Cranberry Place
Inspection history, citations, penalties and survey trends for this long-term care facility in Cranberry Township, Pennsylvania.
- Location
- 5 Saint Francis Way, Cranberry Township, Pennsylvania 16066
- CMS Provider Number
- 395845
- Inspections on file
- 40
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 46
Citation history
Health deficiencies cited at Cranberry Place during CMS and state inspections, most recent first.
A resident with quadriplegia and intact cognition, care planned and documented as requiring a two-person assist for bed mobility, was being checked by a NA who knew another aide was supposed to assist. The NA rolled the resident toward herself, noted a bowel movement, and turned away to look for supplies while waiting for help, despite the two-person assist requirement. During this time, the resident slid off the bed to the floor. She was initially assessed with only redness to the upper back but complained of increased left leg pain, and was later transferred to the hospital, where she was found to have a left femoral neck fracture. Facility investigation determined the NA failed to follow the care plan and Kardex instructions for two-person bed mobility, and the NHA and DON substantiated neglect during care.
A resident with quadriplegia, intact cognition, and documented dependence for mobility was care planned and Kardexed for bed mobility with assist x2. Despite this, a NA began providing bed-level care alone, rolled the resident toward herself, and briefly turned away to locate supplies while waiting for additional help. During this interval, the resident slid from the bed to the floor. The resident was subsequently found on the floor, later complained of left leg pain, and was transferred to the hospital where a left femoral neck fracture was identified. Facility investigation determined that the NA failed to follow the care plan and Kardex requirement for two-person assistance with bed mobility, directly contributing to the accident and resulting harm.
A resident with diabetes, a prior femur fracture, and ESRD experienced a fall and right distal radius fracture when a NA used a one-person stand-and-pivot transfer while preparing the resident for dialysis, despite the most recent Kardex indicating a sit-to-stand transfer with assistance of two. Therapy had changed the resident’s transfer status, but this update was not incorporated into the Kardex or care plan. The ADON reported that therapy provides paper change-of-status notices to nursing, and the NHA confirmed the facility failed to address or implement the therapy instructions as required.
Surveyors found that the facility did not ensure required information was communicated to a receiving health care provider when a resident with HF, Parkinson's disease, and HTN was transferred to the hospital. Review of the clinical record showed no documentation that care plan goals, advance directives, specific instructions for ongoing care, resident representative information, or other necessary details to meet the resident’s needs were sent with the transfer, and the DON confirmed this failure during interview.
The facility failed to ensure call bells were consistently accessible to residents. During a Resident Council meeting, all residents present reported that staff did not leave call bells within reach, and in a separate group meeting, two residents stated that call bells were often placed where they could not reach them. One resident with HTN, GERD, and multiple sclerosis, care planned to have the call light within reach, was observed in bed with the call bell clipped to a pillow in a position that could not be activated using head movement, the only method available due to inability to move the arms. After a NA repositioned the pillow, the resident could activate the call light, and the NA confirmed it had been inaccessible in its prior position. The NHA confirmed the facility’s failure to accommodate these call bell needs.
The facility failed to maintain sufficient nursing staff, resulting in repeated missed showers, delayed call-light responses, and cold meals. Residents and their representatives reported long waits for assistance, including extended delays for toileting and help with meals, and noted that staffing levels varied by day and shift. Staff, including NAs, an RN, and an LPN, confirmed that when staffing was low, showers were not completed, trays were slow to be passed, and call lights had to wait. Several residents with conditions such as HTN, GERD, multiple sclerosis, atrial fibrillation, aphasia, depression, and renal failure missed scheduled showers or experienced prolonged call-light activation while needing pain medication or assistance with a Foley catheter. Facility staffing data also showed excessively low weekend staffing, and the DON acknowledged that the facility did not have enough nursing staff to meet residents’ needs during the identified periods.
Surveyors found that the facility did not ensure necessary pressure ulcer prevention and treatment services for two residents. One resident with quadriplegia was observed using Prafo and bunny boots on a routine schedule described by the resident, but there were no corresponding physician orders or documented schedule for these devices. Another resident with multiple comorbidities had a physician’s order for twice-daily cleansing of the coccyx and peri/groin area with soap and water and application of zinc-based barrier cream, but the Treatment Administration Record showed the treatment was missed on an evening shift. The DON confirmed that ordered pressure ulcer prevention measures were not consistently provided or monitored for these residents.
For three consecutive months, residents unanimously reported during council meetings that staff failed to leave call bells within reach on all units and shifts. A resident also reported being left unattended in a wheelchair without access to a call bell, and the DON confirmed the facility did not effectively address these concerns.
A resident with multiple medical conditions reported being fondled by his roommate and expressed fear, stating that previous concerns had not been addressed. The facility's investigation was incomplete, lacking a written statement from the first responding nurse aide and documentation of the LPN's prior knowledge, despite policy requiring thorough investigation and documentation. The DON confirmed the investigation was not thorough.
A significant medication error occurred when a nurse administered insulin intended for one resident to another, after the recipient answered to the wrong name and the nurse failed to properly verify identity according to policy. The error was discovered after administration, and the affected resident required blood sugar monitoring and IV dextrose.
Surveyors found that several residents did not have proper physician orders, individualized care plans, or complete assessments for the use of wander guards, including missing interventions to check device batteries. Additionally, a resident with multiple chronic conditions received only half the prescribed dose of a medication due to a transcription error during admission. These deficiencies were confirmed by the DON and administrator through record review and interviews.
A resident with moderate cognitive impairment and multiple medical conditions was able to leave the facility unsupervised and was found outside with her belongings packed. The care plan did not include specific interventions or required checks for a wander guard, and the resident was not adequately supervised to prevent elopement, as confirmed by facility leadership.
A resident with significant communication and mobility impairments was physically abused by a nurse aide, who hit the resident multiple times during care. The incident was witnessed by a nurse, who intervened and reported the event. Facility leadership confirmed the abuse was substantiated, indicating a failure to ensure residents are free from abuse as required by policy and regulation.
A nurse aide was hired without prior verification of their professional license, as the required license check was completed after the employment start date. This lapse was confirmed by the HR director during a review of new hire files.
Surveyors observed that open lunch meats, cheeses, pasta, and graham cracker crumbs in the main kitchen were not labeled with open dates, contrary to facility policy requiring all food to be properly wrapped, labeled, and dated. This failure to follow food storage procedures was communicated to the NHA during the exit interview.
A resident with multiple chronic conditions and a cancerous lesion did not receive required weekly comprehensive wound assessments over several weeks, as mandated by facility policy. Staff confirmed the assessments were not completed or documented, despite ongoing physician orders for wound monitoring and care.
Facility staff did not consistently provide medications and wound care treatments as ordered by physicians for two residents, including missed doses of an antidepressant and multiple missed wound care treatments, despite facility policies requiring timely and accurate administration and documentation. These deficiencies were confirmed by the Wound Care Nurse and DON.
A resident with multiple diagnoses, including hypertension and cancer, did not receive two scheduled doses of a prescribed blood thinner because the medication was pending delivery. Facility policy required timely reordering to prevent such lapses, but this was not followed, resulting in a significant medication error as confirmed by the DON.
Two residents experienced actual harm due to failures in staff conduct and adherence to care plans. One resident was left alone in a van by a facility driver in an unfamiliar neighborhood, causing significant fear and mental anguish. Another resident, who required two-person mechanical lift transfers, was moved by a single aide without checking the care plan, resulting in a tibial plateau fracture. Staff interviews and documentation confirmed that established protocols and resident care policies were not followed.
Two residents suffered significant injuries due to inadequate supervision and improper assistance during bed mobility and transfers. One resident with cognitive and physical impairments fell from bed and sustained a head laceration requiring staples when rolled away from the caregiver during care. Another resident, who required two-person assist with a mechanical lift, was transferred by a single aide without the lift, resulting in a tibial plateau fracture. Documentation inconsistencies and failure to follow established procedures contributed to these incidents.
Care plans were not updated for three residents after significant events, including a traumatic transport experience, a head injury, and a fracture with new pain and mobility needs. The care plans did not reflect changes in psychosocial well-being, pain management, or monitoring needs following these incidents.
A resident with Parkinson's disease was prescribed Carbidopa-Levodopa to be taken as two tablets three times a day, but the facility administered only one tablet three times a day for 17 days. Staff interviews confirmed the error, which was not corrected upon admission despite discharge orders indicating the correct dosage.
The facility failed to submit plans and obtain occupancy approval from the Life Safety Division for the replacement of the fire alarm system, including all devices and the remote annunciator panel. This deficiency was confirmed by the maintenance supervisor during an observation and interview.
The facility failed to maintain its kitchen hood suppression system, lacking documentation of monthly visual inspections. Kitchen staff were uncertain about the location and operation of the manual activation for the hood fire suppression system. These issues were confirmed by the maintenance supervisor.
The facility failed to maintain its fire alarm system components, affecting the entire facility. Documentation for essential inspections and tests, such as annual and semi-annual inspections, smoke detector sensitivity, and battery checks, was missing. The maintenance manager confirmed the lack of documentation and noted the recent replacement of the fire alarm system.
The facility failed to maintain its sprinkler system as required, with missing documentation for a three-year full flow trip test and six sprinkler heads in the laundry room covered in dust and corrosion. These issues were confirmed by the maintenance supervisor.
The facility failed to provide necessary documentation for its generator, including the monthly battery-specific gravity or conductance test and the three-year, four-hour load test. An interview with the maintenance supervisor confirmed the absence of these records, indicating a lapse in maintenance and testing protocols.
The facility failed to maintain self-closing fire doors, with two doors not latching properly. One door near a resident room had a leaf that did not latch, and another door near the north nurse station also failed to latch. These issues were confirmed by the maintenance supervisor.
The facility failed to maintain proper means of egress requirements as the evacuation diagrams did not include a 'YOU ARE HERE' notation or exit paths. This deficiency was confirmed by the maintenance supervisor, indicating non-compliance with NFPA standards.
The facility was found to have a deficiency related to combustible decorations, as the door to a resident's room had decorations exceeding allowable coverage. This was confirmed by the maintenance supervisor.
The facility failed to properly store oxygen cylinders in the staff lounge, as they were not separated or labeled as full or empty. This was confirmed by the maintenance supervisor, indicating a breach in the required storage protocol for medical gas cylinders.
The facility failed to communicate necessary resident information to receiving health care providers during transfers for three residents. Despite sending paperwork with the residents, there was no documentation proving what was sent, leading to a deficiency confirmed by staff interviews.
The facility failed to notify three residents or their representatives of the bed-hold policy during hospital transfers. Despite the policy requiring written notification before and at the time of transfer, there was no documented evidence of such notifications for residents with various medical conditions. Interviews with facility staff confirmed this oversight.
The facility failed to notify physicians of abnormal glucose readings and lab results for three residents and did not follow physician orders for two residents. A resident with atrial fibrillation had high blood sugar levels without physician notification, and another with diabetes had multiple low blood sugar readings without intervention. Additionally, a medication order for a resident with heart failure was transcribed incorrectly. These failures were confirmed by the DON and Nursing Home Administrator.
The facility failed to ensure proper labeling of enteral feeding and water flush bags for four residents, as required by policy. This oversight was confirmed by RNs and acknowledged by the DON, affecting residents with various medical conditions, including cancer, quadriplegia, and heart disease.
The facility failed to provide appropriate respiratory care and maintain oxygen equipment for five residents. Issues included lack of specific oxygen saturation parameters in orders, undated oxygen tubing, and improperly stored nebulizer equipment. Staff interviews confirmed these deficiencies, and the DON acknowledged the facility's non-compliance with its policies and regulatory requirements.
The facility did not conduct annual performance evaluations for four nurse aides as required by their policy. The personnel records for these aides, hired on various dates, lacked the necessary evaluations. This was confirmed by the Nursing Home Administrator.
A resident at Cranberry Place, with diagnoses of diabetes, anxiety, and depression, requested to switch to a window bed after their roommate was discharged. Despite the facility's initial agreement to the request, the switch was not executed, and a new roommate was placed in the window bed. This failure was confirmed by the Nursing Home Administrator, indicating non-compliance with resident rights regulations.
The facility failed to document advanced directives or provide the opportunity to formulate them for two residents. One resident, admitted with cancer, depression, and PVD, and another with cancer, high blood pressure, and diabetes, both lacked documentation of advanced directives in their records. Interviews with staff confirmed this deficiency.
A resident with quadriplegia, depression, and anxiety refused enteral feedings on multiple occasions, but the facility failed to notify the physician as required. The facility's policies mandate timely communication of medical care problems, yet the nursing progress notes lacked documentation of physician notification. The DON confirmed this oversight during an interview.
A facility failed to ensure that a resident with moderate cognitive impairment and her representative understood the Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) forms. The resident, admitted in July 2024, signed the forms in August 2024 without proper explanation, as confirmed by the Nursing Home Administrator.
The facility did not meet federal guidelines for posting grievance policies and procedures in three nursing units and common areas. Residents were unaware of how to file grievances anonymously, and postings lacked necessary information such as the grievance officer's contact details and response time frames. The Director of Social Services confirmed these deficiencies.
A resident was not permitted to return to the facility after hospitalization, despite the expectation of return. The facility cited the resident's refusal of medications and care, and the preference for oral intake against physician orders, as reasons for the decision. This action violated the facility's policy and regulatory requirements.
The facility failed to update care plans for three residents, leading to deficiencies in reflecting their current status and care needs. A resident with multiple diagnoses had a care plan lacking specific nutritional interventions. Another resident's care plan did not address their refusal of tube feedings. A third resident's care plan failed to include PICC line care and medication refusal. These deficiencies were confirmed by facility staff.
The facility failed to provide adequate supervision, resulting in two residents eloping without staff knowledge. One resident with severe cognitive impairment exited unsupervised, while another left via a ride service. Additionally, the facility did not adhere to a prescribed NPO diet for a resident at risk of aspiration, allowing the resident to consume fluids against medical advice.
The facility failed to provide appropriate catheter care for three residents. A resident with a suprapubic catheter and another with a condom catheter were observed without privacy-dignity covers. Additionally, a resident with an indwelling catheter had incomplete physician orders and care plan regarding catheter specifications. These deficiencies were confirmed by nursing staff.
A facility failed to maintain consistent communication for a resident with ESRD, as required by their policy. The resident, who attended dialysis three times a week, had missing documentation for User-Defined Assessments on several dates. A registered nurse confirmed the absence of required communication documentation, indicating a failure to adhere to professional standards and the resident's care plan.
A resident with anxiety and depression did not receive necessary behavioral health consults as outlined in their care plan. The facility's Social Service Director confirmed no referrals were made, leading to a failure in maintaining the resident's mental and psychosocial well-being.
The facility failed to timely dispose of or reconcile discontinued medications in the West Medication Room. A basin with various unsecured medications was found, and the DON confirmed the absence of accountability or disposition forms. Medications were discontinued in the system and placed in a bin for weekly pharmacy pickup without proper documentation.
A resident was prescribed quetiapine, an antipsychotic, for anxiety without an appropriate diagnosis documented in their clinical record. The facility's policy requires medication orders to include the clinical condition for which the medication is prescribed, which was not met in this case. Interviews with the NHA and DON confirmed the deficiency.
Neglect During Bed Mobility Leading to Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect during bed mobility care, resulting in a left femoral neck fracture. The resident had diagnoses including quadriplegia, gastroesophageal reflux disease, and hyperlipidemia, and was assessed as cognitively intact with a BIMS score of 15. The resident’s MDS and care plan documented that she was dependent for mobility and required assistance of two staff for bed mobility. The Kardex and care plan both specified a two-person assist for bed mobility due to her functional limitations. On the day of the incident, a nurse aide entered the resident’s room to check on her and was aware that another aide would be coming shortly to assist. Despite the documented requirement for two-person assistance, the aide rolled the resident toward herself and noted a bowel movement, then turned away to look for a towel or other item to begin care while waiting for help. During this time, the resident slid off the side of the bed and onto the floor. The aide reported that the resident slid off in such a way that there was no way to catch her, and immediately scanned the resident for obvious wounds or bleeding before finding a nurse to perform an assessment. Nursing documentation indicated that the resident was found sitting on the floor, leaning against the nightstand with her legs straight out and her head supported on a pillow against the mattress. Initial assessment noted no visible injuries other than redness to the left upper back, and the resident was assisted back to bed with a Hoyer lift and three staff. The resident complained of increased pain to the left leg, and the physician was notified with orders for x‑rays. Later, the resident was transferred to the hospital for altered mental status, decreasing blood pressure, and increased heart rate, and the hospital reported that she had sustained a left femoral neck fracture. The facility’s investigation concluded that the assigned nurse aide did not follow the Kardex and care plan instructions for required two-person bed mobility assistance, and the allegation of neglect was substantiated by the NHA and DON.
Failure to Follow Two-Person Assist Requirements During Bed Mobility Resulting in Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and implement effective bed mobility interventions for a resident, resulting in a preventable accident and actual harm. Facility policy on resident mobility required that residents with limited mobility receive appropriate care, services, equipment, and assistance, and that staff identify and follow the resident’s current mobility status, including bed mobility and transfer needs. The resident’s MDS assessment documented quadriplegia, GERD, and hyperlipidemia, with a BIMS score of 15 indicating intact cognition. The MDS Section GG and the Kardex both identified the resident as dependent for mobility and requiring assistance of two staff for bed mobility. The resident’s care plan, initiated and updated prior to the incident, included a focus on ADL self-care performance deficit and specified that bed mobility required assist x2. Despite these documented requirements, on the day of the incident a nurse aide entered the resident’s room alone and began providing care. The aide rolled the resident toward herself, noted a bowel movement, and then turned away briefly to look for a towel or other item to perform care while waiting for another aide who had not yet arrived. During this time, the resident slid off the side of the bed and onto the floor. Nursing documentation indicated that the resident was found sitting on the floor, leaning against the nightstand with legs extended and her head supported on a pillow against the mattress. Initial assessment noted no obvious injuries other than redness to the left upper back, and the resident was returned to bed with a Hoyer lift and three staff, after which she complained of increased left leg pain. The resident was later transferred to the hospital for altered mental status, decreasing blood pressure, and increased heart rate, and was reported to have sustained a left femoral neck fracture. The facility’s investigation concluded that the assigned nurse aide did not follow the Kardex instructions and care plan requirement for two-person assistance with bed mobility, and that this failure directly contributed to the incident.
Failure to Implement Updated Therapy Transfer Recommendations
Penalty
Summary
Facility staff failed to identify and implement a change in therapy transfer recommendations for one of three reviewed residents, resulting in a fall and injury. The resident, who had diagnoses including diabetes mellitus, a left femur fracture, and end stage renal disease, had an MDS dated 2/8/26 reflecting these conditions. On 3/5/26, while a nursing assistant was getting the resident up for dialysis using a one-person stand-and-pivot transfer, the resident lost balance and fell. The most recent Kardex still indicated the resident required a sit-to-stand transfer with assistance of two staff, but this updated transfer status from therapy had not been incorporated into the Kardex or the care plan. During interviews, the ADON stated that the resident had been working with therapy and that the transfer status had been changed, but this change did not make it to the Kardex or care plan, explaining that therapy provides a paper change-of-status to nursing. An X-ray after the fall showed a right distal radius fracture, and the resident was sent to the hospital. The Nursing Home Administrator confirmed that the facility failed to address or implement therapy instructions for this resident as required, in violation of 28 Pa. Code 201.18(e) and 211.10(c)(d).
Failure to Communicate Essential Information During Facility-Initiated Transfer
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider for a resident who experienced a facility-initiated transfer. Facility policy titled "Transfer and Discharge Notice" dated 2/2026 stated that the resident or representative would be notified prior to transfer or discharge and that documentation would be completed in the medical record. Resident R1 was admitted on an unspecified date and had an MDS dated 1/5/26 reflecting diagnoses of heart failure, Parkinson's disease, and hypertension. The resident was transferred to the hospital on 1/15/26 and did not return to the facility. Review of the resident’s clinical record showed no documented evidence that the facility communicated specific required information to the receiving provider for this transfer. Missing documentation included the resident’s care plan goals, advance directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident’s specific needs at the receiving facility. In an interview on 3/4/26 at 2:45 p.m., the DON confirmed that the facility failed to ensure that the necessary resident information was communicated to the receiving health care provider for this resident with a facility-initiated transfer, in violation of 28 Pa. Code: 201.29 (a)(c.3)(2) regarding resident rights.
Failure to Ensure Call Bells Were Accessible to Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ call bell needs, as required by its own policy on accommodation of needs. Resident Council meeting minutes documented that all 19 residents present unanimously reported that staff do not leave their call bells within reach. During a subsequent resident group meeting, two of seven residents stated that call bells are not always left where they can reach them and that staff put the call bells where residents cannot access them, noting that this happens frequently. These resident reports indicate a pattern of staff inaction in consistently positioning call bells so residents can independently summon assistance. In addition, surveyors reviewed the clinical record of one resident with diagnoses including hypertension, GERD, and multiple sclerosis, whose care plan directed staff to ensure the call light was within reach and to encourage its use for assistance. During observation, this resident was found lying in bed with the call bell clipped to the pillow beside the resident’s head. When asked how the call bell was activated, the resident explained an inability to move the arms and reliance on head movement to trigger the call bell. The resident attempted to move the head vigorously from side to side but could not reach the call bell and stated that even with such effort it could not be activated, and that the pillow needed to be moved to the left. When a nurse aide entered and repositioned the pillow, the resident was then able to activate the call light, and the aide confirmed the resident had been unable to activate it in the original position. The Nursing Home Administrator acknowledged that the facility failed to accommodate call bell needs for the residents identified in the council, group meeting, and observation.
Insufficient Nursing Staff Leading to Missed Showers and Delayed Call-Light Responses
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and competent nursing staff to meet residents’ needs, resulting in missed care, delayed responses to call lights, and unmet basic care needs across multiple timeframes and care areas. Facility policy on sufficient and competent nursing staffing states that the facility will provide enough nursing staff with appropriate skills and competency to deliver care and services in accordance with resident care plans and the facility assessment. However, review of Payroll Based Journal data for one quarter showed excessively low weekend staffing, and resident council minutes from two meetings documented multiple residents’ concerns about long wait times for call lights to be answered. Grievance and concern forms also documented complaints that one staff member was covering half a floor, that it took two to two and a half hours to get a resident on a bedpan, and that this had happened repeatedly. Additional concerns from residents and resident representatives described cold meals and inadequate assistance with showers due to insufficient staffing. Resident council documentation and group resident interviews indicated that staffing adequacy varied by day and shift, and that residents who required a Hoyer lift often did not receive showers on days when staffing was low because two staff were needed to operate the lift. Several residents reported missing scheduled showers for this reason, and multiple residents reported waiting between 30 minutes and two hours for assistance on various shifts. Staff interviews with NAs, an RN, and an LPN corroborated these concerns, with staff stating that when staffing was low, showers were not completed, tray passing was delayed, residents could not always be gotten out of bed, and call lights had to wait. Specific resident records and observations further demonstrated the impact of insufficient staffing. One resident with diagnoses including hypertension, GERD, and multiple sclerosis was scheduled for showers twice weekly but reported frequently missing showers, and documentation showed missed showers on three specified dates, which the DON confirmed. Another resident with atrial fibrillation, hypertension, and pancreatic cancer had a care plan requiring prompt response to call lights; observation showed this resident’s call light active for 17 minutes for pain medication, with the final activation time reaching 22 minutes. A resident with hypertension, aphasia, and hypokalemia, scheduled for showers twice weekly at a set time, missed multiple scheduled showers, and reported that staff attributed missed showers to lack of staffing. Another resident with aphasia, depression, and lack of coordination, scheduled for showers twice weekly on day shift, also missed a scheduled shower and indicated they did not receive showers as scheduled. A further resident with atrial fibrillation, hypertension, and renal failure, care-planned for prompt call light response, had a call light active for 25 minutes for assistance with an indwelling Foley catheter, with the final activation time at 26 minutes, which was confirmed by an RN. The DON acknowledged that the facility failed to have sufficient nursing staff to provide necessary nursing and related services during the identified periods and for the identified residents.
Failure to Follow Pressure Ulcer Prevention and Treatment Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents received necessary services to prevent and treat pressure ulcers in accordance with physician orders and facility policy. For one resident with quadriplegia, high blood pressure, and a neurogenic bladder, surveyors observed the resident in bed on multiple occasions wearing Prafo boots and later reported use of bunny boots according to a schedule the resident described (Prafo boots in the morning while in bed and bunny boots starting at 5:00 p.m.). However, review of the clinical record and physician orders showed no documented orders or schedule for either the Prafo or bunny boots. A registered nurse confirmed that there were no current physician orders or schedules for these devices, despite their ongoing use. For another resident with high blood pressure, malnutrition, and heart failure, the clinical record contained a physician’s order to wash the coccyx and peri/groin area twice daily with soap and water and apply a zinc-based barrier cream, with instructions to report any decline in wound condition. Review of the Treatment Administration Record showed that this ordered treatment was not provided on one evening shift. The DON confirmed that the ordered pressure ulcer prevention treatment was not administered as prescribed and further acknowledged that the facility failed to ensure residents were monitored, assessed, and received necessary services to prevent pressure ulcers or wounds from developing for two of three residents reviewed.
Failure to Address Resident Group Concerns About Call Bell Accessibility
Penalty
Summary
The facility failed to consider and act promptly on the recommendations and concerns raised by the resident group regarding call bells not being left within residents' reach. Over a three-month period, Resident Council meeting minutes consistently documented unanimous resident reports that staff did not leave call bells accessible on all units and shifts. Additionally, a resident representative reported being left unattended in a wheelchair without a remote to call for help. During an interview, the DON confirmed that the facility did not effectively address these concerns raised by the resident group.
Failure to Thoroughly Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse involving a resident who reported that his roommate had fondled his leg and groin. The resident, who had diagnoses including high blood pressure, malnutrition, and low back pain, was visibly shaken and expressed fear following the incident. Documentation indicated that the resident had previously reported similar concerns, but felt that no action had been taken. The facility's policy required all allegations of abuse to be thoroughly investigated and documented, including obtaining written, signed, and dated witness statements. Upon review, it was found that the investigation file lacked a written statement from the nurse aide who first responded to the incident, and there was no documentation clarifying the licensed practical nurse's knowledge of any prior sexual abuse allegations. Although the DON stated that a detailed interview was conducted with the LPN regarding prior knowledge, this interview was not documented. The DON confirmed that the facility did not conduct a thorough investigation as required by policy.
Significant Medication Error Due to Improper Resident Identification
Penalty
Summary
A significant medication error occurred when a registered nurse administered insulin intended for one resident to another resident. The nurse was passing early morning medications and gave the insulin to the wrong resident after the resident answered to the roommate's name and did not question the medication. The nurse failed to properly verify the resident's identity according to facility policy, which requires checking the identification band, photograph, and, if necessary, confirming with other staff. The error was discovered when the nurse realized the mistake and notified the charge nurse, physician, and the resident's family. The resident who received the incorrect medication had a blood sugar check and was given IV dextrose as ordered by the physician. The resident involved had diagnoses including high blood pressure, hyperlipidemia, and a history of falls. Staff interviews revealed that standard practice for medication administration includes verifying the resident's name, checking the medication administration record (MAR), and confirming the resident's picture. However, in this incident, these verification steps were not adequately followed, resulting in the administration of another resident's Lantus insulin. The Director of Nursing confirmed that the facility failed to ensure residents were free from significant medication errors in this case.
Deficiencies in Wander Guard Management and Medication Reconciliation
Penalty
Summary
The facility failed to ensure that residents were provided with appropriate treatment and care by not having physician orders, individualized care plans, and accurate assessments for the use of wander guards for four residents. Specifically, one resident did not have any physician orders for a wander guard despite multiple elopement evaluations indicating no risk, while another resident had orders for a security guard but lacked orders to check the wander guard battery weekly. Additionally, care plans for two residents identified a risk for wandering or elopement but did not include interventions to check the wander guard battery weekly, and physician orders for these residents also omitted this requirement. The Director of Nursing confirmed these omissions and inconsistencies during interviews, and acknowledged that once a resident is identified as an elopement risk, they should remain so unless discharged or bedbound. Another deficiency was identified in the medication reconciliation process upon admission. One resident, who had diagnoses including heart failure, diabetes, and end stage renal disease, was prescribed Calcium Acetate at a specific dose upon discharge from an acute care setting. However, the medication was transcribed incorrectly upon admission to the facility, resulting in the resident receiving only half the prescribed dose. The Certified Registered Nurse Practitioner confirmed that this was a transcription error and that the resident had been receiving the incorrect dose since admission. These findings were based on a review of facility policies, clinical records, and staff interviews. The deficiencies were confirmed by both the Director of Nursing and the Nursing Home Administrator, who acknowledged the lack of appropriate physician orders, care plan interventions, and accurate medication transcription for the affected residents.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent elopement for one resident. According to the facility's policy, residents at risk for wandering or elopement should have specific interventions in place, including orders for a wander guard, regular checks of the device, and quarterly elopement assessments. The resident in question, who had diagnoses of heart failure, diabetes, and cerebral infarction, was assessed as moderately cognitively impaired with a BIMS score of 9. Despite this, the resident's initial elopement evaluation indicated no risk, and appropriate interventions were not implemented. The deficiency was identified when the resident was found outside the facility in the parking lot with her belongings packed, after contacting her husband to pick her up. The receptionist observed the resident outside and assisted her back into the building, notifying nursing staff. At the time of the incident, the resident did not have a wander guard in place, and her care plan lacked resident-specific interventions to address elopement risk. Interviews with the DON and Nursing Home Administrator confirmed that the care plan did not include required checks for the wander guard or battery, and failed to provide adequate supervision to prevent the elopement.
Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
The facility failed to ensure that residents were free from abuse, as required by federal regulations. Specifically, a nurse aide physically abused a resident by hitting them multiple times during care. This incident was witnessed by a nurse, who intervened by stepping between the aide and the resident and then escorting the aide out of the room. The facility's own policies, which define abuse and require staff to treat residents with kindness, respect, and dignity, were not followed in this instance. The resident involved had a history of hypertension, aphasia, and right-sided hemiplegia, and was rarely or never understood according to their most recent assessment. The abuse was reported to facility leadership, and the Director of Nursing confirmed that the allegation of physical abuse was substantiated. This event demonstrates a failure to protect a vulnerable resident from physical harm and to adhere to established protocols for resident safety and rights.
Plan Of Correction
R3 was immediately assessed by CRNP for injury. Wound team to provide ongoing assessments and skin checks. Social services provided emotional support immediately following the incident. Continued emotional support will be provided. A new trauma assessment was completed and Careplan updated. The facility notified the resident's family, DOH, Area Agency on Aging, and Cranberry Township police. All residents were interviewed regarding abuse and neglect. No other concerns were reported. All residents with a BIMS score of 13 or below had a full body skin check to investigate for any signs/symptoms of abuse or neglect. No concerns were identified. The facility will review/revise the onboarding process, including background checks and licensure. The facility will review/revise the orientation process, specifically regarding abuse and neglect education in orientation. All nursing staff will be educated on abuse and neglect. All nursing staff will be educated on Cognitive Deficits and Behaviors. Social Services will interview 10 residents on abuse and neglect weekly x4 weeks, then 10 residents monthly or until substantial compliance has been reached. Results of interviews will be reviewed during QAPI. Any concerns will be reported to leadership for immediate investigation. The facility will review/revise the onboarding process, including background checks and licensure. The facility will review/revise the orientation process, specifically regarding abuse and neglect education in orientation. All nursing staff will be educated on abuse and neglect. All nursing staff will be educated on Cognitive Deficits and Behaviors. Social Services will interview 10 residents on abuse and neglect weekly x4 weeks, then 10 residents monthly or until substantial compliance has been reached. The DON will interview 5 staff members weekly regarding abuse and neglect x4 weeks then monthly or until substantial compliance has been reached. Results of interviews will be reviewed during QAPI. Any concerns will be reported to leadership for immediate investigation.
Failure to Verify Professional License Prior to Employment
Penalty
Summary
The facility failed to verify the professional license of a nurse aide prior to employment, as required by personnel policies and procedures. Specifically, the personnel record for the nurse aide showed a hire date that preceded the date on which the license verification was completed. The human resource director confirmed during an interview that the license verification inquiry was conducted after the employee had already been hired. This deficiency was identified during a review of new hire files and staff interviews, and it affected one out of two employees reviewed.
Plan Of Correction
The human resource director was educated by the NHA related to timely pulling the staff professional license before the date of hire to ensure the license is valid. The new hire files were reviewed by HR. All new hire files will be audited weekly, the Friday before new hires start, to ensure and maintain compliance by the NHA. An audit was completed on all new hire files for license checks before the start date. I certify this document to be a true and correct statement of deficiencies and approved facility plan of correction for the above-identified facility survey.
Failure to Properly Date and Store Food Products
Penalty
Summary
The facility failed to properly date and store food products in the main kitchen, as observed during a survey. Specifically, surveyors found that turkey breast lunch meat, ham lunch meat, provolone sliced cheese, and Swiss sliced cheese in a refrigerator/cooler by the tray line were open and lacked an open date. Additionally, in the dry storage room, four bags of open pasta and one container of graham cracker crumbs were found open and without an open date. These findings were in direct violation of the facility's food safety program and standard operating procedures, which require all food to be properly wrapped, labeled, and dated. The deficiency was communicated to the Nursing Home Administrator during the exit interview.
Failure to Complete Weekly Comprehensive Wound Assessments
Penalty
Summary
The facility failed to complete comprehensive weekly wound assessments for one resident, as required by its own policies and procedures. The facility's wound care policy and skin care and wound management guidelines specify that wound assessments, including documentation of the wound's color, size, and drainage, must be performed at least weekly and whenever there is a change. Review of the resident's clinical records revealed that comprehensive wound assessments were missing for multiple consecutive weeks, despite physician orders to monitor the wound and provide daily care. The resident involved had multiple diagnoses, including diabetes, COPD, hyperlipidemia, and spinal stenosis, and was under care for a cancerous lesion requiring monitoring for infection and wound care. Staff interviews confirmed that the required weekly comprehensive wound assessments were not completed or documented for the resident over several weeks. The deficiency was acknowledged by both the LPN and RN responsible for wound care, as well as communicated to the Nursing Home Administrator.
Failure to Administer Physician-Ordered Medications and Wound Care
Penalty
Summary
Facility staff failed to provide medications and wound care treatments as ordered by physicians for two of six residents. For one resident with diagnoses including rectal cancer, muscle wasting, and diabetes mellitus, physician orders required specific wound care to the buttocks twice daily, including washing, packing with Dakins solution, and applying Calmoseptine, as well as administration of an antidepressant medication. Review of the Treatment Administration Record (TAR) and Medication Administration Record (MAR) revealed multiple missed wound care treatments and several days when the antidepressant medication was not administered due to pending delivery. These omissions were confirmed by the Wound Care Nurse and the Director of Nursing during interviews. Another resident with high blood pressure, low back pain, and bacterial arthritis of the left knee had physician orders for daily wound care to the left knee, ensuring steri strips remained in place and monitoring for infection. The TAR indicated that wound care was not provided on two separate occasions as ordered. The Director of Nursing confirmed these missed treatments during interviews. Facility policies reviewed indicated that medications and treatments are to be administered safely, timely, and as prescribed, with proper documentation and timely reordering of medications. Despite these policies, the facility did not consistently follow physician orders for medication administration and wound care for the two residents, resulting in the identified deficiencies.
Failure to Prevent Significant Medication Error Due to Missed Anticoagulant Doses
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as required by facility policy and state regulations. Review of the clinical record showed that a resident with diagnoses including high blood pressure, cancer, and left knee pain had a physician's order for daily subcutaneous injections of Fondaparinux Sodium, a blood thinner. The resident's Medication Administration Record for May 2025 indicated that the medication was not administered on two consecutive mornings due to the medication being pending delivery. Facility policy required that medications be reordered from the pharmacy at least three days before the last dose to ensure availability, and that all administrations be properly documented. During an interview, the Director of Nursing confirmed that the resident did not receive the ordered medication as required, resulting in a significant medication error for one of the residents reviewed.
Failure to Protect Residents from Abuse and Neglect Resulting in Harm
Penalty
Summary
The facility failed to protect residents from abuse and neglect, resulting in actual harm to two residents. One resident, who was cognitively intact and had diagnoses including diabetes, hypertension, and renal insufficiency, was transported to a medical appointment by a facility driver. On the return trip, the driver deviated from the expected route, stopped at his personal residence in an unfamiliar neighborhood, and left the resident alone in the van for five to ten minutes without explanation. The resident reported feeling terrified, uncertain of her safety, and experienced significant mental anguish during the incident. The driver later admitted to stopping at his home to retrieve his wallet and eat a sandwich, leaving the resident unattended in the vehicle. Another resident, with a history of end stage renal disease, coronary artery disease, and hypertension, required two staff members and a mechanical lift for transfers according to her care plan. Despite this, a nursing assistant transferred the resident alone, without consulting the Kardex for transfer status. During the unassisted transfer, the resident's leg became caught, resulting in severe pain and, upon further evaluation, a fracture of the left tibial plateau. The resident's roommate confirmed hearing the resident scream in pain during the transfer, and the nursing assistant admitted to not checking the Kardex and being unsure of the resident's transfer requirements at the time. Facility documentation and staff interviews confirmed that the required protocols for resident safety and adherence to care plans were not followed in both cases. The incidents resulted in actual harm: mental anguish and fear for one resident, and a significant physical injury for another. The facility's own policies and staff education materials emphasized the importance of following care plans and not leaving residents unattended, yet these were not adhered to, directly leading to the deficiencies identified.
Failure to Provide Adequate Supervision and Assistance During Bed Mobility and Transfers Resulting in Resident Injuries
Penalty
Summary
The facility failed to ensure that residents received adequate supervision and assistance for bed mobility and transfers, resulting in actual harm to two residents. One resident with diagnoses including Alzheimer's disease, neurofibromatosis, and chronic pain required assistance for bed mobility. Documentation showed conflicting information regarding the level of assistance needed, with the Minimum Data Set indicating assist of two, while the Kardex indicated assist of one. During incontinence care, the resident was rolled away from the caregiver, contrary to standard procedure, and fell from the bed, sustaining a head laceration that required eight staples. Staff interviews confirmed that the resident was not rolled toward the caregiver as required, and the bed was elevated during care, contributing to the fall. Another resident with end stage renal disease, coronary artery disease, and hypertension required two staff members and a mechanical lift for transfers, as documented in the care plan. Despite this, the resident was transferred by a single nurse aide without the mechanical lift. During the unassisted transfer, the resident's leg became caught, resulting in a tibial plateau fracture. The resident reported severe knee pain following the incident, and subsequent evaluation confirmed the fracture. Staff interviews and witness statements corroborated that the transfer was performed by one aide, who was unsure of the resident's transfer status at the time. The facility's policies required that all accidents be investigated and reported, and that appropriate support and assistance be provided for activities of daily living, including mobility and transfers. However, the facility did not have a specific policy regarding bed mobility, and staff failed to follow established procedures for safe resident handling. These failures led to significant injuries for two residents, including a head injury and a fracture, as a result of inadequate supervision and improper transfer techniques.
Failure to Revise Care Plans After Significant Resident Events
Penalty
Summary
The facility failed to revise or update care plans for three residents to accurately reflect their current needs following significant events. For one resident with diabetes, hypertension, and renal insufficiency, the care plan did not include monitoring for psychosocial well-being after a traumatic event during a transport, despite the resident expressing fear and distress after being left alone in a van by a driver. Another resident with Alzheimer's disease, neurofibromatosis, and chronic pain was sent to the emergency room for a closed head injury and scalp laceration, but the care plan was not updated to include monitoring for psychosocial well-being following this traumatic event. A third resident with end stage renal disease, coronary artery disease, and hypertension suffered a left lateral tibial plateau fracture during a transfer, resulting in pain, a new brace, and non-weight bearing status. The care plan for this resident was not revised to address psychosocial well-being after the injury, pain management, or skin checks related to brace use. The Director of Nursing confirmed that care plans for all three residents were not updated to reflect these changes in condition and care needs.
Medication Error in Resident's Parkinson's Treatment
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically for one resident who was admitted with a prescription for Carbidopa-Levodopa to be taken as two tablets three times a day. However, the facility's records indicated that only one tablet was administered three times a day throughout the resident's stay. This discrepancy was noted in the discharge orders from the acute hospital stay, but the error was not corrected upon admission to the facility. Interviews with facility staff, including a Certified Registered Nurse Practitioner (CRNP) and the Director of Nursing (DON), confirmed that the resident received only half of the prescribed dosage for 17 days. The CRNP acknowledged that the orders from the discharging facility were not accurately entered into the system, and the DON admitted that multiple checks should have been in place to catch and correct this error at the time of admission. The facility's failure to administer the correct medication dosage resulted in a significant medication error for the resident.
Failure to Obtain Approval for Fire Alarm System Replacement
Penalty
Summary
The facility was found deficient in maintaining general requirements as it failed to submit plans to the State Plan Review and obtain occupancy approval from the Life Safety Division for the replacement of the fire alarm system. This deficiency was identified during an observation on January 29, 2025, at 10:25 a.m., which revealed that the facility had not received the necessary approval for the new fire alarm system, including all devices and the remote annunciator panel. The maintenance supervisor confirmed this deficiency during an interview conducted at the same time as the observation.
Plan Of Correction
Fire panel was replaced. DOH was not notified for plan review. No negative outcomes noted. Maintenance supervisor educated on need for plan review before any changes to current systems. NHA will audit any construction or changes of current systems to ensure compliance. Audits will be completed biweekly. Results will be reviewed at the QAPI meeting.
Deficiencies in Kitchen Hood Suppression System Maintenance
Penalty
Summary
The facility failed to maintain its cooking facilities, specifically the kitchen hood suppression system. During a document review, it was found that there was no documentation of monthly visual inspections being conducted for the kitchen hood suppression system. Additionally, interviews with kitchen staff revealed that they were uncertain about the location and operation of the manual activation for the hood fire suppression system. These deficiencies were confirmed in an interview with the maintenance supervisor.
Plan Of Correction
Kitchen and Maintenance were educated on visually inspecting the Kitchen hood suppression system monthly. Dietary employees were also educated on what the suppression system is, what it does, and when to pull the alarm. Audits will be done weekly for 6 weeks. Results will be reviewed at QAPI meeting.
Failure to Maintain Fire Alarm System Components
Penalty
Summary
The facility failed to maintain its fire alarm system components, which affected the entire facility. During a document review and interview on January 29, 2025, it was revealed that the facility could not provide documentation for several critical inspections and tests. These included the annual inspection/testing, semi-annual visual inspection, smoke detector sensitivity testing, battery-operated smoke detector checks, and six-month battery replacement and policy. The maintenance manager confirmed the absence of this documentation and noted that the fire alarm system had been recently replaced.
Plan Of Correction
We have no battery powered smoke detectors; all are hard wired in. Paperwork was located for annual testing and semi-annual visual inspection. All smoke detectors were replaced on 9/25/2024. Education completed with Maintenance department on timely receipt of paperwork. Audits will be monthly. Results will be reviewed at the QAPI meeting.
Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain compliance with sprinkler system regulations as evidenced by two key deficiencies. Firstly, during a document review, it was found that the facility did not provide documentation for the required three-year full flow trip test of the sprinkler system. This deficiency was confirmed through an interview with the maintenance supervisor. Secondly, an observation revealed that six sprinkler heads in the laundry room were covered with dust and lint and showed signs of corrosion. This build-up of material can insulate the sprinkler's thermal element, potentially impacting its temperature activation and response time, and may lead to inadequate spray coverage. The maintenance supervisor confirmed these deficiencies during an interview.
Plan Of Correction
The sprinkler heads were cleaned on 1/31/25 in the laundry. The maintenance director received an education regarding the importance of sprinkler heads being dust-free. The sprinkler heads will be randomly monitored monthly for 4 months. The NHA will monitor system compliance monthly moving forward and report quarterly to QAPI. The three-year flow test is scheduled to be completed by vendor Granu. Report will be kept on file. The maintenance department were educated on timeliness of receiving testing and paperwork. Audit will be yearly after test completed. Results will be reviewed at QAPI for further recommendations.
Generator Documentation Deficiency
Penalty
Summary
The facility failed to meet the electrical system requirements for its generator, as evidenced by the absence of necessary documentation. During a document review on January 29, 2025, it was found that the facility could not provide records for the monthly battery-specific gravity or conductance test. Additionally, the facility lacked documentation for the three-year, four-hour load test, which is a critical component of ensuring the generator's reliability and compliance with NFPA standards. An interview with the maintenance supervisor on the same day confirmed that the required documentation was unavailable at the time of the survey. This deficiency indicates a lapse in the facility's maintenance and testing protocols for its essential electrical systems, which are crucial for ensuring the safety and functionality of the generator in emergency situations.
Plan Of Correction
4-hour full-load Generator run was completed on 11/3/2024. This was in response to a power outage that lasted 16 hours. The Nursing home administrator educated the maintenance director on ensuring the Generator testing to be completed timely. The NHA will monitor system compliance monthly. Results will be reviewed at the QAPI meeting. The generator at Cranberry Place is a battery specific gravity. The maintenance department was educated on where the battery read out is and record it as per regulation. The testing was completed until August 2024, then was missed. The battery specific gravity test has been recorded. Audits will be weekly for 4 weeks. Results will be reviewed at QAPI for further recommendations.
Deficiency in Self-Closing Fire Doors
Penalty
Summary
The facility failed to maintain doors with self-closing devices, as observed during a survey. Specifically, two corridor fire doors did not function properly. One door near resident room #238 had one of its two leaves fail to positively latch in the frame. Another door near the north nurse station in the center core hall also failed to latch in the frame. These deficiencies were confirmed through an interview with the maintenance supervisor.
Plan Of Correction
Door near room 238 and corridor north positive latching. Both doors were fixed immediately. Education completed with Maintenance Director. Weekly audits will be completed. Results will be reviewed at the QAPI meeting.
Evacuation Diagram Deficiency
Penalty
Summary
The facility failed to maintain proper means of egress requirements in its building component. During an observation on January 29, 2025, it was noted that the evacuation diagrams did not include a notation indicating the location of the viewer on the diagram. This deficiency was confirmed in an interview with the maintenance supervisor, who acknowledged that the diagrams lacked 'YOU ARE HERE' locations and exit paths, as required by NFPA 170-11.2.4 through 11.4.1.
Plan Of Correction
Egress evacuation diagrams have been updated to show two forms of evacuation. Education completed with the maintenance supervisor to have routes of evacuation clearly marked on the evacuation diagrams. Diagrams will be monitored monthly. Results will be reviewed at the QAPI meeting.
Combustible Decoration Deficiency on Resident Room Door
Penalty
Summary
The facility failed to comply with NFPA 101 standards regarding combustible decorations. During an observation on January 29, 2025, at 11:13 a.m., it was noted that the door to resident room #116 had decorations that exceeded the allowable coverage as per the fire safety regulations. This deficiency was confirmed through an interview with the maintenance supervisor, who acknowledged the presence of excessive combustible decorations on the door.
Plan Of Correction
Resident's door decorations removed immediately. Resident, Family, and staff educated on the regulation. Doors will be monitored weekly for 4 weeks then monthly. Results will be reviewed at the QAPI meeting.
Improper Storage of Oxygen Cylinders in Staff Lounge
Penalty
Summary
The facility failed to maintain proper storage of medical gas cylinders in one of its rooms, specifically the staff lounge. During an observation on January 29, 2025, it was noted that oxygen cylinders were stored without being separated or labeled as full or empty. This lack of organization and labeling is a direct violation of the requirements for medical gas cylinder storage, which mandates that empty cylinders be segregated from full ones to avoid confusion. An interview with the maintenance supervisor on the same day confirmed the deficiencies in the storage of oxygen cylinders. The supervisor acknowledged the improper storage practices, which did not comply with the standards set forth for medical gas cylinder management. This oversight in maintaining the storage protocol could potentially lead to safety hazards, although the report does not specify any immediate consequences or risks.
Plan Of Correction
Oxygen tanks storage of full tanks immediately labeled full tanks. Nursing staff educated on the need to keep signage in place. Audits will be weekly. Results will be reviewed at the QAPI meeting.
Failure to Communicate Resident Information During Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider for three residents who were transferred from the facility. This deficiency was identified through a review of clinical records and staff interviews. The residents involved in this deficiency were transferred to the hospital, but there was no documented evidence that the facility had communicated essential information such as care plan goals, advanced directive information, specific instructions for ongoing care, and resident representative information to the receiving health care provider. Resident R70, who was admitted to the facility with diagnoses including cancer, depression, and peripheral vascular disease, was transferred to the hospital. However, the clinical record lacked documentation of the necessary information being communicated to the hospital. Similarly, Resident R76, with diagnoses of high blood pressure, depression, and diabetes, was transferred without the required documentation. Resident R115, admitted with renal insufficiency, atrial fibrillation, and heart failure, also had no documented evidence of communication of necessary information upon transfer. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed the facility's failure to document and communicate the required information for these residents' transfers. The Nursing Home Administrator acknowledged that while paperwork was sent with the residents, there was no documentation to prove what was sent. This lack of documentation and communication led to the identified deficiency.
Plan Of Correction
Residents R70 remains in facility with no negative outcomes. R76 remains in facility with no negative outcomes. R115 has been discharged. A one-week retroactive review of all facility-initiated transfers will be followed by telephone to ensure that all necessary resident information was communicated to the receiving health care provider and provided if necessary. The DON/Designee will educate all licensed nursing on the necessary information requirement found at F622 for transfers to a receiving healthcare provider. The NHA or designee will audit all facility-to-facility transfers to ensure all resident information requirements were met daily x3, then five resident facility-to-facility transfers weekly x8. Results will be reviewed through QAPI for further recommendation.
Failure to Notify Residents of Bed-Hold Policy During Transfers
Penalty
Summary
The facility failed to notify residents or their representatives of the bed-hold policy during hospital transfers for three residents. The policy requires that residents or their representatives receive written information about the bed-hold policy before a transfer and at the time of transfer. However, for Residents R70, R76, and R115, there was no documented evidence that such notifications were provided at the time of their respective hospital transfers. Resident R70, diagnosed with cancer, depression, and peripheral vascular disease, was transferred to the hospital and returned without receiving the required notification. Similarly, Resident R76, with high blood pressure, depression, and diabetes, and Resident R115, with renal insufficiency, atrial fibrillation, and heart failure, were also transferred to the hospital without being informed of the bed-hold policy. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed the failure to notify the residents or their representatives.
Plan Of Correction
Resident R70 returned to the facility 1/7/25. Resident R76 returned to the facility on 8/29/24. Resident R115 did not return to the facility. Residents were not charged any bed-hold fees and as a result had no negative outcome. A retroactive 14-day review of all hospital/leave transfers will be completed to ensure residents/representatives have been provided information regarding the facility bed-hold policy. The NHA or designee will educate all licensed nurses on the facility bed-hold policy and communicating information at the time of transfer. The NHA or designee will audit all hospital/leave transfers daily x3, then five resident transfers weekly x8. Results will be reviewed through QAPI for further recommendation.
Failure to Notify Physicians and Follow Orders
Penalty
Summary
The facility failed to notify a physician of abnormal glucose readings and lab results for three residents, and did not follow physician orders for two residents. Resident R67, who was admitted with conditions including atrial fibrillation and coronary artery disease, had high blood sugar levels recorded on two occasions without the physician being informed, contrary to the physician's orders. Additionally, the facility did not notify the LVAD team of a supratherapeutic PT/INR result, which was required by the resident's care plan. Resident R77, diagnosed with high blood pressure, diabetes, and cancer, had multiple instances of low blood sugar readings without physician notification or documented interventions. The resident's care plan included specific instructions for managing hypoglycemia, but these were not followed, and there were no parameters set for administering glucose treatments during hypoglycemic events. Resident R115, admitted with renal insufficiency and heart failure, had an incorrect transcription of a medication order for Bumex, which was supposed to be administered at a higher dose. This error was identified but not corrected in a timely manner. The Director of Nursing and the Nursing Home Administrator confirmed these failures in communication and adherence to physician orders, which contributed to the deficiencies noted in the report.
Plan Of Correction
Facility is unable to retroactively correct concern of lack of assessment of the residents for signs/symptoms of hypoglycemia or hyperglycemia. Director of Nursing and/or designee reviewed the blood glucoses with the attending physicians for all listed residents. Resident R67 remains at the facility. Resident R67 was seen on 1/16/2025 and no negative outcome was identified. Resident R115 has been discharged as planned with no negative outcomes. All residents receiving blood sugars will have a retroactive 14-day review of blood sugars with notifications to physicians as necessary. R67's PT/INR results will be communicated to the LVAD team as ordered and reviewed with attending physician when new orders are received. A one-week retroactive review of all new admissions will be audited to ensure that orders have been transcribed correctly. The Director of Nursing or designee will educate licensed nurses on facility's policies for assessing for change in condition, physician notifications, hypoglycemia, and medication and treatment orders. The Director of Nursing or designee will audit CBG monitoring summaries for residents who require CBG testing and ensure resident assessment and physician notifications are made when an abnormal CBG is recorded. These audits will be completed on all CBG residents daily x 3 days, then a random five CBG residents three times weekly x 2 weeks and then weekly for 2 months. All new admissions will be audited to ensure orders are transcribed correctly three times weekly x 3 months. All notifications of PT/INR's for LVAD team notifications will be audited three times weekly for two weeks, then weekly for two months. All results to be reviewed through QAPI for further recommendation.
Failure to Properly Label Enteral Feeding Bags
Penalty
Summary
The facility failed to ensure that residents with enteral feeding tubes received appropriate treatment and services to prevent potential complications. This deficiency was identified for four residents who were observed with enteral feeding bags and water flush bags that were not properly labeled with dates. The facility's policy requires that enteral nutrition labels be checked against orders before administration, including the resident's name, ID, room number, type of formula, date, and time the formula was prepared, and rate of administration. Resident R40, who was admitted with diagnoses including difficulty walking, cancer, and hyperlipidemia, had an enteral feeding bag dated correctly, but the water flush bag lacked a date. Similarly, Resident R53, with diagnoses of quadriplegia, chronic pulmonary disease, and anxiety disorder, had a feeding bag dated, but the water flush bag was not labeled. Resident R70, diagnosed with cancer, depression, and peripheral vascular disease, had neither the feeding bag nor the water flush bag dated. Lastly, Resident R103, with coronary artery disease, heart failure, and hypertension, also had both bags without dates. Interviews with registered nurses confirmed the absence of dates on the water flush bags and, in some cases, the feeding bags. The Director of Nursing acknowledged the facility's failure to ensure proper labeling, which is crucial to prevent potential complications associated with enteral feeding. This oversight affected four out of five residents reviewed, indicating a systemic issue in adhering to the facility's enteral feeding management policy.
Plan Of Correction
Residents RO, R52, R70, and R103 tube feeds/water flushes/tubing were dated at the time of survey. A whole house sweep was conducted to ensure all tube feeds/water flush/tubing was dated. The DON or designee will educate all Licensed Nurses on labeling and dating all components of the tube feed system. The DON or designee will audit all tube feeds daily x3, and five tube feeds weekly for proper labeling and dating of tube feed systems. All results to be reviewed through QAPI for further recommendation.
Deficiency in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide appropriate respiratory care and maintain oxygen equipment for five residents, as evidenced by a review of facility policy, clinical records, observations, and staff interviews. The facility's policy on 'Respiratory Therapy' outlines procedures to prevent infection associated with respiratory therapy tasks and equipment, including changing oxygen cannula and tubing every seven days and storing circuits in a plastic bag with the date and resident's name. However, these procedures were not consistently followed for the residents involved. Resident R2's clinical records showed a lack of specific oxygen saturation parameters in the physician's orders, which were only updated after a nurse spoke with a hospice practitioner. Resident R70's oxygen tubing was not dated as required, and Resident R77's nebulizer tubing and mask were found unlabeled and not stored in a bag. Similarly, Resident R103's nebulizer was not stored in a bag, and Resident R317's oxygen tubing and humidifier bottle were not labeled with a date. Interviews with nursing staff confirmed these deficiencies, and the Director of Nursing acknowledged the facility's failure to provide appropriate respiratory care and maintain oxygen equipment for the affected residents. The report highlights the facility's non-compliance with its own policies and the regulatory requirements for respiratory care, as outlined in 28 Pa. Code: 211.10(c) (d) and 211.12(d)(1)(2)(3)(5).
Plan Of Correction
Resident R'2 orders were corrected to include an oxygen saturation percentage at the time of survey. All residents identified in the citation were checked and provided with new oxygen tubing, humidification bottles, nebulizers, and bags for storage as required at the time of survey. A whole house audit was completed for all residents receiving respiratory care for dating, labeling, and storage on 1/21/25. The DON or designee will educate all licensed nursing and respiratory staff on the policy for respiratory therapy. The DON or designee will audit all respiratory care equipment for labeling, dating, and storage daily for 3 days, then 5 residents weekly for 8 weeks. All results will be reviewed through QAPI for further recommendation.
Failure to Conduct Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance evaluations for four nurse aides, identified as Employees E16, E17, E18, and E19. According to the facility's policy titled 'In-Service Training, Nurse Aide' dated August 2024, a performance review of nurse aides should be conducted at least every 12 months. However, a review of the personnel records revealed that these evaluations were not performed based on the hire dates of the employees. The hire dates for the nurse aides were as follows: E16 on February 6, 2023, E17 on July 25, 2022, E18 on July 30, 2012, and E19 on February 7, 2022. This deficiency was confirmed during an interview with the Nursing Home Administrator on January 23, 2025.
Plan Of Correction
The DON or designee will ensure whole house nurse aide performance evaluations are completed by their respective nursing supervisors. The NHA will educate the DON and Human Resources Director on the annual requirement at F730- nurse aide performance reviews. The Human Resource Director or designee will audit all new employees to ensure planning of completion of annual performance reviews are completed through the facility QAPI program.
Failure to Honor Resident's Bed Change Request
Penalty
Summary
Cranberry Place was found to be non-compliant with resident rights as outlined in 42 CFR Part 483, Subpart B, and the 28 PA Code. The deficiency involved a failure to honor a resident's request to switch beds within the facility. Resident R94, who was admitted on November 7, 2024, and has diagnoses of diabetes mellitus, anxiety, and depression, expressed a desire to move from a door bed to a window bed after their roommate was discharged. The resident communicated this request to the facility staff, and the Director of Social Services confirmed that the facility intended to accommodate the request. However, the switch did not occur as planned. On January 24, 2025, it was observed that Resident R94 had not been moved to the window bed, and a new roommate had been placed there instead. The Nursing Home Administrator confirmed that the facility failed to execute the bed switch for Resident R94, thereby not upholding the resident's rights to self-determination and dignity as required by the regulations.
Plan Of Correction
Resident R94 remains in her current bed/ accepted another bed/ was provided a window bed on 1/24/2025. The facility has no other current residents with voluntary outstanding bed requests. The NHA/Designee will educate Social Services and Admission Director on resident rights and the facility procedure of making room moves in a prompt manner. The NHA/Designee will audit any voluntary room move requests weekly x4 and monthly x2 to ensure that moves are completed in a timely manner. Results to be reviewed through QAPI for further recommendation.
Failure to Document Advanced Directives for Two Residents
Penalty
Summary
The facility failed to provide documentation of advanced directives or the opportunity to formulate an advance directive for two residents. Resident R70, admitted on 6/26/23, had no documentation in their clinical record indicating the presence of an advanced directive or that they were given the opportunity to create one. Resident R70's medical history includes cancer, depression, and peripheral vascular disease. Similarly, Resident R77, admitted on 12/6/23, also lacked documentation of an advanced directive in their clinical record. Resident R77's medical history includes cancer, high blood pressure, and diabetes. During interviews, a registered nurse confirmed the absence of advanced directives or documentation of the opportunity to formulate them for both residents. The Director of Nursing also confirmed this deficiency, which violates the residents' rights to formulate an advance directive as per facility policy and state law. The facility's policy, last reviewed on 8/24, mandates that residents or their representatives be provided with written information about their right to formulate an advance directive.
Plan Of Correction
Residents R70 and R77 will be offered the opportunity to complete an Advanced Directive. All residents in the facility will be reviewed to ensure an advanced directive is in place or has been offered to complete one by social services/designee. The facility social services and Admission Director will be educated on requirements to have the opportunity to complete an advance directive. Social Service will offer Advance Directive upon admission and document refusals. Audits of all new admissions will be completed by the SSD/Designee weekly x 4 then monthly x 2 months, to ensure residents are provided the opportunity to complete advanced directives. Audit results will be reviewed through QAPI for further recommendation.
Failure to Notify Physician of Resident's Tube Feeding Refusal
Penalty
Summary
The facility failed to notify the physician of a resident's refusal of tube feedings, which is a requirement under §483.10(g)(14). The resident, who was admitted with diagnoses including quadriplegia, depression, and anxiety, had an order for enteral feeding with Nutren 2.0. The medication administration record (MAR) indicated multiple instances where the resident refused the feedings, marked with the number two (2) on specific dates. Despite these refusals, the nursing progress notes did not document any notification to the physician regarding the resident's refusal of the enteral tube feedings. The facility's policies, including "Guidelines for Notifying Physicians of Clinical Problems" and "Enteral Tube Feeding via Continuous Pump," require that medical care problems and negative consequences of tube use be communicated to the medical staff in a timely manner. However, the Director of Nursing confirmed during an interview that the facility did not notify the physician about the resident's refusal of tube feedings. This oversight is a violation of the regulatory requirement to inform the physician of significant changes in the resident's treatment needs.
Plan Of Correction
R50 no longer resides in the facility. A retroactive review of all residents with tube feedings will be completed to ensure that any required notifications have been completed. The DON/Designee will educate all licensed nursing staff on the "Guidelines for Notifying Physicians of Clinical Problems" policy for physician notification. The DON or designee will audit all residents with tube feeds for physician notification of refusals daily x3, then five residents twice weekly x 3, then weekly 8 weeks. Audit results will be reviewed through QAPI for further recommendation.
Failure to Ensure Understanding of Coverage Notices
Penalty
Summary
The facility failed to ensure that residents were adequately informed about their Medicare and Medicaid coverage and liabilities, specifically regarding the Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) forms. This deficiency was identified through a review of facility admission documents and staff interviews. It was found that the facility did not explain these forms in a manner that was understandable to the residents and their representatives, as required by regulations. This failure was particularly noted in the case of one resident, who had a moderate cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 11. The resident in question, who was admitted to the facility in mid-July 2024, had a responsible party listed as her daughter. Despite the resident's cognitive impairment, the NOMNC and SNF ABN forms were signed by the resident herself in mid-August 2024, without evidence that the forms were explained in a comprehensible manner. The Nursing Home Administrator confirmed this oversight during an interview, acknowledging that the facility did not meet the requirement to ensure that these forms were understood by the resident and her representative.
Plan Of Correction
Resident R27 is in facility. A one-week retroactive review of all notices signed will be completed to ensure that signors have the capacity to consent, and any residents that are unable to consent have been signed by the party responsible. The NHA or designee will educate social services and RNAC's on Notice of Resident Rights and Responsibilities policy. The SSD or designee will audit all ABN/NOMNC's signed to ensure that the appropriate responsible party is receiving and signing the form. Monthly X 3 months. Audit results will be reviewed through QAPI for further recommendation.
Grievance Policy Posting Deficiency
Penalty
Summary
The facility failed to ensure that the posted grievance policy and procedure met federal guidelines across three nursing units and common areas. During a resident group interview, residents expressed unawareness of the grievance policy and the procedure for filing grievances anonymously. This indicates a lack of communication and visibility regarding the grievance process to the residents. During a tour of the facility, it was observed that the grievance policy and procedure were not completely posted in the main dining room, nursing unit lounge areas, and other common areas. The postings lacked the grievance officer's contact information, instructions on how to file grievances anonymously, and the expected time frame for receiving a response. The Director of Social Services confirmed these deficiencies, highlighting the facility's failure to comply with federal guidelines for grievance procedures.
Plan Of Correction
Grievance forms were placed, and official contact information postings were immediately updated at all grievance boxes on all floors upon identification by surveyor. Residents will be notified and reoriented to the grievance procedure, grievance official, grievance box accessibility, availability of forms and response times at the next scheduled resident council meeting. Residents who do not attend resident council will be notified of the grievance procedure in writing or by the activities department. An anonymous grievance box is located in the dining room. Social Services and Activities staff will be educated by the NHA/Designee on the grievance policy and procedure and federal guidelines at F585 Grievances. Audits will be completed by the NHA or designee weekly x 4 weeks, then monthly x 2 months to ensure boxes, postings, and forms are available for resident use. All results to be reviewed through QAPI for further recommendation.
Failure to Permit Resident Return After Hospitalization
Penalty
Summary
The facility failed to permit a resident, identified as Resident R50, to return to the facility after being transferred to the hospital with the expectation of returning. The facility's policy on bed-holds and returns, dated August 2024, outlines that residents and their representatives are informed in writing about the facility and state bed-hold policies, including the duration of the bed-hold, reserve bed payment, and return policy. Despite these policies, Resident R50, who was admitted to the facility in October 2021 and had diagnoses including anemia, hypertension, and quadriplegia, was not allowed to return after hospitalization. The facility cited the inability to meet the resident's needs as the reason for this decision. Interviews with facility staff revealed that the decision not to readmit Resident R50 was due to the resident's refusal of medications, tube feedings, and care, as well as the resident's and his mother's preference for oral intake against physician orders, which posed an aspiration risk. The Social Service Director and the Director of Nursing both confirmed these reasons, and the Nursing Home Administrator acknowledged the failure to permit the resident's timely return. This action was in violation of the facility's policy and regulatory requirements, as the resident was transferred with the expectation of returning to the facility.
Plan Of Correction
Resident R50 was not readmitted to the facility. Resident and mother's physiological and psychological behaviors that have impacted other residents and their rights. To ensure other residents were not affected by the deficient practice, an audit of facility-initiated discharges of the past 30 days will be completed by the DON or designee. The Regional Director of Clinical Support or designee will conduct education to the IDT Members: DON, Administrator, ADON, Social Service Director, the facility readmission policy and F-tag 626 requirements. The NHA or designee will audit all discharges to the hospital or LOA, and readmissions to ensure that all residents that discharged were allowed to return (or offered a bed hold per our Bed Hold policy). This will be done once a week for 3 months. Results will be reviewed at the QAPI meeting.
Care Plan Deficiencies for Three Residents
Penalty
Summary
The facility failed to update the care plans for three residents, resulting in deficiencies in accurately reflecting their current status and care needs. Resident R1, who was admitted with diagnoses including peripheral vascular disease, heart failure, and dependence on renal dialysis, had a care plan that did not address specific nutritional problems, goals, and interventions related to a chronic stage IV pressure ulcer, therapeutic diet, and dialysis. This was confirmed by a registered dietitian during an interview. Resident R50, diagnosed with anemia, hypertension, and quadriplegia, consistently refused tube feedings, as documented in nursing progress notes and the medication administration record (MAR). However, the resident's care plan did not include interventions for the refusal of tube feedings, a deficiency confirmed by the Nursing Home Administrator. Resident R115, admitted with renal insufficiency, atrial fibrillation, and heart failure, had a physician order for PICC line care that was not reflected in the care plan. Additionally, the care plan did not address the resident's refusal of medications and care, as noted in progress notes. The Nursing Home Administrator and Director of Nursing confirmed the care plan's deficiencies in addressing the PICC line care and medication refusal.
Plan Of Correction
Resident R1's care plan has been updated to include focused nutritional interventions. No negative outcomes were identified as a result of the missing care plan. Resident R50 will not be returning to the facility. The care plan has been closed. Resident R115 was discharged from the facility and had no negative outcomes as a result of the CarePlan not being updated. All resident Care Plans will be reviewed for accuracy. The DON or designee will educate all licensed nursing staff, social services, dietician, and MDS coordinators on the requirements of updating the comprehensive care plans. The DON or designee will audit five resident care plans weekly x8 to ensure updates are completed as needed. Results will be reviewed through QAPI for further recommendation.
Inadequate Supervision and Dietary Non-Compliance
Penalty
Summary
The facility failed to provide adequate supervision for two residents, resulting in elopement incidents. Resident R42, who has severe cognitive impairment due to dementia and Parkinson's disease, was able to exit the facility unsupervised on two occasions. Despite being seen outside in the snow without a coat, the facility did not document an assessment upon his return or notify the physician. The Director of Nursing and Nursing Home Administrator did not initially treat these incidents as elopements, as they believed the resident had the right to be in the courtyard, although there was no documentation of supervision. Another resident, R114, who had expressed a desire to leave against medical advice, managed to leave the facility via a ride service without staff knowledge. The facility was unaware of the resident's absence until the following morning and initially categorized the incident as an AMA discharge rather than an elopement. This oversight indicates a lack of adequate supervision and monitoring of residents who are at risk of leaving the facility without authorization. Additionally, the facility failed to follow a prescribed diet order for Resident R50, who was on an NPO diet due to severe aspiration risk. Despite physician orders and speech therapy recommendations, the resident was given fluids by staff members, and the resident's mother provided additional fluids and soups. This failure to adhere to dietary restrictions posed a significant risk to the resident's health, as the facility did not ensure compliance with the prescribed diet order.
Plan Of Correction
Resident R42 remains at the facility and suffered no negative outcomes as a result of his elopements. Resident R114 did not return to the facility and the facility was not notified of any negative outcomes as a result of leaving via UBER ride service. Resident R50 was transferred to the hospital for unrelated health issues and will not be returning to the facility. The facility has installed magnetic alarms at the facility front entrance to alert staff of anyone opening the emergency release when the doors are locked, or a receptionist is not present. The courtyard doors are now to be locked at all times for temps below 50 degrees unless a staff member is present for supervision of any cognitively impaired residents. The facility will install wander guard systems on the courtyard doors. All staff will be educated by the NHA or designee on elopement and required supervision, and courtyard use. All Direct care staff will be educated in following prescribed diet orders. The DON or designee will audit all incidents for elopements and failing to follow prescribed physician orders. All NPO residents will be audited once a week to ensure that physician orders are followed. Courtyard doors will be audited daily to ensure they always remain locked while awaiting wander guard installation. Results will be reviewed through QAPI for further recommendation.
Failure to Provide Appropriate Catheter Care
Penalty
Summary
The facility failed to provide appropriate treatments and services for the use of urinary catheters for three residents. Resident R3, who was admitted with a suprapubic catheter for a neurogenic bladder, was observed without a privacy-dignity bag on her catheter drainage bag, which was confirmed by a registered nurse. Resident R62, who uses a condom catheter due to neurogenic bladder and quadriplegia, was also observed without a privacy-dignity cover on his catheter bag, which was facing the door. This was confirmed by another registered nurse. Additionally, Resident R317, who was admitted with an indwelling catheter, had a physician's order that failed to specify the fluid amount needed for the catheter balloon. The resident's care plan also did not include the size of the catheter or the fluid amount required for the balloon. This oversight was confirmed by a registered nurse and the Director of Nursing, indicating a failure to ensure appropriate catheter-related treatments and services for these residents.
Plan Of Correction
Residents R3 and R62 had dignity bags applied at the time of survey. Resident R317's orders and care plan have been updated to include size and fluid amount needed for the catheter balloon. A whole house sweep has been conducted to ensure all catheters have dignity bag covers. All catheter orders and care plans will be reviewed to ensure they are complete. All licensed nurses will be educated by the DON or designee on physician orders for catheters, care plan requirements and resident dignity bags. The DON or designee will audit all catheter bags for dignity covers, orders for catheters to include size and fluid amount needed for the catheter balloon, and care plans to include the size of catheter or the amount of fluid needed for the catheter balloon. Audits will be completed weekly x 8 weeks. All results to be reviewed through QAPI for further recommendation.
Inconsistent Dialysis Communication for Resident with ESRD
Penalty
Summary
The facility failed to maintain consistent communication regarding dialysis care for a resident with end-stage renal disease (ESRD). According to the facility's policy, residents with ESRD should be cared for according to recognized standards, including clear communication between the facility and the contracted dialysis provider. However, the clinical record for a resident admitted in August 2024, who was dependent on renal dialysis, showed incomplete documentation of User-Defined Assessments (UDA) for several dates in January 2025. Specifically, there were missing post-dialysis communication assessments on five occasions and missing pre and post-dialysis assessments on two occasions. During an interview, a registered nurse confirmed the absence of the required communication documentation for the specified dates. The resident's medical history included peripheral vascular disease and heart failure, and they attended dialysis sessions three times a week. The lack of complete documentation indicates a failure to adhere to the facility's policy and professional standards of practice, as well as the comprehensive person-centered care plan for the resident.
Plan Of Correction
Resident R1 remains in the facility and had no negative outcomes from the missing documentation. The DON or designee will audit all dialysis residents for concerns of missing UDA forms. The DON or designee will educate all licensed staff on completing dialysis UDA forms and auditing to ensure return UDA forms are completed upon return to the facility. The DON or designee will audit all dialysis communication forms for completion daily x3 days, then five resident charts weekly for 8 weeks. All results to be reviewed through QAPI for further recommendation.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to ensure the highest practicable mental and psychosocial well-being for a resident diagnosed with anxiety and depression. The resident, admitted on November 7, 2024, had a care plan that included monitoring and reporting any acute episodes of mood changes to a physician and obtaining behavioral health consults as needed. However, a review of the clinical record revealed that no behavioral health consults were conducted for the resident, despite the care plan's requirements. During an interview, the Social Service Director confirmed that the facility had not sent any referrals for behavioral health services for the resident. This lack of action resulted in the facility's failure to maintain the resident's mental and psychosocial well-being, as required by the facility's policy and regulatory standards.
Plan Of Correction
Resident R94 remains at the facility pending discharge home on 2/10/25. Resident R94 declined behavioral health consult when offered. No negative outcome has been identified as a result of the lack of an as needed behavioral consult. All residents with an "as needed" behavioral consult care plan will be reviewed for behaviors or willingness to receive behavioral care consults. The NHA will educate all social services employees on the social services policy. The Social Services Director or designee will audit any residents requesting behavioral health referrals to ensure the referrals are generated in a timely manner from date of request. Audits will be completed weekly x 8 weeks. All results to be reviewed through QAPI for further recommendation.
Failure to Reconcile and Dispose of Discontinued Medications
Penalty
Summary
The facility failed to dispose of or reconcile discontinued medications in a timely manner in the West Medication Room. During a review, a grey plastic basin containing various medications was found unsecured and unaccounted for on the counter. The medications included Neurontin, Levemir, Lantus, Amlodipine, Ibuprofen, Coumadin, Eliquis, Tylenol, Motrin, Zyrtec, Senna, Lipitor, Remeron, Metoprolol, Prednisone, Mucinex, Ezetimibe, Keflex, Nitroglycerin, Lopressor, Cymbalta, Simethicone, Rochepin, Miralax, Milk of Magnesia, Ertapenem, Lispro, Humalog, Voltaren Gel, and Delsym. These medications were not properly secured or documented, contrary to the facility's policies on medication storage and disposal. The Director of Nursing (DON) confirmed that the facility did not have a system in place for the accountability or disposition of discontinued medications. The DON stated that medications are discontinued in the computer system, removed from carts, and placed in a bin for pharmacy pickup, which occurs approximately once a week. However, there were no accountability or disposition forms filled out for these medications, indicating a lack of proper reconciliation and documentation as required by the facility's policies and federal regulations.
Plan Of Correction
Medications were picked up for disposal by the pharmacy at the time of survey. All medication rooms were audited for medications awaiting pickup disposal at the time of survey. The facility has implemented a carbon copy pharmacy form system for medication reconciliation/disposal as well as a pharmacy request form if medication volume requires more frequent pick up for disposal. The DON or designee will educate all licensed nursing staff on the new forms, reconciliation and disposal process. The DON or designee will audit the medication rooms for proper use of the new reconciliation/disposal system daily for 3 days and then weekly x 8 weeks. All results to be reviewed through QAPI for further recommendation.
Inadequate Indication for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medication had an adequate indication for its use. Specifically, Resident R108 was prescribed quetiapine, an antipsychotic medication, for anxiety without an appropriate diagnosis documented in the clinical record. This was identified during a review of the facility's policy on medication and treatment orders, which requires that medication orders include the clinical condition for which the medication is prescribed. Resident R108 was admitted to the facility with diagnoses including atrial fibrillation, heart failure, high blood pressure, and anxiety disorder. Despite these conditions, the facility did not provide a documented diagnosis justifying the use of quetiapine for anxiety. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed the lack of an appropriate diagnosis for the use of the antipsychotic medication in this case.
Plan Of Correction
Resident R108 remains at the facility with no adverse outcomes. All residents receiving psychotropic medications will be audited to ensure residents have proper clinically indicated diagnosis for use. All licensed nursing staff will be educated on the clinically indicated use of psychotropics including proper diagnosis for use. The DON or designee will audit all psychotropics being used in the facility for proper diagnosis. Audits will be completed weekly x8. All results to be reviewed through QAPI for further recommendation.
Latest citations in Pennsylvania
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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