Systemic Administrative and Clinical Failures Leading to Missed Care, Worsening Wounds, and Medication Errors
Summary
The deficiency involves a failure of facility administration and nursing leadership to provide adequate oversight of wound care, medication administration, treatment administration, quality assurance, and basic activities of daily living. The Administrator-in-Training did not hold a temporary license and had been functioning in the role since July 2025 under a regional VP of Operations who was not present in the building daily. The DON role was filled on an interim basis, and staff reported that management kept office doors closed, was not consistently present in the building, and did not effectively address staffing or care problems. The facility did not have a full-time Activity Director, and activities were not provided daily, with no activity calendar posted and no planned activities after 4:00 PM or on weekends. Multiple residents experienced missed or delayed wound care, skin assessments, and gastrostomy tube (g-tube) care. One resident was admitted without pressure ulcers and later developed a stage 3 coccyx ulcer for which treatment was delayed 24 hours and then missed 16 times, ultimately progressing to a stage IV sacral ulcer with concern for osteomyelitis and hospitalization for severe sepsis. Another resident with a pre-existing stage IV sacral ulcer was hospitalized for sepsis related to the wound and osteomyelitis, returned to the facility, and then had multiple missed wound treatments. This same resident’s rectal tube was accidentally removed and not replaced due to lack of supplies, leaving the sacral wound exposed to fecal matter for extended periods, and g-tube site care and residual checks were repeatedly not completed, with subsequent hospitalization for sepsis with suspected sources including g-tube site infection and the stage IV sacral wound. Medication administration was not reliably carried out as ordered. One resident missed 18 scheduled doses of significant medications, including anticoagulants, anticonvulsants, antihypertensives, nutritional supplements, and stimulants, with documentation indicating medications were on order or not available. Another resident did not receive any scheduled doses of ordered Norco over several days, and additional residents missed multiple doses of anticonvulsants, antihypertensives, and anticoagulant injections. The facility nurse practitioner reported awareness of problems with medication availability. Documentation and oversight of showers and basic hygiene were also deficient, as several residents had no evidence of receiving showers over a two-month period, and the interim DON confirmed that no one was overseeing whether showers were completed and documented. Staff interviews and observations further demonstrated systemic failures in supervision and quality assurance. CNAs and nurses reported chronic short staffing, heavy reliance on agency staff, delayed call light response, missed pain medications, and wound treatments not being done daily. Staff stated that management told them not to disclose issues to surveyors and that concerns about staffing and care were not addressed. The wound nurse/infection preventionist reported not being educated on the wound process, not having wound logs when starting in December 2025, and not being delegated responsibility for monitoring MARs and TARs until early February 2026. The medical director stated that continuity of care was affected by staff and management changes and that he had not been informed of widespread missing treatments, medications, and care concerns. The facility lacked documentation of annual QAPI training for staff, required CNA in-service hours, and quarterly QAA meetings, with leadership confirming that QAA meetings had not been held since July 2025.
Removal Plan
- V2 (Interim DON) and V4 (ADON/Wound Nurse) in-serviced all licensed nurses on Physician Orders—Entering and Processing and Documentation in the Health Record, including the Physician Orders—Entering and Processing policy; orders are entered into the EMR by V2 and V4.
- V2 and V4 in-serviced all licensed nurses on Pressure Injury and Skin Condition Assessment and Documentation—Electronic Health Record policy (entries must be timely, accurate, relevant, and complete by V2 or V1).
- V2 and V4 in-serviced all staff on Change of Condition and Physician-Family Notification, including the Physician-Family Notification—Change in Condition policy.
- V2 and V4 in-serviced all staff on Comprehensive Care Plan/Baseline Care Plan, including the Baseline Care Plan.
- V2 and V4 in-serviced all staff on admission of residents, including the Admission of Resident Care Plan.
- V2 and V4 in-serviced all staff on the Resident/Admission–Readmission Checklist, including the admission checklist.
- V2 and V4 in-serviced the IDT on Comprehensive Care Plan, including the Comprehensive Care Plan.
- V2 and V4 in-serviced all staff on Infection Prevention and Control Program, including the Infection Prevention and Control Program policy.
- Initiated a facility audit to identify all residents with pressure ulcers, including completing wound assessments, contacting the physician and wound nurse, reassessing wounds in 24 hours, and obtaining consents to see the wound physician; 56 residents were assessed.
- V2 and V4 in-serviced staff on Pressure Injury and Skin Condition Assessment and implemented a process requiring the direct care nurse to review the TAR prior to providing wound care.
- V2 and V4 in-serviced staff on Pressure Ulcer Prevention and multiple related policies (Med Error/Adverse Drug Reaction, Physician Orders—Entering and Processing, Documentation—Health Record, Comprehensive Care Plan/Baseline Care Plan) and implemented a process to train staff on pressure ulcer prevention/worsening prevention interventions (review care plan before care; follow skin policy; weekly skin assessments; follow physician orders; identify residents dependent for repositioning; dietary/clinical follow meal ticket/orders for diet/supplements; review MAR/TAR prior to med pass and wound care; skin assessments on return from hospital; open risk management for skin breakdown and notify wound nurse/DON).
- V2 and V4 in-serviced all staff on Pressure Injury and Skin Condition Assessment and Skin Condition Assessment and Monitoring Pressure and Non-Pressure, including the Pressure Injury and Skin Condition Assessment policy.
- V2 and V4 in-serviced all nurses and CNAs on Pressure Ulcer Prevention, including the Pressure Ulcer Prevention policy.
- Began a facility-wide audit of all residents’ wound care plans and updated wound care plans.
- Completed a facility-wide review/audit of residents with wounds for needed changes and updated the physician; produced a wound report.
- Educated all licensed nurses on the complete Gastrostomy Tube—Feeding and Care policy (by V2, V3, and V4).
- Completed a facility-wide audit of all residents with gastrostomy tubes to ensure stoma site treatment orders, tube feeding orders in EHR, residual checks on MAR, monitoring/notification for GI symptoms, documentation of stoma abnormalities and physician notification, and care plan review/updates on TAR by the nurse (V2/designee).
- V3, V4, and V46 in-serviced all licensed staff and CNAs on the facility’s Pain Management Policy.
- V3, V4, and V46 in-serviced all licensed staff and CNAs on the facility’s Pain Assessment Policy.
- V3 and V4 in-serviced all licensed nurses on Medication Administration General Guidelines.
- V3 and V46 in-serviced all licensed nurses and CNAs on the Resident Rounds Policy and procedure.
- V3 and V46 in-serviced all clinical staff on the Bathing—Shower and Tub Policy.
- V3 and V4 in-serviced all staff on the Incontinence Care Policy and Procedures.
- V1 (AIT) in-serviced V25 (Housekeeping Supervisor) on the Activities Program Policy.
- V1 (AIT) in-serviced all staff on the Residents Rights and Dignity Policy.
- V14 (Corporate President of Operations) in-serviced facility leadership on the facility Quality Assurance Performance Improvement (QAPI) Program Procedure.
- V14 in-serviced facility leadership on the Program of Angel Round to ensure leadership availability to residents, families, and staff.
- V14 in-serviced facility leadership on ensuring oversight and implementing policies for wound care, medication administration, treatment administration, quality assurance measures, and basic ADL resident care, including review of job descriptions.
- V14 re-oriented V1 (AIT) on Administrator duties for the facility.
- Held an impromptu meeting with the medical director and interdisciplinary team to discuss the deficiency and facility action plan.
- Performed an audit on one resident per day to ensure residents with pressure injuries have wound prevention orders in EMR and that wound assessments are completed upon admission/re-admission or weekly per policy.
- Performed an audit on one resident per day to ensure treatments were performed and initialed/dated per policy.
- Performed an audit on one resident per day to ensure care plans are revised timely and interventions are linked to the Kardex; treatments are charted and signed off in PCC.
- Performed an audit on one resident per day to ensure wound physician progress notes are reviewed and the Physician Order Sheet is updated (treatments, labs, supplements, pressure-relieving devices) prior to the next scheduled wound care.
- Performed an audit on one resident per day to ensure weekly skin assessments are completed by the responsible nurse.
- Performed an audit on one resident per day (five days per week) to ensure nurses review the TAR prior to performing wound care procedures.
- Performed an audit on one resident per week to ensure the Dietary Department provides the correct diet/supplements.
- Performed an audit on one resident per day to ensure Infection Prevention Guidelines are followed when performing wound care.
- Performed an audit on one new admission per day to ensure all required equipment and supplies are obtained and in the facility.
- Completed the missed administration report and medication administration report daily to ensure MAR accuracy and completeness per policy/procedure.
- Completed a daily audit to ensure residents with gastrostomy tubes have stoma site treatment orders, TAR sign-off for completion, tube feeding orders in EHR, residual checks on MAR, physician notification/documentation for GI symptoms, and documentation/notification for stoma abnormalities.
- Planned to monitor all residents’ MARs daily to ensure residents are not going without medication (including visibility of medications documented as on hold).
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with dementia, schizophrenia, and continuous O2 was observed on the smoking patio with cigarettes and a lighter in a plastic bag in her lap, despite staff stating she was supposed to use a smoking apron and that smoking materials were to be held by staff. Interviews showed the Administrator, DON, and Activity Director knew residents were keeping cigarettes and lighters on their person, that the smoking policy was not being enforced, and that residents with cognitive impairment or on O2 should not have access to smoking materials.
The facility failed to implement its abuse policy when a resident made multiple abuse allegations against two CNAs. Although the administrator, acting as Abuse Coordinator, stated that policy required immediate reporting, investigation, and removal of alleged perpetrators from duty, facility records showed both CNAs continued to work their scheduled shifts during the investigation periods. Additionally, an allegation of verbal abuse by the same resident was not investigated. Review of the abuse policy confirmed the requirement for reporting, investigation, and oversight to ensure policies are followed, but these measures were not carried out, compromising resident protection during the investigation of abuse allegations.
Facility leadership, including the NHA and DON, failed to effectively manage operations and nursing services to ensure adequate resident supervision, resulting in an elopement when a resident did not return from a leave of absence. Review of job descriptions, facility documents, clinical records, and staff interviews showed that the NHA and DON did not carry out their defined responsibilities to operate in accordance with federal and state regulations, and the current NHA and DON acknowledged that administration failed to provide adequate supervision, creating an immediate jeopardy situation.
Administrator A and the DON did not ensure effective management and oversight of resident care and services, resulting in widespread system failures affecting all 45 residents. Surveyors found deficiencies in resident dignity, informed consent for psychotropic medications, self-administration of meds, honoring meal preferences, responses to resident council concerns, protection of health information, grievance procedures, and handling of abuse allegations. Additional problems included missing or inaccurate MDS and PASSR assessments, lack of timely PASSR refiling for new diagnoses, incomplete or delayed baseline and updated care plans, failure to notify physicians of elevated blood sugars, and unaddressed accident hazards related to bed siderails. The facility also had issues with nebulizer and nasal cannula cleaning and storage, siderail assessments and consents, call light response times, controlled substance accountability, medication errors, and improper storage of drugs and biologicals, despite job descriptions assigning the administrator and DON responsibility for regulatory compliance and quality care.
Administration and nursing leadership failed to maintain safe hot water temperatures in all three resident areas (North Hall, South Hall, and corridor rooms). The NHA did not effectively carry out defined duties to ensure a safe, properly maintained environment and regulatory compliance, and the DON did not ensure nursing staff followed facility policies on safe water temperatures. As a result, residents were exposed to unsafe water temperatures in their rooms, creating Immediate Jeopardy under F689 (Accidents) and violating applicable state management and nursing services regulations.
The facility failed to prevent neglect of a resident on continuous oxygen and at high fall risk when staff did not perform required hourly safety checks, administer medications, provide the dinner meal, or ensure oxygen therapy for several hours after the resident was noted missing, and leadership (including the DON and Administrator) were unaware for weeks that the resident had been unaccounted for prior to being found unresponsive and later pronounced deceased. The facility also failed to enforce smoking safety policies for residents with unsafe smoking behaviors and oxygen use by limiting smoking assessments to admission only, not reassessing after repeated incidents, not increasing monitoring, allowing residents to retain smoking materials, and not ensuring oxygen was removed before entry into the smoking room, while the Medical Director was not informed of ongoing noncompliant smoking behavior.
Smoking Materials Not Controlled and Policy Not Enforced
Penalty
Summary
The facility administrative staff failed to use available resources effectively and efficiently to maintain the facility in a safe manner and to ensure the smoking policy was properly implemented. Surveyors observed a designated smoking patio where a resident was sitting in a wheelchair with a plastic bag in her lap that contained cigarettes and a lighter. Staff acknowledged that the resident was supposed to use a smoking apron while smoking and stated they were going to remove the cigarettes from her possession. Review of the resident’s record showed diagnoses of dementia, schizophrenia, and continuous oxygen use. The resident also had a roommate who was ordered to receive continuous oxygen. During interviews, the Administrator stated residents were only permitted to smoke during designated times and were not allowed to smoke in non-designated areas, and that staff were responsible for holding and storing residents’ lighters. The DON stated lighters were expected to be turned in after each smoking session and that the smoking box was kept at the nurse’s station, but acknowledged this restriction was not being enforced by staff. The Medical Director stated that, per facility policy, residents were not permitted to keep cigarettes or lighters and that smoking materials were to be supervised by staff regardless of cognitive level. He further stated that residents with cognitive issues or those receiving oxygen should not have access to smoking materials. The Activity Director acknowledged that multiple residents kept cigarettes and lighters with them and that some families provided smoking supplies. She also stated that she should begin auditing residents to determine who had smoking materials. The Administrator and DON further stated that smoking concerns had been identified months earlier, including residents smoking whenever they wanted, a nonworking fire alarm, and no fire watch, and that the issue had not been brought to QAPI and no PIP was in place.
Failure to Implement Abuse Policy and Protect Residents During Abuse Investigations
Penalty
Summary
The deficiency involves the facility administrator, who also served as the Abuse Coordinator, failing to effectively implement the facility’s abuse policy when allegations of abuse and neglect were made by Resident #1 on two separate occasions involving two different CNAs. Facility documentation and staff interviews showed that, despite the administrator’s statement that the policy required immediate reporting to state agencies, initiation of an investigation, and removal and suspension of the alleged perpetrator from the facility during the investigation, the alleged perpetrators were not removed from duty. In the first incident, involving CNA1, timecard records showed that CNA1 completed the shift on the day of the incident and continued to work subsequent shifts during the investigation period. In the second incident, involving CNA2, timecard records showed that CNA2 completed the scheduled shift on the day of the incident and continued to work multiple scheduled shifts afterward while the allegation was under investigation. The report further notes that Resident #1 also made an allegation of verbal abuse that was not investigated by the facility. Review of the facility’s “Abuse, Neglect, and Exploitation” policy indicated that the facility would designate an Abuse Coordinator responsible for reporting suspected abuse, neglect, or exploitation to the state survey agency and other officials, and that the facility would provide ongoing oversight and supervision of staff to ensure policies were implemented as written. The failure of the Abuse Coordinator to remove the alleged perpetrators from the facility during the investigations and to investigate the verbal abuse allegation did not ensure the safety and protection of Resident #1 and other residents from potential abuse, as stated in the findings.
Failure of Administration and Nursing Leadership to Prevent Resident Elopement
Penalty
Summary
The deficiency involves the failure of the Nursing Home Administrator (NHA) and the Director of Nursing (DON) to effectively manage the facility and ensure adequate supervision of residents, resulting in an elopement incident for one of forty residents (R1). The facility-provided job description for the NHA states that the NHA is responsible for directing the day-to-day functions of the facility, managing all aspects of operations, and ensuring resident safety and comfort in accordance with federal, state, and local regulations. The DON job description states that the DON is responsible for planning, organizing, developing, and directing the overall operation of the nursing department in accordance with Professional Nursing Law and applicable regulations. Despite these defined responsibilities, the facility did not take appropriate action when a resident failed to return from a leave of absence. Based on review of job descriptions, facility documents, clinical records, and staff interviews, surveyors determined that the previously employed NHA and DON did not fulfill their essential job duties to ensure that federal and state guidelines and regulations were followed. Specifically, the facility failed to provide adequate supervision to prevent an elopement, which created an immediate jeopardy situation for one resident. During an interview, the current NHA and current DON confirmed that facility administration had failed to effectively manage the facility to provide adequate supervision to prevent the elopement. The cited regulatory references include 28 Pa. Code 201.14(a) (Responsibility of licensee), 28 Pa. Code 201.18(b)(1)(3)(e)(1) (Management), and 28 Pa. Code 211.12(d)(1)(2)(3)(5) (Nursing services).
Systemic Administrative and Nursing Leadership Failures Affecting Resident Care and Services
Penalty
Summary
Administrator A and DON B failed to operate and administer the facility in a manner that ensured quality of life and overall well-being for all 45 residents. Surveyors, through observation, interview, record review, policy review, and job description review over multiple days, identified a widespread system breakdown in ensuring that services met professional standards. Deficient areas included resident dignity, informed decision-making for psychotropic medications, resident self-administration of medications, honoring resident meal choices and preferences, responding to resident concerns raised in resident council meetings, protecting resident health information, informing residents how to file grievances, and handling allegations of resident abuse. Additional failures involved obtaining and documenting consent and diagnoses for psychotropic medications, timely reporting of allegations, and providing Ombudsman reports upon discharge. Further findings showed failures in clinical and regulatory processes, including inaccurate MDS assessments and PASSR evaluations, not refiling PASSR when residents had new diagnoses, and not developing resident-specific baseline care plans within 48 hours of admission or updating care plans as needed. The facility did not consistently notify physicians of residents' increased blood sugar levels and did not adequately address accident hazards related to bed side rails. There were issues with nebulizer and nasal cannula cleaning and storage, bed siderail assessments, orders and consent, call light response times, controlled substance accountability, medication errors, and storage of drugs and biologicals. Administrator A confirmed responsibility for daily operations and acknowledged frustration with siderail issues, while job descriptions for both the administrator and DON documented their responsibility for ensuring regulatory compliance and quality care, which was not achieved in these areas.
Failure to Maintain Safe Hot Water Temperatures Resulting in Immediate Jeopardy
Penalty
Summary
Facility administration, including the Nursing Home Administrator (NHA) and Director of Nursing (DON), failed to ensure that hot water temperatures in resident care areas were maintained at safe levels. Review of the NHA’s job description showed responsibilities that included overseeing staff, explaining and assisting with facility policies and procedures, assuring the facility is properly maintained, clean and safe, maintaining necessary equipment and supplies, and ensuring adequate, properly trained personnel are on duty to meet resident needs and comply with regulations. Despite these defined duties, surveyors found that water temperatures in resident rooms on the North Hall, South Hall, and corridor rooms were not maintained at appropriate temperatures for resident safety, placing residents at risk for scalding injuries. The DON’s job description indicated responsibility for leading and managing the nursing department, overseeing clinical operations, supervising nursing staff, ensuring regulatory compliance, and collaborating with other department heads to promote quality outcomes in a resident-centered environment. However, the DON did not ensure that nursing staff followed facility policies related to safe water temperatures. As a result, residents in three of three resident areas (North Hall, South Hall, and corridor rooms) were exposed to unsafe water temperatures. Surveyors determined that this failure to maintain safe water temperatures and to ensure adherence to facility policies and regulatory requirements constituted Immediate Jeopardy under F689 (Accidents), as well as violations of specified Pennsylvania Code provisions related to licensee responsibility, management, and nursing services.
Failure to Prevent Resident Neglect and Enforce Smoking Safety Policies
Penalty
Summary
The deficiency involves the facility’s failure to administer operations in a way that ensured residents were free from neglect and that required systems for monitoring and care were functioning. For one resident with continuous oxygen use and a high fall risk, staff became aware around 4:15 PM that the resident could not be located on the unit, yet the facility did not ensure required hourly safety checks, medication administration, oxygen therapy, or provision of the dinner meal from approximately 4:00 PM to 9:00 PM. There was no timely staff communication, physician notification, or escalation of concern despite the resident not being seen for several hours. The resident was later found unresponsive on the floor at 9:49 PM, a STAT call was made, CPR was initiated, EMS took over, and the resident was pronounced deceased at 10:24 PM. The report notes that the DON recalled learning of the event through a hospitalization group chat message sent between 2:00 AM and 3:00 AM, which stated that the resident had been found unresponsive on the floor the prior evening. The DON stated they were not informed that the resident had been reported missing prior to being found and only became aware weeks later that the resident had reportedly been missing for several hours before discovery. The DON also stated that the Infection Control Director knew the resident had initially been reported missing, but this was not discussed in the morning meeting. The Administrator similarly reported first learning of the incident via a hospitalization group chat message after midnight and was unaware that the resident had been reported missing, had not been monitored hourly, had no documented dinner intake, and had not received medications between 4:00 PM and 9:00 PM. A second deficiency concerns the facility’s failure to enforce smoking safety policies for residents with known unsafe smoking behaviors and oxygen use. The Director of Recreation stated that smoking assessments were conducted only upon admission, not reassessed after repeated smoking incidents, and that they continued to provide education without clearly identifying further interventions. The Director of Recreation indicated that a smoking monitor should have removed oxygen before a resident on oxygen entered the smoking room and that residents should not have smoking materials, yet residents were found with such materials, which were then confiscated. The DON stated that one resident on hourly safety checks was not reassessed for safe smoking after each incident and that monitoring frequency was not increased despite repeated noncompliance. The DON also stated they were unaware that other residents had smoking materials or that there were smoking issues until surveyors arrived. The Medical Director reported not knowing about the resident’s noncompliant smoking behavior, acknowledged that smoking in a room with continuous oxygen is dangerous, and could not determine whether the resident was a safe smoker.
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