Majestic Oaks Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Warminster, Pennsylvania.
- Location
- 333 Newtown Road, Warminster, Pennsylvania 18974
- CMS Provider Number
- 395431
- Inspections on file
- 36
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Majestic Oaks Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident with chronic respiratory failure, morbid obesity, and type 2 DM requested hospital evaluation and was transferred to the hospital of their choice. The facility’s bed hold policy stated that a bed must be available for a resident’s return when away for hospitalization or therapeutic leave. After the resident was medically cleared for discharge, the hospital case manager contacted the facility about readmission, but the facility refused, claiming it could not meet the resident’s care needs. There was no documentation in the clinical record to support that the facility was unable to meet those needs, and the Administrator and DON confirmed the resident was not allowed to return.
The facility failed to adhere to food safety standards, as observed during a kitchen tour. Issues included improperly stored tortillas, juices placed on a dirty rack, and stagnant juice in tubing on the floor. Additionally, the ice machine's drainpipe lacked an air gap, posing a contamination risk. These deficiencies were confirmed by the Food Service Director.
The facility did not properly dispose of garbage and refuse in the receiving and dumpster area. During a kitchen tour, trash, food, and debris were observed on the ground around the dumpsters, and one dumpster had an open lid with exposed trash. These issues were noted with the Food Service Director present.
The facility failed to maintain an effective pest control program in the main kitchen. Mice droppings were found in the food storage room, and recommendations to install a door sweep and replace rotten doors were not followed. Observations revealed gaps in doors allowing pest entry and mouse droppings on dish transport equipment, confirmed by the Food Service Director.
The facility did not ensure that the most recent Department of Health Survey results were accessible to residents and visitors. During a resident council meeting, it was found that residents were unaware of the survey results. A tour revealed that the lobby binder was outdated, and no binders were available on the nursing floors. The Administrator confirmed the existence of more recent survey results, but they were not included in the lobby binder.
The facility failed to maintain a clean, safe, and homelike environment, with issues such as peeling mattresses, stained ceiling tiles, and missing baseboards. Residents were served meals on paper plates and drinks in leaking Styrofoam cups due to a shortage of proper dining ware, confirmed by staff.
The facility failed to serve palatable and attractive food, as observed during a lunch meal where multiple residents reported the chicken was dry, cold, or inedible. Residents refused to eat the chicken, describing it as hard and overcooked, indicating a failure to meet the requirement of serving food that is palatable and at a safe temperature.
A facility failed to implement proper use of PPE for a resident on enhanced barrier precautions during care activities. Despite having a policy for EBP to reduce the spread of multi-drug-resistant organisms, staff members did not use EBP while providing incontinence and wound care to a resident with multiple medical conditions, including spastic quadriplegic cerebral palsy and a gastrostomy.
The facility failed to resolve grievances promptly and communicate outcomes effectively. A resident with heart failure, cellulitis, and type 2 diabetes filed a grievance about missing clothing, which was not resolved, leaving the resident without personal clothing. Despite selecting new clothing from a catalog, the items were not ordered, indicating a failure in the grievance process.
A facility failed to identify a bed placed against the wall as a restraint and did not assess a resident's functional status, leading to a fall. The resident, with hemiplegia and hemiparesis, was unable to move the bed independently, resulting in a fall between the bed and the wall after attempting to push the bed away with their legs.
The facility failed to conduct mandatory Elder Abuse and Resident Rights training for a newly hired cook, Employee E4, as required by facility policy. The personnel file review showed no evidence of training completion, confirmed by the HR representative. Additionally, a resident's bed was found against the wall, raising concerns about compliance with state regulations on restraints and nursing services.
A facility failed to notify the State Long-Term Care Ombudsman of unplanned hospital transfers for a resident with multiple medical conditions, including spastic quadriplegia and cerebral palsy. The resident was transferred twice for medical reasons, but the required notifications were not sent, as confirmed by the Nursing Home Administrator.
The facility did not update the PASRR applications for two residents to include new mental health diagnoses. One resident's PASRR lacked updates for Psychosis and related disorders, while another's did not include an anxiety disorder. The Social Worker confirmed these updates were necessary.
The facility failed to develop comprehensive care plans for several residents, including those with diabetes, respiratory needs, and behavioral health diagnoses. A resident with diabetes lacked a care plan for insulin management, while another with a brain injury had no plan for oxygen therapy. Additionally, residents on psychotropic medications and those with mood disorders did not have appropriate care plans, as confirmed by facility staff.
A facility failed to document and follow pain management protocols for a resident with severe pain and multiple diagnoses, including spastic quadriplegic cerebral palsy. The resident's care plan required regular pain assessments and documentation of interventions, but on a specific day, an LPN noted severe pain without evidence of attempted interventions or reassessment. Additionally, the resident was verbally crying out, yet the required documentation was missing.
A facility failed to provide proper pressure ulcer treatment for a resident with a history of peripheral artery disease, diabetes, and paraplegia. The resident had a stage four pressure ulcer on the sacrum upon admission, and the facility did not complete required assessments or documentation of the ulcers. Despite hospitalization for an infection and development of a new ulcer, the facility's records remained incomplete, as confirmed by the Assistant DON.
The facility failed to provide respiratory care and supplemental oxygen as ordered for two residents. One resident had oxygen set incorrectly at 2.5 liters per minute instead of the prescribed 2 liters, and the tubing was unlabeled. Another resident's oxygen tubing was not changed weekly as ordered, with the last change dated over two weeks prior. Staff confirmed these discrepancies.
The facility failed to assess and maintain bedrails for two residents, leading to loose and improperly installed bedrails. One resident, with coordination and mobility issues, expressed dissatisfaction with the bedrails, which were found loose and tightened only after being reported. Another resident, with muscle weakness, reported the bedrails were loose and not useful, with no assessment or physician orders for their use. The DON was informed of these issues.
A resident with moderate cognitive impairment and depression did not receive the recommended psychiatric treatment for anxiety. Despite a PMHNP's recommendation to start Buspar, the facility failed to implement this treatment, as confirmed by a follow-up assessment and a nurse's interview.
A resident with anxiety did not receive prescribed Ativan for three days due to a delay in pharmacy approval, despite a physician's order. The resident, admitted with conditions including congestive heart failure and anxiety disorder, experienced increased anxiety due to a personal event. The delay was confirmed by a RN, highlighting a failure in timely pharmaceutical services.
The facility failed to provide a meal substitute for a resident who requested an alternative and did not accommodate another resident's lactose-restricted diet. One resident, with moderate cognitive impairment and malnutrition, requested a hamburger listed as an alternative but was denied by the kitchen. Another resident, with multiple health issues, reported receiving meals with cheese and milk despite a lactose-restricted diet, leading to adverse effects.
The facility failed to ensure call bells were within reach for several residents, leading to delayed responses and inadequate assistance. A resident's call bell was found on the floor, another's was stuck in a drawer, and the call bell system was unplugged at the nursing station. Additionally, residents reported staff turning off call bells without providing help, and a malfunctioning call bell required replacement.
The facility failed to complete discharge summaries within the required 30 days for two residents. One resident was admitted and discharged within a short period, while another was discharged to the hospital, yet both lacked timely discharge summaries. Interviews with the Nursing Home Administrator confirmed these findings, indicating a lapse in adherence to the facility's policy on discharge documentation.
The facility did not meet the required minimum staffing levels for NAs on multiple occasions across day, evening, and night shifts. The day shift was short by up to 0.7 NAs, the evening shift by up to 0.64 NAs, and the night shift by up to 1.53 NAs. These deficiencies were confirmed through staff care hours review and an interview with the Nursing Home Administrator.
The facility did not meet the required minimum staffing levels for LPNs during the day shift. With a resident census of 158, only 5.00 LPNs were scheduled, falling short of the 6.32 LPNs required by regulation. This was confirmed through staff care hours review and an interview with the Nursing Home Administrator.
The facility did not meet the required minimum of 3.2 nursing care hours per resident per day for 18 out of 21 days reviewed. Staffing records showed care hours per patient per day (PPD) ranged from 2.28 to 3.15, below the mandated minimum. The Nursing Home Administrator confirmed the shortfall in staffing levels.
The facility failed to maintain essential equipment, resulting in inconsistent water temperatures on two nursing floors. Since June 2024, residents have been asked to bathe on different floors due to insufficient hot water, confirmed by staff and maintenance. The issue persisted despite policies assigning maintenance staff the responsibility for ensuring safe water temperatures.
A facility failed to implement a comprehensive care plan for a resident with cerebral infarction and other conditions. The care plan included specific interventions for hygiene and bathing, which were not followed by an agency nursing aide. The aide's actions led to the resident becoming agitated and physically aggressive, escalating the situation. The facility's administration confirmed the care plan was not adhered to, resulting in a deficiency.
The facility did not ensure that nursing staff had the necessary skills to care for residents. An agency nursing aide was not evaluated for competency or oriented to facility practices, leading to a failure to follow a resident's care plan and an escalation of the situation. This was confirmed by the Administrator and DON.
A facility failed to readmit a resident after hospitalization due to concerns about the resident's drug use and potential risk to others. The resident, with multiple medical conditions, was hospitalized after drugs were found in his possession. Despite the hospital's readiness to discharge him back, the facility refused readmission without conducting an assessment or providing documentation to justify their decision.
A resident with a history of hip fracture and vascular dementia missed nine doses of prescribed anticoagulant medication due to refusal, which was not communicated to the physician assistant. This failure in communication and documentation led to the development of Deep Venous Thrombosis (DVT) in the resident. The responsible nurse did not document the refusals or notify the physician assistant, despite being aware of the facility's protocol.
The facility failed to maintain a clean and homelike environment, with a malfunctioning shower on the Third Floor, cold water temperatures, and a broken floor. Residents were not consistently offered alternative showering options. Additionally, leftover breakfast trays were observed on the Second Floor, and a broken cabinet was noted in the main dining room. Staff confirmed these issues.
A facility failed to investigate a bruise of unknown origin on a resident, despite a nurse practitioner's report. The resident, who had multiple medical conditions and cognitive impairment, was found with a large bruise on the left forearm. The facility's policy requires immediate reporting and investigation of such incidents, but no follow-up or documentation was conducted by the nursing staff, and the unit manager was unaware of the issue.
A facility failed to create a comprehensive care plan for a resident with cognitive impairment and hemiplegia, who refused nail care and a hand splint, leading to a contracture and risk of skin breakdown. The care plan lacked measurable objectives to address these refusals.
A resident with multiple health conditions experienced vomiting of coffee ground emesis, indicating possible internal bleeding. The charge nurse contacted the PCP but there was no documentation of a follow-up or physician's response, revealing a deficiency in the facility's practice of managing changes in a resident's condition.
A cognitively impaired resident with diabetes and hemiplegia was not provided with heel boots as ordered to prevent pressure ulcers. Despite a physician's order, observations showed the resident in bed without the boots, and staff confirmed their absence, with no documentation of refusal by the resident.
The facility failed to obtain weekly weights for two residents with significant weight loss. One resident, with conditions including hypertension and dysphagia, lost 18.3% of their weight over a month, and another resident with COPD and dementia lost 8% over two weeks. Despite physician orders for weekly weights, records show these were not obtained due to equipment issues and oversight.
A facility failed to include an end date for a PRN psychotropic medication order for a resident with bipolar disorder and anxiety, violating its policy. The resident's order for Lorazepam lacked a specified duration, contrary to the facility's guidelines requiring PRN orders to be limited to 14 days unless extended with documented rationale.
A resident's lab tests were not completed as ordered by a Nurse Practitioner. The facility's policy requires staff to process and arrange lab tests based on physician orders. Despite an order for labs to be drawn, a review of the resident's clinical record and an interview with the Assistant DON confirmed that the labs were not completed.
Three residents with dysphagia did not receive the prescribed nectar thick fluids during a meal service. A resident was observed with thin water instead of the ordered thickened beverage, and two other residents did not receive any thickened beverages with their meal trays. Staff confirmed the oversight, and the unit clerk mentioned that the kitchen usually sends individual beverages with each meal.
A resident with multiple diagnoses, including schizophrenia and bipolar disorder, expressed a passive death wish to a physiatrist, but the facility failed to document the specifics of this conversation in the resident's clinical record. This lack of documentation hindered the facility's ability to assess the resident's mental state accurately. Interviews with staff revealed a gap in communication and documentation regarding the resident's expressed concerns.
The facility failed to ensure timely delivery of medications for two residents, leading to missed doses and treatments. A resident with chronic pancreatitis did not receive Pancrelipase capsules during meals, and another with viral conjunctivitis did not receive prescribed eye treatment due to pharmacy delays. The lack of documentation and notification to medical staff about the unavailability of medications further highlighted deficiencies in the facility's pharmaceutical services.
A resident with a seizure disorder and anxiety was not administered Lorazepam as prescribed, leading to a tonic-clonic seizure and head injury. The facility's failure to follow physician orders resulted in significant harm to the resident.
A resident repeatedly refused a prescribed laxative medication, and the facility failed to notify the physician as required by policy. This led to the resident being hospitalized twice with symptoms related to constipation.
The facility failed to address the behavioral health needs and discharge planning for a resident with diagnoses of paraplegia, bipolar disorder, and PTSD. Despite documented issues of anxiety and irritability, no care plan was developed to meet the resident's needs, and requests for discharge planning and a motorized wheelchair were ignored.
Failure to Readmit Hospitalized Resident Despite Bed Hold Policy
Penalty
Summary
The facility failed to permit a hospitalized resident to return, contrary to its own bed hold policy and without documented evidence that it could not meet the resident’s care needs. The facility’s undated Bed Hold Policy stated that the Medical Assistance Program would pay the facility to hold a resident’s bed during a hospital stay or therapeutic leave and that a bed must be available when the resident returns. The resident, who had chronic respiratory failure, morbid obesity, and type 2 diabetes mellitus, was admitted to the facility on an unspecified date and later reported not feeling well, requesting a full medical workup at the hospital. In response, the facility arranged for transfer to the hospital of the resident’s choice, and the resident was admitted there. According to the hospital case manager, the resident was later medically cleared for discharge, and the hospital contacted the facility regarding readmission. The case manager reported that the facility refused to readmit the resident, stating they were not able to meet the resident’s care needs. Review of the resident’s clinical record showed no documentation supporting that the facility was unable to meet those needs. In an interview, the Administrator and the DON confirmed that the facility did not allow the resident to return after hospitalization.
Food Safety Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and served in accordance with professional standards for food service safety. During a tour of the Food Service Department, several deficiencies were observed. In the walk-in freezer, two tortillas were found loosely wrapped in plastic wrap without any dates, indicating improper labeling and storage practices. In the dry storage room, juices used for the juice machine were stored improperly; two juice bags were removed from their box and placed directly on a visibly dirty and dusty metal rack. Additionally, one juice bag was not connected, and its tubing was found on the floor with stagnant juice inside, suggesting a lack of proper sanitation and maintenance. Further observations revealed that the drainpipe behind the ice machine was placed directly into the floor drain without an air gap, which is necessary to prevent sewer water backup. This lack of an air gap between the ice machine's drain point and the facility's drain access point poses a potential contamination risk. These observations were confirmed by the Food Service Director during the kitchen tour, highlighting the facility's failure to adhere to food safety requirements.
Plan Of Correction
1. Tortillas unwrapped with no dates were immediately discarded. Two juice bags that were placed on a dirty shelf were discarded and the rack cleaned. The juice tubbing that was not hooked up was cleaned and wrapped in plastic till replaced with another one. The drainpipe behind the ice machine that was placed directly into the floor drain with no air gap was immediately fixed. 2. All other areas rounded to ensure no further concerns. 3. Education provided to Dietary Staff on properly storing food, dating food, properly storing juice bags, ensuring racks are cleaned, what to do if juice runs out and there is not another to replace, and that there must be an air gap between the ice machine and drain access. 4. Random audits by the Administrator/designee to ensure food is properly stored, dated, juice bags being stored properly, racks cleaned, juice tubbing that is not hooked up maintained properly, and that there is an air gap between the ice machine and drain once a week for one month, twice a week for one month, and once a month for one month. The findings of the audits will be brought to the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at the QAPI Committee meeting.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse in the receiving and dumpster area, as observed during a tour of the main kitchen. During the inspection, it was noted that the area outside the kitchen, where food deliveries are accepted and dumpsters are stored, had trash, food, and debris scattered on the ground. Additionally, one of the dumpsters had its lid open, leaving trash exposed. These observations were made in the presence of the Food Service Director, Employee E5.
Plan Of Correction
1. Trash was cleaned up and lid closed. 2. All other areas checked to ensure no other areas that trash was disposed of improperly. 3. Education provided to all kitchen, Housekeeping and Department Heads that trash must be in the dumpster, depress swept up and lid closed. 4. Random audits by the Administrator/designee of dumpster area to ensure proper disposal of garbage and lid down once a week for one month, twice a week for one month, and once a month for one month. The findings of the audits will be brought to the monthly Quality Assurance Improvement Committee (QAPI) meeting for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.
Failure to Maintain Effective Pest Control in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program in the main kitchen, as evidenced by observations and documentation. A pest control report from March 4, 2025, indicated that mice droppings were found in the kitchen food storage room. The pest control company recommended installing a door sweep on the kitchen doors and replacing the rotten doors of a small room next to the dumpster. However, these recommendations were not implemented by the facility. During a tour of the main kitchen on March 17, 2025, a visible gap was observed at the bottom of the double doors leading to the dumpster area, which could allow pests such as mice, roaches, flies, and ants to enter the kitchen. Further observations on March 19, 2025, revealed a significant amount of mouse droppings on a plastic rack dolly used for transporting dish racks, located near the dish room. The Food Service Director confirmed these findings. Additionally, the facility had not addressed the rotten doors with large holes next to the dumpsters, as previously recommended by the pest control company.
Plan Of Correction
1. Door sweep was immediately fixed. Will be replacing the double doors next to the dumpster. Date pending. Plastic Dolly was immediately sanitized. 2. Reviewed last 3 months of pest control reports to ensure nothing else has not been followed up on. 3. Education provided to Maintenance Dept that all recommendation must be reviewed and followed up on timely. Education provided to all staff that if any item has any types of dropping to notify maintenance and mgt immediately, remove item to be sanitized. 4. Random audits by the Administrator/designee to ensure that pest control reports are followed up on timely. Once a week for one month, twice a week for one month, and once a month for one month. Random audits by Administrator/designee to ensure that no items or places have been seen with mouse droppings. The findings of the audits will be brought to the Quality monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.
Failure to Provide Access to Recent Survey Results
Penalty
Summary
The facility failed to ensure that the most recent Department of Health Survey results were readily accessible to residents and visitors across all nursing floors and the lobby. The facility's policy, dated April 27, 2017, mandates that survey reports and plans of correction be accessible in a binder located in the resident's day room. However, during a resident council meeting, it was revealed that the residents were unaware of the recent survey results, indicating a lack of compliance with the policy. A facility tour conducted with the Director of Social Services confirmed that the survey results binder in the lobby was outdated, with the last recorded results from November 2024. Additionally, no survey result binders were available on the second, third, and fourth-floor nursing units. The Administrator confirmed that the facility had more recent survey results, but these were not included in the binder in the front lobby, further contributing to the deficiency.
Plan Of Correction
1. Updated survey results book Added survey books to 2nd, 3rd and 4th floor nurses station. All residents have been updated on status of where survey books are located. 2. Survey book location will be added - Flyer in elevator - Admissions Welcome Packet - Reviewed at Residents Council 3. Education provided to medical records who will keep survey books up to date adding the most recent surveys upon receipt of letter/2567. Education provided to staff as to where survey book is so that when residents ask they know where to find. 4. Random audits by the Administrator/designee once a week for one month, twice a week for one month, and then once a month for one month to ensure residents are aware where to find survey results and that the survey books are located in lobby, and nurses station on 2, 3 and 4. Results of the audits will be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to provide a clean, safe, comfortable, and homelike environment across three nursing units, as evidenced by multiple observations and interviews. In one instance, a resident reported that his mattress was peeling, and he was collecting the peeling material. Observations revealed several issues, including stained ceiling tiles, missing restroom mirrors, and baseboards, as well as a large brown substance spilled on the floor. Additionally, a hole in the ceiling tile and a broken sanitizer were noted, along with a urine odor in one room. The Maintenance Director confirmed these observations, which also included broken baseboards and peeling drywall. Further deficiencies were noted in the dining services, where residents were served meals on paper plates and drinks in Styrofoam cups due to a shortage of proper dining ware. This resulted in a sticky mess for one resident when a Styrofoam cup leaked. The Food Service Director confirmed the use of Styrofoam cups due to a shortage of coffee mugs, affecting the last unit served. These observations indicate a failure to maintain a homelike environment as per the facility's policy.
Plan Of Correction
1. Room 414 mattress replaced. Room 414 ceiling tiles replaced. 413 mirror in restroom hung up. 413 added baseboards to bottom of wall in restroom. 404 picture that was not hung was removed from room. 404 cleaned up substance on floor. 409 replaced ceiling tile. Removed broken sanitizer across from dayroom on 4th floor near 409. 409 cleaned. 418 fixed baseboard next to entrance. 418 fixed drywall. 312 fixed hole in bathroom wall and cleaned up drywall from bathroom floor. Items needed for kitchen to allow not to run out ordered. After 2nd floor R82 and R366 were served lunch on paper plates. 12nd floor R1 served thickened juice in Styrofoam cup. Test tray was served with coffee in Styrofoam cup. 2nd floor R141 and R111 served coffee in Styrofoam cups. 2. Audit of the whole facility completed that includes: - Mattresses - Ceiling tiles - Unhung items - Missing mirrors in bathroom - Missing / damaged baseboards - Dirty floors - Sanitizers - Odor smelly - Drywall damage To identify any additional items that need to be repaired. Audit / count of current dining needs including cups and plates and order what is needed. 3. Educate: - All nursing care staff to notify Maintenance / Administration of any mattresses that need repair/replacement/smelly, along with any rooms that have items in that need addressing. - Educate Maintenance Staff that rounding should include all areas noted: - Ceiling tiles - Unhung items - Missing mirrors - Damaged baseboards - Dirty floors - Sanitizers need replacement - Odorous rooms - Drywall damage. - All staff educated that using paper products is not part of a homelike environment and need to be avoided for this reason as well as for safety. Administration must be notified if there is a need to use paper products. 4. Random audits by the Administrator/designee to ensure that Maintenance Rounds are being completed on the whole facility, items being added to work list and work list is being worked on once a week for one month, twice a week for one month, and once a month for one month. Random audits by the Administrator/designee to ensure that paper products are being avoided to promote homelike environment and safety once a week for one month, twice a week for one month, and once a month for one month. The findings of the audits will be brought to the Quality monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.
Facility Fails to Serve Palatable and Attractive Food
Penalty
Summary
The facility failed to provide food that was palatable and attractive, as evidenced by observations and resident interviews. During a Resident Council meeting, 11 alert and oriented residents reported that the chicken served was dry. Observations during the lunch meal on the same day confirmed these complaints, with multiple residents refusing to eat the chicken due to it being dry or cold. Specific instances included a resident refusing to eat because the chicken was dry, another resident spitting out the chicken, and others describing it as hard and inedible. Further observations revealed that some residents were unable to cut or eat the chicken due to its overcooked and dry nature. Interviews with several alert and oriented residents consistently described the chicken as very dry and inedible. These findings indicate a failure by the facility to meet the requirement of serving food that is palatable, attractive, and at a safe and appetizing temperature, affecting all 20 residents reviewed.
Plan Of Correction
1. Cooks were educated on proper cooking methods for chicken. Residents who did not like their meal were offered alternatives. 2. The Food Committee will discuss concerns with any other foods. Education to Cooks to ensure that they are cooking meals the appropriate way. 3. Education to staff that if residents are not happy with a meal to alert administration and offer an alternative. 4. Random audits by the Administrator/designee of 5 residents to ensure that they are happy with their meal and that it was nutritious, appeared nice, palatable, and at preferred temperature once a week for one month, twice a week for one month, and once a month for one month. The findings of the audits will be brought to the monthly Quality Assurance Improvement Committee (QAPI) meeting for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at the QAPI Committee meeting.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement proper use of personal protective equipment (PPE) for a resident on enhanced barrier precautions (EBP) during morning care and wound observation. The deficiency was identified through a review of facility protocol, observations, interviews, and clinical records. The facility's policy for EBP, revised in December 2024, is intended to reduce the spread of multi-drug-resistant organisms by employing targeted gown and glove use during high-contact resident care activities. EBP is indicated for residents with wounds and/or indwelling medication devices. Resident R102, who was admitted to the facility with spastic quadriplegic cerebral palsy, major depressive and anxiety disorder, dysphagia, and a gastrostomy, had orders to use EBP during tube feedings, incontinence care, and wound care. However, on two separate occasions, staff members failed to use EBP while providing care. On March 17, 2025, a nursing assistant provided incontinence care without EBP, and on March 18, 2025, a unit manager provided wound care without EBP. The Assistant Director of Nursing was informed and confirmed the requirement for EBP use during care.
Plan Of Correction
1. Resident R-102 continues with enhanced barrier precautions. Employees E-13 and E-14 have been re-educated on Enhanced Barrier Precautions. 2. All residents who require Enhanced Barrier Precautions will be identified and protective equipment made available for staff with appropriate identification signs to ensure proper use of PPE for residents on Enhanced Barrier Precautions to ensure infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms to residents. 3. Nurse Educator/Designee will re-educate staff on the policy, Enhanced Barrier Precautions. 4. The DON/Designee will conduct weekly random audits times 2 months to ensure that staff is utilizing the proper PPE in the rooms of residents identified requiring Enhanced Barrier Precautions. 5. Audit results will be reviewed monthly by QAPI Committee.
Failure to Resolve and Communicate Grievance Outcomes
Penalty
Summary
The facility failed to ensure prompt resolution of grievances and effective communication of grievance resolutions for several residents. During a Resident Council meeting, eleven residents expressed concerns that the facility did not provide them with information regarding the resolution of their grievances after investigations were completed. This indicates a lack of communication and follow-through in addressing residents' grievances as per the facility's policy. One specific case involved a resident who was admitted with diagnoses including heart failure, cellulitis, and type 2 diabetes. This resident filed a grievance regarding missing clothing that was sent to the laundry and not returned. Despite the grievance being filed, the issue remained unresolved, and the resident was left using hospital gowns due to the lack of personal clothing. The grievance form indicated that the social worker met with the resident to select new clothing from a catalog, but the items were not ordered, highlighting a failure in the grievance resolution process. The facility's grievance policy, which requires grievances to be resolved within seven days, was not adhered to in this case. The social worker confirmed that the grievance was filed, but no action was taken to order the clothing, leaving the resident without a resolution. This situation exemplifies the facility's failure to make prompt efforts to resolve grievances and communicate effectively with residents about the outcomes of their complaints.
Plan Of Correction
1. Social Services met with R4, R6, R13, R35, R49, R62, R70, R92, R93, R96, R129 to discuss any grievances they have had within that they did not have the outcome of. R30 grievance and that it was resolved and that she was given clothing to wear. Outcome. 2. Reviewed Grievances dated March 1 to current and met with residents/person who initiated the grievance to ensure they are aware of outcome of grievance. 3. Education provided to Social Services and All Department Heads that All Grievance outcomes will be reviewed with the resident/person that initiated the grievance and will have sign off that it was reviewed. 4. Random audits by the Administrator/designee to ensure that Grievance outcomes are being reviewed and signed off on with the resident/person initiated once a week for one month, twice a week for one month, and once a month for one month. The findings of the audits will be brought to the Quality monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.
Failure to Identify Bed Placement as Restraint Leads to Resident Fall
Penalty
Summary
The facility failed to recognize the placement of a resident's bed against the wall as a form of restraint and did not assess the resident's functional status to determine the necessity of this restraint. The facility's policy defines a restraint based on the resident's ability to remove a device, and in this case, the resident was unable to move the bed away from the wall independently. This oversight was identified during a review of the facility's policy, clinical records, observations, and staff interviews. The resident involved was admitted with diagnoses including hemiplegia and hemiparesis affecting the left non-dominant side, acute respiratory failure, and abnormal posture. Observations noted the resident's bed was positioned against the wall, which was intended to prevent the resident from irritating a wound. However, the resident was found on the floor between the bed and the wall after attempting to push the bed away with their legs, indicating the bed's placement restricted the resident's movement and contributed to a fall. This incident highlights the facility's failure to properly assess and document the use of restraints in accordance with the resident's medical needs.
Plan Of Correction
1. Resident R-5 bed was removed from the wall and is now centered in the room. 2. All residents' beds will be assessed to identify and possible restraints to ensure the functional status of the residents and to determine the use of a restraint. 3. Nurse Educator/Designee will re-educate the professional nursing staff on the policy, "Use of Restraints." 4. The DON/Designee will conduct weekly random audits times 2 months to ensure residents with beds against the wall are assessed properly for use of a restraint. 5. Audit results will be reviewed monthly by QAPI Committee.
Failure to Conduct Mandatory Elder Abuse Training for New Hire
Penalty
Summary
The facility failed to ensure that Elder Abuse and Resident Rights training was completed upon hire for one of the employees, specifically Employee E4, who was a cook. The personnel file review revealed that Employee E4 was hired on December 5, 2024, but there was no documented evidence of the completion of the required training. This deficiency was confirmed during an interview with the Business Office/HR representative, Employee E5, who acknowledged the incomplete training for Employee E4. Additionally, the report highlights a separate issue where a Licensed Practical Nurse, Employee E7, confirmed that a resident's bed was positioned against the wall. This observation is linked to the facility's compliance with state regulations regarding the use of restraints and nursing services. However, the report primarily focuses on the failure to conduct mandatory training for new hires, which is a critical component of the facility's policies to prevent abuse, neglect, and exploitation of residents.
Plan Of Correction
1. Abuse In-Service training was provided to E4 who signed the acknowledgement form that it was provided and answered the questions. 2. Review all new hires back to Jan 1, 2025 to ensure that all staff hired since Jan 1 have had abuse training, questions answered and signed education on file. 3. Education provided to HR and all Department Heads that Abuse Training must be completed upon hire, and that in-service sheet must be signed. 4. Random audits by the Administrator/designee of new hires to ensure that Abuse in service training has been completed and in-service sheet has been signed once a week for one month, twice a week for one month, and once a month for one month. The findings of the audits will be brought to the Quality monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to notify the representative of the Office of the State Long-Term Care Ombudsman regarding the unplanned hospital transfers of a resident, identified as Resident R102. This resident was initially admitted to the facility with multiple diagnoses, including spastic quadriplegia, cerebral palsy, major depressive and anxiety disorder, and dysphagia. On two separate occasions, July 7, 2024, and December 18, 2024, Resident R102 was transferred to the hospital due to medical needs, including a surgical gastrostomy and stomach pain, respectively. Despite these transfers, the facility did not provide the required written notices to the State Long-Term Care Ombudsman. This oversight was confirmed by the Nursing Home Administrator on March 20, 2025, indicating a failure to comply with the regulatory requirement to notify the Ombudsman of such transfers, as stipulated in the relevant sections of the Code of Federal Regulations and Pennsylvania Code.
Plan Of Correction
1. The Office of the Ombudsman was notified that R102 was discharged to the hospital on 7/7/24 and that R102 was discharged to the hospital on 12/18/24 and that these residents were left off due to incorrect report pulled. 2. Correct Report pulled from PCC that included bed holds for residents discharged from 1/1/25 to current and resent to the Office of the Ombudsman. 3. Education provided to Social Services and Clinical Mgt Staff on what report to pull and that should include bed holds. 4. Random audits by the Administrator/designee of all discharges to ensure all are on the notification sent to Office of the Ombudsman once a week for three months. The findings of the audits will be brought to the Quality monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.
Failure to Update PASRR with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that revisions were made to the PASRR (Pre-Admission Screening and Resident Review) applications to include updated mental health diagnoses for two residents. For Resident R71, the PASRR completed on July 27, 2023, only listed Mood Disorder and Major Depressive Disorder. However, the resident's clinical record later revealed additional diagnoses, including Psychosis, Psychotic disorder, Suicidal Behavior, and Psychotic disorder with Delusions, as of August 31, 2023. These updates were not reflected in the PASRR documentation. Similarly, Resident R98's PASRR, completed on June 6, 2022, noted bipolar and schizoaffective disorder, but failed to include an anxiety disorder diagnosis that was added to the resident's medical record on August 11, 2023. The facility's Social Worker confirmed that the PASRR forms for both residents should have been updated to reflect these additional mental health diagnoses, indicating a lapse in the coordination of assessments with the PASARR program.
Plan Of Correction
1. R71 and R98 PASARR Forms updated with the additional mental health diagnosis. 2. Audit of all residents to ensure that PASARRS capture mental health diagnosis. 3. Education to Social Services and Clinical Team that all mental health dx must be on PASARR and if there is an addition it must be added. 4. Random audits by the Administrator/designee of 5 residents to ensure PASARR includes all mental health dx. Once a week for one month, twice a week for one month, and once a month for one month. The findings of the audits will be brought to the Quality monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, which is a requirement under §483.21(b). Resident R37, who was admitted with a diagnosis of diabetes, did not have a care plan addressing this condition, despite having orders for insulin and Accu-Cheks multiple times a day. The Director of Nursing confirmed the absence of a care plan for diabetes management for this resident. Resident R115, admitted with a diffuse traumatic brain injury, had a physician's order for oxygen therapy as needed, but the comprehensive care plan did not include this therapy. The Director of Nursing confirmed the lack of a care plan for oxygen therapy. Similarly, Resident R136, who was prescribed Seroquel for psychotic disturbances, did not have a care plan addressing the use of this antipsychotic medication, as confirmed by the unit manager. Resident R75, diagnosed with bipolar disorder and anxiety disorder, was on multiple medications for these conditions, yet there was no care plan for these behavioral health diagnoses. The Assistant Director of Nursing confirmed this omission. Additionally, Resident R97, who had moderate cognitive impairment and a diagnosis of non-Alzheimer's dementia and depression, did not have a care plan addressing their mood disorder, despite a psychiatric assessment indicating feelings of anxiety and depression.
Plan Of Correction
1. Resident R-37 has a care plan in place for Diabetes. Resident R-115 has a care plan in place for respiratory needs. Resident R-97, R-75, and R-136 have care plans in place for use of Psychotropic medications. 2. All residents with diagnosis of Diabetes, use of Psychotropic medications, and respiratory needs will have a comprehensive care plan with interventions to address resident care needs. 3. Nurse Educator/Designee will re-educate the professional nursing staff on the policies, "Care Plan Comprehensive Person-Centered, Diabetes, and Psychotropic Medication." 4. The DON/Designee will conduct weekly random audits times 2 months to ensure residents with diagnosis of Diabetes, Respiratory needs, or use of Psychotropic Medications have a comprehensive care plan with interventions to address their care needs in place. 5. Audit results will be reviewed monthly by QAPI Committee.
Failure to Document and Follow Pain Management Protocols
Penalty
Summary
The facility failed to ensure that Resident R102 received treatment and care in accordance with professional standards of practice. Resident R102, who was admitted with diagnoses including spastic quadriplegic cerebral palsy, major depressive and anxiety disorder, and dysphagia, was completely dependent on staff for all activities of daily living. The resident's care plan required regular pain assessments and documentation of non-pharmacological interventions, as well as medication administration and reassessment if necessary. On December 18, 2024, the resident was documented to be experiencing severe pain, rated 9/10, by an LPN during the day shift. However, there was no evidence that non-pharmacological interventions were attempted, nor was there documentation of medication administration or reassessment for effectiveness. Additionally, the resident was noted to be verbally crying out, but the clinical record lacked the required additional documentation as instructed by the physician. This failure to document and follow physician orders led to the deficiency.
Plan Of Correction
1. Resident R-102's pain is being controlled as per physicians' orders. 2. All residents who exhibit pain will be assessed to ensure that treatment and care in accordance with professional standards of practice occur. 3. Nurse Educator/Designee will re-educate the professional nursing staff on the policy, "Change in Resident Condition." 4. The DON/Designee will conduct weekly random audits times 2 months to ensure residents who have changes in their conditions receive treatment and care in accordance with professional standards of practice. 5. Audit results will be reviewed monthly by QAPI Committee.
Failure to Properly Assess and Document Pressure Ulcers
Penalty
Summary
The facility failed to provide pressure ulcer treatment consistent with professional standards of practice for a resident identified as R18. The resident had a history of peripheral artery disease, diabetes mellitus, paraplegia, and a stage four pressure ulcer on the sacrum upon admission. Despite being at risk for developing pressure ulcers, the facility did not conduct a complete assessment of the resident's pressure ulcers. The nursing admission/readmission evaluations were incomplete, failing to document the type, stage, and measurements of the pressure ulcers. This lack of documentation persisted even after the resident was hospitalized for an infection related to the sacral pressure ulcer and developed a new pressure ulcer on the left knee during the hospital stay. The facility's policy required a full assessment of pressure ulcers, including location, stage, length, width, and depth, but these were not documented for Resident R18. The Assistant Director of Nursing confirmed the inaccuracies and incompleteness of the wound assessments. The resident's clinical records lacked evidence of proper wound assessment and documentation, which was only partially addressed in a wound note dated March 13, 2025. This deficiency highlights the facility's failure to adhere to its own policies and professional standards in managing and documenting pressure ulcers.
Plan Of Correction
1. Resident R16 has an updated skin assessment that includes pressure ulcer location, stage, length, width, and depth measurements. 2. All newly admitted residents will have a skin assessment on admission that lists skin alterations to include location, stage, length, width, and depth measurements to ensure that pressure ulcer treatment is consistent with professional standards of practice. 3. Nurse educator/Designee will re-educate the professional nursing staff on the policy for pressure ulcer/skin assessment. 4. The DON/Designee will conduct weekly random audits times 2 months of residents with pressure ulcers and ensure proper documentation. 5. Audit results will be reviewed monthly by QAPI committee.
Deficiency in Respiratory Care and Oxygen Management
Penalty
Summary
The facility failed to consistently provide respiratory care and supplemental oxygen as ordered by the physician for two residents. Resident R115, who was admitted with a diagnosis of diffuse traumatic brain injury, had a physician's order for oxygen to be administered at 2 liters per minute via nasal cannula to maintain an oxygen level above 92%. However, an observation on March 17, 2025, revealed that the oxygen was set at 2.5 liters per minute, and the tubing was not labeled. A licensed nurse confirmed the incorrect setting and adjusted it to the correct level. Resident R63, admitted with diagnoses including endocarditis, acute and chronic respiratory failure, and muscle weakness, had a physician's order for weekly oxygen tubing changes. An observation on March 18, 2025, showed that the oxygen tubing was labeled with a date of February 27, 2025, indicating it had not been changed weekly as required. A licensed practical nurse confirmed the tubing was overdue for a change.
Plan Of Correction
1. Resident R-115 has orders for Oxygen at 2/L min as needed for shortness of breath and will have Oxygen tubing dated and changed weekly when in use. Resident R-63 has Oxygen tubing dated correctly and changed weekly as per physician orders. 2. All residents with physician orders for supplemental Oxygen use will be assessed to ensure consistent respiratory care as per physician orders. 3. Nurse Educator/Designee will re-educate all professional nursing staff on the policy, "Oxygen Administration." 4. The DON/Designee will conduct random weekly audits times 2 months to ensure that residents who utilize supplemental Oxygen receive consistent respiratory care by labeling and dating Oxygen tubing weekly as per physician orders. 5. Audit results will be reviewed monthly by QAPI Committee.
Failure to Assess and Maintain Bedrails for Residents
Penalty
Summary
The facility failed to appropriately assess and ensure the correct installation, use, and maintenance of bedrails for two residents. Resident R37, admitted with coordination issues, reduced mobility, and a need for assistance, was assessed as a fall risk and care planned to use bedrails. However, the resident expressed dissatisfaction with the bedrails, demonstrating that they were loosely attached. The Maintenance Director confirmed the bedrails were tightened after being found loose and stated that bedrails are only installed upon orders from the Director of Nursing or therapy. The Third Floor Unit Manager confirmed there were no physician orders or assessments for the bedrails. Resident R77, admitted with muscle weakness and difficulty walking, was also identified as a fall risk. The resident reported that the bedrails were loose and not useful, and there was no assessment for entrapment risk or physician orders for the bedrails. The resident did not request the bedrails, and the admission assessment indicated that the resident did not use them for bed mobility. The Director of Nursing was informed of these findings.
Plan Of Correction
1. R37 and R77 bedrails were tightened. They were also assessed for bedrails, physician order obtained, bed rails added to monitoring list. 2. All residents with side rails will be assessed for appropriateness and safety. If appropriate, order will be obtained from physician. Bed rails will be placed on and monitored. 3. Education to all department heads on process of adding and monitoring side rails. 4. Random audits by the Administrator/designee of 5 residents with side rails to ensure that resident has assessment, order and that side rails are tight and have been added to maintenance monitoring list once a week for one month, twice a week for one month, and once a month for one month. The findings of the audits will be brought to the Quality monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.
Failure to Implement Recommended Psychiatric Treatment
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident, identified as R97, who displayed mental disorder or psychosocial adjustment difficulty. The resident, admitted on January 31, 2025, had moderate cognitive impairment and was diagnosed with non-Alzheimer's dementia and depression. The comprehensive Minimum Data Set (MDS) assessment dated February 6, 2025, indicated the resident had moderately severe depression. A psychiatry assessment conducted on March 10, 2025, by a Psychiatric Mental Health Nurse Practitioner (PMHNP) revealed that the resident expressed feelings of anxiety and depression, with staff reporting intermittent behavioral disturbances such as agitation and restlessness. The PMHNP recommended starting the resident on Buspar, an anti-anxiety medication, to support anxiety. However, a follow-up psychiatry assessment on March 17, 2025, indicated that the resident reported feeling sad about the state of the world and experiencing visual hallucinations. It was noted that the staff had not started the resident on Buspar as recommended in the previous assessment. The clinical record showed no documented evidence that the facility implemented the Buspar treatment as advised by the PMHNP. This was confirmed in an interview with a Registered Nurse on March 19, 2025, who acknowledged that the facility did not implement the medication as recommended.
Plan Of Correction
1. Resident R-97 is now receiving Buspar 7.5mg BID as ordered. 2. All residents with Psychotropic medication recommendations will be reviewed to ensure treatment and services are received correctly to attain their highest practicable mental and psychosocial well-being. 3. Nurse Educator/Designee will re-educate the professional nursing staff on the policy, "Medication Orders." 4. The DON/Designee will conduct weekly random audits times 2 months to ensure that residents with recommendations for psychotropic medication changes are followed up timely with the physician. 5. Audit results will be reviewed monthly by QAPI Committee.
Delay in Medication Administration for Resident
Penalty
Summary
The facility failed to ensure the timely acquisition and administration of a prescribed medication for Resident R16, who was admitted with diagnoses including congestive heart failure, alcoholic polyneuropathy, and generalized anxiety disorder. On March 18, 2025, Resident R16 reported experiencing anxiety due to a personal event and stated that a physician had ordered Ativan, which was not received for three days because it was unavailable. The nursing progress note from February 11, 2025, indicated that the resident expressed emotions of grief and anxiety, prompting the physician to order Ativan 0.5 mg by mouth twice a day. However, the medication was not administered until March 14, 2025. The delay in medication administration was attributed to the pharmacy not approving the script in a timely manner, as confirmed by Employee E10, a Registered Nurse, during an interview on March 19, 2025. This failure to provide timely pharmaceutical services resulted in the resident not receiving the necessary medication to address his anxiety, as required by the facility's obligation to meet the needs of each resident through accurate acquiring, receiving, dispensing, and administering of drugs.
Plan Of Correction
1. Resident R-116 has Ativan 0.5mg available as needed for Anxiety. 2. All residents with new orders for PRN Ativan will be assessed to ensure timely acquisition and administration of prescribed medications. 3. Nurse Educator/Designee will re-educate all professional nursing staff on the policy, "Medication Orders." 4. The DON/Designee will conduct random weekly audits times 2 months to ensure residents who have new orders for PRN Ativan have the medication delivered timely from the pharmacy. 5. Audit results will be reviewed monthly by QAPI committee.
Failure to Provide Meal Alternatives and Accommodate Dietary Restrictions
Penalty
Summary
The facility failed to provide a meal substitute for Resident R97, who requested an alternative meal option. Resident R97, who has moderate cognitive impairment and a diagnosis of malnutrition, did not eat the lunch served and requested a hamburger, which was listed as an alternative option on the 'always available menu.' However, when the Unit Clerk, Employee E17, contacted the kitchen to request the hamburger, the kitchen staff stated they could not provide it and informed that hamburgers would be available the next day. Additionally, the facility did not accommodate Resident R6's dietary needs, who was on a lactose-restricted diet due to multiple sclerosis, chronic obstructive pulmonary disease, and muscle weakness. Despite the dietary orders and care plan specifying a lactose-restricted diet, Resident R6 reported receiving meals containing cheese and milk, which led to loose bowel movements. An observation confirmed that Resident R6 was served cheese on top of chicken, contrary to her dietary restrictions.
Plan Of Correction
1. R97 and R6 were provided with a meal that was in house and met allergies, preference. Hamburgers and hotdogs were taken off the always available menu. Dietitian met with resident R6 to ensure that we have allergies noted and address her restrictions. 2. Always available menu will be adjusted if item is unable to be delivered. Audit to ensure that all residents have dietary restrictions and preferences in place. 3. Education provided to Dietician, and Food Service Employees to ensure that preference, restrictions and allergies are being followed. Education that if a item that is on the always available menu is not able to be kept in stock it must be removed. 4. Random audits by the Administrator/designee of 5 residents to ensure that residents are receiving a meal that meets their needs related to allergens, preferences and restrictions once a week for one month, twice a week for one month and once a month for one month. Random audits of the Always available menu to ensure food is available once a week for one month, twice a week for one month and once a month for one month. The findings of the audits will be brought to the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with the coordination of the interdisciplinary team at QAPI Committee meeting.
Deficiency in Resident Call System
Penalty
Summary
The facility failed to ensure that call bells were within reach for five residents, leading to a deficiency in the resident call system. Resident R37, who was assessed as a fall risk, had a call bell that was out of reach and found on the floor. The Maintenance Director explained that the call bell was not broken but was improperly managed by nursing staff, causing it to fall. Similarly, Resident R115's call bell was stuck in a bedside drawer, and the call bell system was found unplugged at the nursing station, resulting in a delayed response to the resident's needs. Additionally, Residents R109 and R153, who required assistance with personal care, had call bells that were not within reach. During a Resident Council meeting, several residents reported that staff would turn off call bells without providing assistance, claiming they were not assigned to the resident. Furthermore, Resident R88 experienced a malfunctioning call bell that remained active even after assistance was provided, indicating a need for maintenance. The Maintenance Director confirmed that the call bell in room 424-B was broken and required replacement, highlighting systemic issues with the call bell system throughout the facility.
Plan Of Correction
1. Residents R-37, R-115, R-153, R-109, and R-88 have their call bells with-in their reach. 2. The facility will assess all residents to ensure that they have their call bell with-in their reach to ensure timely responses to their requests and needs. 3. Nurse Educator/Designee will re-educate all staff on the policy, "Answering Call light." 4. The DON/Designee will conduct weekly random audits times 2 months to ensure residents call bells are with-in their reach. 5. Audit results will be reviewed monthly by QAPI Committee.
Failure to Complete Timely Discharge Summaries
Penalty
Summary
The facility failed to complete discharge summaries within the required 30 days for two residents, as evidenced by a review of closed clinical records and interviews with facility staff. Resident R164 was admitted on December 9, 2024, and discharged on December 18, 2024, but the discharge summary was not completed within the mandated timeframe. Similarly, Resident R162, admitted on November 26, 2013, and discharged to the hospital on January 13, 2025, also lacked a timely discharge summary. Interviews with the Nursing Home Administrator confirmed these findings, indicating a lapse in adherence to the facility's policy on discharge documentation.
Plan Of Correction
1. R164 is discharged and record closed. R162 is discharged and record closed. 2. All discharges from March 20 will be audited to ensure 30 day discharge note from attending physician has been completed. 3. Education to all attendings that a discharge summary must be completed within 30 days completed. 4. Random audits by the Administrator/designee of up to 5 residents to ensure that the attending has completed a 30 days discharge note once a week for one month, twice a week for one month, and once a month for one month. The findings of the audits will be brought to the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.
Deficiency in Nurse Aide Staffing Levels
Penalty
Summary
The facility failed to meet the required minimum staffing levels for nurse aides (NAs) on several occasions across different shifts. During the day shift, the facility did not provide the required number of NAs for the resident census on two specific days, resulting in a shortfall of 0.7 and 0.43 NAs, respectively. Similarly, the evening shift experienced a deficiency in staffing on three days, with shortfalls ranging from 0.36 to 0.64 NAs. The night shift was also affected, with four days showing a lack of adequate staffing, with shortfalls ranging from 0.53 to 1.53 NAs. These deficiencies were confirmed through a review of nursing staff care hours and an interview with the Nursing Home Administrator.
Plan Of Correction
1. Administrator, Director of Nursing, Staffing Coordinator and/or Designee will continue to recruit and advertise to satisfy the staffing regulation to ensure that quality of care is provided to the residents. This will be done by rounding, observation, auditing, communication with residents and families through daily interaction, care conferences and resident council. 2. Staffing for the facility was reviewed to ensure that the center is meeting and adhering to ensure that the facility had adequate resident to nurse aide (NA) ratio to meet the regulatory requirement effective July 1, 2024 of a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening and 1 nurse aide per 15 residents overnight. 3. Education regarding the nurse aide ratio of a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening and 1 nurse aide per 15 residents overnight was provided to the staffing coordinator, HR, nursing administration to ensure that the center is in compliance. 4. A weekly audit of nurse aide ratio staffing will be conducted by the NHA/designee to ensure that the facility meets regulatory requirements. The findings of the audits will be brought to the Quality monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.
Deficiency in LPN Staffing Levels
Penalty
Summary
The facility failed to meet the required minimum staffing levels for Licensed Practical Nurses (LPNs) during the day shift. Specifically, on March 19, 2025, the facility had 5.00 LPNs scheduled for a resident census of 158, which required 6.32 LPNs to comply with the regulation of one LPN per 25 residents. This deficiency was confirmed through a review of nursing staff care hours and an interview with the Nursing Home Administrator on March 20, 2025, at 11:00 a.m., who acknowledged that the staffing levels did not meet the required minimums.
Plan Of Correction
1. Administrator, Director of Nursing, Staffing Coordinator and/or Designee will continue to recruit and advertise to satisfy the staffing regulation to ensure that quality of care is provided to the residents. This will be done by rounding, observation, auditing, communication with residents and families through daily interaction, care conferences and resident council. 2. Staffing for the facility was reviewed to ensure that the center is meeting and adhering to ensure that the facility had adequate resident to LPN ratio to meet the regulatory requirement: minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening and 1 LPN per 40 residents overnight. 3. Education regarding the LPN ratio of a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening and 1 LPN per 40 residents overnight was provided to the staffing coordinator, HR, nursing administration to ensure that the center is in compliance. 4. A weekly audit of nurse aide ratio staffing will be conducted by the NHA/designee to ensure that the facility meets regulatory requirements. The findings of the audits will be brought to the Quality monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day for 18 out of 21 days reviewed. The deficiency was identified through a review of nursing staffing hours and confirmed by an interview with the Nursing Home Administrator. Specific dates where the facility fell short include October 3, 4, 7, 8, and 9, 2024; December 27, 28, 29, 30, and 31, 2024; January 1 and 2, 2025; and March 13, 14, 16, 17, 18, and 19, 2025. On these days, the facility's nursing care hours per patient per day (PPD) ranged from 2.28 to 3.15, consistently below the required 3.2 PPD. The deficiency was further substantiated by the facility's own records, which showed that the total nursing care hours provided were insufficient for the resident census on the specified dates. For instance, on January 2, 2025, the facility provided only 341.25 care hours for 150 residents, resulting in a PPD of 2.28, significantly below the mandated minimum. The Nursing Home Administrator acknowledged the shortfall in staffing levels during an interview conducted on March 20, 2025.
Plan Of Correction
1. Administrator, Director of Nursing, Staffing Coordinator and/or Designee will continue to recruit and advertise to satisfy the staffing regulation to ensure that quality of care is provided to the residents. This will be done by rounding, observation, auditing, communication with residents and families through daily interaction, care conferences and resident council. 2. Staffing for the facility was reviewed to ensure that the center is meeting and adhering to meet the regulatory requirement. Effective July 1, 2024, the total number of hours of general nursing care provided in each 24 hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident. 3. Re-education regarding the total minimum number of direct resident care hours effective July 1, 2024, the total number of hours of general nursing care provided in each 24 hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident was provided to the staffing coordinator, HR, nursing administration to ensure that the center is in compliance. 4. A weekly audit of direct care hours will be conducted by the NHA/designee to ensure that the facility meets regulatory requirements. The findings of the audits will be brought to the Quality monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.
Failure to Maintain Comfortable Bathing Temperatures
Penalty
Summary
The facility failed to maintain essential mechanical equipment to ensure comfortable bathing temperatures on two of its three nursing floors, specifically the Second and Fourth floors. The deficiency was identified through interviews with residents and staff, as well as a review of temperature logs. The facility's policy on safe water temperatures, dated December 2009, assigns the responsibility of maintaining safe and comfortable water temperatures to the maintenance staff. However, since June 2024, the facility has been experiencing issues with water temperatures, which varied depending on the location within the building. This resulted in nursing staff having to use different floors to bathe residents due to the warm water running out and becoming too cool for comfortable bathing. Interviews with the Nursing Home Administrator and the maintenance director confirmed that the essential equipment, such as mixing valves and holding tanks, was not fully functioning, leading to inconsistent water temperatures. Residents reported being asked to bathe on different floors to receive a warm shower, and on some days, the hot water would run out, causing delays in bathing. Nursing staff corroborated these reports, stating that they had been instructed to take residents to different units for bathing since June 2024 due to the ongoing issue with insufficient hot water.
Failure to Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for a resident, identified as Resident R1, who was admitted with diagnoses including cerebral infarction, hemiplegia, hemiparesis, lack of coordination, and adjustment disorder with mixed anxiety disorder. The care plan, last revised in January 2024, included specific interventions for hygiene and bathing, such as allowing extra time for communication and leaving the resident alone if they resisted care. However, an incident occurred where an agency nursing aide, Employee E5, did not adhere to these interventions. During the incident, Employee E5 attempted to undress Resident R1 for bed, which led to the resident becoming agitated and physically aggressive. The aide then restrained the resident's legs to prevent being kicked, escalating the situation further. This action was contrary to the care plan's directive to leave the resident alone and try again later if they resisted care. The facility's Administrator and Director of Nursing confirmed that the agency staff did not follow the care plan, leading to the deficiency noted in the report.
Failure to Evaluate Nursing Staff Competency
Penalty
Summary
The facility failed to ensure that nursing staff possessed the required skills to properly care for residents' needs. This deficiency was identified through a review of personnel files, facility documentation, and staff interviews. Specifically, an agency nursing aide, Employee E5, was not evaluated for competency to ensure they had the necessary skills to care for residents and were not oriented to the facility's practices and care plans. This lack of evaluation and orientation led to Employee E5 failing to follow the care plan for a resident, resulting in an escalation of the situation. The deficiency was confirmed during an interview with the Administrator and the Director of Nursing.
Facility Fails to Readmit Resident After Hospitalization Due to Drug Use
Penalty
Summary
The facility failed to allow a resident to return after hospitalization, violating its own admission policies. The resident, who had multiple medical conditions including paraplegia and opioid dependence, was hospitalized following an incident involving illegal drug possession. An anonymous call led to a search of the resident's room, where drugs and paraphernalia were found. The resident was sent to the hospital for evaluation and treatment, but upon discharge, the facility refused to readmit him, citing concerns about his drug use and the potential risk to other residents. The Director of Nursing stated that the decision to refuse readmission was due to the resident's active drug use and the risk of him obtaining drugs again. However, there was no clinical documentation or assessment conducted to support the facility's claim that they could not meet the resident's needs. The facility's failure to conduct an assessment or document the resident's status at the time of discharge from the hospital contributed to the deficiency, as it did not provide evidence to justify the refusal of readmission.
Failure to Communicate Medication Refusal Leads to DVT
Penalty
Summary
The facility failed to communicate a resident's refusal of a prophylactic anticoagulant medication to the resident's physician assistant, resulting in the resident missing nine doses of the medication. This deficiency was identified during a review of the facility's policies, clinical records, and staff interviews. The facility's policy requires that any refusal of medication be documented and communicated to the resident's medical practitioner and family. However, this protocol was not followed in the case of the resident, leading to a significant oversight. The resident involved had a complex medical history, including a left hip fracture, vascular dementia, and atherosclerotic heart disease. After a fall and subsequent surgery for a hip fracture, the resident was prescribed Enoxaparin, an anticoagulant, to prevent blood clots. Despite the prescription, the resident missed several doses due to refusal, which was not properly documented or communicated to the medical practitioner. This lack of communication and documentation resulted in the development of Deep Venous Thrombosis (DVT) in the resident. Interviews with facility staff revealed that the licensed nurse responsible for administering the medication was aware of the resident's refusal but failed to document the refusals or notify the physician assistant. The nurse reported the refusals verbally to the medical doctor and the family but neglected to document these notifications. The physician assistant confirmed that they were unaware of the refusals until after the resident exhibited symptoms of DVT, highlighting a critical lapse in communication and adherence to facility protocols.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment in the main dining room and two of three nursing units, specifically on the Second and Third Floors. Observations revealed a deteriorated and malfunctioning shower on the Third Floor, with a broken concrete floor, moldy walls, and a missing drain cover. The water temperature in the shower was significantly below the ideal range for bathing, and the drain was inoperable, causing water to pool on the floor. Interviews with residents indicated that they were aware of the shower's poor condition, with some residents expressing concerns about the cold water and broken floor. Despite these issues, residents were not consistently offered alternative showering options on other floors. Additionally, on the Second Floor, a utility cart with leftover breakfast trays was observed in front of the dining room, indicating a lack of cleanliness and organization as the lunch service was about to begin. In the main dining room on the First Floor, a broken cabinet used for storing items was noted. These observations were confirmed by staff members, including the Nursing Home Administrator, Director of Nursing, Maintenance Director, and Food Service Director, highlighting a failure to provide a safe, clean, and comfortable environment for residents.
Failure to Investigate Bruise of Unknown Origin
Penalty
Summary
The facility failed to conduct a complete and thorough investigation to rule out abuse or neglect for a bruise of unknown origin on a resident. The facility's policy on abuse and neglect, revised in March 2018, mandates that any suspicion of abuse, neglect, exploitation, misappropriation of resident property, or injury of unknown source must be reported immediately to the administrator and other officials as per state law. However, in this case, the facility did not adhere to its policy. A nurse practitioner identified a large bruise on the resident's left forearm during an examination and reported it to the nursing staff, but there was no follow-up documentation or assessment from the nursing staff indicating awareness or investigation of the bruise. The resident involved had a medical history that included hypertension, cerebral infarction, contracted right elbow and wrist, dysphagia, and congestive heart failure, and was cognitively impaired as per the Annual Minimum Data Set Assessment. Despite the nurse practitioner's report of the bruise, the Third Floor Unit Manager was unaware of the bruise and confirmed that no investigation was conducted. This lack of action and documentation represents a failure to comply with the facility's policies and state regulations, specifically 28 Pa. Code 201.18(b)(1)(3), 28 Pa. Code 211.10(d), and 28 Pa. Code 211.12(c).
Failure to Address Resident's Refusal of Care in Comprehensive Plan
Penalty
Summary
The facility failed to develop and implement an individualized, comprehensive care plan with measurable objectives and interventions for a resident with moderate cognitive impairment and functional limitations. The resident, who has hemiplegia and muscle weakness, requires substantial assistance with personal care. The care plan, last revised in February 2024, identified a risk for skin alterations due to weakness and included an intervention to apply a resting hand splint. However, the care plan did not address the resident's behaviors of refusing care, such as nail care and wearing the hand splint, which are critical to managing the resident's left-hand contracture. Observations revealed that the resident had a contracture of the left hand with long, dirty fingernails, while the right-hand nails were trimmed and clean. Interviews with staff confirmed the resident's refusal of nail care and the hand splint, contributing to the risk of skin breakdown. Despite the resident's history of refusing care, there was no documented evidence of a care plan addressing these behaviors or measurable objectives to meet the resident's needs related to the refusal of care and the left-hand contracture.
Failure to Document Physician Follow-Up After Resident's Medical Event
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice concerning a change in a resident's medical condition. Specifically, for one resident, there was a lack of documentation and follow-up after a significant medical event. The resident, who had a history of hypertension, cerebral infarction, contracted right elbow and wrist, dysphagia, and congestive heart failure, experienced an episode of vomiting a large amount of coffee ground emesis, which is indicative of internal bleeding in the upper gastrointestinal tract. The charge nurse contacted the resident's primary care physician (PCP) regarding this incident and was awaiting a response. However, there was no documentation in the nursing notes to indicate that the physician returned the call or provided any orders following the report of the resident's condition. An interview with the unit manager confirmed the absence of follow-up contact with the physician, highlighting a deficiency in the facility's adherence to its policy on notifying physicians of changes in a resident's condition.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to implement necessary interventions for the prevention of pressure ulcers for a resident identified as being at risk. The resident, who was cognitively impaired and had diagnoses of diabetes mellitus and hemiplegia, was noted in their care plan to require heel boots to offload pressure while in bed. Despite a physician's order dated February 23, 2024, to apply heel boots every shift, observations on May 22, 2024, revealed the resident was in bed without the heel boots, and no boots were available in the room. A nurse aide and a licensed nurse confirmed the absence of the heel boots, and there was no documentation indicating the resident refused to wear them.
Failure to Obtain Weekly Weights for Residents with Weight Loss
Penalty
Summary
The facility failed to ensure that weekly weights were obtained for two residents with a history of weight loss. Resident R39, who had diagnoses including hypertension, cerebral infarction, dysphagia, and congestive heart failure, experienced a significant weight loss of 18.3% from October to November 2023. Despite a physician's order for weekly weights starting November 21, 2023, there was no documented evidence that these weights were obtained. The 3rd floor Unit Manager confirmed the absence of weekly weight records for Resident R39. Similarly, Resident R454, diagnosed with COPD, dementia, hypertension, and deep vein thrombosis, experienced an 8% weight loss from January to February 2024. A physician's order for weekly weights starting February 20, 2024, was not fulfilled due to issues with the weighing scale, as noted in nursing records. The 4th floor Unit Manager confirmed that the scale was not functioning properly, preventing the collection of the required weights.
Failure to Include End Date for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that as-needed psychotropic medication orders included an end date for discontinuation, as required by their policy. This deficiency was identified during a review of Resident R25's clinical records. The facility's policy on psychotropic medication use, revised in July 2022, mandates that such medications should not be prescribed or administered on a PRN basis unless necessary for a diagnosed condition documented in the clinical record. Additionally, PRN orders for psychotropic medications are limited to 14 days unless the physician provides a rationale for extending the order and specifies the duration. In the case of Resident R25, who was admitted with diagnoses including bipolar disorder, intermittent explosive disorder, anxiety, restlessness, and agitation, a physician's order dated April 30, 2024, prescribed Lorazepam to be administered every 12 hours as needed for agitation and anxiety. However, the order did not specify a duration period for the medication, which is a violation of the facility's policy. This oversight was identified through a review of clinical records, staff interviews, and the facility's policy documentation.
Failure to Complete Ordered Lab Tests
Penalty
Summary
The facility failed to ensure that laboratory tests were completed as per physician orders for a resident. According to the facility's policy, the physician is responsible for identifying and ordering lab tests based on the resident's needs, and the staff is responsible for processing test requisitions and arranging for the tests. A physician order was placed on January 23, 2024, by a Nurse Practitioner for laboratory values to be drawn on January 24, 2024, for a resident. However, a subsequent assessment by the same Nurse Practitioner revealed uncertainty about whether the labs had been drawn. A review of the resident's clinical record confirmed that the labs ordered for January 24, 2024, were not completed. This was further confirmed during an interview with the Assistant Director of Nursing.
Failure to Provide Thickened Liquids as Ordered
Penalty
Summary
The facility failed to provide beverages consistent with the needs of three residents who had orders for thickened liquids due to dysphagia. Resident R1, who was cognitively impaired, had a physician's order for nectar thick fluids since January 25, 2024, and a care plan intervention to provide these fluids. However, during a lunch meal service on May 22, 2024, Resident R1 was observed with a cup of thin water instead of the prescribed thickened beverage. The licensed nurse, Employee E20, confirmed the incorrect beverage consistency and was unsure of who provided it. Similarly, Resident R140, with moderate cognitive impairment and a diagnosis of dysphagia, had an order for nectar thick fluids and a care plan intervention to provide 120 mL of these fluids every shift. Despite this, observations during the same meal service revealed that Resident R140 did not receive the thickened beverage. Additionally, Resident R34, who was also cognitively impaired and had a diagnosis of dysphagia, was not provided with the ordered nectar thick fluids during the lunch meal. The facility's failure to provide the correct beverage consistency was confirmed by Employee E20, and the unit clerk, Employee E23, noted that the kitchen typically sends individual beverages with each meal tray.
Incomplete Documentation of Resident's Mental Health Concerns
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident, identified as Resident R89, which is a violation of accepted professional standards. The facility's policy on Charting and Documentation requires that all services provided, progress toward the care plan, and any changes in the resident's condition be documented in the medical record. However, the clinical record for Resident R89 did not include the specific comments made by the resident to the physiatrist regarding a passive death wish, which was documented by the physiatrist during a consultation. This lack of documentation prevented the facility from making a proper assessment of the resident's mental state. Resident R89, who has diagnoses including schizophrenia, bipolar disorder, diabetes, seizures, and glaucoma, expressed feelings of depression and a passive death wish to the physiatrist. The physiatrist communicated this to the Director of Therapy, who was to ensure the resident received psychological services. However, the nursing notes by Employee E12, a licensed nurse, did not capture the specifics of the conversation with the physiatrist, only noting that the resident did not express thoughts of self-harm or harm to others. Interviews with Employee E12 and the Director of Nursing revealed that neither had knowledge of the specific comments made by the resident, indicating a gap in communication and documentation within the facility.
Failure to Ensure Timely Medication Delivery
Penalty
Summary
The facility failed to ensure timely delivery of medications from the pharmacy for two residents, leading to missed doses and treatments. Resident R133, diagnosed with chronic pancreatitis and Tinea Cruris, did not receive Pancrelipase capsules during meal times on multiple occasions due to the medication being on order or awaiting delivery. Additionally, Miconazole Nitrate Powder for a fungal rash was not applied on specified dates for the same reasons. These lapses were confirmed with the Nursing Home Administrator. Resident R39, with a history of hypertension, cerebral infarction, and congestive heart failure, was diagnosed with viral conjunctivitis and prescribed Ocusoft Lid Scrub Cleanser. The treatment was not administered as ordered on numerous occasions, with the Medication Administration Record (MAR) indicating the medication was on hold due to awaiting pharmacy delivery. There was a lack of documentation explaining the unavailability of the medication, and no evidence that the nurse practitioner or physician was notified about the missed treatments. The report highlights deficiencies in the facility's pharmaceutical services, as medications were not delivered or administered as required, impacting the care of the residents. The facility's policy on pharmacy services was not adhered to, resulting in a failure to provide necessary medications and treatments in a timely manner. Interviews with staff confirmed these findings, and the lack of documentation further exacerbated the issue.
Failure to Administer Medication as Prescribed Resulting in Seizure and Head Injury
Penalty
Summary
The facility failed to ensure that a benzodiazepine medication was administered as ordered by the physician, resulting in actual harm to a resident who experienced a tonic-clonic seizure and was diagnosed with a closed head injury and left frontal scalp hematoma. The resident, who was under hospice care for protein-calorie malnutrition and had diagnoses of seizure disorder, epilepsy, and anxiety disorder, had a physician's order for Lorazepam to be administered every 6 hours and as needed for seizure activity. However, the medication was not administered as prescribed on multiple occasions, leading to the resident experiencing symptoms of Lorazepam withdrawal and a subsequent seizure and fall on February 25, 2024. The resident's care plan, initiated on December 15, 2022, included interventions to administer Lorazepam as needed for seizure activity. Despite this, the Medication Administration Record (MAR) for February 2024 showed that the resident missed several doses of Lorazepam on February 24 and 25, 2024. The nursing notes for February 2024 did not document any reasons for the omission of the medication. On February 25, 2024, the resident was being assisted with eating when they suddenly began seizing, fell, and hit their head, resulting in a large hematoma to the left forehead. The Director of Nursing confirmed that the Lorazepam was not administered as prescribed on February 24 and 25, 2024, and that the omission of the medication contributed to the resident's seizure and subsequent head trauma. The physician's progress note indicated that the root cause of the seizure and fall was due to benzodiazepine withdrawal symptoms. The facility's failure to administer the medication as ordered led to significant harm to the resident, including a tonic-clonic seizure and head injury.
Failure to Notify Physician of Medication Refusals
Penalty
Summary
The facility failed to notify the physician of a resident's repeated refusals of a prescribed laxative medication, Miralax, which was part of a bowel protocol to prevent constipation. The resident, who was cognitively intact and always incontinent of bowel, refused the medication on multiple occasions in March and April 2024. Despite the facility's policy requiring staff to inform the healthcare provider of any treatment refusals, there was no documentation indicating that the physician was notified of these refusals. This lack of communication persisted even though the resident's clinical record showed continuous medication refusals on specific dates in March and April 2024. As a result of the facility's failure to notify the physician, the resident was admitted to the hospital twice in April 2024 with symptoms including abdominal pain, nausea, vomiting with coffee-ground emesis, and a moderate to large stool burden indicating constipation. Hospital diagnostic imaging confirmed the presence of a significant amount of stool within the colon. The Director of Nursing confirmed that the physician had not been informed of the resident's routine medication refusals for bowel treatment and prevention of constipation.
Failure to Address Behavioral Health Needs and Discharge Planning
Penalty
Summary
The facility failed to address the behavioral health needs and services for one of its residents, identified as Resident R1. The facility's policy on behavioral health services mandates that residents experiencing emotional or psychosocial distress receive appropriate services to meet their needs. Additionally, the policy on comprehensive person-centered care plans requires the development and implementation of a care plan with measurable objectives to meet the resident's physical, psychosocial, and functional needs. Despite these policies, Resident R1, who has diagnoses of paraplegia, bipolar disorder, and post-traumatic stress disorder, did not receive the necessary behavioral health services or a comprehensive care plan addressing his needs. Resident R1's clinical records revealed multiple instances of irritability, anxiety, and dissatisfaction with the nursing staff, as well as a desire to be discharged back to the community to be with his children. The resident's psychiatrist noted feelings of irritability and anxiety, and the resident reported that interactions with staff were causing distress. Despite these documented issues, there was no evidence that the facility developed or implemented a care plan to address Resident R1's behavioral health needs or his requests for discharge planning. Additionally, the resident's request for assistance in obtaining a motorized wheelchair to aid his mobility was not addressed. Interviews with the Director of Nursing and the Social Worker confirmed that there was no care plan developed for Resident R1's discharge planning or behavioral health needs. The facility's failure to provide the necessary behavioral health services and to develop a comprehensive care plan for Resident R1 resulted in unmet needs related to his anxiety, irritability, loneliness, depression, and mobility. This deficiency highlights a significant lapse in the facility's responsibility to ensure the well-being of its residents as per its own policies and regulatory requirements.
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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