Failure to Follow Care Plan for Mechanically Altered Diet Results in Resident Death
Summary
The facility failed to implement and follow the care plan for a resident who was ordered to receive a mechanically altered diet. Despite the resident's dietary restrictions, a Certified Nursing Assistant (CNA) provided the resident with a sandwich, which was not consistent with the prescribed pureed snack. This action was observed by the Administrator through facility camera footage. As a result of receiving the inappropriate food item, the resident was sent to the local emergency room and subsequently transferred to a hospice facility, where the resident expired. The incident was recognized as a failure to comply with federal regulatory requirements related to quality of care and comprehensive care planning for residents with altered diets. The Administrator and Director of Nursing were aware of the incident and acknowledged that the resident's care plan was not followed. The facility's noncompliance was determined to have caused or had the likelihood to cause serious injury, harm, impairment, or death to residents, leading to the identification of Immediate Jeopardy for multiple federal regulations.
Removal Plan
- An Ad Hoc Quality Performance Improvement (QAPI) meeting was held with the Administrator, Social Services Director (SSD), the DON, Corporate Operations Consultant (COC), and Food Service Director (FSD) to identify the root cause of failure to follow R165's care plan. The facility's Modified Texture of Food Policy, Care Plan Policy, and Resident Food Preferences Policy were reviewed; no changes were made.
- The Administrator's job description was reviewed with the Administrator, FSD, SSD, and DON by the COC. No revisions were made.
- The COC in-serviced the Administrator, DON, FSD, and SSD on how to implement a process on how to verify diet orders before distributing resident meal trays, how to track and trend to determine a root cause analysis, and communication among departments on reviewing and updating resident care plans timely. The facility's QAPI policy was reviewed specifically regarding how to determine root cause analysis (RCA).
- The COC reviewed and approved the facility's audit forms and Plan of Correction (PoC) for any further areas of concern. Name of Audits- Daily Diet Verification Audit and Snack Distribution Audit. Residents' diets and care plans were discussed with the Administrator, DON, and FSD. Interventions were put into place, such as removing accessible snacks from the nurse stations; snacks were placed inside the pantry and available upon request. A snack diet reference sheet was initiated and placed inside the pantry.
- The Corporate Nurse Consultant (CNC) and DON audited the resident's diet orders and meal tray cards. The audits are named Daily Diet Verification Audit and Snack Distribution Audit. The Administrator, DON, and FSD will discuss all diet order changes in the morning and the clinical meeting to ensure all care plans are updated and accurate. Documentation will be monitored through the Abuse Performance Improvement Plan (PIP) and reported during QAPI by the DON and Administrator. The SSA reviewed and compared Diet Master from the Dietary Department and the Facility's Diet Type Report for all residents in the facility; no discrepancies were found.
- The COC met with the Administrator and DON to review the process of providing direct oversight of the following correct processes in the building as it relates to following care plans for resident diet orders. There is ongoing educational training for all members of the facility through the company's online courses. The Administrator was also in-service on how to conduct a QAPI meeting and how to identify and complete an RCA by the COC. The SSA reviewed in-service education related to the QAPI meeting and RCA with no concerns.
- The corrective actions were completed, and the facility alleges that the immediate jeopardy was removed. All corrective actions were completed. The facility's IJ was determined to be Past Noncompliance, removed.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with dementia, schizophrenia, and continuous O2 was observed on the smoking patio with cigarettes and a lighter in a plastic bag in her lap, despite staff stating she was supposed to use a smoking apron and that smoking materials were to be held by staff. Interviews showed the Administrator, DON, and Activity Director knew residents were keeping cigarettes and lighters on their person, that the smoking policy was not being enforced, and that residents with cognitive impairment or on O2 should not have access to smoking materials.
Facility leadership, including the NHA and DON, failed to effectively manage operations and nursing services to ensure adequate resident supervision, resulting in an elopement when a resident did not return from a leave of absence. Review of job descriptions, facility documents, clinical records, and staff interviews showed that the NHA and DON did not carry out their defined responsibilities to operate in accordance with federal and state regulations, and the current NHA and DON acknowledged that administration failed to provide adequate supervision, creating an immediate jeopardy situation.
The facility failed to implement its abuse policy when a resident made multiple abuse allegations against two CNAs. Although the administrator, acting as Abuse Coordinator, stated that policy required immediate reporting, investigation, and removal of alleged perpetrators from duty, facility records showed both CNAs continued to work their scheduled shifts during the investigation periods. Additionally, an allegation of verbal abuse by the same resident was not investigated. Review of the abuse policy confirmed the requirement for reporting, investigation, and oversight to ensure policies are followed, but these measures were not carried out, compromising resident protection during the investigation of abuse allegations.
Administrator A and the DON did not ensure effective management and oversight of resident care and services, resulting in widespread system failures affecting all 45 residents. Surveyors found deficiencies in resident dignity, informed consent for psychotropic medications, self-administration of meds, honoring meal preferences, responses to resident council concerns, protection of health information, grievance procedures, and handling of abuse allegations. Additional problems included missing or inaccurate MDS and PASSR assessments, lack of timely PASSR refiling for new diagnoses, incomplete or delayed baseline and updated care plans, failure to notify physicians of elevated blood sugars, and unaddressed accident hazards related to bed siderails. The facility also had issues with nebulizer and nasal cannula cleaning and storage, siderail assessments and consents, call light response times, controlled substance accountability, medication errors, and improper storage of drugs and biologicals, despite job descriptions assigning the administrator and DON responsibility for regulatory compliance and quality care.
Administration and nursing leadership failed to maintain safe hot water temperatures in all three resident areas (North Hall, South Hall, and corridor rooms). The NHA did not effectively carry out defined duties to ensure a safe, properly maintained environment and regulatory compliance, and the DON did not ensure nursing staff followed facility policies on safe water temperatures. As a result, residents were exposed to unsafe water temperatures in their rooms, creating Immediate Jeopardy under F689 (Accidents) and violating applicable state management and nursing services regulations.
The facility failed to prevent neglect of a resident on continuous oxygen and at high fall risk when staff did not perform required hourly safety checks, administer medications, provide the dinner meal, or ensure oxygen therapy for several hours after the resident was noted missing, and leadership (including the DON and Administrator) were unaware for weeks that the resident had been unaccounted for prior to being found unresponsive and later pronounced deceased. The facility also failed to enforce smoking safety policies for residents with unsafe smoking behaviors and oxygen use by limiting smoking assessments to admission only, not reassessing after repeated incidents, not increasing monitoring, allowing residents to retain smoking materials, and not ensuring oxygen was removed before entry into the smoking room, while the Medical Director was not informed of ongoing noncompliant smoking behavior.
Smoking Materials Not Controlled and Policy Not Enforced
Penalty
Summary
The facility administrative staff failed to use available resources effectively and efficiently to maintain the facility in a safe manner and to ensure the smoking policy was properly implemented. Surveyors observed a designated smoking patio where a resident was sitting in a wheelchair with a plastic bag in her lap that contained cigarettes and a lighter. Staff acknowledged that the resident was supposed to use a smoking apron while smoking and stated they were going to remove the cigarettes from her possession. Review of the resident’s record showed diagnoses of dementia, schizophrenia, and continuous oxygen use. The resident also had a roommate who was ordered to receive continuous oxygen. During interviews, the Administrator stated residents were only permitted to smoke during designated times and were not allowed to smoke in non-designated areas, and that staff were responsible for holding and storing residents’ lighters. The DON stated lighters were expected to be turned in after each smoking session and that the smoking box was kept at the nurse’s station, but acknowledged this restriction was not being enforced by staff. The Medical Director stated that, per facility policy, residents were not permitted to keep cigarettes or lighters and that smoking materials were to be supervised by staff regardless of cognitive level. He further stated that residents with cognitive issues or those receiving oxygen should not have access to smoking materials. The Activity Director acknowledged that multiple residents kept cigarettes and lighters with them and that some families provided smoking supplies. She also stated that she should begin auditing residents to determine who had smoking materials. The Administrator and DON further stated that smoking concerns had been identified months earlier, including residents smoking whenever they wanted, a nonworking fire alarm, and no fire watch, and that the issue had not been brought to QAPI and no PIP was in place.
Failure of Administration and Nursing Leadership to Prevent Resident Elopement
Penalty
Summary
The deficiency involves the failure of the Nursing Home Administrator (NHA) and the Director of Nursing (DON) to effectively manage the facility and ensure adequate supervision of residents, resulting in an elopement incident for one of forty residents (R1). The facility-provided job description for the NHA states that the NHA is responsible for directing the day-to-day functions of the facility, managing all aspects of operations, and ensuring resident safety and comfort in accordance with federal, state, and local regulations. The DON job description states that the DON is responsible for planning, organizing, developing, and directing the overall operation of the nursing department in accordance with Professional Nursing Law and applicable regulations. Despite these defined responsibilities, the facility did not take appropriate action when a resident failed to return from a leave of absence. Based on review of job descriptions, facility documents, clinical records, and staff interviews, surveyors determined that the previously employed NHA and DON did not fulfill their essential job duties to ensure that federal and state guidelines and regulations were followed. Specifically, the facility failed to provide adequate supervision to prevent an elopement, which created an immediate jeopardy situation for one resident. During an interview, the current NHA and current DON confirmed that facility administration had failed to effectively manage the facility to provide adequate supervision to prevent the elopement. The cited regulatory references include 28 Pa. Code 201.14(a) (Responsibility of licensee), 28 Pa. Code 201.18(b)(1)(3)(e)(1) (Management), and 28 Pa. Code 211.12(d)(1)(2)(3)(5) (Nursing services).
Failure to Implement Abuse Policy and Protect Residents During Abuse Investigations
Penalty
Summary
The deficiency involves the facility administrator, who also served as the Abuse Coordinator, failing to effectively implement the facility’s abuse policy when allegations of abuse and neglect were made by Resident #1 on two separate occasions involving two different CNAs. Facility documentation and staff interviews showed that, despite the administrator’s statement that the policy required immediate reporting to state agencies, initiation of an investigation, and removal and suspension of the alleged perpetrator from the facility during the investigation, the alleged perpetrators were not removed from duty. In the first incident, involving CNA1, timecard records showed that CNA1 completed the shift on the day of the incident and continued to work subsequent shifts during the investigation period. In the second incident, involving CNA2, timecard records showed that CNA2 completed the scheduled shift on the day of the incident and continued to work multiple scheduled shifts afterward while the allegation was under investigation. The report further notes that Resident #1 also made an allegation of verbal abuse that was not investigated by the facility. Review of the facility’s “Abuse, Neglect, and Exploitation” policy indicated that the facility would designate an Abuse Coordinator responsible for reporting suspected abuse, neglect, or exploitation to the state survey agency and other officials, and that the facility would provide ongoing oversight and supervision of staff to ensure policies were implemented as written. The failure of the Abuse Coordinator to remove the alleged perpetrators from the facility during the investigations and to investigate the verbal abuse allegation did not ensure the safety and protection of Resident #1 and other residents from potential abuse, as stated in the findings.
Systemic Administrative and Nursing Leadership Failures Affecting Resident Care and Services
Penalty
Summary
Administrator A and DON B failed to operate and administer the facility in a manner that ensured quality of life and overall well-being for all 45 residents. Surveyors, through observation, interview, record review, policy review, and job description review over multiple days, identified a widespread system breakdown in ensuring that services met professional standards. Deficient areas included resident dignity, informed decision-making for psychotropic medications, resident self-administration of medications, honoring resident meal choices and preferences, responding to resident concerns raised in resident council meetings, protecting resident health information, informing residents how to file grievances, and handling allegations of resident abuse. Additional failures involved obtaining and documenting consent and diagnoses for psychotropic medications, timely reporting of allegations, and providing Ombudsman reports upon discharge. Further findings showed failures in clinical and regulatory processes, including inaccurate MDS assessments and PASSR evaluations, not refiling PASSR when residents had new diagnoses, and not developing resident-specific baseline care plans within 48 hours of admission or updating care plans as needed. The facility did not consistently notify physicians of residents' increased blood sugar levels and did not adequately address accident hazards related to bed side rails. There were issues with nebulizer and nasal cannula cleaning and storage, bed siderail assessments, orders and consent, call light response times, controlled substance accountability, medication errors, and storage of drugs and biologicals. Administrator A confirmed responsibility for daily operations and acknowledged frustration with siderail issues, while job descriptions for both the administrator and DON documented their responsibility for ensuring regulatory compliance and quality care, which was not achieved in these areas.
Failure to Maintain Safe Hot Water Temperatures Resulting in Immediate Jeopardy
Penalty
Summary
Facility administration, including the Nursing Home Administrator (NHA) and Director of Nursing (DON), failed to ensure that hot water temperatures in resident care areas were maintained at safe levels. Review of the NHA’s job description showed responsibilities that included overseeing staff, explaining and assisting with facility policies and procedures, assuring the facility is properly maintained, clean and safe, maintaining necessary equipment and supplies, and ensuring adequate, properly trained personnel are on duty to meet resident needs and comply with regulations. Despite these defined duties, surveyors found that water temperatures in resident rooms on the North Hall, South Hall, and corridor rooms were not maintained at appropriate temperatures for resident safety, placing residents at risk for scalding injuries. The DON’s job description indicated responsibility for leading and managing the nursing department, overseeing clinical operations, supervising nursing staff, ensuring regulatory compliance, and collaborating with other department heads to promote quality outcomes in a resident-centered environment. However, the DON did not ensure that nursing staff followed facility policies related to safe water temperatures. As a result, residents in three of three resident areas (North Hall, South Hall, and corridor rooms) were exposed to unsafe water temperatures. Surveyors determined that this failure to maintain safe water temperatures and to ensure adherence to facility policies and regulatory requirements constituted Immediate Jeopardy under F689 (Accidents), as well as violations of specified Pennsylvania Code provisions related to licensee responsibility, management, and nursing services.
Failure to Prevent Resident Neglect and Enforce Smoking Safety Policies
Penalty
Summary
The deficiency involves the facility’s failure to administer operations in a way that ensured residents were free from neglect and that required systems for monitoring and care were functioning. For one resident with continuous oxygen use and a high fall risk, staff became aware around 4:15 PM that the resident could not be located on the unit, yet the facility did not ensure required hourly safety checks, medication administration, oxygen therapy, or provision of the dinner meal from approximately 4:00 PM to 9:00 PM. There was no timely staff communication, physician notification, or escalation of concern despite the resident not being seen for several hours. The resident was later found unresponsive on the floor at 9:49 PM, a STAT call was made, CPR was initiated, EMS took over, and the resident was pronounced deceased at 10:24 PM. The report notes that the DON recalled learning of the event through a hospitalization group chat message sent between 2:00 AM and 3:00 AM, which stated that the resident had been found unresponsive on the floor the prior evening. The DON stated they were not informed that the resident had been reported missing prior to being found and only became aware weeks later that the resident had reportedly been missing for several hours before discovery. The DON also stated that the Infection Control Director knew the resident had initially been reported missing, but this was not discussed in the morning meeting. The Administrator similarly reported first learning of the incident via a hospitalization group chat message after midnight and was unaware that the resident had been reported missing, had not been monitored hourly, had no documented dinner intake, and had not received medications between 4:00 PM and 9:00 PM. A second deficiency concerns the facility’s failure to enforce smoking safety policies for residents with known unsafe smoking behaviors and oxygen use. The Director of Recreation stated that smoking assessments were conducted only upon admission, not reassessed after repeated smoking incidents, and that they continued to provide education without clearly identifying further interventions. The Director of Recreation indicated that a smoking monitor should have removed oxygen before a resident on oxygen entered the smoking room and that residents should not have smoking materials, yet residents were found with such materials, which were then confiscated. The DON stated that one resident on hourly safety checks was not reassessed for safe smoking after each incident and that monitoring frequency was not increased despite repeated noncompliance. The DON also stated they were unaware that other residents had smoking materials or that there were smoking issues until surveyors arrived. The Medical Director reported not knowing about the resident’s noncompliant smoking behavior, acknowledged that smoking in a room with continuous oxygen is dangerous, and could not determine whether the resident was a safe smoker.
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.
