and required set-up assistance with feeding. After the soup was served, the resident spilled it on their chest, resulting in a second-degree burn. Observations and clinical documentation confirmed the presence of a significant burn area on the resident's chest and abdomen, and the resident reported pain following the incident. Progress notes and wound care consults documented the extent and treatment of the burn. Interviews and facility documentation revealed that the nurse did not follow the required procedure for checking food temperature, and there was no evidence of temperature documentation for the soup. The Nursing Home Administrator confirmed that the staff member had not been trained on the safe food heating policy, and further acknowledged that all direct care staff, including nurses and nursing assistants, had not received this education. This lack of staff education and failure to follow policy led to an Immediate Jeopardy situation when the resident sustained a burn from overheated food.
Removal Plan
- Education was provided to the staff
- A whole house audit was conducted to check all microwaves in the facility had thermometers attached to it
- All residents were assessed to ensure no other residents received a burn from re-heated food items
- Process signage for re-heating food in the microwave were attached to the microwaves
- House-wide education developed and implemented for all facility staff on re-heating process, education was implemented and presented during the new hire and agency orientation
- Dietary performed audits to ensure thermometers are present and functioning on all microwaves in resident areas
- Audits were completed and ongoing
- The outcome of audits will be reviewed at the QA meeting
Failure to Supervise Severely Cognitively Impaired Resident During Offsite Appointment
Penalty
Summary
The facility failed to provide adequate supervision to prevent elopement for a resident with severe cognitive impairment, resulting in an immediate jeopardy situation for multiple residents. Specifically, a resident with a BIMS score of 6, indicating severe cognitive impairment, was allowed to leave the facility unaccompanied for a medical appointment, despite facility policy requiring an escort for residents with a BIMS score lower than 13. The resident was not identified as at risk for elopement in the care plan, and the physician's order permitted the resident to leave unaccompanied when arranged by the facility. During the appointment, the resident was left unsupervised in the lobby, was not picked up as planned, and subsequently left the premises independently by calling a ride service and returning to his home. Review of facility records revealed that several other residents with severe cognitive impairment also had orders allowing them to leave the facility unaccompanied, contrary to the established escort protocol. Staff interviews confirmed that residents with severe cognitive impairment should not be permitted to leave unaccompanied, and that new residents should not have such orders until evaluated by a provider. Despite these protocols, the facility failed to ensure that care plans and physician orders were consistent with the residents' cognitive status and supervision needs. The incident was further compounded by the lack of elopement-related goals and interventions in the affected resident's care plan, and the absence of appropriate supervision during the transfer process. The resident was reported missing after the appointment, prompting a police search and notification of emergency services. The resident was eventually located at his home, having left the appointment site without facility staff knowledge or supervision. This failure to provide adequate supervision and to follow established protocols resulted in an immediate jeopardy situation for all residents with similar cognitive impairments.
Removal Plan
- Complete AMA discharge at residence.
- Call emergency services for hospital transfer for PICC removal.
- Notify Adult Protective Services.
- Notify Ombudsman.
- Review escort protocol.
- Educate staff on sending residents to appointments with escorts.
- Update elopement book.
- Conduct wellness check on resident.
- Conduct elopement drills every shift.
- Validate appointment returns.
- Develop protocol for offices to call building or driver for return and not put residents in the lobby.
- Review upcoming appointments and determine if escorts are needed in morning meeting.
- Update care plans.
Failure to Ensure Nursing Staff Competency with Insulin Pump Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies and skill sets to care for a resident using an insulin pump, resulting in immediate jeopardy to the resident's health and safety. The Director of Nursing confirmed that there was no policy in place for insulin pumps, and the facility's policy on competent nursing staff was not followed in this case. Clinical record review showed that a resident with multiple diagnoses, including diabetes, was admitted with an insulin pump, but the nursing admission evaluation did not document the presence of the pump, and the care plan did not address its management. Multiple interviews with RNs and LPNs revealed that none of the nursing staff, including agency staff, had received education or training on insulin pumps. Staff members were unfamiliar with the device, its maintenance, and its operation, with some only having personal knowledge from outside the facility. One LPN, who was working her first shift at the facility, transcribed hospital discharge orders incorrectly, entering the wrong insulin type and route of administration due to lack of training and orientation. This error led to the administration of insulin subcutaneously instead of refilling the pump, resulting in the resident experiencing hypoglycemia and requiring hospital transfer for an accidental insulin overdose. The employee file for the LPN who made the error did not contain evidence of facility orientation or training on the admission process, order transcription, or insulin pump management. The Director of Nursing and Nursing Home Administrator confirmed that staff were not trained on insulin pumps or related processes, and that this lack of training and competency directly resulted in a negative outcome for the resident.
Removal Plan
- Audit residents to identify specialty equipment. If specialty equipment is identified, obtain physician orders. Update care plans to include specialty equipment if applicable.
- Audit admission assessments for residents for special equipment specifically insulin pumps and/or continuous glucose monitors.
- Audit physician orders from discharge paperwork for residents for accuracy.
- Conduct pre-admission resident screening to identify any special equipment. Communicate special equipment needs to the nursing team prior to resident admission. Educate Admissions Director on this process.
- Educate licensed nursing staff (including agency) on conducting pre-admission resident screening to identify any special equipment and communicating special equipment needs to the nursing team prior to resident admission.
- Educate licensed nursing staff (including agency) on assessing residents upon admission for special equipment including insulin pumps/continuous glucose monitors.
- Educate licensed nursing staff (including agency) on obtaining physician orders for specialty equipment.
- Educate licensed nursing staff (including agency) on accurate order transcription and admission red lining processes.
- Educate licensed nursing staff (including agency) on care plan updates on specialty equipment.
- Educate licensed nursing staff (including agency) on updated processes.
- Update and review facility policy on medication administration to include specialty equipment, obtaining physician orders, and updating care plans.
- Conduct audits of new resident admission assessments to ensure assessments, redlining, and orders are completed and accurate.
- Submit findings of audits through facility Quality Assurance and Performance Improvement program.
Failure to Prevent Elopement and Identify At-Risk Residents
Penalty
Summary
The facility failed to provide adequate supervision and monitoring to prevent accidents, specifically elopement, for two residents. One resident, who was assessed as being at risk for elopement due to cognitive impairment, poor decision-making skills, and exit-seeking behavior, was able to leave the facility unsupervised. This resident exited the building when a CNA was assisting other residents to a smoking area, and the door was opened using a code that temporarily disabled the Wanderguard alarm system. The resident was not identified as a smoker and was not being directly supervised at the time, allowing him to leave unnoticed until another resident alerted staff. Another resident, also with cognitive impairment and a history of exit-seeking behavior, was not properly identified as an elopement risk. Although this resident had previously been assessed as at risk and had a Wanderguard device ordered, the device was discontinued after one week without documented evidence of ongoing risk assessment or justification. Staff interviews revealed that this resident had managed to exit the building with visitors and had to be redirected frequently due to continued exit-seeking behaviors. However, the resident was not included in the facility's elopement risk binder, and key staff, including the NHA, were unaware of her risk status or previous incidents. Observations and staff interviews indicated a lack of consistent documentation and communication regarding which residents were at risk for elopement and who required supervision during high-risk activities such as smoking breaks. Staff relied on informal knowledge rather than documented lists, and there was insufficient supervision during these times. The facility's failure to identify and supervise residents at risk for elopement resulted in one resident leaving the premises without staff knowledge and another resident's risk not being properly managed or communicated.
Removal Plan
- The facility reviewed and revised the elopement policy.
- The Director of Nursing or designee will complete assessments on all residents to identify their risk for elopement, and care plans will be updated to reflect the residents' current condition, risk for elopement and resident centered interventions.
- A list of residents at risk for elopement will be placed at each nursing station to inform staff of residents at risk.
- The Nursing Home Administrator or Designee will educate all staff, including agency staff, on elopement policies and procedures, documenting residents with exit seeking behaviors, reporting exit seeking behaviors to administration and implementing proper interventions for these residents prior to staff's next scheduled shift.
- The facility will allocate additional staff members to supervise smokers to ensure appropriate supervision is available to meet residents.
- The facility will have one staff member for every eight residents who smoke.
- The Facility will complete a head count of all residents each shift to ensure residents are safe and provided adequate supervision.
- The Director of Nursing of Designee will review progress notes daily to identify any residents with new exit seeking behaviors to ensure appropriate interventions are in place.
- The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for frequency of audits.
Failure to Prevent Elopement Due to Inadequate Supervision and Care Planning
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident who was identified as being at risk for wandering and exit-seeking behaviors. The resident had a history of cognitive impairment, poor decision-making skills, and demonstrated wandering and exit-seeking behaviors, as documented in an Elopement Risk Assessment. Despite these findings, the resident's care plan did not include any interventions to address elopement risk, and there were no physician orders for elopement prevention measures. On the day of the incident, the resident was last seen by staff in a recliner in the community room and later in another resident's room before being returned to his own room around 7:30 p.m. The resident was left unsupervised, and staff failed to monitor the front door, which allowed the resident to exit the facility without detection. The absence of supervision at the front desk was confirmed by video footage, contradicting an initial staff statement. The facility did not document the resident's wandering behaviors in the progress notes, and there was no immediate notification to local authorities by the facility when the resident was discovered missing. The resident was found by police in a nearby residential area without shoes and with no memory of how he arrived there. The police were alerted by a passer-by, not the facility, and the resident was subsequently taken to the emergency department for evaluation. The incident revealed gaps in supervision, documentation, and adherence to elopement prevention protocols, resulting in an immediate jeopardy situation for the resident.
Removal Plan
- Complete a root cause analysis to validate the cause of the resident elopement.
- Complete a head count to ensure all residents are accounted for.
- Reassess the resident upon return from the hospital and implement frequent checks.
- Audit all elopement books to ensure accuracy.
- Review and assess all residents for elopement risk, wandering, and update care plans and orders to include appropriate interventions.
- Assess all residents in house for elopement risk by the Director of Nursing or designee.
- Review and update care plans for residents identified with elopement risks with interventions to prevent elopement by the Director of Nursing or designee.
- Add all residents identified to be elopement risk to Elopement Binder per protocol.
- Conduct a house audit on all doors and exit points to ensure that facility is secure and alarms are functional by Maintenance.
- Conduct education to all facility staff regarding dementia/behavior in LTC residents, elopement risk and mitigation, and elopement policy and procedures to include keeping doors secure.
- Educate all staff on elopement interventions such as responding to alarms, reorienting wandering patients, encouraging activities, monitoring the front lobby and sign in sheet, code 10, and safety checks.
- Educate staff that all residents assessed as an elopement risk will have their picture and face sheet in the elopement book.
- Place elopement books with identified resident photos on all nurses' stations in addition to the current one at the receptionist's desk by the Administrator or designee.
- Screen newly admitted residents for elopement risk on admission, quarterly and as needed, and update care plans appropriately.
- Place new admissions and any resident assessed as an elopement risk in the elopement book that includes photograph and face sheets. Book is available for staff to review and monitor at all times.
- Investigate all incidents, perform root cause analysis and follow up with appropriate interventions by the DON or designee.
- Review elopement interventions and update as required by the QAPI team.
- Ensure the front door is monitored 24 hours 7 days a week by the RN supervisor until the wander guard system is installed.
- Review the lobby monitoring sign in sheet regularly.
- Audit door alarms daily by maintenance.
- Conduct elopement drills monthly on all shifts.
- Monitor the plan of correction by QAPI including all door audits, elopement book, elopement drills and all new admissions will be audited for elopement risk.
- Monitor the plan of correction at the Quality Assurance and Process Improvement meeting until consistent substantial compliance has been met.
Failure to Prevent Elopement and Ensure Smoking Safety
Penalty
Summary
The facility failed to implement sufficient monitoring interventions and supervision to prevent an elopement incident involving a resident. The resident, who had a history of traumatic subdural hemorrhage, mild cognitive impairment, COPD, type 2 diabetes, repeated falls, anxiety, depression, and nicotine dependence, was able to exit the facility without staff awareness. The resident left the premises by unlocking the door and leaving the property to purchase cigarettes, despite the facility's status as a tobacco-free, non-smoking environment. Staff interviews and documentation confirmed that the resident was able to access the door release button and leave the facility unsupervised. Prior to the elopement, there was no evidence that the facility had conducted a safe smoking assessment or implemented any safety interventions related to the resident's smoking habits. Progress notes indicated that the resident had previously been caught smoking inside the facility and had expressed frustration about not being able to smoke, but no additional safety measures or care plan updates were documented. The resident's care plan and progress notes lacked any interventions or updates addressing elopement risk or smoking safety from the time of the incident until the investigation several days later. Staff interviews revealed that the resident's cigarettes and lighter were kept in a locked medication cart, and when the resident requested a cigarette, staff would provide them and allow the resident to smoke on the porch. However, there was no supervision or monitoring in place to prevent the resident from leaving the property. The facility was unable to provide a smoking policy when requested, and there was no documentation of the elopement in the progress notes until the investigation began. At the time of the investigation, no elopement prevention interventions had been implemented for the resident.
Removal Plan
- Resident will have a smoking assessment completed. Resident will have supervised smoking three times per day until discharged to a smoking facility, or until discharged to his residence.
- All residents will be assessed for elopement risk by the director of nursing or designee.
- All care plans for residents identified with elopement risks will be reviewed and updated if needed with interventions to prevent elopement by the Director of Nursing or designee.
- A facility care feed message will be sent to families reminding them that the facility is a non-smoking facility and resident smoking is prohibited.
- Education will be completed by all staff on elopement risks, assessments, and supervision of residents by the director of nursing or designee.
- Education will be provided to all staff on facility smoking policy. Facility is a non-smoking facility for residents.
- Elopement books with identified resident photos will be placed on all nurses stations in addition to the current one at the receptionist's desk by the Administrator or designee.
- A protective device will be placed over the exit door button to prevent residents from access.
- Audits will be implemented to ensure residents are adhering to the facility smoking policy by the Director of nursing or designee.
- New admissions will be audited for elopement and smoking risks at morning stand up meeting by the director of nursing or designee to ensure appropriate interventions are in place as needed.
- An Ad Hoc Quality Assurance and Process Improvement Meeting will be held by the Administrator or designee.
- This part of correction will be monitored at the Quality Assurance and Process Improvement meeting until such time consistent substantial compliance has been met.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Protocol Lapses
Penalty
Summary
A deficiency occurred when a resident with a history of repeated falls, difficulty walking, pelvic fracture, and cognitive impairment was able to leave the facility without a physician's order for a leave of absence (LOA) and without staff supervision. The resident, who required one-person assistance for ambulation and had a moderately impaired cognitive status as indicated by a BIMS score of 10, exited the third floor via elevator and walked out the front entrance using a walker. The resident was not identified as having an LOA order in the clinical records, and there was no documentation of staff being notified or a sign-out process being followed. Facility policy required that residents at risk for wandering or elopement have care plans with specific interventions and that staff intervene if a resident attempts to leave. However, the receptionist on duty did not recognize the resident as a facility resident, mistaking her for a visitor due to her appearance. The receptionist was distracted by personal computer use and failed to follow the protocol of ensuring all residents and visitors sign out and wear visitor badges. Surveillance footage confirmed that the receptionist opened the door for the resident, who then left the premises unchallenged. Staff interviews revealed that the assigned nursing assistant was aware the resident wanted to walk but did not clarify the resident's intentions or monitor her whereabouts. The resident was later found approximately 1.2 miles away in a busy area after being missing for about two hours. The failure to provide adequate supervision and to follow established LOA and visitation protocols resulted in the resident leaving the facility unsupervised, placing her at high risk for injury.
Removal Plan
- Resident was assisted back to the Center and assessed by RN Supervisor for injuries.
- The Center completed a headcount of all residents and compared it to the midnight census to ensure all residents were accounted for.
- The Nursing Administration held huddles with staff to discuss residents who go on frequent LOAs and signs and symptoms that may indicate risk for leaving the Center without staff notification.
- Shift RN Supervisor provided immediate education to receptionist on duty.
- RN Supervisors were educated on the completion of headcount of all residents compared to midnight census and the immediate reporting of any discrepancy to the Director of Nursing/designee.
- Staff were educated on signs and symptoms that may indicate a risk of elopement.
- Reception/security staff were educated on the process of each visitor receiving a badge that must be returned prior to door being opened and visitor leaving the premise.
- Staff educated on elopement/missing person policy and procedure including code yellow announcement to notify staff in Center, search both on the premises and the surrounding areas, notification processes including local police department.
- Staff educated on elopement drills including how often and expected response.
- All the training above will be added to our general orientation schedule for all new future employees.
- Residents with a current unsupervised LOA order were re-educated on the LOA policy/agreement and understood the sign out process with both the nursing staff on the unit.
- Auditing census compared to headcount every 4 hours for 3 days then every shift for 14 days then daily. All variances will be reported to the QAPI Committee monthly.
- Random audit of five visitors to ensure compliance with the visitor pass system two times daily for 14 days then daily for two months. All variances will be reported to the QAPI Committee monthly.
- Daily audit of LOA log to ensure reception/security staff are checking for clearance to leave the Center. The audit will be completed daily for three weeks with all variances reported during the clinical meeting.
- The QAPI Committee will make recommendations to ensure continued compliance. Upon sustained compliance, the QAPI Committee will recommend the reduction or resolution of the audits and the reception/security staff.
Explore Popular Searches
