Little Sisters Of The Poor
Inspection history, citations, penalties and survey trends for this long-term care facility in Pittsburgh, Pennsylvania.
- Location
- 1028 Benton Avenue, Pittsburgh, Pennsylvania 15212
- CMS Provider Number
- 396116
- Inspections on file
- 22
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Little Sisters Of The Poor during CMS and state inspections, most recent first.
A resident with dementia, depression, and muscle weakness, care planned as dependent for transfers and requiring a full-body mechanical lift with two-person assistance, was injured during a transfer when a NA attempted to use a Hoyer lift without proper sling attachment and without a second staff member actively assisting. Another NA entered the room and found the resident already suspended in the lift, leaning forward with missing sling attachments, and while attempting to help move the resident to bed, the resident slid out of the improperly secured sling and fell to the floor, sustaining a scalp laceration that required staples. Staff interviews confirmed that facility policy required two staff for mechanical lift use and that the sling should have all required hooks attached, and that the NA involved had previously been reminded not to use the lift alone.
The facility did not provide required training on effective communication to nine out of ten direct care staff, including multiple nurse aides, an LPN, and an RN. This was confirmed through review of training records and staff interviews, resulting in a deficiency related to staff development and management requirements.
A review of education records and staff interviews revealed that three nurse aides did not receive required QAPI training, as confirmed by the Nursing Educator. This failure to provide mandatory training was found to be noncompliant with staff development and management regulations.
The facility did not provide Compliance and Ethics training to three nurse aides, as confirmed by a review of training records and staff interview. This failure was verified by the Nursing Educator and is not in accordance with required staff development regulations.
The facility did not provide required behavioral health training to two nurse aides and an LPN, as shown by missing documentation in their training records and confirmed by the Nursing Educator.
A resident requiring assistance with ADLs and with multiple diagnoses was left unsupervised in a bath chair by an untrained agency NA, resulting in the resident sliding down in the chair with safety mechanisms not in place. The resident was found yelling for help, with water up to the collarbone, and reported feeling terrified during the incident. Facility records and staff interviews confirmed that required supervision and safety procedures were not followed.
A nurse aide did not receive required training on Resident Rights, as confirmed by a review of education records and staff interview. The Nursing Educator acknowledged that this staff member was not provided the mandated education.
A resident with Parkinson's disease, bipolar disorder, and anxiety disorder was injured when a medical driver failed to properly position a van lift during hospital transport, resulting in a fall that required immediate medical attention. Facility documentation and staff interviews confirmed the lift was not in the correct position, leading to the incident.
A resident with Parkinson's disease, bipolar disorder, and anxiety experienced psychological distress after a fall from a van during transport. Despite a psychiatric recommendation for counseling, the facility did not arrange for these services, as no counseling provider had been available since the previous year.
A resident with dementia and moderate impairment eloped from a facility due to inadequate supervision and lack of updated care plans. Despite documented wandering and confusion, the facility failed to conduct regular elopement risk assessments or implement sufficient safety measures, resulting in the resident exiting the building unsupervised.
A resident with dementia and high risk for elopement was involved in multiple wandering incidents at the facility. Despite the facility's policy requiring physician notification within twelve hours of such incidents, the physician was not informed. The Nursing Home Administrator and DON confirmed this failure to comply with regulatory requirements.
The NHA and DON failed to manage the facility effectively, leading to a resident's elopement. Despite their responsibilities to ensure adherence to policies and regulations, the facility did not prevent the incident, placing residents in Immediate Jeopardy.
A facility failed to notify the Department of Health about six out of seven elopement incidents involving a resident with dementia and cerebral infarction. The resident was found in various unauthorized areas of the facility, indicating a high risk for elopement. Despite the facility's policy requiring timely notification of such incidents, the appropriate agency was not informed, compromising patient safety.
The facility did not notify the Department of Health about a reportable event when the fire alarm was activated and the fire company arrived. The DON stated they did not think it was necessary to report the incident, which was a failure to comply with notification requirements.
A visually impaired resident was injured during an activity involving a horse due to inadequate supervision. The resident, who is legally blind, was bitten by a horse, resulting in a finger fracture. The facility's care plan lacked specific safety measures for the resident's visual impairment, contributing to the incident.
The facility failed to date food items upon receipt, risking improper rotation, and stored kitchen items without inverting them, risking cross-contamination. Additionally, an employee did not properly wash hands after handling dirty dishes, potentially leading to foodborne illness.
The facility did not post required information about the Medicaid Fraud Control Unit on the First and Second Floor bulletin boards. This was confirmed by the DON during a survey, violating 28 Pa. Code: 201.14(a) and 201.18e.
The facility failed to make the Department of Health Survey Results readily accessible to residents and visitors. Observations showed no information on bulletin boards about the survey results on the First and Second Floors. During an interview, residents were unaware of the location of the survey results binder. The DON found the binders inside desks, confirming they were not visible or accessible.
The facility failed to provide appropriate respiratory care for four residents by not labeling oxygen tubing with dates, as required by their protocol. Observations revealed that residents with various medical conditions, including respiratory failure and hypertension, were receiving oxygen through undated nasal cannulas. Interviews with RNs confirmed the absence of dates, indicating non-compliance with the facility's policy to routinely change and label oxygen equipment.
The facility failed to conduct ongoing assessments for bedrail use for five residents, despite having policies requiring annual reassessment. Residents with conditions such as blindness, hypertension, and osteoarthritis had physician orders and care plans for side rail use, but no additional assessments were completed. Observations confirmed the presence of side rails, and the DON acknowledged the lack of ongoing assessments.
The facility failed to monitor personal refrigerators for two residents, lacked Enhanced Barrier Precautions for two residents with medical devices, and did not maintain a sanitary medication room. Additionally, infection control practices were not followed during a dressing change for a resident, leading to potential cross-contamination risks.
The facility did not provide communication training to four direct care staff members, as required by its policy and the Pennsylvania Code. Despite the policy mandating verification of educational preparation and competency, including communication skills, the facility's 2023 records lacked evidence of such training for these employees. Interviews with the Human Resources Director and the Director of Nursing confirmed this deficiency.
The facility did not provide required training on resident protection from abuse and neglect for two staff members. Despite policies mandating such training during orientation and ongoing employment, a review of 2023 education documents showed that these employees were not trained. This was confirmed by the DON and HR Director.
The facility did not provide mandatory QAPI training to seven staff members, including RNs and NAs, as required by its policy. Despite the policy mandating ongoing educational preparation and competency verification, a review of 2023 education documents showed no QAPI training for these employees. Interviews with HR and the DON confirmed this deficiency.
The facility failed to provide mandatory infection control training for five staff members, as required by its policies. The training records for an RN and four NAs did not include infection control education, which was confirmed by the HR Director and DON. This deficiency violates specific state codes related to staff development and management.
The facility failed to provide Compliance and Ethics training for two staff members, Employees E11 and E13, as required by their policy on Nursing Education, Mandatory Training, and Competency Evaluation. A review of 2023 education documents showed that these employees did not receive the necessary training, which was confirmed by the DON. The HR Director noted that education is conducted annually.
The facility failed to provide the required 12 hours of annual in-service education for five nurse aides, as mandated by facility policy. A review of 2023 education documents showed that none of the aides met the required training hours, with the highest being 7.75 hours. This deficiency was confirmed by the DON and noted under relevant state regulations.
The facility did not provide required Behavioral Health training for three staff members, including two RNs and one NA, as per its policy on Nursing Education and Competency Evaluation. This deficiency was confirmed by the DON.
A resident was unable to smoke at requested times due to insufficient staff willing to supervise her smoking breaks, as required by facility policy. The resident, who is legally blind and requires assistance, expressed that she often could not go outside to smoke because non-smoking staff were unwilling to accompany her. The ADON confirmed that staffing limitations led to this deficiency in care.
A facility failed to assess a resident's ability to self-administer medications, as required by their policy. The resident's care plan and physician orders did not include provisions for self-administration, and no assessment was documented. An RN was observed leaving medications at the resident's bedside, which was not permitted. The DON confirmed the absence of a self-administration policy and acknowledged the oversight.
A facility failed to maintain a safe and homelike environment in one of its nursing units. An observation revealed a missing door handle in a resident's room, leaving an exposed, sharp piece of metal. The DON confirmed the deficiency, acknowledging the failure to uphold safety and homelike standards as required by Pennsylvania Code.
A resident with high blood pressure, respiratory failure, and shortness of breath filed a grievance that was not addressed by the facility until several months later, contrary to the facility's grievance policy. Interviews with the resident and staff, including the DON and Nursing Home Administrator, confirmed the delay in addressing the grievance.
The facility failed to communicate necessary information to the receiving health care provider for two residents transferred to the hospital. One resident had depression and legal blindness, while the other had high blood pressure and reduced mobility. The lack of documentation of essential information such as care plan goals and advanced directives was confirmed by the ADON.
The facility failed to provide required written notifications for hospital transfers of two residents, including details such as the reason for transfer and contact information for the Ombudsman. The Assistant Director of Nursing confirmed this deficiency.
The facility failed to notify two residents or their representatives of the bed-hold policy during hospital transfers, as required by their policy. Both residents were transferred without receiving written information about the duration of the bed-hold policy, and the Assistant Director of Nursing confirmed this oversight.
A resident with diabetes experienced multiple low blood glucose readings, but the facility failed to implement the hypoglycemia protocol or document interventions. Additionally, the resident refused to be weighed on several occasions, and the facility did not notify the physician as required. The facility also administered Metolazone despite the resident's weight being below the threshold specified in the physician's order.
The facility failed to properly store medical supplies and biologicals in one of two medication rooms. The policy requires medications to be maintained within specific temperature ranges. An observation revealed that the temperature log for the first-floor medication room refrigerator was not completed on three specific dates, as confirmed by an RN.
Neglect During Mechanical Lift Transfer Resulting in Resident Head Injury
Penalty
Summary
The facility failed to protect a resident from neglect during a mechanical lift transfer, resulting in a fall and scalp laceration requiring three staples. Facility policy on abuse, neglect, and misappropriation defined neglect as the failure to provide necessary goods and services to avoid physical harm, and the mechanical lift policy required two staff members for all mechanical lift transfers. The resident involved had non-Alzheimer’s dementia, depression, and muscle weakness, and the care plan and MDS documented that the resident was dependent on staff for transfers and required a full-body lift with assistance of two persons. On the date of the incident, progress notes and hospital records showed that the resident slipped out of the lift pad and onto the floor, was found lying on their back with bleeding from the back of the head, and was transferred to the hospital where a scalp laceration was treated with three staples. Multiple witness statements described that NA E1 had already placed the resident in the air in a whole-body (Hoyer) lift without proper sling attachment and without a second staff member actively assisting. NA E3 entered the room seeking help for another transfer and observed the resident in the lift, leaning forward with upper straps around the neck and shoulders, and noted that not all straps were hooked to the lift, including the absence of the middle hook. Witnesses, including NAs and an RN, consistently reported that facility practice and policy required two staff for mechanical lift transfers and that the sling should have three rings attached. NA E2 reported having previously seen NA E1 coming out of the resident’s room alone with the lift days before the incident and had reminded NA E1 that two people were required for lift use. On the day of the event, NA E3 attempted to assist in moving the resident to the bed, but due to the improper sling application, the resident slid through the lift pad and fell to the floor, striking the back of the head. The DON and RN confirmed that the resident required a mechanical lift with two staff for transfers and that the resident fell from the lift pad during a transfer performed by NA E1, resulting in the scalp laceration.
Failure to Provide Effective Communication Training for Direct Care Staff
Penalty
Summary
The facility failed to provide required training on effective communication for nine out of ten direct care staff members, including nurse aides, an LPN, and an RN. Review of facility education documents and training records showed that these staff members did not receive education on effective communication as mandated. This finding was confirmed during an interview with the Nursing Educator, who acknowledged the lack of such training for the identified staff. The deficiency was cited under relevant Pennsylvania Codes related to licensee responsibility, management, and staff development. No information was provided regarding the involvement or condition of any residents in relation to this deficiency.
Failure to Provide QAPI Training to All Staff
Penalty
Summary
The facility failed to provide mandatory Quality Assurance and Performance Improvement (QAPI) training to three out of ten nurse aide staff members, as evidenced by a review of facility education documents and training records. Specifically, the records for these three nurse aides did not include documentation of QAPI education as required. This deficiency was confirmed during an interview with the Nursing Educator, who acknowledged that the training had not been provided to these staff members. The findings reference noncompliance with state regulations regarding staff development and management responsibilities.
Failure to Provide Compliance and Ethics Training to Staff
Penalty
Summary
The facility failed to provide required Compliance and Ethics training to three out of ten nurse aide staff members, as evidenced by a review of facility education documents and training records. Specifically, the records for these three nurse aides did not include documentation of education on Compliance and Ethics, which is mandated. This deficiency was confirmed during an interview with the Nursing Educator, who acknowledged that the training had not been provided to these staff members. The findings reference specific state regulations regarding the responsibility of the licensee, management, and staff development.
Failure to Provide Behavioral Health Training to Staff
Penalty
Summary
The facility failed to provide required behavioral health training to three out of ten staff members, specifically two nurse aides and one LPN, as evidenced by a review of facility education documents and training records. The records for these staff members did not include documentation of behavioral training as mandated by facility policy and regulatory requirements. This deficiency was confirmed during an interview with the Nursing Educator, who acknowledged that the behavioral training had not been provided to the identified staff members. No information regarding residents, their medical history, or their condition at the time of the deficiency was included in the report.
Failure to Provide Adequate Supervision During Bathing
Penalty
Summary
The facility failed to provide adequate supervision during bathing for one resident, resulting in a deficiency related to accident hazards and supervision. According to facility policy, staff are required to remain with residents at all times during bathing, ensure all safety mechanisms such as seatbelts and locked wheels are in use, and never leave a resident unattended. However, a resident with diagnoses including high blood pressure, arthritis, and schizophrenia, who was cognitively intact and required assistance with activities of daily living, was left alone in a bath chair by an agency nurse aide who was unfamiliar with the equipment and procedures. The incident occurred when the resident was placed in the tub by the agency nurse aide, who then left the room immediately after asking the resident how the machine worked. The resident was found by staff after yelling for help, sliding down in the bath chair with water up to the collarbone/neck, the safety belt unfastened, the handlebar not in place, and the chair wheels unlocked. The resident reported feeling terrified during the incident and estimated being left alone for about ten minutes. The resident denied going under the water and was assessed with stable vital signs and no injuries following the event. Facility documentation and staff interviews confirmed that the agency nurse aide had not been trained on the use of the bathing equipment and that the resident was left unsupervised in violation of facility policy and federal regulations. The deficiency was identified through review of facility records, policies, and interviews, which established that the required supervision and safety measures were not provided during the resident's bath.
Failure to Provide Resident Rights Training to Staff Member
Penalty
Summary
The facility failed to provide required training on Resident Rights to one of ten staff members, specifically a nurse aide identified as Employee E4. This deficiency was identified through a review of facility education documents and training records, which showed that Employee E4 had not received the mandated education on Resident Rights. During an interview, the Nursing Educator confirmed that this staff member had not been trained as required. The deficiency is cited under 28 Pa Code: 201.14 (a) Responsibility of licensee, 28 Pa Code: 201.18 (b)(1) Management, and 28 Pa Code: 201.20 (a)(6)(d) Staff development.
Resident Fall Due to Improper Use of Van Lift
Penalty
Summary
A deficiency occurred when a resident with diagnoses of Parkinson's disease, bipolar disorder, and anxiety disorder was not properly protected from neglect during transportation to a hospital. The facility's medical driver failed to ensure that the van lift was in the correct position before assisting the resident out of the vehicle. As a result, the resident fell from the van, striking the left side of their body, and required immediate evaluation and treatment by hospital staff and paramedics. Facility documentation, including a witness statement from the medical driver and confirmation from the Director of Nursing, indicated that the lift was not properly positioned and that this failure directly led to the resident's fall. The incident was reported to the state survey office, and it was confirmed that the facility did not adhere to its own policy regarding the prevention of neglect, as necessary precautions were not taken to avoid physical harm to the resident.
Failure to Provide Medically-Related Social Services After Traumatic Incident
Penalty
Summary
A deficiency was identified when the facility failed to provide medically-related social services to a resident with a history of Parkinson's disease, bipolar disorder, and anxiety disorder. The resident experienced a traumatic incident when she fell from a van while being transported for a medical appointment, resulting in her being evaluated and treated in the emergency room. Following the incident, the resident exhibited ongoing psychological distress, including preoccupation with the fall, repeated questioning, and a desire to speak with a counselor. Despite a psychiatric evaluation recommending psychological counseling for the resident due to her persistent distress after the fall, the facility did not arrange for such services. An interview with a social service employee confirmed that the facility had not had a counseling service available since the previous year and had not set up a counseling appointment for the resident. This lack of action resulted in the failure to provide necessary medically-related social services as required.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to ensure adequate supervision for a resident, resulting in an elopement incident. The resident, who had a history of dementia and was moderately impaired, was found outside the building on a loading dock, having exited the facility without staff knowledge. The resident's clinical records indicated a moderate risk for elopement, yet the facility did not update care plans or implement sufficient interventions to prevent such incidents. The resident had multiple episodes of wandering and confusion, which were documented in progress notes. Despite these documented behaviors, the facility did not consistently complete elopement risk assessments or notify the resident's family and physician. The facility also failed to update care plans or implement additional safety measures to address the resident's wandering and exit-seeking behaviors. The facility's lack of response to the resident's elopement risk was further evidenced by the absence of wander guard alarms on doors and elevators that did not lock when a wander guard bracelet was detected. This oversight, combined with the failure to conduct regular elopement risk assessments and update care plans, contributed to the resident's ability to leave the facility unsupervised, creating an immediate jeopardy situation.
Plan Of Correction
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? (Resident R1) - Resident R1 now has a Wander Guard and was moved to the first floor where the Wander Guard alarms are located. Resident R1 was assessed for injury and family was notified on 4/16/2025. The physician was notified of the elopement on 4/05/2025 at 16:30. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? - Elopement risk assessments were completed on all residents on 4/16/2025. Any resident identified as at-risk for elopement was reviewed by the interdisciplinary team for appropriate interventions to prevent elopements. Sign-in/Sign-out sheets were initiated on 4/19/2025 to monitor all resident whereabouts on and off the nursing units. 3. What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur? The Elopement - Assessment, Risk & Prevention Policy was revised to include: - Added that the Elopement Risk Assessment will be performed quarterly as part of the resident's care plan review. This is in addition to performing the assessment on admission (or readmission), for changes in the residents' condition or cognition, after an elopement attempt, upon verbalizing their desire to leave the facility, and any time a staff member feels that the resident should be reassessed. - Rounds were added on an hourly basis from 11:00 PM to 7:00 AM every night and every hour for weekend shifts. These rounds will be recorded in logbooks on every nursing unit. - Sign-in/Sign-out logs were added to every unit to update staff when the residents are off the unit for an activity, appointment, or outing. Binders are at every nursing station with at-risk resident photographs and their individualized care plans. Binders are at the front desk with at-risk resident photographs. - In the event of an elopement, a full body assessment will be included. All departments (agency and staff) were educated about elopement risks and procedures, that included recognizing elopement, completing risk assessments, care plans, supervision to prevent elopement, and the Wander Guard system. - Further education will be ongoing and will be included in the new hire curriculum and at least annually with all staff education days. An emergency QAPI meeting was held on April 22, 2025, to review elopement policies and procedures. Another QAPI meeting is scheduled for May 5, 2025, to review elopement policies and procedures and progress with implementation. - CNA meetings were held on April 22, 2025, and a Licensed Nurse meeting was held on April 23, 2025, to educate clinical staff on the changes to the Elopement Policy and to discuss concerns. A Daily Stand-Up Meeting and Policy was developed and will begin on May 1, 2025. These meetings will review the 72-hour nursing report every Monday and will review the 24-hour nursing report every other weekday. The Stand-Up Meeting will address new business and reportables, high-risk review elements, and any events to be reported to the attending physicians and/or the medical director. A binder with the Stand-Up Meeting notes will be maintained by the nurse educator. - Elopement drills will be held on at least a quarterly basis, with every shift evaluated on at least a yearly basis. An elopement drill is scheduled to be conducted on 5/02/2025. A directed In-Service on 42 CFR 483.25 Accidents/Hazard/Supervision F689 will be held on May 7, 2025, by Masters crafted in Healthcare, LLC. This In-Service will include a review of all the federal regulations cited along with a review of the accompanying guidelines and be conducted on all shifts and recorded for any staff unable to attend. All staff will also be educated on new and revised policies at this time. The staff will continue to ensure that the new policies will be followed. This will be monitored at the daily Stand-Up Meetings, and audits of the rounding logbooks. All will be reported quarterly at QAPI. 4. How will the corrective action be monitored to ensure that the deficient practice will not recur; i.e., what quality assurance programs will be established? 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. 5. Dates of when the corrective action will be completed - May 16, 2025.
Removal Plan
- An elopement assessment will be done on every resident.
- Resident R1 now has a wander guard and is moved to the first floor where the alarms are located.
- Resident R1 has been assessed for injury and family was notified of all the events.
- Elopement care plans, which include resident specific interventions, will be done on every resident.
- Hourly rounds will be added to all night and weekend shifts.
- Wander guard placement will be checked every shift, and wander guard function will be checked daily.
- At risk residents must be supervised when out of bed by a staff member to ensure residents are safe.
- Educate all departments including agency on Elopement Risk and Assessment, Care plans, Supervision, Wander guards, How to activate wander guards and where they are located, Color light indicators.
- Elopement policy revised to add head to toe assessment (full body), elopement risk assessments will be done quarterly with care plan review, elopement binders will be on each nurse's station and front desk, to include picture and room number.
- Emergency Quality Assurance Performance Improvement (QAPI) meeting will be held with all supervisors and committee members.
- All other incidents will be reviewed at regular QAPI meetings.
- Audits will be completed.
- Daily audits will be completed by DON or designee daily for two weeks, then weekly for three weeks, then monthly for three months, and then quarterly.
- Hourly Round tool will be conducted at night and on the weekends.
- Facility called an emergency QAPI meeting, and signature sheet was provided and reviewed.
Failure to Notify Physician of Resident Elopements
Penalty
Summary
The facility failed to comply with the requirement to notify a physician of elopements for a resident, identified as Resident R1, who was involved in multiple incidents of wandering and elopement. The facility's policy mandates that a physician and responsible party must be notified of any accident or incident within twelve hours. However, the facility did not adhere to this policy for Resident R1, who was found in various locations outside of her designated area on several occasions. These incidents included being found on the ground level near the kitchen, in a closet downstairs, and at the reception desk by the front door, among others. Despite these occurrences, the facility did not notify the physician as required. Resident R1, who was admitted to the facility with diagnoses including high blood pressure, dementia, and cerebral infarction, was identified as being at high risk for elopement. The resident's clinical records and interviews with facility staff confirmed the lack of physician notification for these incidents. The facility's failure to notify the physician was acknowledged by the Nursing Home Administrator and Director of Nursing during an interview, confirming the deficiency in meeting the regulatory requirements for quality of care.
Plan Of Correction
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? - Resident R1 now has a Wander Guard and was moved to the first floor where the Wander Guard alarms are located. Resident R1 was assessed for injury and family was notified on 4/16/2025. The physician was notified of the elopement on 4/05/2025 at 16:30. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? - On 5/01/2025 an audit was completed on the nursing notes for all residents over the past 30 days. Only Resident R1 is exit-seeking and verbalizing desire to leave. This occurs almost every day. On the night shift there will always be a staff person to monitor her whereabouts. - All nursing staff were educated on the facility policy including physician notification with elopement events on 4/15/2025 and 4/16/2025. 3. What Measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur? - The facility Elopement Assessment, Risk and Prevention Policy includes notifying the attending physician with any elopement incidents and was reviewed by the Quality Assurance Team on 4/16/2025. - The Change in Condition Policy has been updated to include elopement incidents and attending physician notification. Nursing staff were educated on recognizing elopement and physician notification following any elopement incidents on 4/15/2025 and 4/16/2025. 4. How will the corrective action be monitored to ensure that the deficient practice will not recur; i.e., what quality assurance programs will be established? - An Elopement Prevention Audit Tool, which includes physician notification, is being completed by the DON or designee daily for 2 weeks beginning 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. 5. Date of when the Corrective Action will be completed - May 16, 2025.
Failure to Prevent Resident Elopement
Penalty
Summary
The Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility, resulting in the elopement of a resident, identified as Resident R1. The job descriptions for both the NHA and DON emphasize their responsibilities in ensuring adherence to policies and procedures, as well as having a thorough knowledge of federal and state regulations governing long-term care facilities. Despite these outlined duties, the facility did not prevent the elopement, which placed the residents in Immediate Jeopardy. The deficiency was identified through a review of job descriptions, clinical records, and staff interviews. During an interview, the NHA and DON were informed of their failure to manage the facility effectively to prevent the elopement. The report highlights that the NHA and DON did not fulfill their essential job duties to ensure compliance with federal and state guidelines and regulations, as evidenced by the elopement incident involving Resident R1.
Plan Of Correction
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The Nursing Home Administrator and the Director of Nursing reviewed their job descriptions with the Human Resources Director, with a focus on the essential job functions. The Nursing Home Administrator completed her review on 4/30/2025. The Director of Nursing completed her review on 5/01/2025. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The Nursing Home Administrator and the Director of Nursing will attend the directed In-Service on 42 CFR 483.25 Accidents/Hazard/Supervision F689, which will be held on the week of May 5, 2025, by Masters crafted in Healthcare, LLC. This In-Service will include a review of all the federal regulations cited along with a review of the accompanying guidelines. The Elopement Assessment, Risk, and Prevention Policy was updated to include the definition of elopement. New policies were developed and implemented on Investigating and Reporting Accidents and Incidents, for both Administration and Nursing Staff. 3. What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur? The Nursing Home Administrator and Director of Nursing will continue to ensure that the new policies will be followed. This will be monitored at the daily Stand-Up Meetings, through audits of the electronic medical records. All will be reported quarterly at QAPI. 4. How will the corrective action be monitored to ensure that the deficient practice will not recur; i.e., what quality assurance programs will be established? The Nursing Home Administrator and Director of Nursing are in attendance at each morning Stand-Up Meeting where resident specific issues and outcomes are reviewed. 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. 5. Dates of when the corrective action will be completed - May 16, 2025.
Failure to Report Elopement Incidents
Penalty
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.
Failure to Notify Department of Health of Reportable Event
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 deficiency was identified based on facility reports and staff interviews. On February 3rd, the fire alarm was activated, and the fire company arrived at the facility. During an interview, the Director of Nursing (DON) stated that they did not think it was necessary to report the incident. This oversight was confirmed by the DON, indicating a failure to comply with the notification requirements for events that seriously compromise quality assurance and patient safety.
Plan Of Correction
Immediate Action: The fire alarm event was reported to the Department of Health and accepted. No substantial disruption of services occurred. All supervisors were instructed on reportable events and event reporting will be part of our yearly training sessions. Event reporting will be discussed at safety meetings and quarterly at QAPI meetings. Reportable incidents will be monitored by the Safety Officer and reported monthly at the Safety Committee. All reports will be submitted quarterly at QAPI. Staff in-services will instruct staff on notification of residents as to the status of the event (false alarm, partial evacuation, etc.). An event report was created for the Incident Commander or designee to complete the details of the event, what actions were taken, and who was notified of the event. Subsequently, the Department of Health will be notified according to PA Code 51.3. The Fire Policy was updated to include event reporting to the Department of Health. The corrective action will be completed by February 10, 2025.
Inadequate Supervision Leads to Resident Injury During Activity
Penalty
Summary
The facility failed to provide adequate supervision for a visually impaired resident during an activity involving a horse, resulting in the resident being bitten and sustaining a fracture. The resident, identified as R17, is legally blind and has a history of depression and anxiety. During the activity, the resident was in a wheelchair and unaware that other residents were feeding carrots to the horse. The resident's hand movements were mistaken by the horse for a carrot, leading to the bite. The incident occurred when the resident was participating in an activity where horses were present, and other residents were feeding them treats. The facility's care plan for the resident did not include specific interventions or safety precautions related to the resident's visual impairment during such activities. The lack of supervision and failure to implement safety measures contributed to the incident, as the resident was unable to perceive the danger due to her blindness. Interviews with staff and the resident revealed that there were several staff and volunteers present during the activity, but none witnessed the actual bite. The resident did not feel the bite due to a lack of sensation in her fingers and only became aware of the injury when others noticed the bleeding. The facility's failure to provide adequate supervision and safety measures for the visually impaired resident during the activity led to the resident sustaining a fracture in her finger.
Food Safety and Hygiene Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to proper food safety protocols, as evidenced by several observations and staff interviews. During a review of the facility's food safety policy, it was noted that food items in the Dry Foods Storage Area, Walk-In Refrigerator, and Walk-In Freezer were not dated upon receipt, which is necessary for ensuring proper food rotation. This was confirmed by the Dietary Supervisor, who acknowledged the oversight. Additionally, in the Dish Room, various kitchen items such as casserole dishes, bowls, serving platters, saucepans, and frying pans were stored without being inverted, increasing the risk of cross-contamination. Furthermore, a significant lapse in hand hygiene was observed in the Dish Room. An employee, identified as KP Employee E8, was seen wearing gloves while handling dirty dishes and failed to properly wash hands with soap and water before handling clean dishes. The employee only rinsed gloved hands under water for about two seconds, which was insufficient for maintaining hygiene standards. This was confirmed by both the employee and the Dietary Supervisor, highlighting a failure in proper handwashing practices, which could potentially lead to foodborne illness.
Failure to Post Medicaid Fraud Control Unit Information
Penalty
Summary
The facility failed to comply with regulatory requirements by not posting necessary information about the Medicaid Fraud Control Unit on the bulletin boards located on the First and Second Floor nursing care units. This deficiency was observed during a survey conducted from November 25, 2024, through November 27, 2024. The absence of this information was confirmed during an observation and interview with the Director of Nursing on November 27, 2024, at 11:10 a.m. The failure to post this information is a violation of 28 Pa. Code: 201.14(a) and 28 Pa. Code: 201.18e, which outline the responsibilities of the licensee and management, respectively.
Survey Results Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the Department of Health Survey Results were readily accessible to residents and visitors, as required. Observations on the First and Second Floor bulletin boards revealed that there was no information posted regarding the availability of the survey results. During a group interview, ten out of ten residents were unaware of where the survey results binder was located. Additionally, the Director of Nursing found the survey results binders inside desks on both floors, confirming that they were not visible or accessible to residents and visitors. This deficiency was observed during the survey conducted from November 25, 2024, through November 27, 2024.
Failure to Label Oxygen Tubing in Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for four residents, as evidenced by the lack of proper labeling on oxygen tubing. The facility's policy requires that nasal cannulas, face masks, and nebulizer setups be changed routinely to decrease the chance of infections, with the date written on tape and applied to the tubing. However, during observations, it was noted that the nasal cannula tubing for Residents R15, R25, R27, and R29 did not have dates, indicating a failure to adhere to the facility's protocol for changing and labeling oxygen equipment. Resident R15, who has diagnoses of high blood pressure, respiratory failure, and shortness of breath, was observed receiving oxygen without a date on the nasal cannula tubing. Similarly, Resident R25, with peripheral vascular disease, diabetes, and hypothyroidism, was also observed with undated tubing. Resident R27, diagnosed with hypertension, diabetes, and hyperlipidemia, and Resident R29, with hypertension, diabetes, and hyperlipidemia, were both found to have undated oxygen tubing. Interviews with registered nurses confirmed the absence of dates on the tubing, highlighting the facility's failure to provide appropriate respiratory care as per their established protocols.
Failure to Conduct Ongoing Bedrail Assessments
Penalty
Summary
The facility failed to conduct ongoing accurate assessments to ensure that bedrails were used to meet resident needs and the risks associated with bedrail usage for five residents. The facility's policy on bed rail use, dated 11/6/23, required that a resident's condition be reassessed at least annually or upon a change in condition by Physical Therapy to determine the need for continuing use of half-length rails. However, the clinical records for Residents R17, R21, R27, R29, and R30 revealed that no additional siderail assessments were completed after the initial PCE - Siderails assessment. Resident R17, who was legally blind and required assistance with personal care, had a physician order and care plan indicating the use of top two side rails for mobility. Despite this, there were no additional siderail assessments completed after the initial assessment. Similarly, Resident R21, with diagnoses including high blood pressure and hyperlipidemia, had orders and a care plan for side rail use, but no further assessments were conducted. Observations confirmed the presence of side rails on their beds. Residents R27, R29, and R30 also had physician orders and care plans for the use of side rails to aid in mobility and transfer. However, their clinical records lacked any additional completed siderail assessments beyond the initial one. Observations showed that the side rails were present on their beds, either in the up or down position. The Director of Nursing confirmed the absence of ongoing assessments for all five residents, indicating a failure to adhere to the facility's policy and regulatory requirements.
Infection Control and Monitoring Deficiencies in LTC Facility
Penalty
Summary
The facility failed to properly monitor the personal refrigerators of two residents, R17 and R29, to ensure that food was stored and maintained correctly. Observations revealed that both residents had thermometers in their refrigerators, but there were no temperature logs present. Interviews with staff confirmed that the household aides were responsible for monitoring these refrigerators, yet multiple dates in October and November were missing temperature documentation. The facility also failed to implement Enhanced Barrier Precautions (EBP) for two residents, R1 and R3, who were at increased risk of multidrug-resistant organism (MDRO) acquisition due to their medical conditions. Resident R1, with a feeding tube, and Resident R3, with a suprapubic catheter, did not have orders or care plans for EBP, as confirmed by the Director of Nursing. This lack of precautionary measures was a significant oversight in infection control practices. Additionally, the facility did not maintain a safe and sanitary environment in one of the medication rooms, where personal items such as a lunch bag, water bottle, and purse were found on the counter. The medication room freezer also contained ice packs and ice buildup. Furthermore, during a dressing change for Resident R29, infection control practices were not followed. The RN failed to use a clean barrier field, did not perform hand hygiene after cleansing the wound, and completed the wound care without gloves, leading to potential cross-contamination risks.
Failure to Provide Communication Training to Direct Care Staff
Penalty
Summary
The facility failed to provide communication training to four out of seven direct care staff members reviewed, specifically Employees E1, E10, E12, and E14. The facility's policy on Nursing Education, Mandatory Training, and Competency Evaluation, dated 11/4/24 and previously dated 11/6/23, mandates the establishment, implementation, and maintenance of written policies and procedures for verifying educational preparation and competency, including communication skills. However, upon review of the facility's education documents for 2023, it was found that these employees did not receive training on effective communication. Interviews with facility staff, including the Human Resources Director and the Director of Nursing, confirmed the lack of communication training for these employees. The Human Resources Director noted that education is conducted on a calendar year basis, from January through December. Despite this, the facility's records did not show evidence of communication training for the specified employees, which is a requirement under the facility's policy and the Pennsylvania Code sections 201.14(a) and 201.20(c) regarding staff development.
Failure to Provide Mandatory Abuse and Neglect Training
Penalty
Summary
The facility failed to provide mandatory training on resident protection from abuse and neglect for two of its staff members, identified as Employees E11 and E13. According to the facility's policies on Nursing Education and Abuse, all staff are required to receive training during orientation and on an ongoing basis. However, a review of the facility's education documents for the year 2023 revealed that these two employees did not receive the necessary training. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the oversight. The Human Resources Director also stated that education is conducted on a calendar year basis, from January through December.
Failure to Provide QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training on Quality Assurance and Performance Improvement (QAPI) for seven staff members, including Registered Nurses and Nurse Aides. The facility's policy on Nursing Education, Mandatory Training, and Competency Evaluation, dated 11/4/24 and previously dated 11/6/23, requires the establishment, implementation, and maintenance of written policies and procedures for verifying educational preparation and competency. This includes certification and/or licensure in good standing upon hire and on an ongoing basis while employed. However, a review of facility education documents for the year 2023 revealed that none of the seven staff members received training on QAPI education. Interviews with the Human Resources Director and the Director of Nursing confirmed the lack of QAPI training for these staff members. The Human Resources Director stated that education is conducted by calendar year, running from January through December. Despite this, the facility's records did not include QAPI training for the identified employees. This deficiency was confirmed by the Director of Nursing, who acknowledged the facility's failure to provide the required training. The report cites violations of specific Pennsylvania Code regulations related to the responsibility of the licensee, management, and staff development.
Infection Control Training Deficiency
Penalty
Summary
The facility failed to provide mandatory training on infection control for five out of seven staff members, specifically Employees E1, E9, E10, E12, and E14. The facility's policy on Nursing Education, Mandatory Training, and Competency Evaluation, dated 11/4/24 and previously dated 11/6/23, requires the establishment, implementation, and maintenance of written policies and procedures for verifying educational preparation and competency, including certification and/or licensure in good standing, upon hire and on an ongoing basis. The Infection Control policy, also dated 11/4/24 and previously dated 11/6/23, states that initial orientation for new employees should cover infection control, universal precautions, and hand washing, with this information reviewed annually. Upon reviewing the facility's education documents for 2023, it was found that the training records for RN Employee E1, NA Employees E9, E10, and E12, and RN Employee E14 did not include infection control education. During interviews, the Human Resources Director confirmed that education is conducted by calendar year, and the Director of Nursing confirmed the lack of infection control training for these staff members. This deficiency is a violation of 28 Pa Code: 201.14 (a) Responsibility of licensee, 28 Pa Code: 201.18 (b)(1) Management, and 28 Pa Code: 201.20 (a)(c) Staff development.
Failure to Provide Compliance and Ethics Training
Penalty
Summary
The facility failed to provide training on Compliance and Ethics for two out of seven staff members, specifically Employees E11 and E13. The facility's policy on Nursing Education, Mandatory Training, and Competency Evaluation, dated 11/4/24 and previously dated 11/6/23, requires the establishment, implementation, and maintenance of written policies and procedures for verifying educational preparation and competency, including certification and/or licensure in good standing, upon hire and on an ongoing basis. However, a review of the facility's education documents for the year 2023 revealed that Nurse Aide (NA) Employees E11 and E13 did not receive the required training on Compliance and Ethics. This was confirmed during an interview with the Director of Nursing on 11/27/24. The Human Resources Director, Employee E15, stated that education is conducted by calendar year, running from January through December.
Failure to Provide Required In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that all nurse aide staff received the mandated minimum of twelve hours of in-service education training annually. This deficiency was identified for five nurse aide employees (E9, E10, E11, E12, and E13) based on a review of facility documents and staff interviews. The facility's policy on Nursing Education, Mandatory Training, and Competency Evaluation, dated 11/4/24, requires the establishment and maintenance of written policies and procedures for verifying educational preparation and competency, including certification and licensure. However, the review of the facility's education documents for the year 2023 revealed that none of the five nurse aides met the required 12 hours of in-service training. Specifically, the records showed that Employee E9 received 7.75 hours, Employee E10 received 2.5 hours, Employee E11 received 5.75 hours, Employee E12 received 4.0 hours, and Employee E13 received 7.75 hours of in-service training. These findings were confirmed during an interview with the Director of Nursing, who acknowledged the facility's failure to provide the required annual in-service education. The deficiency was noted under the regulations 28 Pa. Code 201.19(7) Personnel policies and procedures and 28 Pa. Code 201.20(a)(d) Staff development.
Failure to Provide Behavioral Health Training
Penalty
Summary
The facility failed to provide required Behavioral Health training for three out of seven staff members, specifically Employees E1, E10, and E14. The facility's policy on Nursing Education, Mandatory Training, and Competency Evaluation, dated 11/4/24 and previously 11/6/23, mandates the establishment, implementation, and maintenance of written policies and procedures for verifying educational preparation and competency, including certification and/or licensure in good standing, upon hire and on an ongoing basis. However, a review of the facility's education documents for 2023 revealed that Registered Nurse (RN) Employee E1, Nurse Aide (NA) Employee E10, and RN Employee E14 did not receive training on Behavioral Health education. This deficiency was confirmed during an interview with the Director of Nursing on 11/27/24.
Failure to Provide Supervised Smoking Breaks for Resident
Penalty
Summary
The facility failed to honor a resident's right to a dignified existence and self-determination by not allowing Resident R17 to smoke at requested times. The facility's policy on residents' rights emphasizes maintaining a supportive environment that promotes self-esteem and personal dignity. Additionally, the facility's smoking policy requires that residents needing supervision while smoking be provided with supervised smoking breaks in designated areas. Resident R17, who is legally blind and requires assistance with personal care, expressed a desire to smoke outside but was unable to do so due to a lack of available staff or volunteers to assist her. Interviews with Resident R17 revealed that she was often unable to go outside to smoke because there were not enough staff members willing to accompany her, particularly those who do not smoke and wish to avoid secondhand smoke. The Assistant Director of Nursing confirmed that the facility's staffing limitations and the preferences of non-smoking staff members contributed to the resident's inability to smoke at her requested times. This failure to accommodate Resident R17's requests for smoking breaks was acknowledged as a deficiency in providing care that promotes and maintains quality of life.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to determine the ability of a resident, identified as Resident R24, to self-administer medications. The facility's policy on medication administration, dated November 6, 2023, requires staff to remain with residents to ensure medications are swallowed. However, there was no documentation in Resident R24's physician orders or care plan regarding medication self-administration, nor was there a Self-Administration of Medication Assessment present in the clinical record. During an observation, a registered nurse (RN) was seen leaving a medication cup with assorted pills on Resident R24's overbed table, which the RN later confirmed was not in accordance with any order allowing the resident to keep medications in her room. Interviews with staff, including the Director of Nursing, revealed that the facility lacked a policy on medication self-administration and confirmed that medications should not be left at the bedside. The Director of Nursing acknowledged that the facility failed to assess the resident's ability to self-administer medications. This deficiency was identified for one of three residents reviewed, highlighting a lapse in the facility's adherence to its own medication administration policies and state regulations.
Facility Fails to Maintain Safe Environment Due to Missing Door Handle
Penalty
Summary
The facility failed to maintain a safe and homelike environment in one of its four nursing units, specifically in the St. [NAME] unit. During an observation of a resident's room on November 25, 2024, it was noted that the door handle was missing, leaving an exposed, sharp piece of metal protruding from the mount where the handle should have been. This deficiency was confirmed during an interview with the Director of Nursing (DON) on November 27, 2024, who acknowledged the missing handle and the exposed metal piece. The failure to address this issue compromised the safety and homelike environment expected in the facility, as outlined in the relevant Pennsylvania Code sections regarding management, resident rights, and the administrator's responsibility.
Delayed Response to Resident Grievance
Penalty
Summary
The facility failed to address a resident's grievance in a timely manner, as required by their grievance policy. The policy, last reviewed on 11/4/24, mandates prompt resolution of grievances and keeping the resident informed throughout the process. Resident R15, who has diagnoses of high blood pressure, respiratory failure, and shortness of breath, filed a grievance on 7/8/24. However, there was no documentation of the facility investigating or addressing the grievance until 11/8/24. During interviews, both Resident R15 and facility staff, including the Director of Nursing and the Nursing Home Administrator, confirmed the delay in addressing the grievance.
Failure to Communicate Necessary Information During Resident Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider for two residents who were transferred to the hospital. Resident R17, who was admitted to the facility with diagnoses including depression, need for assistance with personal care, and legal blindness, was transferred to the hospital. However, there was no documented evidence that the facility communicated essential information such as care plan goals, advanced directive information, specific instructions for ongoing care, and resident representative information to the receiving health care provider. Similarly, Resident R35, who had diagnoses of high blood pressure, reduced mobility, and weakness, was also transferred to the hospital. The facility again failed to document the communication of necessary information to the receiving health care provider. This lack of documentation was confirmed by the Assistant Director of Nursing during an interview, indicating a deficiency in the facility's process for handling facility-initiated transfers.
Failure to Notify of Resident Transfers
Penalty
Summary
The facility failed to provide timely written notification of resident transfers to the hospital, as required by regulations. Specifically, the facility did not notify the resident, their representative, or the Office of the State Long-Term Care Ombudsman about the transfers of two residents, identified as R17 and R35, in writing. This notification should have included the reason for the transfer, the date and location of the transfer, the resident's appeal rights, and the contact information for the Ombudsman. Resident R17, who had diagnoses of depression, required assistance with personal care, and was legally blind, was transferred to the hospital without the required notification being documented. Similarly, Resident R35, who had high blood pressure, reduced mobility, and weakness, was also transferred to the hospital without the necessary written notification. The Assistant Director of Nursing confirmed the facility's failure to provide these notifications during an interview.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify residents or their representatives of the bed-hold policy during hospital transfers, as required by their own policy. This deficiency was identified for two residents, who were transferred to the hospital without receiving written information about the duration of the bed-hold policy. The facility's policy, dated 11/4/24, mandates that such notification be provided at the time of transfer for hospitalization or therapeutic leave. Resident R17, who was admitted to the facility with diagnoses including depression, need for assistance with personal care, and legal blindness, was transferred to the hospital on 11/16/24. Similarly, Resident R35, with diagnoses of high blood pressure, reduced mobility, and weakness, was transferred on 11/22/24. In both cases, the clinical records lacked documented evidence of the required notification. The Assistant Director of Nursing confirmed the oversight during an interview.
Failure to Implement Hypoglycemia Protocol and Notify Physician of Weight Refusals
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident, identified as R21, by not implementing the hypoglycemia protocol as per the facility's policy. The resident, who has a history of diabetes, hyperlipidemia, and heart failure, experienced multiple instances of low blood glucose levels, as recorded in their vitals records. Despite these abnormal readings, the facility's progress notes did not document the implementation of the hypoglycemia protocol. Interviews with the Director of Nursing confirmed this oversight. Additionally, the facility did not notify the physician of the resident's refusal to be weighed on several occasions, as required by a physician's order. The resident's Medication Administration Record (MAR) indicated multiple refusals to be weighed, but there was no documentation in the progress notes that the physician was informed of these refusals. This lack of communication with the physician was acknowledged by the Director of Nursing during an interview. Furthermore, the facility failed to adhere to a physician's order regarding the administration of Metolazone, a medication prescribed for weight gain above 240 pounds. The resident's weight records showed that their weight was consistently below this threshold, yet the medication was administered on two occasions. This discrepancy between the physician's order and the actual administration of medication was confirmed by the Director of Nursing.
Improper Storage of Medical Supplies and Biologicals
Penalty
Summary
The facility failed to properly store medical supplies and biologicals in one of two medication rooms. The facility's policy on Medication Storage, last reviewed on 11/4/24, requires that all medications be maintained within specific temperature ranges as noted by the United States Pharmacopeia and the Centers for Disease Control. During an observation on 11/26/24, it was found that the temperature log for the first-floor medication room refrigerator was not completed on three specific dates: 11/11/24, 11/19/24, and 11/21/24. This was confirmed by Registered Nurse Employee E6 during an interview, indicating a failure to adhere to the facility's medication storage policy.
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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