Failure to Report Elopement Incidents
Summary
The facility failed to notify the Department of Health of six out of seven reportable elopement events involving a resident. The resident, who was admitted with diagnoses including high blood pressure, dementia, and cerebral infarction, was involved in multiple incidents where they were found outside their designated area. These incidents occurred over a period of time and included the resident being found on different floors and areas of the facility, such as near the kitchen and at the reception desk. Despite these occurrences, the facility did not report these elopements to the appropriate agency as required by regulation. The resident was assessed as being at high risk for elopement, as indicated by an Elopement Evaluation score. The facility's policy required that any accidents or incidents involving residents be reported to the physician and responsible party within twelve hours, but this protocol was not followed in terms of notifying the Department of Health. The Nursing Home Administrator and Director of Nursing confirmed the failure to report these events, which seriously compromised quality assurance and patient safety as outlined in the regulatory requirements.
Plan Of Correction
The facility reported the elopement to the DOH on 4/5/25. The facility developed an Event Reporting Policy that includes an outline of the incidents and events that are required to be reported per Chapter 51.3. The facility updated its Change in Condition Policy to include elopement incidents and the required reporting and follow-up. All departments (Agency and staff) were educated about elopement risks and procedures, that included recognizing elopement and reporting of elopement incidents immediately to their immediate supervisor and then the Nursing Home Administrator and Director of Nursing. This education will also be included in the new hire curriculum and at least annually with all staff education days. The Elopement Prevention Audit Tool, which includes physician orders, treatment record documentation, elopement binders, incident reports, hourly logbooks, event reporting, and physician notification is being completed by the DON or designee daily for 2 weeks starting on 4/16/2025, then weekly for 3 weeks, then monthly for 3 months, and then quarterly thereafter with the results reported to the Quality Assurance Committee for further follow-up. Completion date - May 16, 2025.
Penalty
A resident experienced an unwitnessed fall resulting in a lumbar compression fracture, which was not reported to the Department of Health. The DON stated the incident was not reported as the resident did not go to the hospital. Both the Nursing Home Administrator and DON confirmed the failure to notify the Department of Health.
The facility inaccurately reported an incident of narcotics misappropriation involving tampered morphine bottles for two residents. The incident was incorrectly categorized in the state reporting system, as confirmed by interviews with the Nursing Home Administrator and the DON.
The facility failed to report an interruption of heating services to the State Agency in a timely manner. The boiler stopped functioning, leading to a loss of heating, but the incident was not reported until several days later.
A facility failed to notify the Department of Health about a fire hazard incident involving a resident's room. A nurse aide detected a 'burning plastic' smell, leading to the evacuation of two residents. The fire department identified the source as a melting overhead light. The Nursing Home Administrator did not report the incident, believing it was unnecessary.
The facility did not notify the Department of Health about a month-long disruption of tap bell service on the 2nd floor, 2 main. This deficiency was confirmed through staff interviews and a review of facility documentation, which showed no report was submitted as required.
The facility failed to report critical incidents involving two residents to the State Licensing Agency. One resident sustained a head laceration during a mechanical lift transfer, requiring hospital transfer. Another resident experienced a choking episode, necessitating the Heimlich Maneuver, CPR, and hospital transfer, where the resident later expired. These events were not reported, compromising compliance with mandated reporting requirements.
Failure to Report Resident Fall Resulting in Fracture
Penalty
Summary
The facility failed to notify the Department of Health of a reportable event involving a resident who experienced an unwitnessed fall. This incident occurred on April 19, 2025, and resulted in the resident sustaining a lumbar compression fracture, a type of spinal fracture where the vertebrae collapses. The clinical record review confirmed that the resident did not have a prior diagnosis of a lumbar compression fracture before the fall. During interviews, the Director of Nursing stated that the incident was not reported because the resident did not require hospitalization. Both the Nursing Home Administrator and the Director of Nursing acknowledged that the facility did not notify the Department of Health about this reportable event, which is a requirement under the regulations for events that seriously compromise quality assurance and patient safety.
Plan Of Correction
1. Reportable submitted and accepted for identified fall during complaint survey on 5/1/2025. 2. A 30 day look back audit was completed to ensure that no other falls experienced an injury of similar nature and went unreported. 3. NHA to educate DON/designee on events that require a report to be submitted. 4. DON/designee to audit falls and ensure reports are made for any falls with transfer and/or injury daily x 2 weeks, then 2x/week for 2 weeks, and 1x/week for 2 weeks. 5. Results to be submitted to QAPI for review and approval.
Misappropriation of Narcotics Misreported
Penalty
Summary
The facility failed to accurately report an incident involving the misappropriation of narcotics, specifically morphine 20MG/ML bottles, for two residents. During a clinical record review and staff interviews, it was discovered that the morphine bottles for these residents had been tampered with. The facility had entered this incident into the state reporting system under the incorrect category of "other" instead of "misappropriation of patient/resident property." Interviews with the Nursing Home Administrator and the Director of Nursing confirmed the misclassification of the incident. This misreporting was identified during a review of four facility-reported incidents, highlighting a deficiency in the facility's reporting practices. The failure to accurately categorize the incident in the state reporting system indicates a lapse in the facility's management and responsibility to ensure proper documentation and reporting of significant events.
Plan Of Correction
A - Resident's morphine was replaced at the cost of the facility and not charged to resident's insurance. B - Audit of all reportable incidents in last 30 days to ensure reported accurately. C - Previous DON and NHA educated on proper classification of reportable incidents of misappropriation in the PA event reporting system. Current DON and NHA aware of reporting category. D - Weekly x 4 then monthly x 2 audits by regional nurse or designee of reportable incidents to ensure accurate reporting. Results discussed during QAPI meetings.
Failure to Report Heating Service Interruption
Penalty
Summary
The facility failed to report an interruption of heating services to the State Agency in a timely manner. On April 6, 2025, the boiler stopped functioning, leading to a loss of heating in the building. Maintenance Employee E2 confirmed during an interview that the boiler malfunction occurred on Sunday afternoon, April 6, 2025. However, the Nursing Home Administrator was not informed of the malfunction until later that day at 4:36 p.m. Despite the loss of heating services, the facility did not include this incident in their reported incidents from April 6 to April 9, 2025. It was only on April 9, 2025, during an electronic communication at 2:31 p.m., that the Nursing Home Administrator confirmed the facility's failure to report the heating service interruption to the State Agency. This oversight constitutes a deficiency in the facility's obligation to notify the appropriate authorities of significant disruptions in services.
Plan Of Correction
The Nurse Home Administrator (NHA) reported the interruption of heating services via ERS on 4/9/25. The NHA will be educated by the Regional Administrator on the PA reporting requirements BY 4/23/25. All maintenance, dietary, and laundry/housekeeping employees will be educated by NHA on reporting interruption of services to NHA promptly. The Regional Administrator will audit daily audits completed by maintenance for the boilers, air temperatures, and water temperatures along with the work order system used by maintenance to ensure that disruption of any service is reported to the state agency. Observation and audit findings will be reviewed at the facility's monthly quality assurance meeting.
Failure to Report Fire Hazard Incident
Penalty
Summary
The facility failed to notify the Department of Health of a reportable event, as required by regulation 51.3 (g)(1-14). The incident involved a potential fire hazard in a resident's room, where a nurse aide detected a 'burning plastic' smell. Upon investigation, staff could not initially locate the source of the smell, but the room began to fill with haze and smoke. The resident and their roommate were promptly evacuated to another room, and the fire department was called to the scene. The fire department identified the source of the smell as the roommate's overhead light, which was burning and melting plastic. Despite the potential risk to patient safety and the significant disruption of services, the Nursing Home Administrator did not report the incident to the Department of Health. During an interview, the administrator stated that they did not believe the incident needed to be reported. This oversight constitutes a failure to comply with the notification requirements for events that seriously compromise quality assurance and patient safety.
Plan Of Correction
Reportable event was completed on 3.11.2025. Moving forward, the facility will report follow the state requirement for reporting events. To prevent this from recurring, the RDCS educated the NHA/DON on the licensure requirements for notification (0009). To monitor and maintain ongoing compliance, the DON/designee will audit facility events/progress notes weekly x4 then monthly x 2. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Failure to Notify Health Department of Service Disruption
Penalty
Summary
The facility failed to notify the Department of Health about a disruption of service, specifically regarding the inoperability of tap bells on the 2nd floor, 2 main, which had been non-functional for about a month. This deficiency was identified during a facility tour and confirmed through an interview with the Unit Manager and the Director of Nursing. The facility's documentation review revealed that no report was submitted to the Department of Health regarding this disruption, as required by regulation.
Plan Of Correction
1. Report for 2 main call light system was submitted to the department of health via electronic reporting system (#1075769). 2. An audit was conducted of outstanding work orders to ensure any service outages were reported to the department of health. No issues identified. 3. The administrator or designee will in-service the maintenance department on reporting service outages to administration so they can be reported to the department of health in a timely manner. 4. Administrator or designee will audit outstanding work orders weekly for 4 weeks to ensure any service outages are reported to the department of health. Audit findings will be shared with QAPI committee.
Failure to Report Critical Incidents
Penalty
Summary
The facility failed to notify the State Licensing Agency, Department of Health, Division of Nursing Care Facilities, of reportable events involving two residents. Resident 157 sustained a head laceration during a mechanical lift transfer, which required emergency medical evaluation and transfer to a hospital. This incident was documented in the nursing records and a facility investigative report dated August 30, 2024. Additionally, Resident 266 experienced a choking episode that necessitated the Heimlich Maneuver, CPR, and transfer to a hospital, where the resident subsequently expired. This incident was documented in the nurse's notes and a facility investigative report dated January 19, 2025. Upon review, it was confirmed that the facility did not submit these reportable events to the Department of Health, compromising compliance with mandated event reporting requirements.
Plan Of Correction
Step 1- R266 & R157's events were reported. Step 2- To identify other residents that have the potential to be affected, the NHA/Designee will review the last 14 days of incident and accident events to ensure any events that meet the criteria of a state reportable event are reported to the state agency as required. Step 3- To prevent this from reoccurring, re-education was provided by the regional nurse to the NHA/ANHA/DON re: state reportable events. Step 4- To monitor and maintain compliance the NHA/Designee will audit incident and accident reports to ensure any events that meet the criteria of a reportable event to the state is submitted as required. The audits will be completed weekly times 4 weeks and then monthly times 3. The results of the audits will be forwarded to QAPI committee for further review and recommendations.
Trusted data from CMS and state health departments
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.
Trusted by long-term care providers and associations.
