Quality Life Services - Chicora
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicora, Pennsylvania.
- Location
- 160 Medical Center Road, Chicora, Pennsylvania 16025
- CMS Provider Number
- 395118
- Inspections on file
- 36
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 42 (2 serious)
Citation history
Health deficiencies cited at Quality Life Services - Chicora during CMS and state inspections, most recent first.
Surveyors found that a resident dining room near the kitchen was being used to store maintenance equipment and tools, including carts, unattached hand railings, a nail gun, a drill with bits, metal ratchets, scraping tools, a shop vacuum, and fans, while the room’s doors were not locked despite signage stating it was closed. The DON stated there was no policy specific to maintaining a safe, clean, and homelike environment, and a project manager explained that the equipment was related to an ongoing nighttime renovation project and acknowledged that the maintenance equipment had not been secured behind a locked door as required.
A resident with muscle weakness and a need for assistance with personal care sustained superficial burns to the thighs and abdomen after hot tea was spilled during dinner service. Dietary staff poured hot water for beverages without checking temperatures and then moved to the opposite side of the dining room, with their backs turned when the resident cried out. A tablemate reported that a kitchen staff member had just poured hot water into the resident’s cup and then continued serving others before the cup was found tipped over. At the time, two dietary staff were in the dining room and the assigned aide was occupied with another resident, and the NHA confirmed that water temperatures were not checked prior to service, resulting in inadequate supervision and a burn injury.
Surveyors found that a COVID-positive resident with COPD and other conditions was ordered and care planned for droplet precautions per facility policy, which required appropriate signage and a closed door. Observations showed that, although droplet precaution signage was posted, the resident’s door remained wide open to the hallway on multiple checks. An RN acknowledged the door should remain closed to prevent cross contamination, and the DON confirmed the facility failed to follow droplet precautions for this resident.
The facility did not maintain comfortable air temperature levels in a resident room and two common areas, despite having an Extreme Weather policy addressing risks of excessive cold for geriatric residents. After the boiler, the facility’s heat source, required resetting, subsequent observations with the Maintenance Director showed temperatures of 68°F in a resident room, 67.3°F in a common room, and 70.5°F in the dining room. The NHA acknowledged that these conditions did not meet the requirement to provide a safe, comfortable, and homelike environment for residents.
A resident with dementia, depression, and anxiety, care planned as an elopement risk and wanderer, exited a locked memory unit by following their husband, who knew the door code and left the unit without checking behind him. The resident, who was documented as rarely/never understood and did not have a completed BIMS, was later found ambulating in another hallway approximately 36 feet from the memory unit and was returned by staff. Facility records showed behavioral notes without exit-seeking behaviors, and leadership acknowledged that supervision was insufficient to prevent this elopement.
A resident with diabetes and other conditions sustained a burn after being served hot coffee by the Activities department without the temperature being checked, while another resident with dementia and a history of wandering eloped twice due to lack of individualized supervision and interventions. Facility staff and leadership confirmed failures to follow policies on accident prevention and elopement.
The facility failed to ensure all nursing staff received required abuse/neglect education before working and annually, and did not timely identify, report, or investigate allegations that an LPN administered medications without orders, resulting in residents being overly sedated and unable to eat or wake up. The LPN continued to work after allegations were made, and the facility did not promptly suspend the staff member or initiate an investigation.
Staff reported that an LPN was administering medications such as melatonin and Tylenol to residents without proper orders, leading to residents appearing sedated, unable to eat, and an increase in deaths on the memory impaired unit. Despite these reports, facility leadership delayed reporting the allegations to required authorities for ten days, failing to follow mandated procedures for timely investigation and notification.
The NHA and DON failed to implement the facility's abuse and neglect policy and did not report alleged criminal activity involving an LPN to authorities, resulting in immediate jeopardy for all residents. This deficiency was identified through review of job descriptions, records, and staff interviews, and confirmed during an interview with the Chief Nursing Officer.
Four direct care nurse aides did not receive the minimum 12 hours of annual training required by regulation, as confirmed by facility documentation and staff interviews.
A resident with severe cognitive impairment and high fall risk experienced an unwitnessed fall resulting in injury. Despite facility policy requiring prompt notification, the physician was not informed until three days later and the family was notified twenty days after the incident. Staff interviews and documentation confirmed the delay in communication and failure to follow established protocols.
A resident with dementia and anxiety was administered Ativan PRN over an extended period without a 14-day stop date or documented physician rationale for continued use. Non-pharmacological interventions were not documented prior to medication administration, and staff confirmed that facility policy was not followed regarding psychotropic medication use and documentation.
A resident with severe cognitive impairment and multiple diagnoses required substantial assistance with toileting and hygiene. After a fall resulting in injury, the clinical event was documented by the Nursing Home Administrator, who is not a nurse, contrary to professional standards of practice. Staff interviews confirmed that only nursing personnel should document such events.
A resident with cognitive impairment and multiple diagnoses was given PRN acetaminophen for pain without documented evidence of a physical assessment, vital signs, or non-pharmacological interventions prior to administration. Staff interviews confirmed that required assessments and documentation were not completed, and the DON acknowledged the failure to follow facility policy and state regulations.
A resident with severe cognitive impairment and high fall risk experienced a fall while unsupervised during toileting, resulting in injury. Required fall prevention interventions, timely physical assessment, and neurological checks were not implemented as per policy. There were also significant delays in notifying the family and physician, and staff failed to document and monitor the resident as required.
A resident with a documented Tylenol allergy was given Tylenol by an LPN who did not check the chart before administration, resulting in a significant medication error. The error was identified during charting, and facility leadership confirmed the failure to follow medication administration protocols.
The facility did not provide required QAPI training to one direct care staff member, as confirmed by review of education records and staff interviews. This failure was identified during a review of staff development practices and cited under relevant state regulations.
A resident with multiple diagnoses who regularly visited his wife in an attached personal care unit was found outside the skilled facility, prompting a new physician's order requiring staff escort for such visits. The care plan was not updated to reflect the resident's preference for visiting his wife or the new escort requirement, as confirmed by the Nursing Home Administrator.
A resident with heart failure, anxiety, and depression reported being handled roughly by a nurse aide during care, describing the incident as sexual abuse and expressing significant emotional distress. Although the event was reported as physical abuse and the staff member was suspended, the specific allegation of sexual abuse documented by an LPN was not communicated to the DON and was not investigated, resulting in a failure to follow facility policy for abuse investigation.
The facility failed to properly label and date food items and maintain clean equipment in the Main Kitchen, as observed by surveyors. Unlabeled whipped topping, pies, and turkey were found, and a fan used for drying dishes was covered in a gray, fuzzy substance, indicating non-compliance with food safety and sanitation policies.
The facility failed to communicate necessary resident information to the receiving health care provider for five residents transferred to a hospital. The missing documentation included care plan goals, advanced directives, and specific care instructions, despite the residents having conditions like Alzheimer's, diabetes, and coronary artery disease. The Director of Nursing confirmed this failure, violating resident rights.
The facility failed to notify residents or their representatives of the bed-hold policy during hospital transfers or therapeutic leaves for four residents with conditions such as Alzheimer's, dementia, and coronary artery disease. The facility's policy requires written notification at the time of transfer, but no documentation was found to confirm this was done.
The facility failed to reassess a resident for safe smoking practices and did not adequately monitor elopement prevention devices for several residents. A resident with a history of heavy smoking and medical conditions was not reassessed for smoking safety as required. Additionally, Wanderguard devices for residents with cognitive impairments were not monitored according to physician orders, with multiple instances of missed checks. These deficiencies were confirmed by the DON.
The facility failed to lock a medication room refrigerator containing narcotics and did not label open medications with a date. An LPN confirmed these issues. Additionally, medications and treatments were not stored properly on two medication carts, with expired insulin and unlabeled medications found. An LPN acknowledged these deficiencies.
The facility failed to monitor personal refrigerators for two residents, did not implement proper infection control during a dressing change for a resident with paraplegia, and neglected to review infection control policies annually. Additionally, the facility did not notify residents or their representatives about COVID-19 and Norovirus outbreaks, as confirmed by the DON.
Two residents with significant assistance needs were left without timely help during meals, compromising their right to a dignified dining experience. One resident with Alzheimer's and malnutrition required substantial assistance, while another with dementia and diabetes was fully dependent on staff for eating. Observations showed both residents unattended with meals in front of them, while staff were busy assisting others. A nursing assistant admitted to not reporting the need for more staff, and the Assistant Director of Nursing confirmed the deficiency.
A resident with hyperlipidemia and depression developed skin issues, including scratches and a yeast infection. An aide and an RN noted these conditions and applied creams, but the facility failed to notify the physician of the change in condition. This deficiency was confirmed by the DON.
A facility failed to ensure a resident with moderate cognitive impairment understood the SNF ABN form, as required by regulations. The resident, with a BIMS score of 8, signed the form without adequate explanation, violating resident rights and admission policies.
A facility failed to obtain a physician order and develop a resident-centered care plan for placing a resident's bed against the wall. The resident, diagnosed with coronary artery disease, hypertension, and hyperlipidemia, had a care plan to prevent falls, but it did not include the bed placement. This oversight was confirmed by staff and violated facility policy and resident rights, which prohibit restraints without medical necessity.
A resident with an indwelling urinary catheter did not have a privacy cover on their catheter bag, as required by facility policy. The resident, diagnosed with neurogenic bladder, had a physician's order for a foley catheter. An LPN confirmed the absence of the privacy cover during an observation.
Facility staff failed to maintain communication with the dialysis center for two residents, leading to incomplete dialysis communication sheets. An LPN admitted to not filling out the top portion of the sheets, while an RN confirmed the necessity of completing them. The DON acknowledged the deficiency in communication and documentation for the residents receiving dialysis.
A resident did not receive their prescribed Mercaptopurine on two consecutive days due to unavailability, and the physician was not notified of the missed doses. This was confirmed by the DON, indicating a failure to prevent significant medication errors as per facility policy and state regulations.
The facility did not conduct QAA meetings with all required members from January to March 2024. The QAPI Committee, as per policy, should include members like the Medical Director and Infection Preventionist, who were absent. This was confirmed by the Nursing Home Administrator.
The facility failed to provide mandatory effective communication training for a NA, as required by the Employee Handbook. A review of the NA's personnel file showed no documentation of such training over a specified period, which was confirmed by the DON.
A resident with Alzheimer's and anemia, dependent on mechanical lift assistance, was manually lifted by three NAs without using the prescribed mechanical lift, resulting in a shoulder injury. The NAs cited unavailability of equipment and lack of knowledge about the resident's transfer status. The DON and Administrator confirmed the neglect in not using the safest transfer method.
A resident with Huntington's Disease eloped from a facility due to inadequate supervision and failure to adhere to elopement prevention policies. The resident, who was cognitively intact, left the courtyard unsupervised and was found outside. Additionally, another resident with Alzheimer's disease was improperly transferred without a mechanical lift, contrary to their care plan, resulting in shoulder swelling. The facility failed to complete timely risk evaluations and ensure safe transfer practices, as confirmed by the NHA and DON.
The facility did not maintain a clean and safe environment in the Miller's Crossing Nursing Unit shower room. Observations revealed a brown substance on the shower stall wall, debris and grime buildup on the floor, and an unsecured baseboard. These issues were confirmed by the Nursing Home Administrator.
A resident with severe cognitive impairment eloped from the facility due to inadequate supervision. The RN Supervisor and DON failed to complete necessary post-elopement procedures, and the facility's lack of communication and security measures contributed to the incident.
The facility failed to implement policies and procedures to investigate an elopement incident involving a resident with severe cognitive impairment. The RN Supervisor did not complete an incident report or post-elopement assessment, and the facility was unaware of the elopement until the following day. The Director of Nursing confirmed a breakdown in communication and lack of required documentation.
A facility failed to investigate an elopement involving a resident with severe cognitive impairment. The RN Supervisor did not complete an incident report, assess the resident, or update the care plan. The DON confirmed a breakdown in communication and failure to follow policies on neglect and elopement prevention.
The facility failed to update a resident's care plan after the resident, who had severe cognitive impairment, eloped to an unauthorized area. Despite the facility's policies requiring updates to care plans based on ongoing assessments, the RN Supervisor did not assess the resident, complete an incident report, or update the care plan, as the resident was unharmed. The Director of Nursing confirmed this lapse in care planning.
The facility failed to provide adequate supervision for a resident with severe cognitive impairment, resulting in an elopement incident. The RN Supervisor did not complete an incident report or conduct a post-elopement assessment, and the facility was unaware of the elopement until the following day. The resident was able to exit the unit without restricted access, leading to the incident.
Unsecured Maintenance Equipment Stored in Resident Dining Room
Penalty
Summary
Surveyors determined that the facility failed to provide a clean, safe, comfortable, and homelike environment by improperly storing maintenance equipment in an unsecured resident dining room located directly outside the kitchen. During a tour, the dining room was observed to contain maintenance equipment and carts, unattached resident hand railings, a nail gun, a drill with bits, a case of metal ratchets and pieces, scraping tools, a shop vacuum, fans, and other repair tools, while the doors to the room were not secured with locks at either the front or side entrances. Although a sign on the doors indicated the room was closed and to keep doors closed when not in use, the equipment remained accessible in this resident area. The DON reported that the facility did not have a policy specific to maintaining a safe, clean, and homelike environment, and the project manager confirmed that the equipment was related to an ongoing renovation and painting project that had been occurring at night for several weeks to give the facility a makeover, and acknowledged that the facility failed to secure the maintenance equipment behind a locked door as required. No specific residents, medical histories, or clinical conditions were identified in the report as being directly involved in or affected by this deficiency.
Inadequate Supervision and Hot Beverage Handling Resulting in Resident Burn
Penalty
Summary
The facility failed to provide adequate supervision and a safe environment, resulting in a hot liquid burn to one resident. Facility policy on Accidents and Incidents stated that a safe environment would be provided for all residents. The resident involved had diagnoses including high blood pressure, muscle weakness, and a need for assistance with personal care, as documented on an MDS assessment. On the date of the incident, a change in status note recorded that the resident was served a dinner tray, took her tea to drink, and dropped it on herself, resulting in burns to multiple areas including the right thigh, left inner and outer thigh, and right and left lower and upper abdominal quadrants, with specific burn measurements documented. An Emergency Department note stated that a staff member at the nursing home accidentally dropped hot water for tea on the resident, causing a superficial first-degree burn to the upper abdomen and right thigh, with no blistering. Witness statements from dietary staff indicated that hot beverages were poured for residents without checking the temperature of the coffee/tea water, and that the dietary aide was on the other side of the dining room with her back to the resident when the resident cried out. Another statement from the resident’s tablemate reported that a kitchen staff member poured hot water into the resident’s cup, moved on to other tables, and was on the other side of the dining room when the resident screamed and the cup was seen tipped over. The Nursing Home Administrator confirmed that kitchen staff did not check the temperature of the water before service and that, at the time of the incident, two dietary staff were in the dining room while the assigned nurse aide was occupied bringing another resident to the dining room, resulting in inadequate supervision and a burn injury to the resident.
Failure to Maintain Closed Door for Resident on Droplet Precautions
Penalty
Summary
The deficiency involves the facility’s failure to follow its own infection prevention and control policy for droplet precautions for one resident on isolation precautions. Facility policy titled "Covid Positive Steps" dated 12/1/25 required that a COVID-positive resident have an appropriate sign on the door, the door remain closed, vitals taken every shift while in isolation, isolation maintained for 10 days, and appropriate PPE stationed by the room. The resident, who had diagnoses including hypertension, COPD, and depression, was admitted on an unspecified date and tested positive for COVID-19 on 3/6/26. Physician orders dated 3/6/26 and the resident’s care plan dated 3/6/26 directed that droplet precautions be maintained every shift. On 3/9/26 at 11:59 a.m., surveyor observation showed that the resident’s door displayed droplet precaution signage but was standing wide open to the outer hallway. At 12:00 p.m., an RN confirmed that the resident was COVID-positive, on droplet precautions, and that the door should remain closed at all times to prevent cross contamination potential. A subsequent observation at 1:17 p.m. again found the door wide open despite the droplet precaution signage. At 1:20 p.m., the DON confirmed that the facility failed to follow droplet precautions for this resident in isolation precautions. The deficiency was cited under 28 Pa Code: 201.14(a), 201.28(b)(1)(e)(1), and 211.10(d).
Failure to Maintain Comfortable Air Temperatures in Resident Room and Common Areas
Penalty
Summary
The facility failed to ensure comfortable air temperature levels in one resident room and two resident common areas, as required by its policy and resident rights to a safe, clean, comfortable, and homelike environment. The facility’s Extreme Weather policy dated 12/1/25 stated that excessive cold for lengthy periods can negatively impact center operations, poses severe potential harm to confused exit-seeking residents, and that geriatric residents are at greater risk of hypothermia because their bodies do not effectively regulate internal temperatures. The Nursing Home Administrator reported that on 1/25/26 the facility’s boiler, which serves as the heat source, needed to be reset. During observations on 1/28/26 from 12:15 p.m. to 12:45 p.m. with the Maintenance Director, air temperatures were measured at 68°F in one resident room, 67.3°F in the Miller Common Room, and 70.5°F in the dining room. In an interview later that day, the Nursing Home Administrator confirmed that the facility failed to ensure comfortable air temperature levels in one of 34 resident rooms and two of three resident areas.
Elopement of Cognitively Impaired Resident From Locked Memory Unit
Penalty
Summary
The facility failed to ensure adequate supervision to prevent an elopement for a resident identified as an elopement risk and wanderer. Facility policy on Elopement Prevention required that residents be properly assessed and care planned to prevent accidents related to wandering or elopement, including completion of a Wandering Risk Assessment upon admission, readmission, quarterly, and as needed, and development of a comprehensive elopement prevention care plan when warranted. The resident’s MDS showed diagnoses of depression, dementia, and anxiety, and Section C0100 indicated the resident was rarely/never understood, with the BIMS not completed. The resident’s care plan, dated 5/22/24, identified the resident as an elopement risk/wanderer based on a history of attempts to leave home unattended prior to admission and included interventions such as identifying patterns of wandering and monitoring the resident’s frequent location. On the date of the incident, documentation showed the resident was observed ambulating outside the locked memory unit on another resident hallway, approximately 36 feet from the memory unit. An interview revealed that the resident’s husband had visited and exited the locked unit, believing the resident was far enough from the door when he left and stating he was in a hurry and did not look behind him. A witness statement from an LPN indicated the resident followed the husband out of the unit and staff later noticed the resident in the hallway and returned the resident to the locked memory unit. Review of progress notes from 6/1/25 through 1/28/26 showed documented behaviors for the resident but none were exit-seeking. The DON stated that when she worked in the locked memory unit, the resident’s husband would come and go because he knew the door code. The NHA and DON confirmed that the facility failed to ensure each resident received adequate supervision, resulting in this elopement event.
Failure to Provide Adequate Supervision Resulting in Resident Burn and Elopement
Penalty
Summary
The facility failed to provide adequate supervision and a safe environment for two residents, resulting in one resident sustaining a burn and another resident eloping from the facility. For the first incident, a resident with diagnoses including diabetes, depressive disorder, and hypertension was admitted to the facility and had physician's orders for restorative dining. During an activity in the dining area, coffee provided by the Activities department was served without checking its temperature. The resident spilled the coffee in her lap, resulting in a red, blistered burn. The incident was reported by a CNA, and it was confirmed that the coffee temperature was not measured prior to serving. In the second incident, a resident with anemia, renal insufficiency, and vascular dementia, who had a known history of wandering and was assessed as an elopement risk, was not provided with adequate supervision or individualized interventions to prevent elopement. The resident's baseline care plan did not include specific interventions for supervision or elopement prevention. Despite being fitted with a wander guard, the resident was able to remove it and eloped to another unit within the facility. On a subsequent occasion, the resident exited the facility through the front doors, triggered the wander guard alarm, and was found outside by another resident's family member. Staff interviews, facility policy reviews, and documentation confirmed that the facility did not follow its own policies regarding accident prevention and elopement. The Director of Nursing and the Nursing Home Administrator acknowledged the lack of adequate supervision and failure to implement resident-centered interventions for the identified elopement risk, as well as the failure to ensure a safe environment in the dining area, which resulted in the resident's burn.
Failure to Educate Staff and Timely Respond to Abuse/Neglect Allegations
Penalty
Summary
The facility failed to ensure that all nursing staff were educated on abuse and neglect prior to working in the facility and annually, as required by policy. Specifically, one LPN did not receive abuse/neglect education before starting work, and two other nursing staff members did not receive annual abuse/neglect education. This lack of training was confirmed through review of employee files, facility documents, and staff interviews. Additionally, the facility did not complete required onboarding documentation for agency staff prior to their start date. Multiple staff members reported concerns regarding the actions of an LPN working on the memory impaired unit, including allegations that the LPN administered medications such as melatonin and Tylenol to all residents regardless of physician orders. Staff observed that residents appeared more sedated, lethargic, and unable to eat or wake up during the day when this LPN was on duty. There were also concerns raised about an increase in resident deaths and changes in resident conditions, such as hypothermia, that were not properly reported or followed up by nursing staff. Despite these reports, the facility failed to identify, report, and investigate these allegations of abuse and neglect in a timely manner. The facility allowed the LPN who was the subject of abuse/neglect allegations to continue working after the concerns were reported, without immediate suspension or implementation of a supervision plan. The Director of Nursing and Nursing Home Administrator confirmed that they did not initiate an investigation or report the allegations to appropriate agencies promptly. Witness statements and interviews revealed that staff were aware of the allegations but did not report them immediately, and the facility did not obtain witness statements until several days after being notified of the concerns.
Removal Plan
- Review current medical records for any signs of abuse/neglect and interview all interviewable residents for any signs and/or symptoms of abuse and/or neglect. If any is found, follow abuse policy and begin investigation and reporting immediately.
- Interview all staff for allegations of abuse/neglect that have not been reported. If any are identified, begin investigations and reporting immediately.
- Provide education by the Chief Nursing Officer to the Director of Nursing and Nursing Home Administrator on immediate reporting of any allegation/neglect.
- Provide education by the Chief Nursing Officer to the Director of Nursing and Nursing Home Administrator on the immediate suspension of an employee with an allegation of abuse/neglect.
- Provide education by the DON/Designee to Licensed Nursing Staff both in house and agency on the appropriate medication administration and following Physician's orders.
- Audit each resident's Medication Administration Record (MAR) and Treatment medication Record (TAR) to ensure medications and treatments have been administered/given as ordered.
- Review the Abuse/Neglect Policy and update if needed.
- Educate all house staff and agency staff on the abuse/neglect policy and reporting abuse by the DON and/or designee.
- Review all audits and policy changes related to immediate jeopardy at an ad hoc Quality meeting.
- Interview all staff for instances of abuse/neglect that were not reported. Report and investigate any incidents timely.
- Require all licensed nursing staff, not educated, to verify education on physician orders and MAR/TARs.
Failure to Timely Report and Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to identify and timely report criminal allegations of abuse and neglect involving an LPN to local law enforcement and required agencies. Multiple staff members, including housekeepers and nurse aides, reported concerns that the LPN was administering medications such as melatonin and Tylenol to residents without proper orders, resulting in residents appearing sedated, lethargic, and unable to eat or remain awake during the day. Staff also noted an increase in resident deaths on the memory impaired unit during shifts when the LPN was working. These concerns were documented in witness statements and interviews, with specific observations of residents' abnormal behavior and changes in condition, such as hypothermia and excessive sleepiness. Despite these serious allegations and observations, the facility did not promptly initiate an investigation or report the incidents to the Area Agency on Aging, the Department of Health, or local law enforcement as required by state law and facility policy. The Director of Nursing and Nursing Home Administrator were made aware of the allegations but delayed reporting for ten days, only notifying authorities after being prompted during the survey process. The DON dismissed the initial reports as hearsay and gossip, contributing to the delay in addressing the allegations. The failure to act on staff reports and to follow mandated reporting procedures resulted in an immediate jeopardy situation, as the facility did not ensure the protection of residents from potential abuse or neglect. The deficiency was identified through review of facility documentation, staff interviews, and examination of resident records, which confirmed that the facility did not comply with legal and policy requirements for timely reporting and investigation of suspected abuse and neglect.
Removal Plan
- Review current residents' medical records for signs of abuse/neglect by the DON and/or designee. Interview all interviewable residents for any signs and/or symptoms of abuse and/or neglect. If any allegations of abuse/neglect are found, follow abuse policy, and begin investigation and reporting immediately.
- Interview staff for review of abuse/neglect allegations that have not been reported to the DON and/or designee. If any allegations are identified, begin investigation and reporting immediately.
- Update review of Electronic event report for neglect allegation by the DON/designee to accurately reflect concern for Nurse giving Tylenol and Melatonin to all residents on the memory unit whether there is an order or not thus causing potential harm.
- Review Abuse/Neglect Policy, Incidents and Accidents Policy, and reporting criteria by NHA and/or designee and update if needed.
- Educate all house staff and agency staff on the abuse/neglect policy and reporting abuse by the DON and/or designee prior to their next shift worked.
- Audit all residents who have had an allegation of abuse/neglect in the last 30 days by the DON and/or designee to ensure that it was reported appropriately and timely.
- Review all audits and policy changes related to IJ 609 at an Ad hoc Quality meeting.
Failure to Implement Abuse Policy and Report Alleged Criminal Activity Creates Immediate Jeopardy
Penalty
Summary
The Nursing Home Administrator (NHA) and Director of Nursing (DON) failed to effectively manage and implement the facility's abuse and neglect policy, and did not report alleged criminal activity involving an LPN to the appropriate authorities. This failure was identified through a review of job descriptions, clinical records, and staff interviews. The NHA's job description required oversight of day-to-day operations, ensuring compliance with federal, state, and local standards, and maintaining effective systems for resident care and safety. The DON's responsibilities included nursing management, setting care standards, and ensuring regulatory compliance. Despite these outlined duties, both the NHA and DON did not fulfill their essential roles in upholding the facility's policies and legal requirements. As a result of these actions and inactions, all 95 residents were placed in an immediate jeopardy situation. The facility did not implement its abuse and neglect policy and failed to report the alleged criminal activity, as required by regulations. The deficiency was confirmed during an interview with the Chief Nursing Officer, who was notified of the failures by the NHA and DON. The report cites specific Pennsylvania Codes related to the responsibilities of the licensee, management, and nursing services, which were not adhered to in this instance.
Failure to Provide Required Annual Nurse Aide Training
Penalty
Summary
The facility failed to provide the required minimum of 12 hours of annual training for nurse aides, as mandated by regulations. Review of the job description and facility documents confirmed that nurse aides are expected to attend all assigned in-service classes. However, documentation for four direct care nurse aides did not show evidence of completing the required annual training hours. During staff interviews, the Chief Nursing Officer confirmed that these nurse aides did not receive the mandated training for the calendar year reviewed.
Failure to Timely Notify Physician and Family After Resident Fall
Penalty
Summary
The facility failed to ensure timely notification of a physician following a resident's change in condition after a fall. According to the facility's policy, licensed nurses are required to promptly assess and notify the physician and family when a resident experiences a change in condition. In the case reviewed, a resident with severe cognitive impairment, high risk for falls, and multiple diagnoses including anxiety, muscle weakness, and hypertension, experienced an unwitnessed fall while attempting to transfer from the toilet. The resident sustained a skin tear and reported pain and dizziness. Although the incident was documented and the resident's family was eventually notified, the physician was not informed until three days after the fall, and the family was notified twenty days later, contrary to facility policy and regulatory requirements. Staff interviews confirmed that the expected protocol was immediate notification of both the physician and family following such incidents. Documentation revealed inconsistencies in communication and a lack of timely documentation regarding the incident and subsequent actions. The failure to notify the physician and family in a timely manner was acknowledged by both nursing staff and the facility administrator, confirming noncompliance with established resident care policies and state regulations.
Failure to Prevent Unnecessary Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary psychotropic medication. Clinical record review showed that a resident with diagnoses of dementia, anxiety, and high blood pressure was prescribed Ativan 0.5 mg every six hours as needed for a period of three months. The physician's order did not include a required 14-day stop date, nor was there any documented rationale for extending the medication beyond 14 days. The resident received Ativan on 27 occasions in one month and 22 occasions in the following month. Additionally, there was no documentation in the resident's progress notes indicating that non-pharmacological interventions were attempted prior to administering the Ativan. Staff interviews confirmed that facility policy requires the use of non-pharmacological interventions before administering psychotropic medications and mandates documentation of both the interventions and the behaviors. The Chief Nursing Officer acknowledged that the facility did not ensure the resident's medication regimen was free from unnecessary psychotropic medication.
Non-Nursing Staff Documented Clinical Event in Resident Record
Penalty
Summary
The facility failed to follow professional standards of practice in documentation for one resident. A resident with diagnoses of anxiety, muscle weakness, and high blood pressure, and with a severe cognitive impairment, required substantial assistance with toileting and hygiene. The resident experienced a fall while attempting to transfer from the commode to a wheelchair, resulting in a skin tear and headache. The incident was documented as a late entry progress note by the Nursing Home Administrator, who is not a nurse. Interviews with facility staff confirmed that documentation of clinical events should not be completed by non-nursing personnel, and that the Nursing Home Administrator was not authorized to enter such notes. This failure to adhere to professional standards of documentation was identified for one of eight residents reviewed, as supported by facility policy review, resident record review, and staff interviews.
Failure to Provide Non-Pharmacological Interventions and Assessment Prior to PRN Pain Medication
Penalty
Summary
The facility failed to ensure that a resident was provided with non-pharmacological interventions and a proper assessment prior to administering as-needed pain medication. According to facility policy, all residents should be screened and assessed for pain, with documentation of interventions and responses, especially for those who are cognitively impaired or unable to communicate effectively. In this case, a resident with diagnoses including anxiety, Alzheimer's disease, and high blood pressure, who was unable to verbalize pain, was administered PRN acetaminophen for a reported pain level of 7/10. The clinical record did not show evidence that a physical assessment or vital signs were obtained prior to the administration, nor that non-pharmacological interventions were attempted or documented before giving the medication. Further review of the resident's clinical record revealed that after the administration of acetaminophen, the resident's pain was reassessed and found to be zero. However, later that same day, the resident exhibited a significant change in condition, including a low rectal temperature, bradycardia, hypotension, and unresponsiveness. The nurse notified the family and the resident was sent to the emergency room, where they were admitted for altered mental status and a urinary tract infection. Staff interviews confirmed that the required assessments and documentation of non-pharmacological interventions were not completed prior to administering the PRN medication. Staff interviews also indicated that the resident typically exhibited behaviors such as yelling out and clenching fists, which were used as non-verbal indicators of pain. However, the LPN responsible for administering the medication could not recall if non-pharmacological interventions were implemented or documented prior to giving the acetaminophen. The DON confirmed that the facility did not ensure the resident received non-pharmacological interventions and an assessment before administering pain medication as required by facility policy and state regulations.
Failure to Implement Fall Prevention and Post-Fall Monitoring
Penalty
Summary
The facility failed to implement fall prevention interventions and conduct post-fall monitoring for a resident identified as high risk for falls. The resident had diagnoses including anxiety, muscle weakness, and high blood pressure, and was assessed as having severe cognitive impairment and requiring substantial assistance with toileting and transfers. The care plan specified the use of bed/chair alarms and assistance with toileting every two hours, but these interventions were not consistently implemented. An incident occurred in which the resident fell in the bathroom while attempting to transfer from the toilet to the wheelchair without adequate staff assistance. The fall resulted in a skin tear and complaints of dizziness and headache. Although the facility's policy required immediate physical assessment, timely documentation, and prompt initiation of neurological checks after a fall, these actions were not completed as required. Neurological checks were not started until nearly a day after the fall, and there was no evidence of a timely physical assessment or Q15 minute checks in the clinical record. Additionally, there were significant delays in notifying the resident's family and physician about the fall, with the family being notified 20 days later and the physician three days after the incident. Staff interviews confirmed that required assessments and documentation were not completed promptly, and that staff were unclear about their responsibilities regarding post-fall monitoring and communication. These failures resulted in noncompliance with facility policy and state regulations regarding accident prevention and resident care.
Failure to Prevent Significant Medication Error Due to Allergy
Penalty
Summary
A resident with diagnoses including dementia, aphasia, and malnutrition, and a documented allergy to Tylenol, was administered Tylenol by an LPN without a physician's order and despite the allergy being noted in the clinical record. The LPN did not review the resident's chart prior to administering the medication. The error was discovered when the nurse began charting the administration, at which point it was realized that Tylenol was both not ordered and listed as an allergy for the resident. Facility policy requires that medications be administered as prescribed, following the five rights of medication administration, and that staff verify these rights at multiple points during the process. In this incident, the LPN failed to adhere to these protocols, resulting in a significant medication error. The event was confirmed by both the LPN involved and the Chief Nursing Officer during interviews.
Failure to Provide QAPI Training to Direct Care Staff
Penalty
Summary
The facility failed to provide mandatory Quality Assurance and Performance Improvement (QAPI) training to one of five direct care staff members reviewed. According to the Nursing Assistant job description, staff are required to attend all assigned in-service classes and complete assignments. Review of facility education documents for the year 2024 showed that one nurse aide did not receive QAPI training. This was confirmed by the Chief Nursing Officer during staff interviews, who acknowledged that the required training had not been provided to the identified staff member. The deficiency was cited under 28 Pa. Code: 201.14(a) Responsibility of Licensee and 28 Pa. Code: 201.20(a) Staff Development.
Failure to Update Care Plan After Change in Resident Status
Penalty
Summary
The facility failed to revise the care plan for a resident to accurately reflect the resident's current status and preferences. The resident, who was alert and oriented, had a history of high blood pressure, muscle weakness, and malnutrition. Documentation showed that the resident regularly visited his wife in the attached personal care unit, Vista, and was found there by staff after being reported missing from the skilled facility. Following this incident, a physician's order was obtained allowing the resident to visit his wife if escorted by staff, and both staff and the resident were educated on this requirement. Despite these developments, the resident's care plan was not updated to include his preference for visiting his wife or the new requirement for staff escort during these visits. This omission was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the care plan had not been revised as required by facility policy and regulatory standards.
Failure to Investigate Sexual Abuse Allegation per Policy
Penalty
Summary
The facility failed to implement written policies and procedures to ensure a complete and thorough investigation of an allegation of sexual abuse for one resident. The facility's policy requires immediate notification of the Nursing Home Administrator (NHA) or Director of Nursing (DON), reporting to the state health department, contacting the County Area Agency on Aging, and conducting an internal investigation for all abuse allegations. However, documentation and interviews revealed that a specific allegation of sexual abuse was not fully investigated as required by policy. A resident with diagnoses of heart failure, anxiety, and depression reported being handled roughly by a nurse aide during incontinence care, describing the experience as extremely painful and humiliating. The resident stated that the incident felt like sexual abuse and expressed ongoing emotional distress. The event was initially reported as physical abuse, and the involved staff member was suspended pending investigation. The resident was assessed for physical injury, and law enforcement was contacted. However, the specific allegation of sexual abuse, as documented in a behavior note by an LPN, was not communicated to the DON and was not included in the facility's investigation. Interviews with staff confirmed that the LPN who documented the resident's statement about sexual abuse did not recall reporting it to anyone, and the DON stated she was unaware of the sexual abuse allegation. As a result, the facility did not conduct a complete and thorough investigation into the sexual abuse allegation, failing to follow its own policies and procedures for abuse prevention and investigation.
Deficiencies in Food Storage and Equipment Cleanliness
Penalty
Summary
The facility failed to adhere to its policies on food storage and cleaning, leading to deficiencies in food safety and sanitation. During observations in the Main Kitchen, it was noted that several food items, including packages of whipped topping, lemon meringue pies, and sliced turkey, were not properly labeled and dated as required by the facility's food storage policy. This oversight was confirmed by the Dietary Supervisor. Additionally, a fan used to dry clean dishes was found to be covered in a gray, fuzzy substance, indicating a failure to maintain clean equipment. This was confirmed by a Registered Dietitian, highlighting a breach in the facility's cleaning and sanitation policy designed to prevent foodborne illness.
Failure to Communicate Resident Information During Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider for five out of six residents who were transferred from the facility to a hospital and expected to return. The facility's policy, dated 7/22/24 and last reviewed on 11/8/24, required that a transfer form be completed and appropriate documentation be sent with the resident. However, upon review of the clinical records for Residents R2, R13, R82, R83, and R88, there was no documented evidence that the facility had communicated specific information to the receiving health care provider. This information should have included the residents' care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the residents' specific needs at the receiving facility. The residents involved had various medical conditions, including high blood pressure, Alzheimer's disease, diabetes, muscle weakness, depression, anemia, dementia, coronary artery disease, and hyponatremia. Despite these conditions, the facility did not provide the necessary documentation to ensure continuity of care during the transfers. The Director of Nursing confirmed during an interview that the facility failed to communicate the required information for these residents, which is a violation of resident rights as per 28 Pa. Code 201.29 (a) (c.3) (2).
Failure to Notify Residents of Bed-Hold Policy
Penalty
Summary
The facility failed to notify residents or their representatives of the bed-hold policy during hospital transfers or therapeutic leaves for four residents. The facility's policy requires that residents be informed in writing about the bed-hold policy at the time of transfer. However, upon review of clinical records, it was found that there was no documented evidence that this information was provided to the residents or their representatives for the specified transfers. The residents involved had various medical conditions, including high blood pressure, Alzheimer's disease, dementia, diabetes, and coronary artery disease. Despite these conditions, the facility did not adhere to its policy of notifying the residents or their representatives about the bed-hold policy during their transfers to hospitals or therapeutic leaves. This deficiency was confirmed by the Director of Nursing during an interview.
Failure to Assess Smoking Safety and Monitor Elopement Devices
Penalty
Summary
The facility failed to assess a resident for safe smoking practices and did not adequately monitor elopement prevention devices for several residents. Resident R42, who has a history of smoking three packs a day and medical conditions including coronary artery disease, hypertension, and hyperlipidemia, was not reassessed for safe smoking after the initial assessment on 6/10/24, despite facility policy requiring such assessments upon admission, quarterly, and as needed. The Director of Nursing confirmed that no further assessments were completed for Resident R42 as required. Additionally, the facility did not ensure proper monitoring of Wanderguard devices for Residents R67, R69, and R72, all of whom have cognitive impairments such as dementia. Physician orders required weekly checks of the Wanderguard battery percentage and checks of placement, function, and skin integrity every shift. However, records show multiple instances where these checks were not completed as ordered, with specific dates and shifts noted for each resident. The Director of Nursing confirmed the failure to monitor these devices as required. These deficiencies indicate a lack of adherence to facility policies and physician orders, potentially compromising resident safety. The facility's policies on smoking assessments and elopement prevention were not followed, leading to lapses in monitoring and assessment that were confirmed by the Director of Nursing during interviews.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that a medication room refrigerator containing narcotics was properly locked and that open medications stored in the refrigerator were labeled with a date upon opening. During an observation, it was found that the refrigerator in the [NAME] Crossings Medication Room was unlocked and contained three opened boxes of Lorazepam and an undated vial of Tubersol solution. An LPN confirmed these findings, acknowledging the failure to secure the refrigerator and properly label the medications. Additionally, the facility did not store medications and treatments properly to prevent cross-contamination on two medication carts. Opened tubes of Biofreeze gel and an Albuterol inhaler were found on a medication cart without proper labeling. Furthermore, expired insulin medications and medications not stored in pharmacy-labeled bags were found on Settlers Cart 6. An LPN confirmed the presence of expired medications and the lack of proper labeling, indicating a failure to adhere to storage and labeling protocols.
Infection Control and Communication Deficiencies
Penalty
Summary
The facility failed to properly monitor the personal refrigerators of two residents, as neither contained a thermometer or a temperature log for daily monitoring. This oversight was confirmed by an LPN during interviews and observations. Additionally, the facility did not implement proper infection control practices during a dressing change for a resident with paraplegia, diabetes, and depression. The LPN involved did not clean the bedside stand or place a barrier before placing dressings, used ungloved hands to place a barrier under the resident, and did not perform hand hygiene after cleansing the wound and applying new dressings. The facility also failed to review its infection control policies annually, with the last review dated back to 2014. Furthermore, the facility did not notify residents or their representatives about two infectious outbreaks, COVID-19 and Norovirus, as confirmed by the Director of Nursing. The resident group was unaware of the Norovirus outbreak, indicating a lack of communication from the facility regarding these health concerns.
Failure to Provide Timely Meal Assistance
Penalty
Summary
The facility failed to provide a dignified dining experience by not offering timely assistance with meals to two residents, R35 and R55. Resident R35, who has diagnoses of depression, malnutrition, and Alzheimer's disease, requires substantial maximal assistance with eating, as indicated by their MDS assessment. During an observation, it was noted that Resident R35 was left without assistance at a dining table with their meal in front of them, while four staff members were occupied assisting other residents. Similarly, Resident R55, who has high blood pressure, diabetes, and dementia, is completely dependent on assistance for eating, as per their MDS assessment. This resident was also observed sitting at a dining table with their meal in front of them without receiving the necessary assistance. A nursing assistant acknowledged the lack of staff to assist with feeding and had not yet reported the need for additional help. The Assistant Director of Nursing confirmed the facility's failure to provide timely meal assistance, thus compromising the residents' right to a dignified dining experience.
Failure to Notify Physician of Change in Resident's Condition
Penalty
Summary
The facility failed to notify the physician of a change in condition for one resident. The resident, who was admitted with diagnoses of hyperlipidemia and depression, was found to have skin issues including scratches on the right hip, raised patches on the abdomen and right side, and a yeast infection under the left breast. These conditions were noted by an aide and confirmed by a registered nurse, who instructed the application of anti-fungal and barrier creams. However, there was no documentation indicating that the physician was notified of these changes in the resident's condition. This deficiency was confirmed during an interview with the Director of Nursing.
Failure to Ensure Understanding of SNF ABN Form
Penalty
Summary
The facility failed to ensure that residents were given proper notice and understanding of their Medicaid/Medicare coverage and potential liability for services not covered. Specifically, the facility did not adequately explain the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) form to Resident R84, who had a BIMS score of 8, indicating moderate cognitive impairment. This score suggests that the resident may not have fully understood the implications of signing the SNF ABN form without proper explanation or assistance. The deficiency was identified during a review of facility admission documents and staff interviews. The Registered Nurse Assessment Coordinator (RNAC) confirmed that the facility did not ensure the SNF ABN was explained in a manner that Resident R84 or their representative could understand. This oversight was in violation of several Pennsylvania Code regulations related to admission policy, licensee responsibility, management, and resident rights.
Failure to Obtain Physician Order for Bed Placement
Penalty
Summary
The facility failed to obtain a physician order and develop a resident-centered care plan for the placement of a bed against the wall for Resident R42. The facility's policy on physical restraints, last reviewed on 11/8/24, mandates that restraints should only be used as a last resort and must be justified by medical symptoms. However, during an observation and interview on 11/14/24, it was confirmed by Nurse Assistant Employee E12 that Resident R42's bed was positioned against the wall without a physician's order. The Director of Nursing also confirmed this oversight. Resident R42's clinical record indicated diagnoses of coronary artery disease, hypertension, and hyperlipidemia. The resident's care plan, revised on 10/1/24, aimed to prevent falls but did not include the placement of the bed against the wall. This oversight was a violation of the facility's policy and resident rights, which state that residents should be free from restraints unless medically necessary. The facility's failure to adhere to these policies resulted in a deficiency as per the cited Pennsylvania Code regulations.
Failure to Provide Privacy Cover for Catheter Bag
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with an indwelling urinary catheter. The facility's policy on indwelling urinary catheters, last reviewed on 11/8/24, requires that catheters not medically justified be discontinued as soon as clinically warranted and that catheter bags have a privacy cover unless one is built in by the manufacturer. However, during an observation on 11/12/24, it was noted that the resident's foley catheter bag was hanging on the bed frame without a privacy cover, which was confirmed by an LPN. The resident in question was admitted with a diagnosis of anemia, hypertension, and neurogenic bladder, and had a physician's order for a 16 French foley catheter with a 10cc balloon. The resident's care plan also indicated the use of an indwelling foley catheter related to neurogenic bladder. Despite these documented needs, the facility did not adhere to its policy regarding the privacy cover for the catheter bag, leading to the deficiency noted in the report.
Failure to Maintain Communication with Dialysis Center
Penalty
Summary
The facility staff failed to maintain ongoing communication with the dialysis center for two residents, leading to a deficiency in providing safe and appropriate dialysis care. Resident R57, diagnosed with anemia, hypertension, and end-stage renal disease (ESRD), was to receive dialysis three times a week. However, the review of dialysis communication sheets revealed that two out of 21 sheets were not completed prior to dialysis sessions. Similarly, Resident R59, diagnosed with heart failure, hypertension, and ESRD, also required dialysis three times a week. The review showed that 18 out of 20 communication sheets were not completed before dialysis sessions. During interviews, an LPN admitted that the top portion of the dialysis sheets was not normally filled out, while an RN acknowledged the necessity of completing this section and sending the book along with any order summaries. The Director of Nursing confirmed the incompleteness of the dialysis books and the failure to maintain communication with the dialysis center for the two residents. This lack of communication and documentation was identified as a deficiency in the facility's compliance with the required standards for dialysis care.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that residents are free from significant medication errors, as evidenced by the case of one resident who did not receive their prescribed medication, Mercaptopurine, on two consecutive days. The facility's policy requires that physician orders are followed and medications are administered as prescribed. However, the resident's Medication Administration Record indicated that the medication was not available on the specified dates, leading to missed doses. Additionally, the clinical record did not show any evidence that the physician was notified about the missed doses of Mercaptopurine. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged the failure to prevent significant medication errors for the resident in question. The deficiency was identified under several Pennsylvania Code regulations related to nursing services, resident rights, resident care policies, and pharmacy services.
QAA Meetings Lacked Required Members
Penalty
Summary
The facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all required committee members for the period of January 2024 through March 2024. The facility's policy, dated 7/22/24 and last reviewed on 11/8/24, mandates that the QAPI Committee should include specific members such as the Nursing Home Administrator, Director of Nursing, Medical Director, and others. However, a review of the QAPI Committee meeting sign-in sheets revealed that the Medical Director/designee and Infection Preventionist were not in attendance during this period. This deficiency was confirmed by the Nursing Home Administrator during an interview on 11/15/24.
Failure to Provide Effective Communication Training
Penalty
Summary
The facility failed to provide mandatory training on effective communication for one of its staff members, specifically a Nurse Aide (NA) identified as Employee E9. According to the facility's Employee Handbook, all employees are required to participate in mandatory training programs to maintain the necessary skills for superior resident care. However, a review of NA Employee E9's personnel file revealed a lack of documentation for effective communication training between November 14, 2023, and November 14, 2024. This deficiency was confirmed during an interview with the Director of Nursing on November 14, 2024.
Failure to Use Safe Transfer Method for Resident
Penalty
Summary
The facility failed to ensure that residents were free from neglect by not using the safest transfer method for a resident, identified as Resident R2. Resident R2, who was diagnosed with depression, Alzheimer's disease, and anemia, was dependent on mechanical lift assistance for transfers as per physician orders and care plan. However, during a transfer from a shower chair, three Nursing Assistants (NAs) manually lifted the resident without using the mechanical lift, resulting in a popping sound from the resident's shoulder. Although initially assessed with no noticeable injuries, swelling was later observed, and the resident, who is nonverbal, showed signs of pain. Interviews with the involved NAs revealed a lack of adherence to the prescribed transfer method. NA Employee E1 acknowledged knowing the resident required a mechanical lift but cited the unavailability of a hoyer pad as the reason for manual lifting. NA Employee E3 admitted to not knowing how to verify a resident's transfer status and assumed the resident required less assistance due to her small stature. The Director of Nursing confirmed the incorrect transfer method was used, and both the Nursing Home Administrator and the Director of Nursing acknowledged the facility's failure to prevent neglect by not adhering to the safest transfer protocol for the resident.
Inadequate Supervision and Transfer Practices
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for residents, resulting in an elopement incident involving a resident with Huntington's Disease, malnutrition, and a personality disorder. The resident, who was cognitively intact according to a recent assessment, was able to leave the facility unsupervised despite being in an enclosed courtyard. The resident had a history of refusing to wear a wander guard, a device meant to alert staff if a resident approaches an exit. On the day of the incident, the resident was left unsupervised for approximately two minutes, during which time they exited the courtyard and were found outside the facility. This incident highlighted the facility's failure to complete timely and accurate wandering and elopement risk evaluations for residents, as well as the lack of physician orders to check the function of wander guards. Additionally, the facility failed to ensure safe transfer practices for another resident diagnosed with depression, Alzheimer's disease, and anemia. The resident was dependent on mechanical lift assistance for transfers, as indicated in their care plan and physician orders. However, during a transfer from a shower chair, three nursing assistants manually lifted the resident without using the mechanical lift, resulting in a popping sound and subsequent swelling in the resident's shoulder. The nursing assistants involved were unaware of the resident's transfer status and cited the unavailability of necessary equipment as the reason for not following the prescribed transfer method. The facility's policies on elopement prevention and resident protection from neglect were not adequately followed, as evidenced by the incidents involving both residents. The nursing home administrator and director of nursing confirmed these deficiencies, acknowledging the failure to provide adequate supervision and to adhere to safe transfer protocols. The report also noted that the facility's management and nursing services did not meet the required standards, as outlined in the relevant state codes.
Deficiency in Shower Room Cleanliness and Safety
Penalty
Summary
The facility failed to provide a clean, safe, and homelike environment in one of its shower rooms, specifically the Miller's Crossing Nursing Unit shower room. During an observation, it was noted that the shower stall had a brown substance on the back wall, and the flooring had a buildup of debris and grime along the baseboard and corners. Additionally, the baseboard was not properly secured, posing a potential risk for resident injury. These findings were confirmed by the Nursing Home Administrator during an interview.
Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
The facility failed to ensure that residents were free from neglect by not providing adequate supervision for one of three residents, resulting in an elopement. Resident R1, who had severe cognitive impairment with a BIMS score of 5, was found in the Personal Care building after wheeling through the cafeteria. The facility's policy defines neglect as the failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress. Despite the resident's known condition and the need for increased supervision, the facility did not adequately monitor Resident R1, leading to the elopement incident. The Director of Nursing (DON) and RN Supervisor failed to complete necessary post-elopement procedures, including an incident report, witness statements, and a new Wandering Risk Assessment. The RN Supervisor admitted to not assessing Resident R1 after the elopement and did not complete an incident report, believing it was unnecessary since the resident was unharmed. The facility's lack of communication and procedural follow-through contributed to the failure in providing adequate supervision, as confirmed by the DON and Nursing Home Administrator. Additionally, the State Agency was able to exit the unit and enter the Personal Care Home without restricted access, highlighting the facility's inadequate security measures.
Failure to Investigate Elopement Incident
Penalty
Summary
The facility failed to implement written policies and procedures to ensure a complete and thorough investigation of an incident involving the potential for neglect, resulting in an elopement of Resident R1. Resident R1, who had severe cognitive impairment with a BIMS score of 5, was found in an unauthorized area by Personal Care staff. The RN Supervisor did not complete an incident report or conduct a post-elopement assessment, and the facility was not aware of the elopement until the following day. The Director of Nursing confirmed that there was a breakdown in communication and that the required documentation and assessments were not completed. During interviews, the RN Supervisor admitted to overhearing that Resident R1 was found in Personal Care but did not take further action because the resident was not harmed and did not make it outside the facility. The Nursing Home Administrator and Director of Nursing confirmed that the facility did not obtain witness statements from staff on duty at the time of the elopement and failed to follow their own policies and procedures for investigating such incidents.
Failure to Investigate Elopement
Penalty
Summary
The facility failed to conduct a thorough investigation of an elopement involving a resident with severe cognitive impairment. The resident, who had diagnoses of high blood pressure, dementia, and muscle weakness, was found in an unauthorized area without the facility's knowledge. The incident was not reported immediately, and no physical assessment, vital signs check, or Wandering Risk Assessment was completed after the resident was returned to the facility. The Director of Nursing (DON) confirmed that the RN Supervisor did not complete an incident report or obtain witness statements from staff on duty at the time of the elopement. The RN Supervisor admitted to overhearing that the resident was found in the Personal Care building but did not take any action because the resident was not harmed. The supervisor did not assess the resident, call the physician, complete an incident report, or update the care plan as required. The Nursing Home Administrator and DON acknowledged that there was a breakdown in communication and that the facility failed to conduct a thorough investigation to rule out neglect. The facility's policies on Resident Protection from Abuse, Neglect, Mistreatment, or Exploitation and Elopement Prevention were not followed, leading to the deficiency.
Failure to Update Care Plan After Resident Elopement
Penalty
Summary
The facility failed to ensure that a resident's care plan was updated and revised to reflect the resident's specific care needs after the resident eloped from the facility. Resident R1, who had severe cognitive impairment with a BIMS score of 5, was found in an unauthorized area after wheeling through the cafeteria and into Personal Care. Despite this incident, the resident's care plan did not include goals and interventions related to the elopement. The facility's policy on Elopement Prevention requires that a comprehensive elopement prevention plan be documented as part of the care plan, and the Care Plan and Interdisciplinary Care Conferences policy mandates that the care plan be reviewed and updated based on ongoing assessment and evaluation of resident needs. However, these policies were not followed in this case. During interviews, the RN Supervisor admitted to not assessing Resident R1 after the elopement, not completing an incident report, and not updating the care plan, as the resident was not harmed. The Director of Nursing confirmed that the facility failed to update and revise the care plan to reflect the resident's specific care needs after the elopement. This deficiency was identified for one of three residents reviewed, indicating a lapse in adherence to the facility's policies and procedures for care planning and elopement prevention.
Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
The facility failed to ensure adequate supervision for Resident R1, resulting in an elopement incident. Resident R1, who had severe cognitive impairment as indicated by a BIMS score of 5, was found in the Personal Care building after wheeling through the cafeteria. The facility's policy on Elopement Prevention required a comprehensive elopement prevention plan and regular Wandering Risk Assessments, which were not completed following the incident. Additionally, the facility's policy on Accidents and Incidents mandated a physical assessment, vital signs check, and a risk management report, none of which were performed after Resident R1 was returned. The RN Supervisor failed to complete an incident report or conduct a post-elopement assessment, as confirmed by the DON. The RN Supervisor admitted to overhearing about the elopement but did not take any action because Resident R1 was not harmed. This lack of action was a breakdown in communication, and the facility was not aware of the elopement until the following day. The RN Supervisor also failed to update the care plan or complete a new Wandering Risk Assessment. During a tour of the facility, it was observed that the Fairgrounds Village Unit could be exited through the Settlers Dining Room and into the Personal Care Home without restricted access. This allowed Resident R1 to elope without being noticed by staff. The Nursing Home Administrator and DON confirmed that the facility did not provide adequate supervision, leading to the elopement incident for Resident R1.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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