Unverified Individual Assigned to Provide Direct Resident Care Without Screening or Orientation
Summary
The deficiency involves the facility’s failure to administer an effective screening and onboarding system for non-employee staff, which allowed an unknown individual (S12) to be assigned to provide direct resident care without verification of employment, credentials, or required training. On the morning of 03/12/2026, S12 entered the locked building after inquiring about job openings and was allowed entry by a CNA (S14). She was directed to the nurses’ station to speak with LPNs identified as S10 and S13. After briefly leaving to change her footwear at the request of S10, she re-entered the building and was allowed back in by staff member S9R. Upon her return, S12 told S10, S11, and S13 that she was agency staff reporting for an open shift. Without verifying her identity, employment with the staffing agency, or CNA credentials, S11 provided S12 with a temporary ID badge and assigned her to a group of residents (R1 through R10) on the daily assignment sheet, where her name was handwritten. These residents had significant medical conditions, including hemiplegia and hemiparesis following cerebral infarction or other cerebrovascular disease, chronic obstructive pulmonary disease with acute exacerbation, gastrostomy malfunction, unspecified atrial fibrillation, non-traumatic subarachnoid hemorrhage, hypertensive urgency, acute infarction of the spinal cord, and encephalopathy. S12 reported that she rounded on residents, answered call lights, and obtained snacks from the kitchen for some residents. She specifically described answering a call light for one resident on barrier precautions, donning gown and gloves, entering the room, rolling the resident to remove a brief, and becoming soiled with feces before calling other CNAs for assistance and then leaving the room. Interviews with administrative nursing staff confirmed that there was no process in place at the time to verify the identity of non-employees upon entry, to confirm agency assignment and credentials, or to provide facility orientation, abuse/neglect training, or competency evaluation before assigning resident care. S13, identified as part of the administrative staff, acknowledged that when S12 presented herself as agency staff, neither she nor S10 verified S12’s agency status or credentials before S11 placed S12 on the assignment sheet for residents R1–R10. S11 confirmed she did not verify that S12 was agency staff and still issued a temporary ID and resident assignment. S10 and the DON (S2) both confirmed that the facility frequently used agency staff but had no existing process to pre-screen non-employees, verify credentials, or ensure completion of orientation and abuse/neglect training prior to allowing them to provide direct care. The administrator (S1) further confirmed that there was no process to verify the identity of non-employees upon entry and that S12 was not employed by the facility or its staffing agency, yet was allowed to provide care to residents for approximately two hours before the issue was discovered. The surveyors determined that this failure to verify and approve agency personnel prior to assignment of resident care created an Immediate Jeopardy situation beginning at 8:00 a.m. on 03/12/2026, when S12 first presented herself as agency staff and was subsequently assigned to provide direct care to residents R1 through R10. The facility’s ineffective administrative system for screening and onboarding agency personnel resulted in residents being placed at a likelihood of serious harm, injury, impairment, or death, as stated in the report. The visitor log for that day did not list S12, further evidencing the lack of a functioning entry and verification process for non-employees.
Removal Plan
- Removed the individual (S12) from the facility and ensured only verified nursing staff were permitted to provide resident care.
- Conducted an immediate search of the facility to locate S12 and confirmed she was no longer present in the building.
- Verified with the staffing agency that S12 was not employed by the agency and confirmed through the facility staffing system that she was not an active employee.
- Ensured S12 was not permitted to provide resident care and confirmed she was no longer present in the building.
- Contacted the Police Department to document the incident and obtain identifying information related to S12.
- Implemented monitoring of the front entrance to ensure all individuals entering are identified, verified, and logged in before entering.
- Interviewed residents assigned to the unit where S12 was listed on the assignment sheet to determine whether she provided care or performed CNA duties.
- Interviewed all residents with a BIMS score of 8 or greater regarding concerns related to care provided by unknown staff.
- Completed head-to-toe assessments for residents with a BIMS score less than 8 to evaluate for signs of injury, neglect, abuse, or improper care.
- Implemented a trained facility staff member as a front desk monitor to verify all individuals entering the facility.
- Required all staff and visitors entering the building to sign in and out at the front desk.
- Continuously monitored the front desk to ensure the entry process is followed and unknown individuals are not allowed entry.
- Changed keypad door codes throughout the facility, deleted previously stored codes, and input new codes to prevent unauthorized access.
- Educated all staff in all departments on verification of agency staff to be completed by the scheduler and/or Payroll Benefits Coordinator and maintained on file prior to placement on the daily schedule; on weekends/holidays verification to be performed by the DON.
- Verified abuse training requirements for agency staff by obtaining documentation from the agency and providing facility abuse training at the beginning of the agency staff member’s first scheduled shift.
- Educated staff on the responsibility to report unknown individuals attempting to provide resident care immediately to the DON or Administrator after ensuring resident safety.
- Educated staff on facility entry procedures and sign-in requirements.
- Educated staff on abuse prevention and resident safety.
- Completed education for staff not present during initial sessions prior to their next scheduled shift.
- Provided education/training for leadership/administrative staff by the Chief Nursing Officer with the Regional Director of Clinical.
- Implemented regional/corporate onsite monitoring of administrative staff compliance with agency staff verification and abuse training, and compliance with sign-in/out and continuous front desk monitoring.
- Restricted resident care assignments to only nursing staff whose employment status, credentials, and agency authorization have been verified by facility leadership prior to assignment.
- Administrator and DON to review the entry sign-in log daily and ongoing to ensure all staff entering are verified.
- Administrator, DON, ADON, and SDC to conduct random audits of staffing assignments and ongoing to confirm only verified employees/agency staff provide resident care.
- Required verification of agency staff credentials and agency confirmation to be completed prior to assigning any agency staff to provide resident care by the Scheduler/Payroll Benefits Coordinator.
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.
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