John J Kane Regional Center-ro
Inspection history, citations, penalties and survey trends for this long-term care facility in Pittsburgh, Pennsylvania.
- Location
- 110 Mcintyre Road, Pittsburgh, Pennsylvania 15237
- CMS Provider Number
- 395606
- Inspections on file
- 45
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at John J Kane Regional Center-ro during CMS and state inspections, most recent first.
A cognitively impaired resident with multiple sclerosis, dementia, and a cognitive communication deficit, and a BIMS score indicating severe impairment, had physician orders for a wander guard to be checked each shift and was permitted to ambulate on the unit but not to exit the safe area without supervision. Despite facility policies on abuse, neglect, and elopement prevention, and documentation that a wander/elopement alarm was used daily, the resident was found on another floor by staff there while original unit staff were performing morning rounds. The wander guard remained in place, and the resident was redirected back to the unit, but the DON at the time later reported being unaware of the incident until months afterward, demonstrating a failure to supervise and protect the resident from neglect related to elopement.
A resident with severe cognitive impairment and diagnoses including MS and dementia was found on a different floor while looking for breakfast, with a wander guard in place, and was redirected and monitored by staff. Facility policy required that any suspected abuse or neglect, including such incidents, be promptly reported to designated authorities and fully investigated. The DON at the time was unaware of the event until months later, and no complete, thorough investigation was conducted, demonstrating a failure to implement the written abuse/neglect prevention and investigation procedures.
The facility failed to follow its abuse/neglect reporting policy when an elopement-type incident involving a cognitively impaired resident with MS, dementia, and a cognitive communication deficit was not reported to required authorities. Nursing documentation showed the resident, who had a severe BIMS impairment score and wore a wander guard, was found on a different floor while staff were doing morning rounds and was redirected without noted distress. However, the DON later stated she was unaware of the incident at the time and only learned of it months later, and the event was not included in the facility’s reports to the State Survey Agency as an elopement or neglect incident.
A resident with severe cognitive impairment, dementia, and multiple sclerosis had physician orders for a wander guard to be checked each shift and was permitted to move about the unit but not to exit the safe area without supervision. One morning, staff from another floor found the resident on their unit looking for breakfast and returned the resident to the assigned unit, with documentation noting the wander guard was still in place and the resident was redirected and monitored. Despite facility policies requiring prompt reporting and full investigation of all alleged abuse, neglect, and elopement incidents, the event was not reported to leadership or the State Survey Agency, and no investigation was initiated, as later confirmed by interviews with the RNAC/former DON and the NHA.
A resident with multiple sclerosis, dementia, and a cognitive communication deficit had an MDS assessment that inaccurately coded a wander/elopement alarm as not used, despite physician orders, the MAR, and the care plan all documenting that a wander guard was to be in place at all times and checked every shift. The RAI Manual requires coding alarms based on actual use during the 7‑day look‑back period, and facility policy requires incorporating physician orders and clinical records into the MDS. The RNAC confirmed that the MDS did not accurately reflect the resident’s status, constituting a failure to ensure an accurate assessment.
A resident with multiple sclerosis, dementia, and severe cognitive impairment, who had a daily wander/elopement alarm and orders restricting unsupervised exit from the unit, was found on another floor while staff were performing morning rounds. Documentation showed the resident’s wander guard was in place and the resident was redirected and monitored, but the existing elopement care plan, initiated earlier in the month, was not revised or updated after this elopement event. The RNAC/DON later reported being unaware of the incident at the time, and the facility did not ensure the resident’s person-centered care plan was individualized and updated to reflect the elopement.
A resident with multiple sclerosis, dementia, severe cognitive impairment (BIMS score of 3), and a cognitive communication deficit had physician orders for a wander guard to be in place and checked each shift, and the MAR showed daily use of a wander/elopement alarm. An elopement evaluation nonetheless classified the resident as minimal risk, indicated no elopement care plan was needed, and the MDS did not reflect use of a wander/elopement alarm. The resident, who was ambulatory or independent in wheelchair locomotion, left her room on an upper floor, entered an elevator alone, and arrived on the first floor without staff supervision, where ancillary staff found her confused and lost and waited with her until nursing staff escorted her back, demonstrating a failure to provide adequate supervision to prevent elopement.
A resident with neurogenic bladder, lymphedema, and frail skin sustained a significant skin tear when staff improperly placed a Foley catheter bag down her pants during dressing, contrary to the care plan. The catheter bag hook caught the resident's leg, causing a laceration that required emergency room care. Staff interviews and documentation confirmed the injury resulted from improper catheter bag handling.
A resident with traumatic spinal cord dysfunction, anemia, neurogenic bladder, and lymphedema suffered a significant leg wound during care, yet the care plan was not updated to include interventions for lymphedema or skin integrity. Staff and administration confirmed the care plan did not reflect the resident's current needs.
A resident was not properly assessed or prepared for transfer or discharge, and the facility did not ensure that the process met the resident's needs and preferences, resulting in a deficiency in care planning and transition.
A resident who required two-person assistance for bed mobility due to an air mattress was left unattended by a nursing assistant, resulting in a fall and injuries including a forehead hematoma, laceration above the eye, and knee hematoma. The care plan and assignment sheet specified the need for two staff, but the NA was unaware and left the resident near the bed's edge, leading to the incident. Staff interviews confirmed the assistance requirement was documented, and the DON acknowledged the failure as neglect.
Two residents experienced actual harm when staff failed to provide necessary equipment and supervision: one resident with dementia and a fractured foot was transported in a wheelchair without footrests, resulting in further injury, while another resident requiring two-person assistance for bed mobility was left unattended and fell from bed, sustaining multiple injuries. Staff interviews and observations revealed inconsistent use of safety equipment and lack of awareness of care plan requirements.
Two residents with cognitive impairments and histories of confusion and wandering were able to elope to unsupervised or unauthorized areas due to the facility's failure to update elopement assessments and care plans after significant changes or incidents. Despite the use of wanderguards and supervision requirements, staff did not consistently monitor or revise interventions, and there were gaps in communication and documentation regarding residents at risk for elopement.
Surveyors observed that food items in the Main Kitchen were not properly stored, labeled, or dated, and expired food products were present in the walk-in cooler. The Food Service Director confirmed that these practices did not follow facility policy and that expired items, including bologna, pepperoni, turkey, and pureed egg salad, were not removed.
The facility failed to provide adequate supervision and implement person-centered care plan interventions, resulting in two residents at risk for elopement exiting to unsupervised or unauthorized areas without staff knowledge. This lack of effective management by the Administrator and DON created an immediate jeopardy situation and did not meet professional standards of care.
Four residents with diabetes and other chronic conditions had physician orders for FreeStyle Libre devices, but their care plans did not include instructions for the care and management of these devices, as confirmed by the RN Assessment Coordinator and review of clinical records.
The facility did not ensure proper care for residents with enteral feeding tubes, including failing to label and date feeding and flush bags, and not verifying tube placement before medication administration. These deficiencies were observed in three residents with complex medical conditions, and staff confirmed the lapses in required procedures.
Three residents did not receive proper respiratory care, including one receiving oxygen at an incorrect rate with an empty humidification bottle, another whose BiPAP mask was not stored in a bag as required, and a third using an undated nasal cannula. Nursing staff and the DON confirmed these failures to follow respiratory care protocols.
Essential emergency equipment, including two crash carts and three AEDs, were not properly maintained, with missing documentation of required checks and expired AED electrodes. Interviews with the DON and NHA confirmed that regular maintenance and testing were not consistently performed, leaving critical equipment potentially non-operational.
Staff failed to provide a dignified dining experience by standing while assisting a resident with lunch, contrary to facility policy. Additionally, a housekeeping employee entered two residents' rooms without knocking or requesting permission, failing to respect their privacy. Both the DON and the involved staff confirmed these lapses.
A resident room was found unlocked and unattended, containing a large maintenance cart with tools, exposed wires where lights had been removed, and a light bulb on the floor. The room, which lacked beds or furniture, shared a bathroom with an occupied room. The Environmental Services Director and the Nursing Home Administrator confirmed the safety risk and the failure to maintain a clean, safe, and homelike environment.
Two residents with diabetes experienced low blood glucose episodes, but staff did not notify the physician or fully implement the hypoglycemia protocol as required by orders and facility policy. The DON confirmed these lapses in care.
Two residents with limited mobility and physician orders for palm guards did not consistently receive the required equipment and care. One resident's care plan omitted management of a prescribed palm guard, while another was repeatedly observed without bilateral palm guards despite orders. Nursing staff and the DON confirmed these failures to provide appropriate services and equipment to maintain or improve ROM.
Surveyors found that one medication cart and one medication room contained insulin pens and vials without open or expiration dates, as well as an expired insulin vial and a tuberculin multi-dose vial used past the allowed 28 days. An LPN and the DON confirmed these deficiencies, which were not in accordance with facility policy or regulatory requirements.
Two residents' medical records contained nutrition progress notes that used non-standard abbreviations to describe pressure injuries and dietary recommendations. The registered dietitian confirmed using these terms, which were not recognized as acceptable medical terminology, and the assistant director of nursing acknowledged that this practice did not meet professional standards, resulting in incomplete and inaccurate documentation.
A resident with a G tube and multiple medical conditions had orders and a care plan requiring enhanced barrier precautions (EBP). Despite EBP signage, an LPN was observed administering medication through the G tube without wearing a gown, as required by facility policy. The DON confirmed the failure to follow EBP protocols.
Two registered nurses did not receive required training on the facility's Quality Assurance and Performance Improvement (QAPI) Program, as confirmed by review of education records and staff interviews.
Two residents experienced neglect when one was given food despite being NPO and requiring enteral feeding, and another was showered by a single nurse aide despite needing two-person assistance per physician order. Staff failed to follow care plans and facility policy, resulting in unapproved actions for both residents.
The facility failed to properly reheat food items in two unit pantries, creating a risk of cross-contamination and food-borne illness. Staff did not use thermometers to ensure food reached a safe temperature, relying instead on feeling the outside of containers. Residents reported meals were often cold, and the Director of Nursing confirmed the absence of thermometers, acknowledging the facility's failure to ensure food safety.
A facility failed to ensure accurate accounting of controlled medications and proper handling of medication cart keys during a shift change. An LPN left without conducting a required medication count and took the keys, leading to missing narcotics. The incident was confirmed by the DON.
The facility failed to secure medications in the 3-West Low hall medication cart, as observed on two occasions without staff present to lock it. The ADON confirmed the deficiency, which violated the facility's policy and state regulations.
The facility failed to implement proper infection control measures, including incorrect PPE removal procedures for a resident under respiratory precautions. Additionally, unsanitary conditions were observed, such as soiled linens on the floor, unclean commodes, and dirty floor mats in several residents' rooms. These issues were confirmed by staff and acknowledged by the DON.
The facility did not meet the required staffing levels for nurse aides during a night shift, with only 6 nurse aides present instead of the required 7.67 for 115 residents. This occurred once during the review period, as confirmed by the Nursing Home Administrator.
A resident with documented allergies was administered hydralazine by an RN, despite having an allergy to the medication. The resident, diagnosed with dementia, hypertension, and renal insufficiency, experienced a hypertensive episode and gastrointestinal symptoms following the administration. The pharmacy alerted the staff to the allergy, and the resident was subsequently transferred to a hospital for further care.
A facility failed to report an incident of neglect involving a resident with dementia, hypertension, and renal insufficiency in a timely manner. The resident experienced dark coffee ground emesis, and despite obtaining verbal orders for medication, the facility delayed reporting the incident to the State Office by 10 days, violating the 24-hour reporting requirement for non-serious bodily injury incidents.
A facility failed to develop and implement a comprehensive care plan for a resident with dementia, hypertension, and renal insufficiency. The care plan did not address high blood pressure, and staff did not follow the existing plan for the resident's adverse behaviors, including medication refusal. Documentation inconsistencies were noted in the administration of a Clonidine patch, with no record of refusal or staff intervention.
A resident with dementia and hypertension was hospitalized due to the facility's failure to administer a prescribed Clonidine patch, resulting in withdrawal and uncontrolled hypertension. The resident was also mistakenly given Hydralazine, to which they were allergic. The oversight was only identified after the resident was sent to the hospital.
A resident with dysphagia and specific dietary needs was given a regular diet instead of the prescribed pureed diet, leading to a coughing episode requiring suctioning. The resident's medical history included muscle weakness and hemiplegia/hemiparesis following cerebral infarction. The incident was confirmed by the Nursing Home Administrator.
A resident with Pica and dysphagia experienced two choking episodes due to inadequate supervision and failure to update the care plan. The first incident involved ingestion of chewing tobacco pouches, leading to a fall and injury. The second required the Heimlich maneuver after the resident choked on food items. Despite known risks, the facility did not provide consistent monitoring or update the care plan, resulting in actual harm.
The facility failed to properly label and date opened food packages in the Main Kitchen, as observed in the walk-in cooler where opened containers of iced tea, lemonade, and peaches lacked labels or dates. Additionally, an opened bottle of iced tea was improperly stored among chemicals in the chemical room. These deficiencies were confirmed by the FSD, indicating non-compliance with the facility's food storage policy.
The facility failed to communicate necessary resident information during transfers for four residents with significant medical conditions, such as heart failure and Alzheimer's disease. Required details like care plan goals and advance directives were not documented as sent to the receiving health care provider, as confirmed by the DON.
The facility failed to notify the Office of the Long-Term Care Ombudsman Division about the hospital transfers of three residents, as required by federal regulations. These residents, with various medical conditions including heart failure, hypertension, and Alzheimer's disease, were transferred and returned without the necessary notifications being documented. This deficiency was confirmed by a Social Services employee.
The facility failed to notify residents or their representatives of the bed-hold policy during hospital transfers, as required by their policy. Four residents with various medical conditions were transferred to the hospital without receiving the necessary notifications. The Director of Nursing confirmed these deficiencies.
The facility failed to provide baseline care plan summaries to three residents and their representatives within 48 hours of admission. Despite significant medical conditions, these residents did not receive the required documentation. Interviews with staff, including the MDS Coordinator and DON, confirmed this deficiency.
The facility failed to provide trauma-informed care for three residents with PTSD, as their care plans did not identify specific triggers or strategies to mitigate them. This deficiency was confirmed by a social worker, highlighting a lapse in adhering to the facility's policy on Behavior Management and Trauma Informed Care.
The facility failed to obtain necessary hospice diagnoses for four residents with various medical conditions, including stroke and Alzheimer's. Additionally, the hospice communication binder for a resident was incomplete, missing essential documents like the plan of care and consents. This deficiency was confirmed by the Nursing Home Administrator.
A resident with dementia and dysphagia ingested non-food items, including chewing tobacco, leading to a choking incident. The facility's investigation was incomplete, lacking a statement from a nurse aide present during the event. The Director of Nursing confirmed the investigation's inadequacy, as she was on vacation, and the facility failed to adhere to its policies on neglect.
A resident with a history of dementia and pica ingested chewing tobacco pouches and a paper towel, leading to a choking incident. Despite security footage showing the event and staff presence, the facility failed to obtain a witness statement from a nurse aide involved, resulting in an incomplete investigation. The DON confirmed the investigation was not thorough, highlighting a deficiency in the facility's compliance with its abuse and neglect policy.
A facility failed to notify a physician of abnormal CBG levels for a resident with diabetes and did not assess for hyper-/hypoglycemia. Another resident experienced emesis and elevated temperature, but the facility did not obtain physician orders for a Quad swab or isolation. The DON confirmed these deficiencies.
The facility failed to provide appropriate urinary catheter care for two residents. One resident's drainage bag lacked a dignity cover, and another resident's catheter irrigation tray was not changed daily as required. The LPN and DON confirmed these deficiencies.
Failure to Prevent Elopement of Cognitively Impaired Resident with Wander Guard
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect related to inadequate supervision and elopement prevention. Facility policies on abuse, neglect, and elopement required that residents be protected from neglect, that alleged violations be promptly reported and investigated, and that safety measures be implemented for residents who wander or are at risk for elopement. Neglect was defined as the failure of the facility, staff, or service provider to provide necessary goods and services to avoid or that may result in physical harm, pain, mental anguish, or emotional distress. The Wanderguard and Elopement Policy specified that safety measures were to be implemented for residents at risk for elopement to attempt to prevent such events. The resident involved (CR1) had diagnoses including multiple sclerosis, dementia, and a cognitive communication deficit, and had a BIMS score of 3, indicating severe cognitive impairment. The resident’s MDS indicated that a wander/elopement alarm was used daily, and physician orders directed staff to check the function of the wander guard daily on the night shift and to check and document wander guard placement every shift. Another physician order stated that the resident could move about the floor without supervision but could not exit the unit or safe area without supervision. A physician progress note documented that staff had previously reported possible UTI due to altered mental status and wandering, indicating that wandering behavior had been observed by staff despite the MDS section indicating no wandering behavior. On the date of the incident, a nurse progress note documented that while staff on the resident’s unit were performing morning rounds with other residents, staff from the second floor brought the resident back to the unit after finding the resident on their floor looking for breakfast. At that time, the resident’s right lower extremity wander guard monitor was still in place, and the resident was cooperative with redirection. The note indicated that a nurse aide was monitoring and redirecting the resident by her room after the incident. During a later interview, the RNAC, who was the DON at the time of the incident, stated she had been unaware that the resident had been found on the second floor on that date and only became aware of the incident months later, confirming that the facility failed to protect the resident from neglect due to lack of supervision resulting in an elopement from the designated safe area.
Failure to Investigate Elopement Incident as Required by Abuse/Neglect Policy
Penalty
Summary
The deficiency involves the facility’s failure to implement its written policies and procedures to prohibit and prevent abuse and neglect by not conducting a complete and thorough investigation of an elopement incident. The facility’s abuse/neglect policy, dated 1/2/25, states that abuse or neglect of residents will not be tolerated, that any suspected occurrence will be promptly investigated, and that alleged violations must be reported to the Administrator, the PA Department of Health, the Area Agency on Aging, the Compliance Officer, and the Executive Director, with a full investigation conducted. Despite these requirements, an incident in which a resident was found on a different floor than their own, without the facility’s knowledge, was not recognized or investigated as a potential neglect or elopement event in accordance with policy. The resident involved (CR1) had diagnoses including multiple sclerosis, dementia, and a cognitive communication deficit, and had a BIMS score of 3, indicating severe cognitive impairment. A nurse progress note documented that during morning rounds, staff from the second floor brought the resident to their unit after finding the resident there looking for breakfast, with a wander guard still in place, and that the resident was redirected and monitored by a nurse aide. The Resident Nurse Assessment Coordinator, who was the DON at the time of the incident, reported being unaware of this event until months later and confirmed that the facility failed to implement its abuse/neglect policies by not conducting a complete and thorough investigation of this elopement incident for the resident.
Failure to Report Elopement Incident as Neglect
Penalty
Summary
The facility failed to implement its abuse and neglect reporting policies by not reporting an incident of potential neglect involving one resident. Facility policy titled "Abuse - Resident and Reasonable Suspicion of a Crime" dated 1/2/25 required that any suspected abuse or neglect be promptly investigated and reported to the Administrator, the PA Department of Health, the Area Agency on Aging, the Compliance Officer, and the Executive Director. Neglect was defined as the failure of the facility, staff, or service provider to provide goods and services necessary to avoid or that may result in physical harm, pain, mental anguish, or emotional distress. Despite this policy, documentation submitted by the facility to the State Survey Agency did not include a report of an elopement incident for one resident on 12/23/25. The resident involved (CR1) had diagnoses including multiple sclerosis, dementia, and a cognitive communication deficit, and had a BIMS score of 3, indicating severe cognitive impairment, per the MDS dated 12/3/25. A nurse clinical progress note dated 12/23/25 at 6:34 a.m. documented that while staff were doing morning rounds with other residents, second floor staff brought this resident to the unit, noting the resident was on their unit looking for breakfast. The note indicated the resident denied pain or discomfort, had no complaints, and still had a right lower extremity wander guard monitor in place, and that a nurse aide was monitoring and redirecting the resident. However, the former DON (now RNAC) stated in an interview that she was unaware of the resident being found on the second floor on that date and only became aware of the incident months later, adding that it would have been reported if she had known. This sequence of events demonstrated that the facility did not follow its own procedures to recognize and report the incident as neglect.
Failure to Investigate Elopement Incident for Cognitively Impaired Resident
Penalty
Summary
The facility failed to initiate a thorough investigation into an incident of elopement involving one resident (CR1). Facility policies on Abuse - Resident and Reasonable Suspicion of a Crime and on Wanderguard and Elopement required that all suspected abuse or neglect, including elopement, be promptly investigated and reported to the Administrator, the Department of Health, the Area Agency on Aging, the Compliance Officer, and the Executive Director. These policies defined neglect as the failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress, and defined elopement as a resident leaving the premises or safe area without the facility’s knowledge and supervision. The policies also required implementation of safety measures for residents who wander or are at risk for elopement and an evaluation to identify root causes of non-goal-directed wandering. Resident CR1 had multiple diagnoses including multiple sclerosis, dementia, and a cognitive communication deficit, and had a BIMS score of 3, indicating severe cognitive impairment. The resident’s MDS indicated that a wander/elopement alarm was used daily, and physician orders directed staff to check the function of the wander guard daily on the night shift and to check and document its placement every shift. Another physician order specified that the resident could move about the floor without supervision but could not exit the unit or safe area without supervision, and an ADL order required assist/supervision for ambulation every shift. A physician progress note documented that staff had previously reported possible UTI due to altered mental status and wandering. On the date of the incident, a nurse progress note documented that while staff were doing morning rounds, staff from the second floor brought the resident back to the unit, reporting that the resident had been on their unit looking for breakfast. The note indicated that the wander guard monitor remained in place on the resident’s right lower extremity, and that a nurse aide was monitoring and redirecting the resident, with the resident cooperative and safety maintained. However, documentation submitted by the facility to the State Survey Agency did not include any report of an investigation into an elopement for this resident related to that incident. During interviews, the RNAC and former DON stated she was unaware of the resident being found on the second floor at that time and only became aware months later, acknowledging that an investigation would have been conducted if she had known. The surveyors concluded that the facility failed to initiate a thorough investigation of the elopement incident for this resident, in violation of state regulatory requirements for licensee responsibility, management, and nursing services.
Inaccurate MDS Coding of Wander/Elopement Alarm Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s Minimum Data Set (MDS) assessment accurately reflected the resident’s actual status regarding the use of a wander/elopement alarm. The RAI User’s Manual requires that staff review the medical record and code alarms in Section P based on their use during the 7‑day look‑back period, with specific codes for not used, used less than daily, or used daily. The facility’s own policy on MDS/RAI and care planning states that MDS assessments must comply with federal and state requirements and incorporate physician orders, medication and treatment records, practitioner notes, and therapy plans. Despite these requirements, the MDS dated 3/5/26 for one resident with multiple sclerosis, dementia, and a cognitive communication deficit coded the wander/elopement alarm as “0 – not used,” indicating the device was not used during the look‑back period. Clinical documentation and orders showed that this coding was inaccurate. Physician orders dated 5/16/25 directed staff to check the function of the wander guard daily on the night shift, and a subsequent order dated 7/9/25 required the wander guard to be in place at all times, with placement and function checked and documented every shift. The medication administration record from 2/19/26 through 3/18/26 documented daily use of the wander/elopement alarm, and the resident’s care plan, initiated 12/4/25, included an intervention for a wander guard at all times with function and placement checks every shift due to potential for elopement. During an interview, the RN Assessment Coordinator confirmed that the facility failed to ensure the MDS accurately reflected the resident’s status, resulting in an inaccurate assessment for this resident under 28 Pa. Code 211.12(c)(d)(5) Nursing services.
Failure to Update Person-Centered Care Plan After Elopement Incident
Penalty
Summary
The deficiency involves the facility’s failure to update and individualize a resident’s person-centered care plan following an elopement incident. Facility policies on Wanderguard and Elopement, Assessment – MDS/RAI and Care Planning, and Comprehensive Person-Centered Care Planning require implementation of safety measures for residents at risk for elopement, compliance with MDS/RAI requirements, and development, review, and revision of comprehensive person-centered care plans by an interdisciplinary team. The Resident Assessment Instrument (RAI) manual guidance on the BIMS was cited, and the resident’s MDS dated 12/3/25 documented diagnoses of multiple sclerosis, dementia, and cognitive communication deficit, with a BIMS score of 3 indicating severe cognitive impairment. The same MDS showed no documented wandering behavior in Section E, but Section P indicated daily use of a wander/elopement alarm. Physician orders included a directive for a wander guard to be in place at all times with placement checked and documented every shift, and another order allowing the resident to move about the floor without supervision but not to exit the unit/safe area without supervision. A physician progress note later referenced staff reports of possible UTI due to altered mental status and wandering. On 12/23/25, a nurse progress note documented that while staff were doing morning rounds on other residents, staff from the second floor brought the resident back to the unit after finding the resident on their floor looking for breakfast. The note indicated the resident denied pain or discomfort, had the right lower extremity wander guard monitor still in place, and was being monitored and redirected by a nurse aide, with the resident cooperative and safety maintained. Despite this event, review of the resident’s elopement care plan, initiated on 12/4/25, showed no updates or revisions to goals and interventions after the elopement incident. During an interview, the RN Assessment Coordinator, who was the DON at the time of the incident, stated she was unaware of the resident being found on the second floor on 12/23/25 until months later and confirmed that the facility failed to ensure the resident had an updated, person-centered care plan individualized to specific needs after the elopement.
Failure to Adequately Supervise Resident With Severe Cognitive Impairment, Resulting in Unsupervised Elevator Travel
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent elopement for one resident, identified as CR1, who had severe cognitive impairment and was ordered to have a wander guard in place at all times. The resident’s MDS dated 3/5/26 documented diagnoses of multiple sclerosis, dementia, and a cognitive communication deficit, with a BIMS score of 3 indicating severe impairment. Although the MDS Section E indicated the resident had not exhibited wandering behavior and Section P indicated no wander/elopement alarm was used, physician orders from 5/16/25 and 7/9/25 required daily function checks of a wander guard on the night shift and verification of wander guard placement and documentation every shift. The MAR from 2/19/26 through 3/18/26 showed that a wander/elopement alarm was used daily during that period. An Elopement Evaluation dated 2/13/26 documented that the resident was ambulatory or independent in wheelchair locomotion, but indicated no elopement risk factors were identified or verbalized and concluded the resident was at minimal risk for elopement, stating that an elopement care plan was not needed at that time. The same evaluation note added that the resident made no further statements about leaving that night and that she had a wander guard on and did not leave her room that night. Despite the presence of severe cognitive impairment and the use of a wander guard as reflected in orders and the MAR, the resident was not care planned for elopement risk at that time, and the facility’s documentation did not align the resident’s cognitive status and safety device use with an appropriate elopement risk assessment and care plan. On 3/17/26, the resident left her room on the third floor at approximately 12:02 p.m., entered the elevator at 12:03 p.m., and arrived on the first floor at 12:05 p.m. without staff supervision. A late-entry clinical progress note recorded that the resident got onto the elevator and was found on the first floor, then escorted back to the unit without incident. Employee statements from the DON’s secretary and the EVS manager indicated they saw the resident exiting the elevator on the first floor alone, described her as confused and lost, and noted that she stated she had an appointment but could not recall with whom. They contacted nursing, confirmed there were no scheduled appointments, and waited with the resident until an aide arrived to escort her back to the unit. The NHA and DON later confirmed that the facility failed to provide adequate supervision to prevent elopement for this resident, constituting the cited deficiency.
Failure to Protect Resident from Neglect During Catheter Care and Dressing
Penalty
Summary
A deficiency occurred when staff failed to protect a resident from neglect during the provision of catheter care and dressing. The resident, who had a history of traumatic spinal cord dysfunction, anemia, neurogenic bladder, lymphedema, and frail skin, was dependent on staff for all toileting and hygiene needs. According to the care plan, a string was to be used to hang the Foley catheter bag, not a plastic clip. However, staff placed the catheter bag down the leg of the resident's pants while dressing her, contrary to the care plan instructions. During the dressing process, the hook from the urine bag caught the resident's leg, resulting in a laceration on the right anterior medial shin. The wound was described as a v-shaped skin flap with visible fatty tissue and serosanguinous discharge, and the surrounding skin was noted to be shiny, fragile, and edematous. The injury required assessment by a physician assistant and transfer to the emergency room, where it was determined that the wound was non-reparable and was closed with steri-strips. Staff interviews and documentation confirmed that the injury occurred as a direct result of improper handling of the catheter bag during dressing. The resident reported that staff continued to use the same technique despite her daughter's request for a different approach. The facility's own investigation acknowledged that the catheter bag should not have been threaded through the resident's pants, and staff were subsequently educated on safer practices.
Failure to Update Care Plan for Resident with Lymphedema and Skin Integrity Issues
Penalty
Summary
The facility failed to revise and update the care plan to accurately reflect the current status and care needs of a resident with multiple medical conditions. Upon review, it was found that the resident had diagnoses including traumatic spinal cord dysfunction, anemia, neurogenic bladder, and lymphedema with frail skin. The resident sustained a laceration to the right anterior medial shin when staff were assisting with dressing, which was attributed to the hook from a urine bag catching the leg. Documentation indicated the wound was significant, with a v-shaped skin flap, visible fatty tissue, and serosanguinous drainage, and the resident's skin was described as shiny, fragile, and edematous. Despite these findings and the resident's history of lymphedema and skin integrity issues, the current care plan did not include any interventions for lymphedema or preventative measures for impaired skin integrity. Interviews with staff, including a nurse aide and a registered nurse, confirmed that the care plan lacked these necessary interventions. The Nursing Home Administrator also acknowledged that the care plan had not been revised to reflect the resident's current needs, resulting in a deficiency under the cited regulations.
Failure to Ensure Safe and Individualized Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not followed, resulting in a deficiency related to resident care planning and transition.
Failure to Provide Required Two-Person Assistance for Bed Mobility Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a nursing assistant (NA) failed to provide the required two-person assistance for bed mobility to a resident with an air mattress, as specified in the resident's care plan and assignment sheet. The resident, who was cognitively intact and had diagnoses including depression, hypertension, and diabetes, required total assistance for toileting and bed mobility, and substantial assistance for bathing. The care plan clearly indicated that two staff members were needed for bed mobility tasks due to the increased risk of injury associated with the air mattress. On the day of the incident, the NA placed the resident in a lateral position near the edge of the bed and left the resident unattended while stepping out to consult with a nurse about a spinal cord stimulator. During this time, the resident rolled out of bed and sustained injuries, including a hematoma on the left side of the forehead, a laceration above the left eye, and a hematoma to the right knee with associated pain. The NA later stated that she was unaware of the two-person assistance requirement, despite the assignment sheet reflecting this instruction. Multiple staff interviews confirmed that the assignment sheets contained information about required assistance levels and that residents on air mattresses or with similar needs should not be left unattended during care. The incident resulted in actual harm to the resident, as documented by physical assessments and progress notes, and was acknowledged by the Director of Nursing as a failure to provide appropriate goods and services to prevent falls, constituting neglect.
Failure to Prevent Accidents Due to Lack of Equipment and Supervision
Penalty
Summary
The facility failed to provide appropriate equipment and supervision to prevent accidents for two residents, resulting in actual harm. One resident with severe cognitive impairment and a history of right foot fracture was transported in a wheelchair without footrests by nursing assistants. During transport, the resident's foot dropped to the floor, her shoe came off, and she sustained a bruise and an acute fracture of the right fifth toe. Staff interviews revealed a lack of awareness and inconsistent use of wheelchair leg rests, with some staff stating they would ask residents to hold their legs up if footrests were unavailable. Observations confirmed multiple residents being pushed in wheelchairs without leg rests, and the DON acknowledged that staff were not informed about which residents required leg rests, relying instead on whether the equipment was present on the chair. Another resident, who was cognitively intact but required two-person assistance for bed mobility due to an air mattress, was left unattended by a nursing assistant during care. The assistant placed the resident near the edge of the bed in a lateral position and stepped out of the room to consult with a nurse, leaving the resident unsupervised. The resident subsequently rolled out of bed, sustaining a hematoma and laceration above the left eye, a hematoma to the right knee, and reported pain. Documentation and staff interviews confirmed that the resident's care plan and assignment sheet specified the need for two-person assistance, but the nursing assistant was unaware of this requirement despite having access to the assignment sheet. Facility policies required maintaining an environment free from accident hazards and providing adequate supervision and assistive devices. However, the facility did not ensure staff were aware of or followed these requirements, resulting in residents being exposed to preventable harm. Staff interviews and observations highlighted gaps in communication and adherence to care plans, directly contributing to the incidents of injury.
Failure to Provide Adequate Supervision and Person-Centered Interventions Resulting in Resident Elopement
Penalty
Summary
The facility failed to ensure that each resident received adequate supervision and person-centered care plan interventions, resulting in elopement incidents for two residents identified as at risk for elopement. Both residents had documented cognitive impairments and histories of confusion, agitation, and wandering behaviors. Despite these risk factors, the facility did not consistently update or revise elopement assessments or care plans following significant changes in the residents' conditions or after incidents indicating increased risk. One resident, with diagnoses including metabolic encephalopathy, repeated falls, and diabetes, exhibited fluctuating cognition, periods of confusion, and a history of wandering and falls. The resident was found unsupervised in restricted areas of the facility on multiple occasions, including the basement and another floor, despite care plan interventions such as a wanderguard and supervision requirements. Documentation showed that after these incidents, the facility did not complete timely elopement observations or update the care plan to reflect the increased risk or necessary interventions. Another resident, diagnosed with dementia and severe cognitive impairment, was found unsupervised in a closed and unstaffed unit's break room. The resident's care plan and elopement risk assessment were not updated after documented episodes of increased confusion, sundowning, and behavioral changes. The care plan failed to reflect a resident-centered approach or include appropriate interventions until several months after the incident. Staff interviews revealed inconsistencies in the identification and monitoring of residents at risk for elopement, lack of updated wander lists, and unclear responsibilities for the wander management program.
Removal Plan
- DON/Designee will immediately re-evaluate Resident R6 and Resident R111 for elopement risk.
- DON/Designee will re-evaluate all residents for exit seeking behaviors.
- Nursing staff/Designee will provide every one-hour safety checks on all residents. Residents who are at risk of elopement will have every one-hour safety checks ongoing to ensure resident safety.
- DON/Designee will provide appropriate supervision levels for all residents in their orders and person-centered care plans to include interventions such as resident specific activities such as 1:1 interactions, cards, outside to courtyard with supervision, etc. Review and update quarterly, annually or with any significant changes or with any event where elopement is an identified risk.
- DON/Designee will audit appropriate supervision levels.
- DON/Designee will thoroughly investigate all incidents for root cause analysis and follow up with interventions.
- DON/Designee will audit all incidents.
- DON/Designee will implement interventions for residents identified as an elopement risk to prevent residents from eloping.
- DON/Designee will audit all interventions.
- DON/Designee will update elopement assessments quarterly, annually or with any significant change or with any event where elopement is an identified risk.
- Security/Designee to take photographs of residents upon admission to the facility to ensure updated wander books, if they are at risk of elopement. Security providing all nursing units with wander books, with photographs and names/room numbers of residents, and will be updated upon resident's admission and/or discharge.
- Policy for Wanderguard and elopement has been reviewed and facility will add addendum regarding supervision levels and also Security/Designee taking photos of residents upon admission to the facility to ensure resident at risk of elopement are placed in wander books are updated with names/room numbers. Wander books to be updated upon resident admission/discharge and with room changes.
- Staff Educator/Designee will educate all staff on policies for Elopements, Assessments, Care Plan, Supervision, and Accidents.
- Facility will review incidents at QI/QAPI.
Failure to Properly Store, Label, and Date Food in Main Kitchen
Penalty
Summary
The facility failed to properly store, label, and date food items and did not monitor expiration dates of food products in the Main Kitchen. During an observation in the Main Kitchen Walk-in Cooler, an opened bag of French fries was found unsealed, unlabeled, and undated. Additionally, a plastic bag containing bologna, a plastic bag of pepperoni, and a plastic bag of turkey were all marked with use-by dates that had already passed. A container of pureed egg salad was also found with a use-by date that had expired. The Food Service Director confirmed these findings and acknowledged that the facility did not adhere to its own policies regarding food storage, labeling, dating, and monitoring of expiration dates.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Care Planning
Penalty
Summary
The Nursing Home Administrator and Director of Nursing did not effectively manage the facility to ensure that necessary care and services were provided to residents requiring adequate supervision to prevent elopement. Review of job descriptions, clinical records, and staff interviews revealed that the facility failed to maintain necessary supervision and implement person-centered care plan interventions, resulting in two residents exiting to unsupervised or unauthorized areas without the facility's knowledge. This failure constituted an immediate jeopardy situation for two of the 21 residents identified as at risk for elopement. The facility did not ensure that residents received treatment and care in accordance with professional standards of practice, facility policies, physician orders, and the comprehensive person-centered policy.
Failure to Include FreeStyle Libre Device Management in Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans addressing the care and management of the FreeStyle Libre 2 Sensor or Reader for four residents. Each of these residents had physician orders specifying the use and scheduled changes of the FreeStyle Libre device as part of their diabetes management. However, reviews of their care plans revealed that none included instructions or interventions related to the care and management of these devices, despite the orders being present in their clinical records. The residents involved had diagnoses including high blood pressure, diabetes, muscle weakness, heart failure, and arthritis. The deficiency was confirmed during an interview with the Registered Nurse Assessment Coordinator, who acknowledged that the care plans for these residents did not reflect the required care and management of the FreeStyle Libre devices. This failure was found to be inconsistent with the facility's own policy on comprehensive person-centered care planning and relevant state regulations.
Failure to Provide Appropriate Care for Residents with Feeding Tubes
Penalty
Summary
The facility failed to ensure that residents with enteral feeding tubes received appropriate treatment and services to prevent potential complications, as evidenced by multiple deficiencies in labeling, dating, and verifying feeding tube placement. For one resident with diagnoses including high blood pressure, dementia, and diabetes, the enteral feeding bag in use was observed to be outdated and not properly labeled with the resident's name or the formula, and the water bag for flushes was not dated. Staff interviews confirmed that feeding and flush bags should be changed daily and properly labeled, but this was not done. Another resident with a history of stroke and difficulty swallowing had a care plan requiring verification of feeding tube placement before medication administration. However, during observation, an LPN failed to check the tube's placement prior to administering medication, a lapse confirmed by the DON. A third resident with Alzheimer's disease and muscle weakness was also observed receiving enteral feeding from an unlabeled bag, with staff confirming the lack of labeling. The DON acknowledged that the facility did not provide appropriate treatment and services for these residents, as required by policy and physician orders.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents as evidenced by multiple observations and staff confirmations. One resident with diagnoses including high blood pressure and muscle weakness was observed receiving oxygen at a rate higher than ordered by the physician, and the humidification bottle attached to the oxygen setup was empty. A registered nurse confirmed that the resident was not receiving oxygen at the prescribed rate and that the humidification bottle was not filled as required. Another resident with chronic obstructive pulmonary disease, anemia, and obstructive sleep apnea had a physician's order and care plan for BiPAP use at night. However, the BiPAP mask was repeatedly observed left on the bed and not stored in a bag as required by facility policy, with two different LPNs confirming this failure. A third resident, diagnosed with Alzheimer's disease, difficulty swallowing, and muscle weakness, was observed receiving oxygen via nasal cannula that was not dated as required. A registered nurse confirmed the lack of dating on the nasal cannula. The Director of Nursing acknowledged that the facility failed to provide appropriate respiratory care for these three residents.
Failure to Maintain Crash Carts and AEDs in Safe Operating Condition
Penalty
Summary
The facility failed to ensure that essential emergency equipment, specifically crash carts and Automated External Defibrillators (AEDs), were maintained in safe operating condition. Observations revealed that two of four crash carts did not have completed documentation verifying that they had been checked as required, and the associated AEDs had not been tested or confirmed operational on multiple occasions. One crash cart was found with a blank emergency cart log, indicating no checks had been performed or recorded for an extended period. Additionally, three of six AEDs were found with expired electrodes, and there was no evidence that these had been replaced or that the devices were fully operational. Interviews with the Director of Nursing and the Nursing Home Administrator confirmed these lapses, with the NHA noting that AEDs were only serviced annually by an external safety officer. Facility policy requires regular checks and maintenance of emergency equipment, but documentation and observations showed these procedures were not consistently followed, resulting in equipment that may not have been ready for use in an emergency.
Failure to Ensure Dignified Dining and Respect Resident Privacy
Penalty
Summary
The facility failed to ensure a dignified dining experience and respect for residents' private space on the Three East unit. During a dining observation, a nurse assistant was seen standing while feeding a resident lunch, rather than sitting as required by facility policy. The nurse assistant acknowledged awareness of the expectation to sit while assisting with meals. Additionally, a housekeeping employee entered two residents' rooms without knocking or requesting permission, which did not protect or value the residents' private space. The Director of Nursing and the housekeeping employee both confirmed these failures during interviews.
Unsafe and Unattended Maintenance Area in Resident Room
Penalty
Summary
Facility staff failed to maintain a clean, safe, comfortable, and homelike environment in one of three resident areas, specifically in an unoccupied resident room. During an observation, a large maintenance cart containing handheld drills, scraping tools, a caulk gun, screws, wires, and other maintenance equipment was found left in the room, which had no beds or furniture. The lights above the bed areas had been removed, leaving wires visibly protruding from the wall, and a light bulb was found on the floor near the closet. The room was unlocked and unattended, and it shared a bathroom with an occupied resident room. The Environmental Services Director confirmed these observations and acknowledged the safety risk posed by the situation. The Nursing Home Administrator also confirmed the facility's failure to provide a safe and homelike environment in this area.
Failure to Notify Physician and Implement Hypoglycemia Protocol for Diabetic Residents
Penalty
Summary
The facility failed to notify the physician of decreased capillary blood glucose (CBG) levels as required by physician orders and did not implement the hypoglycemia protocol for two residents with diabetes. For one resident with diagnoses including depression, coronary artery disease, and diabetes, blood glucose readings below 70 mg/dL were recorded on multiple occasions, including values as low as 53 mg/dL and 59 mg/dL. Despite physician orders to call the physician for CBG readings less than 70 mg/dL, there was no documentation that the physician was notified or that the hypoglycemia protocol was followed during these incidents. Another resident with diagnoses of high blood pressure, diabetes, and hyperlipidemia also experienced hypoglycemic episodes, with blood glucose readings of 49 mg/dL and 61 mg/dL. Although the resident was treated with orange juice and graham crackers and blood glucose was rechecked, the physician was not notified as required by the physician order and facility protocol. The Director of Nursing confirmed that the facility did not notify the physician or fully implement the hypoglycemia protocol for these residents.
Failure to Provide Required Mobility Equipment and Services
Penalty
Summary
The facility failed to ensure that residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve their range of motion (ROM). For one resident with a history of high blood pressure, hemiplegia, and stroke, a physician order required the use of a right palm guard at all times except during hygiene. However, the resident's care plan did not include care and management of the palm guard, a fact confirmed by the Registered Nurse Assessment Coordinator. Another resident, also with diagnoses including high blood pressure, hemiplegia, and anemia, had physician orders for bilateral palm guards to be worn at all times except for hygiene, and for daily cleaning and reapplication of the hand braces. Despite these orders, observations on two separate occasions found the resident without the required palm guards applied. This was confirmed by a registered nurse, and the Director of Nursing acknowledged that the facility failed to provide the necessary services, equipment, and assistance to maintain or improve mobility for these residents.
Improper Storage and Labeling of Medications and Biologicals
Penalty
Summary
The facility failed to ensure proper storage and labeling of drugs and biologicals in one of three medication carts and one of three medication rooms. During a review of the Three East Med Cart, surveyors observed multiple insulin products, including Insulin Glargine Pen, Tresiba Insulin Pen, and Humalog Insulin Pen, that lacked open dates or expiration dates. Additionally, a Humalog Insulin Vial was found to be expired. These findings were confirmed by an LPN who acknowledged the presence of expired and undated insulin products on the medication cart. In the medication room on the Three [NAME] unit, a tuberculin multi-dose vial was found to be past the 28-day permissible period after opening, as verified by another LPN. The Director of Nursing confirmed that the facility did not properly store medical supplies in the identified medication cart and medication room. These deficiencies were found to be in violation of facility policy and state regulations regarding pharmacy and nursing services.
Failure to Use Standard Medical Terminology in Resident Documentation
Penalty
Summary
The facility failed to maintain and complete accurate and appropriate documentation in the medical records for two residents. For one resident, the clinical record included nutrition progress notes that used non-standard abbreviations such as 'Gr X' and 'Gr 3' to describe pressure injuries, and 'bmf' to refer to between meal feedings. These terms were not recognized as acceptable medical terminology. The resident had diagnoses including high blood pressure, cerebrovascular accident, and muscle weakness, and was documented as having a stage three pressure injury to the coccyx and an unstageable pressure injury to the left ankle. For the second resident, the clinical record also contained a nutrition progress note using the term 'Gr2' to describe a stage two pressure injury. This resident had diagnoses of high blood pressure, dementia, and difficulty swallowing, and was documented as having a stage two pressure injury and an unstageable pressure injury to the coccyx. During staff interviews, the registered dietitian confirmed the use of these non-standard terms, and the assistant director of nursing acknowledged that such terminology does not meet acceptable standards of practice, resulting in incomplete and inaccurate documentation in the medical records.
Failure to Follow Enhanced Barrier Precautions During G Tube Medication Administration
Penalty
Summary
The facility failed to follow its own policy on enhanced barrier precautions (EBP) for infection control during high-contact resident care activities. According to facility policy, EBP requires the use of gowns and gloves during care involving devices such as a G tube. A resident with a history of stroke, difficulty swallowing, and high blood pressure had a physician order and care plan indicating the need for EBP due to a G tube. Despite signage indicating EBP at the resident's doorway, an LPN was observed administering medication through the resident's G tube without wearing a gown as required. The Director of Nursing confirmed this failure to adhere to EBP protocols for the resident.
Failure to Provide QAPI Training to All Staff
Penalty
Summary
The facility failed to provide mandatory training on its Quality Assurance and Performance Improvement (QAPI) Program to two out of eight staff members, specifically two registered nurses. Review of facility education documents for the year 2024 showed that these two staff members did not have documentation of QAPI education. The Assistant Director of Nursing confirmed during interviews that the required QAPI training was not provided to these individuals. This deficiency was identified through review of facility documents and staff interviews, and it was determined to be non-compliant with state regulations regarding staff development and management responsibilities.
Failure to Prevent Resident Neglect in Nutrition and Bathing Assistance
Penalty
Summary
The facility failed to protect two residents from neglect as required by policy and regulation. For one resident with diagnoses including high blood pressure, dementia, and diabetes, who was receiving nutrition through an enteral feeding tube and was designated NPO, an activity employee provided a cookie to the resident without proper authorization. The activity employee stated she had asked the speech therapist for permission, but the speech therapist denied giving approval, noting that the resident had returned from the hospital and required a full evaluation before any oral intake could be recommended. Documentation confirmed the resident was to remain NPO until assessed by the speech therapist. In a separate incident, another resident with high blood pressure, weakness, and wheelchair dependence, who required two-person assistance for bathing, was given a shower by a single nurse aide. The aide proceeded without a second staff member, contrary to physician orders and facility policy. The incident was observed and reported by a registered nurse, who reiterated the requirement for two-person assistance and educated the aide on proper procedure. Both the nursing home administrator and director of nursing confirmed that these actions constituted neglect of the residents involved.
Failure to Properly Reheat Food in Unit Pantries
Penalty
Summary
The facility failed to properly reheat food items in the unit pantries, which created the potential for cross-contamination and food-borne illness in two of the three units, specifically 2 East Pantry and 3 East Pantry. The facility's policy on reheating food, last reviewed on January 2, 2025, outlines the procedure for ensuring food is reheated to a safe temperature of 140 degrees or less. However, observations and staff interviews revealed that the policy was not being followed. Nurse Aid Employee E2 admitted to not using a thermometer to check food temperatures, instead relying on feeling the outside of the cup or plate. Similarly, LPN Employee E6 was unable to locate a thermometer in the pantry, indicating a lack of adherence to the facility's reheating policy. Residents reported that their meals, particularly breakfast and dinner, were often cold by the time they reached the units. While some residents mentioned that staff would reheat their meals upon request, the lack of proper temperature checks posed a risk of serving food at unsafe temperatures. The Director of Nursing confirmed the absence of thermometers in the pantries, acknowledging the facility's failure to ensure food safety. This deficiency was noted in the context of the facility's responsibility under 28 Pa. Code: 201.14(a) and 201.18(b)(1) to manage and ensure the safety of food services.
Medication Management Lapse During Shift Change
Penalty
Summary
The facility failed to implement procedures to ensure accurate accounting of controlled medications and proper handling of medication cart keys during a shift change. On one occasion, an Agency LPN left the facility without conducting a required physical inventory of medications with the incoming nurse, as per the facility's policy. The LPN left the medication cart keys in her car, which was taken by her son, resulting in the keys being unavailable for the incoming nurse. This incident occurred on the 3-West low hall medication cart, and the failure to follow protocol was confirmed by the Director of Nursing. During the shift change, the incoming LPN was unable to access the medication cart due to the absence of keys and did not perform the necessary medication count with the outgoing LPN. The RN Supervisor and the incoming LPN later conducted a count and discovered discrepancies, with two narcotic medications missing. The facility's policy requires that any discrepancies be addressed immediately with a supervisor, but this procedure was not followed initially. The incident highlights a lapse in adherence to established protocols for medication management and key handling during shift changes.
Plan Of Correction
Immediate education regarding Policy M-N-19 Medications - Narcotics Controlled Substances, DEA's, was provided to every licensed staff member working the 3-11, 11-7 shift on 2-4-2025 and daylight on 2-5-2025. DON/ADON/Designee will continue education regarding Policy M-N-19 Medications - Narcotics Controlled Substances, DEA's to all licensed nursing staff daily and Policy will be included with orientation packet for all agency licensed nursing staff. Audits of the controlled inventory sheets will be done at change of shift daily x 7 days, 3x per week for 2 weeks, weekly x4. All results will be reported to the QAPI Committee for review.
Medication Cart Security Deficiency
Penalty
Summary
The facility failed to store medications securely in one of its medication carts, specifically the 3-West Low hall medication cart. According to the facility's "Medication administration general guidelines" policy, all medications must be kept secured and in a locked environment. However, during observations on February 3, 2025, at 12:13 p.m., the 3-West unit's low hall medication cart was found unlocked, with no registered nurse, licensed practical nurse, or any other staff member present to secure the cart. Further observations at 12:17 p.m. on the same day confirmed that the 3-West low hall medication cart #1 remained unlocked, again with no staff present to secure it. During an interview at 12:18 p.m., the Assistant Director of Nursing (ADON) confirmed the facility's failure to store medications securely in one out of six medication carts as required by regulations. This deficiency was noted under the relevant state codes for pharmacy and nursing services.
Plan Of Correction
- Immediate termination of agency RN assigned to the med cart on 3 West Low Hall during complaint survey. - Immediate education to all licensed nursing staff regarding Policy N-M-05 Medication Administration General Guidelines including emphasis on requirement that the medication cart MUST be locked at all times when not in use. - DON/ADON/Designee will continue education on policy N-M-05 Medication Administration General Guidelines including emphasis on requirement that the medication cart MUST be locked at all times when not in use to all licensed staff. - Audits of the meds cart are being completed 2x per shift x 10 days, 3x per week for 2 weeks and weekly x4. - All results will be reported to the QAPI Committee for review.
Infection Control and Sanitation Deficiencies
Penalty
Summary
The facility failed to implement proper infection prevention and control measures, particularly concerning respiratory precautions for a resident. Staff members, including registered nurses and licensed practical nurses, incorrectly indicated that the N95 respirator should be removed inside the respiratory precautions room, contrary to guidelines that require it to be removed outside the room. This misunderstanding was confirmed during an interview with a registered nurse who was unaware of the correct procedure. Additionally, the facility's policy on cleaning and preventative maintenance was not adhered to, as evidenced by the presence of soiled linens on the floor in a resident's room. Further observations revealed unsanitary conditions in several residents' bathrooms and living areas. Three residents had commodes with dried brown substances, indicating a lack of proper cleaning. Additionally, floor mats in the rooms of four residents were found to be dirty, with debris and dried food substances present. These findings were confirmed by staff members during tours of the facility. The Director of Nursing acknowledged the facility's failure to implement infection prevention and control monitoring policies effectively.
Plan Of Correction
Facility immediately had toilets in rooms 385, 293 and 284 cleaned and facility immediately removed soiled fall mats and replaced them with clean fall mats on 1/14/2025. Education provided to staff immediately on 1/14/2025 for proper doffing of face masks and respirators between resident rooms and dirty linen on the floor. Staff educator/designee will educate all staff on Infection Control Policy and Procedures. Staff educator/designee will educate all housekeeping staff on cleaning rooms/bathrooms properly and cleaning of the fall mats. Educator/Designee will provide education to nurses' aides regarding dirty linen and fall mats; aides are to stand mats up and lean them up against the wall (only when resident is out of bed) to facilitate thorough cleaning of the equipment by Housekeeping. Baseline whole house audit will be completed for both fall mats and resident bathrooms. Ongoing audits will continue weekly x 4 weeks, bi-weekly x 2 months and monthly x 3. Audits on PPE and dirty linen will occur; 10 random rooms will be checked daily for one week, then 3 times a week x 1 month, then 1 time a week x 1 month. All results will be reported to the QAPI Committee for review.
Staffing Deficiency on Night Shift
Penalty
Summary
The facility failed to meet the state-mandated staffing requirements for nurse aides during the night shift on one occasion within the reviewed period from December 24, 2024, to January 13, 2025. Specifically, on December 27, 2024, the facility had a census of 115 residents, necessitating a minimum of 7.67 nurse aides to comply with the regulation of one nurse aide per 15 residents. However, only 6 nurse aides were present, resulting in a staffing shortfall. This deficiency was confirmed by the Nursing Home Administrator during an interview conducted on January 14, 2025.
Plan Of Correction
DON/ ADON/ RN Charge Nurse will be re-educated on maintaining state required staffing levels. Daily audits will be completed by the Director of Nursing/ ADON/ Staffing Coordinator on maintaining state mandated staffing levels and ratios for each shift. Audits will be completed by DON/ Designee on state mandated PPD/ratio requirements weekly x 4 weeks and monthly x 3. All results will be presented to the QAPI committee, which will review for need of ongoing audits and evaluation to make recommendations as needed.
Failure to Protect Resident from Medication Allergy
Penalty
Summary
The facility failed to protect a resident from neglect, as evidenced by the administration of a medication to which the resident was allergic. The resident, who had been diagnosed with unspecified dementia, hypertension, and renal insufficiency, was admitted to the facility with documented allergies to hydralazine, naproxen, and penicillin. Despite this, a registered nurse administered hydralazine to the resident after receiving a verbal order from a physician to manage the resident's high blood pressure. The nurse had access to the resident's clinical record, which included the allergy information, but failed to notice it. Following the administration of hydralazine, the resident experienced a hypertensive episode and was found to have dark coffee ground emesis, indicating potential gastrointestinal bleeding. The pharmacy later notified the nursing staff of the resident's allergy to hydralazine, prompting a reevaluation of the resident's condition. The resident's family was informed of the situation and requested that the resident be transferred to a hospital for further evaluation and treatment. The facility's failure to recognize and act upon the documented allergy resulted in the resident being exposed to a medication that could cause harm.
Plan Of Correction
This plan of correction constitutes my written allegation of compliance for the deficiencies in which the facility was cited for. However, the submission of this plan of correction is not an admission that a deficiency exists or that one was cited correctly. This plan of correction is submitted to meet the requirements established by state and federal law. - Immediately during complain survey, ERS submitted for Neglect on 12/18/2024. - All medication errors will be screened for abuse/neglect and reported if it meets criteria to ERS. - Electronic Medical Record feature activated for alert for all residents, related to resident allergies to specific medications, to populate red/pink screen alerting RN/LPN to allergy. - Licensed nursing staff will receive education on N-M-05 Medication Administration General Guidelines and N-M-300 Medication Documentation and N-M-150 Medication Error Reporting, Analysis and Correction (MERF). - DON/ADON/Designee to audit all medication errors for abuse/neglect weekly x4 and bi-weekly x2. - Results of audit will be reviewed and evaluated at QAPI meeting.
Failure to Timely Report Incident of Neglect
Penalty
Summary
The facility failed to report an incident of neglect in a timely manner, as required by regulations. The incident involved a resident who presented with dark coffee ground emesis on a specific date, and the nursing supervisor contacted the on-call physician to obtain verbal orders for medication. However, it was noted that the resident had a listed allergy to one of the medications prescribed. Despite the seriousness of the situation, the facility did not report the incident to the State Office until 10 days later, which is a violation of the requirement to report such incidents within 24 hours if they do not result in serious bodily injury. The resident involved had a medical history that included unspecified dementia, hypertension, and renal insufficiency. The facility's policy on abuse and reasonable suspicion of a crime mandates that any alleged violations must be reported immediately or within 24 hours, depending on the severity of the incident. During an interview, the Nursing Home Administrator and Director of Nursing confirmed the late reporting of the incident, acknowledging the facility's failure to comply with the timely reporting requirements.
Plan Of Correction
Immediately during the complaint survey, ERS submitted for Neglect on 12/18/2024. All allegations of abuse and neglect will be reported in the required parameters. DON/ADON will be re-educated on policy A-A-05 - Abuse - Resident and Reasonable Suspicion of a crime and timely reporting requirements. All staff will receive education regarding policy A-A-05 and timely reporting requirements. DON/ADON/Designee will audit all medication errors for abuse/neglect and timeliness of reporting weekly x4 and biweekly x2. Results of audit will be reviewed and evaluated at QAPI meeting.
Failure to Develop and Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident, identified as Resident R1, who was admitted with diagnoses including unspecified dementia, hypertension, and renal insufficiency. The deficiency was identified through a review of facility documentation, clinical records, and staff interviews. The facility's policy requires staff to document all care and services provided, including identification, evaluation, intervention, and attempts to revise the care plan to address changing needs. However, the review revealed that there was no care plan specifically addressing the resident's high blood pressure, despite it being a significant medical condition. Additionally, the facility did not follow the existing care plan for Resident R1's identified adverse behaviors, which included resisting care. The medication administration record showed inconsistencies in the application of a prescribed Clonidine patch, with some entries left blank and no documentation of the resident's refusal or staff's attempts to address the refusal. Interviews with the Nursing Home Administrator and Director of Nursing confirmed the absence of a care plan for high blood pressure and acknowledged the failure to follow the care plan for behavioral issues related to medication refusal.
Plan Of Correction
Resident R1's care plan was immediately updated upon return from hospital. All like residents, with Hypertension and Dementia, that interferes with daily living, will have care plan(s) and orders to prevent or lessen the risk of negative outcomes as it relates to the diagnoses and adverse behaviors. All staff will receive education on policy N-A-01 All Policy and Procedures: General Guidelines, N-A-40 Assessment-MDS/RAI and Care Planning and N-A-44 Assessment-Comprehensive Person-Centered Care Planning. DON/ADON/Designee to audit all current care plans to ensure proper interventions for all residents as it relates to Hypertension and Dementia, potential interference with activities of daily living and med refusals, and able to document use of interventions in EMR weekly x4 and bi-weekly x2. Results of audit will be reviewed and evaluated at QAPI meeting.
Failure to Administer Clonidine Patch Leads to Hospitalization
Penalty
Summary
The facility failed to adhere to a physician's order for a resident, resulting in a significant health event. The resident, who was admitted with diagnoses including unspecified dementia, hypertension, and renal insufficiency, was prescribed a weekly Clonidine patch to manage their blood pressure. However, the medication administration record (MAR) showed that the patch was not applied as scheduled on several occasions, with no documented reason for the omission on December 6th. This oversight led to the resident experiencing elevated blood pressure and other symptoms, necessitating hospitalization. Upon review, it was discovered that the resident had not received the Clonidine patch for several weeks, leading to Clonidine withdrawal and uncontrolled hypertension. The resident was sent to the emergency room with symptoms including elevated blood pressure, increased pulse, and vomiting. The hospital staff identified the presence of an old Clonidine patch dated from a previous month, indicating a lapse in medication administration. Additionally, the resident was mistakenly given Hydralazine, to which they were allergic, further complicating their condition. Interviews with the resident's family and facility staff confirmed the failure to follow the physician's order for the Clonidine patch. The family was informed of the resident's condition and the medication error after the resident was already hospitalized. The facility's administration acknowledged the oversight and the failure to identify the issue until alerted by the hospital, highlighting a significant lapse in the facility's medication administration and monitoring processes.
Plan Of Correction
Initial audit was performed by DON/ADONs of all medication patches. Initial education was provided to all licensed staff on policy N-M-05 Medication Administration General Guidelines and N-M-115 Medication Administration Transdermal. All licensed nursing staff will be educated on N-M-05 Medication Administration General Guidelines, N-M-115 Medication Administration Transdermal and N-M-150 Medication Error Reporting, Analysis and Correction (MERF). DON/ADON/Designee to audit medication patches weekly x4 and bi-weekly x2. Results of audit will be reviewed and evaluated at QAPI meeting.
Failure to Provide Appropriate Food Consistency
Penalty
Summary
The facility failed to provide food in the appropriate consistency for a resident with specific dietary needs. The resident, who was admitted with diagnoses including muscle weakness, hemiplegia/hemiparesis following cerebral infarction, and dysphagia, had a physician's order for a pureed diet with thin liquids. However, on the morning of October 13, 2024, the resident was given a regular diet instead of the prescribed pureed diet. This led to an episode where the resident experienced coughing and required suctioning after consuming some of the regular consistency food items, such as French toast and oatmeal. The incident was confirmed by the Nursing Home Administrator during an interview on October 16, 2024.
Inadequate Supervision Leads to Choking Incidents
Penalty
Summary
The facility failed to provide adequate supervision for a resident, identified as Resident R52, who experienced two choking episodes. The first incident involved the resident ingesting chewing tobacco pouches and a paper towel, which led to a fall and a laceration on the forehead. Despite the resident's known diagnosis of Pica, a condition characterized by eating non-food items, the facility did not update the resident's care plan following this incident. The resident's care plan had previously identified risks related to placing non-food items in her mouth and taking food from other residents' trays, but interventions were not effectively implemented to prevent these behaviors. In a subsequent incident, Resident R52 was found choking on food items, including long red onions, which required the Heimlich maneuver to be performed by nursing staff. This episode occurred despite the resident being on a prescribed puree diet due to dysphagia, a condition that makes swallowing difficult. The facility's failure to provide one-to-one supervision and to ensure that non-food items and inappropriate food were kept out of the resident's reach contributed to the choking incident. Interviews with staff revealed a lack of consistent monitoring and supervision for Resident R52, despite her known risks. The Director of Nursing confirmed that the facility did not contact poison control after the first incident and did not update the resident's care plan. Staff members expressed an understanding of the need to monitor residents with Pica closely, but the facility's management did not ensure that these practices were consistently followed, leading to actual harm for Resident R52.
Improper Food Storage and Labeling in Main Kitchen
Penalty
Summary
The facility failed to adhere to its food storage policy, which requires food products to be labeled and dated with the receiving date, and to ensure that chemicals are not stored with food and paper supplies. During an observation in the Main Kitchen's walk-in cooler, an opened gallon of iced tea, an opened half-gallon container of lemonade, and a plastic container of peaches were found without labels or dates. This was confirmed by the Food Service Director (FSD) Employee E18, indicating a failure to properly label and date opened food packages to prevent foodborne illness. Additionally, during another observation, an opened bottle of iced tea was found stored in the chemical room among chemicals, which was also confirmed by FSD Employee E18. This indicates a failure to properly segregate food and chemicals, further violating the facility's food storage policy.
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 during facility-initiated transfers for four residents. The facility's policy required that specific information, including contact details of the practitioner and resident representative, advance directives, care plan goals, and other necessary medical information, be sent to the receiving facility. However, upon review, it was found that for Residents R2, R41, R81, and R118, there was no documented evidence that this information was communicated when they were transferred to the hospital and expected to return. Each of the residents had significant medical conditions, such as heart failure, hypertension, anemia, Alzheimer's disease, quadriplegia, and bipolar disorder, which necessitated clear communication of their care needs. Despite these requirements, the clinical records for these residents lacked documentation of the necessary information being sent to the receiving health care provider. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the failure to communicate the required information for these residents.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide a transfer notice to the Office of the Long-Term Care Ombudsman Division for three residents, identified as R2, R41, and R81, when they were transferred to the hospital. This deficiency was identified through a review of facility policy, clinical records, and staff interviews. The regulations under Title 42 Code of Federal Regulations S483.15(c)(5) require that a written notice of transfer or discharge must include specific information, such as the reason for transfer, effective date, location, appeal rights, and contact information for the Ombudsman. However, the facility did not document evidence of providing this notification for the mentioned residents. Resident R2, who had diagnoses of heart failure, hypertension, and anemia, was transferred to the hospital and returned to the facility without the required notification being sent. Similarly, Resident R41, with heart failure, hypertension, and depression, and Resident R81, with high blood pressure, Alzheimer's disease, and muscle wasting, were also transferred to the hospital and returned without the necessary notification to the Ombudsman. The Social Services Employee E11 confirmed the facility's failure to provide the transfer notice during an interview.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify residents or their representatives of the bed-hold policy during hospital transfers, as required by their policy dated 1/3/24. This policy mandates that written notice of the bed-hold policy be provided upon admission, during hospital transfers, or when a therapeutic leave exceeds 24 hours. However, for four residents (R2, R41, R81, and R118), there was no documented evidence that such notifications were given at the time of their respective hospital transfers. Resident R2, diagnosed with heart failure, hypertension, and anemia, was transferred to the hospital on 9/29/23 without receiving the required notification. Similarly, Resident R41, with heart failure, hypertension, and depression, was transferred on 1/13/24, and Resident R81, with high blood pressure, Alzheimer's disease, and muscle wasting, was transferred on 12/31/23, both without documented notifications. Resident R118, diagnosed with quadriplegia, bipolar disorder, and neck pain, was also transferred on 4/3/24 without receiving the necessary information. The Director of Nursing confirmed these deficiencies during an interview.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility failed to ensure that residents and their representatives were provided with a summary of their completed baseline care plans within 48 hours of admission. This deficiency was identified for three residents, each with significant medical conditions. Resident R41, who was admitted with heart failure, hypertension, and depression, did not receive a summary of the baseline care plan. Similarly, Resident R71, with coronary artery disease, atrial fibrillation, and a seizure disorder, and Resident R82, with chronic kidney disease, depression, and diabetes, also did not receive their baseline care plan summaries. Interviews with facility staff confirmed the deficiency. The MDS Coordinator, Employee E16, admitted to not providing residents or their families with copies of the baseline care plans. The Director of Nursing also confirmed the facility's failure to provide these summaries for the three residents in question. This lack of documentation and communication with residents and their representatives is a violation of the facility's obligations under the specified Pennsylvania Code regulations.
Failure to Provide Trauma-Informed Care for PTSD Residents
Penalty
Summary
The facility failed to provide trauma-informed care to three residents diagnosed with PTSD, as required by their policy on Behavior Management and Trauma Informed Care. The policy mandates that the Interdisciplinary Team should identify and address triggers that could lead to distress in residents with PTSD. However, upon review of the care plans for Residents R83, R88, and R99, it was found that the facility did not identify specific triggers for these residents, nor did they outline strategies to avoid or mitigate these triggers. The deficiency was confirmed during an interview with Social Worker Employee E17, who acknowledged that the facility did not identify PTSD triggers for the affected residents. This oversight could potentially lead to re-traumatization of the residents, as their care plans lacked the necessary information to prevent or manage distressing situations. The facility's failure to adhere to its own policy and provide adequate trauma-informed care was noted as a deficiency under the relevant Pennsylvania Code sections.
Failure to Obtain Hospice Diagnosis and Incomplete Documentation
Penalty
Summary
The facility failed to obtain a diagnosis for hospice services for four residents, which is a requirement for hospice care admission. The residents involved had various medical conditions, including stroke, dysphagia, muscle wasting, heart failure, hypertension, depression, Alzheimer's disease, and malnutrition. Despite these conditions, the physician orders for hospice services did not include a diagnosis related to the need for hospice care, which is necessary for the approval and authorization of hospice services according to the facility's policy. Additionally, the facility did not maintain a complete hospice communication binder for one resident. The binder, which is essential for communication between the facility and the hospice agency, was missing critical documents such as the resident's plan of care, consents, orders, and the facility notification of hospice admission form. This lack of documentation was confirmed during an interview with the Nursing Home Administrator, highlighting a deficiency in the facility's management of hospice services.
Incomplete Investigation of Choking Incident
Penalty
Summary
The facility failed to implement written policies and procedures to ensure a complete and thorough investigation of an incident involving potential neglect for a resident, identified as Resident R52, who experienced a choking incident. The facility's policy on abuse and neglect defines neglect as the failure to provide necessary goods and services to avoid physical harm or distress. However, the investigation into the incident involving Resident R52 was incomplete, as it did not include a witness statement from a nurse aide who was present during the event. Resident R52, who has a history of dementia, intellectual disabilities, and dysphagia, was involved in an incident where she ingested non-food items, including chewing tobacco pouches and a paper towel, leading to a choking episode. The resident was found on the floor with a laceration on her forehead and cyanotic in the face. After vomiting the ingested items, her condition improved. The incident was captured on security footage, showing Resident R52 taking the contents of another resident's chew cup and later falling in the hallway. The facility's investigation documentation was incomplete, as it failed to include a statement from NA Employee E3, who was seen on security footage interacting with Resident R52 shortly before the fall. The Director of Nursing confirmed that the investigation was not thorough, as she was on vacation at the time, and a statement from the nurse aide was not obtained. This lack of a complete investigation highlights the facility's failure to adhere to its policies and procedures regarding neglect.
Failure to Investigate Choking Incident Thoroughly
Penalty
Summary
The facility failed to conduct a thorough investigation of a choking incident involving a resident, identified as Resident R52, who has a history of dementia, intellectual disabilities, and dysphagia. The resident's care plan noted a tendency to place non-food items in her mouth due to pica, with goals to prevent choking or aspiration on such items. On the day of the incident, Resident R52 was found on the floor with a laceration on her forehead and cyanotic in the face. Upon assessment, she began vomiting clear brown fluid with a strong smell of tobacco, along with 3-5 pouches of chewing tobacco and a paper towel, which she had ingested. The incident was captured on security footage, showing Resident R52 entering the dining hall and putting the contents of another resident's chew cup into her mouth. Despite the presence of staff, including a nurse aide who appeared to attempt to take something from Resident R52, the resident was able to ingest the tobacco pouches and paper towel. The facility's investigation documentation was incomplete, as it failed to include a witness statement from the nurse aide involved, NA Employee E3, who did not return a call from the State Agency for a statement. The Director of Nursing confirmed that the facility did not conduct a thorough investigation of the incident, as she was on vacation at the time and assumed a statement was not obtained from NA Employee E3. This lack of a comprehensive investigation to rule out neglect was identified as a deficiency by the surveyors, as it did not comply with the facility's policy on abuse and neglect, which requires obtaining written statements from all parties involved in such incidents.
Failure to Notify Physician and Obtain Orders for Residents
Penalty
Summary
The facility failed to notify the physician of abnormal Capillary Blood Glucose (CBG) levels and did not assess a resident for hyperglycemia and hypoglycemia. Specifically, Resident R73, who had diagnoses of diabetes, muscle weakness, and depression, had several instances of abnormal CBG readings. On multiple occasions, the resident's CBG levels were either low or high, yet the facility did not implement its policy to assess the resident for hyper-/hypoglycemia or notify the physician of these abnormal results. Additionally, the facility did not obtain necessary physician orders for another resident, Resident R369, who had diagnoses of diabetes, chronic kidney disease, and osteoarthritis. This resident experienced episodes of emesis and an elevated temperature, prompting the facility to perform a Quad swab to rule out various respiratory viruses. However, the clinical record lacked a physician's order for the Quad swab and for placing the resident in isolation while awaiting test results. The Director of Nursing confirmed these deficiencies during interviews, acknowledging the failure to notify the physician of abnormal CBG levels for Resident R73 and the lack of physician orders for the Quad swab and isolation for Resident R369. These actions and inactions led to the identified deficiencies in the facility's care and services.
Deficiency in Urinary Catheter Care
Penalty
Summary
The facility failed to provide appropriate treatments and services for the use of urinary catheters for two residents. Resident R2, who has diagnoses of heart failure, hypertension, and anemia, was observed with a urinary drainage bag hanging from the bed frame without a dignity bag, contrary to the facility's policy. The physician's order for Resident R2 required catheter care every shift for wound healing, but the observation indicated non-compliance with the policy to cover drainage bags with a dignity bag. Resident R82, diagnosed with diabetes, depression, and chronic kidney disease, was observed with an opened piston and irrigation catheter tray on the nightstand, dated two days prior to the observation. The facility's policy requires that open solutions be discarded after twenty-four hours, and the physician's order for Resident R82 specified flushing the urinary catheter with saline water three times a day. The LPN confirmed the tray was not changed daily as required, and the DON acknowledged the facility's failure to provide appropriate catheter care for these residents.
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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