Citations in Pennsylvania
Statistics, citations and compliance trends for long-term care facilities in Pennsylvania.
Statistics for Pennsylvania (Last 12 Months)
Financial Impact (Last 12 Months)
Compliance trends in Pennsylvania
Data through Apr 2026Comparisons below measure the most recent period May 2025 – Apr 2026 against the prior period May 2024 – Apr 2025 (two equal 12-month windows). The most recent 1 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 1-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025; the most recent 1 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 1 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Some of the Latest Corrective Actions taken by Facilities in Pennsylvania
- Updated resident care plans to require continuous supervision outside the living unit for residents at risk of elopement (K - F0689 - PA)
- Trained activities staff on elopement/accidents/hazards expectations for residents with Wanderguard devices or deemed at risk (no unsupervised time before/during/after first-floor activities until safely returned) (K - F0689 - PA)
- Completed whole-house education on elopement/accidents/hazards (K - F0689 - PA)
- Implemented a defined staffing coverage plan for first-floor dining-room group activities (four-person coverage across room, hallway transport, elevator transport, and hallway observation) (K - F0689 - PA)
- Modified the activities program to reduce first-floor dining-room activities and shift other/smaller activities to resident floors/dayrooms (K - F0689 - PA)
- Implemented environmental controls for first-floor activities (closed dining-room door once residents were inside and installed a bell on the door to alert staff to door opening) (K - F0689 - PA)
- Established leadership support for large group activities (leadership assisted with transport and provided additional direct-supervision support, using a standup-meeting request and sign-up process) (K - F0689 - PA)
- Implemented an elopement-risk identification process for new admissions (evaluation discussed in morning meeting; if at risk, binders updated, Wanderguard placed, and IDT notified) (K - F0689 - PA)
- Implemented Nursing Home Administrator audits of first-floor group activities to monitor for proper resident supervision (K - F0689 - PA)
- Established daily review of psychiatry and progress notes for behavior changes to ensure interventions were in place (K - F0689 - PA)
- Trained nursing staff on behaviors/self-harm and trained staff on 1:1 observation expectations (with staff sign/acknowledgement requirement) (K - F0689 - PA)
- Implemented ongoing audits of psychiatry/progress notes to verify behavior changes had interventions in place (K - F0689 - PA)
- Changed food distribution/collection practices (stopped leaving trays in dining room; stored food brought to nursing stations in a locked pantry) and trained nursing/dietary staff with sign/acknowledgement requirement (K - F0689 - PA)
- Implemented audits of food distribution and collection (K - F0689 - PA)
- Trained nursing and dietary staff on providing ordered adaptive equipment (with staff sign/acknowledgement requirement) (K - F0689 - PA)
- Implemented audits to ensure adaptive equipment was available and provided (K - F0689 - PA)
- Trained staff on exit-door security (with staff sign/acknowledgement requirement) and implemented audits to ensure exit doors were secured and not propped open (K - F0689 - PA)
- Implemented facility-wide staff training on signs/symptoms of alcohol/substance consumption and required reporting/escalation to supervisors (including physician/family notification when consumption occurred) (J - F0689 - PA)
- Removed alcohol-based hand sanitizer products from resident-accessible areas (including removing refills, dispensers, and free-standing bottles) and implemented staff-only pocket hand sanitizers with instructions to keep them on-person (J - F0689 - PA)
- Implemented every-shift unit audits to monitor for hazardous items/hand sanitizer access and continued reporting audit results to QAPI (J - F0689 - PA)
Elopement Due to Inadequate Supervision After First-Floor Group Activity
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent an elopement for one resident who had been assessed as at risk for elopement. The facility’s own policy defined elopement as a resident leaving a safe area without staff knowledge or entering an unsafe area without staff presence. The resident at the center of the incident had a history that included bipolar disorder, diabetes, moyamoya disease, and moderate cognitive impairment per the MDS. Elopement risk assessments for this resident had fluctuated, with the resident identified as an elopement risk on one assessment and not at risk on two others. The physician had ordered an electronic monitoring bracelet (Wanderguard), and the care plan for behavior symptoms such as wandering and suicidal ideations included checking the Wanderguard placement, providing the device, and using diversions. On the day of the incident, the resident participated in a first-floor group activity (cooking club). After the activity concluded, activities staff began transporting residents back to their home units using an elevator that could only hold four people at a time. One activities aide reported that while transporting residents from the first floor to the upper floors, the resident left the first-floor area near the elevator where she had been waiting to return to her third-floor room. Another statement from the same aide indicated that she had to leave some residents waiting by the elevator due to capacity limits, and when she returned to the first floor, the resident was no longer there. The aide then sought help from other staff to locate the resident. An environmental services employee confirmed seeing the resident and another resident sitting by the elevator, then later finding the resident gone and assuming she had been taken back to her floor before learning she was missing. A code white was called when staff realized the resident could not be found in nearby rooms, restrooms, or on the unit. Multiple staff statements described searching inside and outside the building, including the basement, surrounding doors, parking lot, and nearby alleyways. Staff obtained information from bystanders outside who reported seeing a woman in a wheelchair and pointed out the direction she had traveled. Staff ultimately found the resident outside in a nearby alley, wheeling herself along the berm of the road toward a local convenience store she frequently visited with family during authorized leaves of absence. Progress notes documented that the resident was returned to the facility, was alert and oriented, tearful, and stated she had not intended to cause trouble but wanted to go to the store. A head-to-toe assessment and vital signs check revealed no injuries or distress. During subsequent interviews, staff confirmed that the resident had been left unsupervised near the elevator after the activity and that activities staff did not have ready access to or awareness of an elopement binder listing residents at risk for elopement, contributing to the failure to provide adequate supervision. The surveyors determined this failure created an immediate jeopardy situation for ten residents identified by the facility as at risk for elopement.
Removal Plan
- Resident was returned to the facility.
- Full body assessment was completed with no negative findings.
- Physician and family were notified.
- Resident care plan will be updated to include that resident will be supervised at all times outside of her living unit.
- Nursing Home Administrator completed Elopement/Accidents and Hazards education with Activities Staff that residents coming to the first floor dining room for activities that have a Wanderguard device or are deemed at risk for elopement will not be unsupervised at any time (before, during, or after the activity) until they are returned safely to their respective living area.
- Whole house education on Elopement/Accidents and Hazards was initiated and completed.
- Elopement assessments were completed on current residents and are under evaluation in the resident medical chart.
- Elopement binders were verified for accuracy and completion.
- Activities on the first floor will continue with an implemented plan to ensure resident safety and decreased risk of elopement.
- Facility leadership will assist during large group activities planned for the first floor dining room to ensure direct supervision support.
- Leadership will support activities staff in transporting residents to/from the first floor dining room and provide additional supervision during the activity.
- Activity Director will verbalize the need for help in morning standup meeting and provide a sign-up sheet for leadership to secure.
- Residents with a Wanderguard device or residents at risk of elopement will not be left unsupervised.
- Four people will be used for coverage: one in the room, one transporting in the hallway, one transporting the elevator, and one observing the hallway.
- Facility reduced the number of activities in the first-floor dining room to larger primary activities (auction, birthday party, cooking club, special events).
- Once all residents are in the first-floor dining room, the door will be closed.
- A bell was placed on the dining room door to alert staff if someone is attempting to open the door.
- Other activities will be modified to be completed on the resident floors in the dayrooms.
- Smaller integrated activities (e.g., Church and Resident Council) will be scheduled in the 3A dayroom moving forward.
- New admissions will be evaluated for elopement and findings discussed during the morning meeting process.
- If a resident is deemed an elopement risk, elopement binders will be updated, a Wanderguard will be placed, and the interdisciplinary team will be made aware.
- Audits of group activities occurring in the first-floor dining room will be completed by the Nursing Home Administrator for proper supervision of residents.
- All education, care plan updates, and activity modifications will be completed.
- Audits will begin with the next large group activity scheduled.
Failure to Supervise Residents at Risk for Elopement, Self-Harm, and Choking
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and monitoring for residents identified as being at risk for elopement and self-harm. One resident with diagnoses including acute kidney failure, anxiety, depression, and a history of suicidal ideation was assessed as having no memory impairment and being able to walk independently. After this resident climbed out of a window by removing safety brackets, screws, and the screen, the physician ordered a Wander Guard and 1:1 supervision due to elopement risk, and the care plan reflected 1:1 observation and Wander Guard use. Despite this, clinical and behavioral notes over the following weeks documented ongoing agitation, irritability, mood changes, accusatory statements, suicidal thoughts, and passive death ideation, including statements about stabbing herself or overdosing, while the resident remained on ordered 1:1 observation. On multiple occasions, the resident engaged in behavior indicating potential self-harm while 1:1 supervision was supposed to be in place. A nurse documented that the resident removed her Wander Guard while on 1:1 observation. Later, staff documented that the resident had two metal butter knives at her bedside, walked to an electrical outlet, and attempted to put the knives into the outlet while on 1:1 observation. A nurse aide’s written statement confirmed that the resident obtained butter knives and moved toward the outlet, and that later in the shift, while outside with other residents, the resident made a statement about wanting to harm herself. Subsequent psychology and psychiatry notes recorded continued suicidal thoughts, passive death ideation, and the resident’s admission that she had stuck knives in the outlet hoping to cause a fire so she could get out of the facility. On March 24, a Patient Watch Observation Sheet for this resident, who remained on 1:1 supervision due to destructive behavior, agitation, exit-seeking, and attempts to cause physical destruction, was observed on her dresser and was not completed, with no documented evidence that 1:1 supervision was in place at all times. The facility also failed to maintain a safe environment to prevent elopement for another resident at risk. An employee exited through a hallway door marked as alarmed with instructions to keep it closed and propped it open. While the door remained propped open and unsupervised, a resident with nicotine dependence, cognitive communication deficit, and a care plan identifying elopement risk walked into the hallway by the open door and verbalized not knowing why he was there, not wanting to be there, and asking how he could get out. The door stayed open and unsupervised for approximately ten minutes, posing a safety risk for residents at risk for elopement. In addition, the facility failed to provide adequate supervision and ordered interventions to prevent choking for a resident with dysphagia, schizophrenia, and dementia. This resident had memory impairment, required set-up assistance with eating, and could walk without assistance. Physician orders required staff monitoring during all meals and snacks to ensure the proper diet, a puree texture diet, and use of a sippy cup for all drinks with encouragement to drink slowly for choking prevention. Nursing and psychiatry documentation over several months showed repeated episodes of the resident taking food from other residents’ plates, trash cans, and medication carts, coughing episodes after consuming inappropriate foods such as sandwiches and peanut butter, and ongoing food-focused behaviors including pacing and repeatedly seeking food and fluids. One nurse note described the resident being found on the floor turning blue and coughing up a semi-chewed peanut butter sandwich, and another documented a choking episode in the dining room. On March 19, facility documentation showed that the resident was observed in the dining room eating a peanut butter and jelly sandwich obtained from a cart left in the dining room, after which she alerted therapy staff that she did not feel well and was assessed by nursing to be choking, with drooling, cyanosis, and inability to speak. A Life Vac device was used to remove a large piece of sandwich. Subsequent observation on March 24 revealed that this resident was in the dining room drinking from a regular mug, and later was provided another regular mug with a beverage, rather than the ordered sippy cup. These observations demonstrated that the facility did not consistently provide the physician-ordered adaptive equipment or adequate supervision to prevent choking for this resident.
Removal Plan
- Resident 1 was placed on 1:1 observation.
- Resident 1 was provided plastic utensils.
- Resident 1's wander guard placement was checked every shift.
- An audit was completed of all residents who verbalized wanting to harm themselves.
- The facility will review psychiatry notes and progress notes daily for any changes in behaviors.
- Education was provided to nursing staff on behaviors and self harm; staff must sign and acknowledge the trainings on their next scheduled work day.
- Education was provided to staff on the expectations of 1:1 duties; staff must sign and acknowledge the trainings on their next scheduled work day.
- Staff assigned will complete the 1:1 form.
- Audits will be completed of the psychiatry notes and progress notes to ensure changes in behaviors have interventions in place.
- Resident 2 will be redirected during periods of behavioral symptoms and placed on 1:1 supervision as needed.
- An audit was completed of residents seeking food outside their diets.
- Food trays will no longer be left in the dining room, and food brought to the nursing stations will be taken into the locked pantry.
- Education was provided to nursing and dietary staff on food distribution and collection; staff must sign and acknowledge the trainings on their next scheduled work day.
- Audits will be completed on food distribution and collection.
- Resident 2 was provided her sippy cup.
- An audit was completed to ensure adaptive equipment was available and provided.
- Adaptive equipment will be provided to residents as ordered.
- Education was provided to nursing and dietary staff on providing adaptive equipment; staff must sign and acknowledge the trainings on their next scheduled work day.
- Audits will be completed to ensure adaptive equipment is available and provided.
- The exit door was closed.
- An audit of exit doors was completed to ensure they were secured.
- Education was provided to staff on door security; staff must sign and acknowledge the trainings on their next scheduled work day.
- Audits will be completed to ensure exit doors are secured and not propped open.
Failure to Maintain and Change Midline IV Dressing per Policy and Standards
Penalty
Summary
The deficiency involves the facility’s failure to provide safe and appropriate care and management of a midline peripheral venous access device in accordance with its own policy and professional standards of practice for one resident. Facility policy required staff to inspect the catheter-skin junction and surrounding area, palpate through the intact dressing for redness, tenderness, swelling, and drainage, note any pain, numbness, or tingling, and change a midline dressing weekly or if soiled, with physician orders specifying dressing type and frequency. CDC guidelines cited in the report recommend replacing transparent dressings on short-term central vascular catheter sites at least every seven days. The resident involved was admitted with osteomyelitis of the sacral/coccyx area and a stage four sacral pressure wound, was cognitively intact, and had IV access for daily IV ceftriaxone for osteomyelitis. The clinical record, including the Medication Administration Record for February and March, showed no physician orders for care and maintenance of the midline access site. The resident’s care plan identified risk for complications related to IV medication and included interventions for staff to observe the right chest wall dressing every shift and to change the dressing weekly, but these interventions were not carried out as required. Surveyor observations on two occasions on the same day showed that the resident had a midline peripheral access site in the right chest wall with a transparent dressing dated more than 30 days earlier, indicating the dressing had not been changed weekly as required. The bottom part of the dressing was not fully adhered to the skin. In an interview, the resident stated that staff had not changed the dressing. There was a lack of documentation to support that the facility had assessed the access site or changed the dressing at least every seven days and as needed, and the DON confirmed that the dressing date showed it should have been changed weekly but was not.
Removal Plan
- Upon resident return, review the resident's chart and follow physician's orders.
- Assess residents with a PICC line to assure appropriate measures for care and management of a midline peripheral venous access device are in place and ensure weekly dressing changes are properly ordered by the physician and completed.
- Review residents admitted with a PICC line to assure physician's orders include weekly dressing changes; RN Supervisor will ensure orders are in place.
- Review the policy and procedures for PICC and wound management to ensure professional standards are provided.
- Educate licensed nursing staff on the policy and procedure related to care and management of a midline peripheral venous access device and wounds.
- Educate licensed nursing staff on obtaining physician's orders when any new skin alteration is identified.
- Educate all staff scheduled for the evening shift on the policy and procedure related to care and management of a midline peripheral venous access device and wounds and on obtaining physician's orders when any new skin alteration is identified.
- Educate all staff scheduled for the night shift on the policy and procedure related to care and management of a midline peripheral venous access device and wounds and on obtaining physician's orders when any new skin alteration is identified.
- Educate all other licensed staff and providers via telephone on the policy and procedure related to care and management of a midline peripheral venous access device and wounds and on obtaining physician's orders when any new skin alteration is identified.
- Remove from the schedule any licensed staff who cannot be reached pending completion of education.
- Review new admissions/re-admissions to ensure all physicians' orders are verified; audit and report results in QAPI.
- Conduct random audits of residents with PICC/wounds to ensure dressing changes are completed as ordered; audit and report results to QAPI.
Failure to Follow Abuse Policy, Conduct Timely Background Checks, and Protect Resident from Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to follow its own abuse, neglect, and exploitation policy, including required criminal background checks and mandated reporting and investigation of abuse/neglect allegations. The facility’s written policy stated that all employees must have criminal background checks completed prior to hire and that records of such checks must be retained in employee files. Review of the social worker’s (Employee E1) personnel file showed a hire date of 1/27/26, but the criminal background check for this employee was not completed until 3/12/26. During an interview, the DON and NHA confirmed that this staff member began working without a completed background check, contrary to facility policy. The deficiency also includes the facility’s failure to identify, report, and investigate an allegation of abuse/neglect involving one resident, and failure to protect that resident from the alleged perpetrators. Resident R1, who had bilateral above-knee amputations and opioid dependence and was documented as cognitively intact with a BIMS score of 15, reported that on 3/11/26 he experienced verbal and attempted physical abuse from the NHA and felt unsafe when the NHA was in the facility. The resident stated he wrote a letter detailing the events and gave it the same day to an RN supervisor (Employee E3), whom he described as the only person he trusted. The resident reported that the facility did nothing, did not investigate, and allowed the alleged perpetrators to continue working. Multiple staff interviews corroborated that an incident occurred and that the NHA continued to work afterward. A COTA (Employee E5) stated he arrived about five minutes after the incident, described the NHA as intimidating with a short fuse, and confirmed the NHA worked the remainder of that day. The Director of Maintenance (Employee E4) confirmed he had to remove the NHA from the resident’s room to deescalate the situation and that the NHA continued to work that day. The resident’s written letter described verbal and attempted physical abuse by the NHA, a HIPAA violation involving personal information being yelled in the hall, and an LPN (Employee E2) making an obscene gesture behind a curtain and then directly to the resident when confronted. The RN supervisor (Employee E3) confirmed receiving the written concern on 3/11/26 and stated she was unsure to whom to give it because the allegation involved the NHA. The facility failed to document or process this allegation as an incident and did not report it to the State Agency or other required entities at the time it occurred. Review of facility incident logs and information submitted to the State Agency on 3/11/26 and 3/12/26 showed no inclusion of Resident R1’s abuse/neglect allegation. The DON acknowledged being aware of a verbal altercation on 3/11/26 and stated that the NHA was asked to see the resident and that corporate instructed them not to call the police. The DON confirmed that the NHA and LPN E2 were not suspended and continued to work in the facility, and that the facility failed to timely report, investigate, notify appropriate agencies, and protect residents from further abuse/neglect related to this event. The NHA was only suspended two days after the alleged abuse/neglect occurred. These failures, combined with the lack of a timely background check for Employee E1, resulted in an immediate jeopardy situation as cited by surveyors.
Removal Plan
- Identify root cause of the Immediate Jeopardy as staff failure to follow the facility abuse policy.
- Assess Resident R1 for adverse outcomes related to the abuse/neglect allegation.
- Offer Resident R1 coping and trauma support by RN Supervisor or designee.
- Ensure appropriate services are provided to Resident R1 if adverse outcomes occurred from abuse/neglect by Mobile DON or designee.
- Assess/interview all residents for abuse/neglect for indications of fear, trauma, or abuse/neglect by Mobile DON or designee.
- Notify physician/POA (if applicable) of any adverse findings and update the medical record.
- Review and update care plans as appropriate by Mobile DON or designee.
- Complete head-to-toe skin assessments for all residents and document findings in the medical record.
- Notify attending physicians of any negative results from resident assessments.
- Report any adverse outcomes/findings to appropriate agencies.
- Interview staff for allegations of abuse/neglect that have not been reported in the last 30 days by Regional Director of Operations or designee.
- Review incidents to ensure no incidents occurred that went unreported and immediately report any that meet criteria by Mobile DON or designee.
- Review the Abuse/Neglect Policy for appropriateness, including what to do if the alleged perpetrator is the DON or NHA, and update if needed.
- Add the corporate compliance hotline number to the abuse/neglect policy for staff to use if DON/NHA are involved or staff are uncomfortable reporting to facility leadership.
- Re-educate all house staff on the abuse/neglect policy, including use of the corporate compliance hotline when leadership is involved, by Regional Director of Operations or designee.
- Educate HR (or designee) that criminal background checks must be completed prior to hire.
- Audit all staff HR files to ensure all background checks are present and do not allow any employee to return to work until a missing criminal background check is completed.
- Conduct audits to ensure all existing employee files contain criminal background checks and all new hires have checks completed prior to start date.
- Conduct audits of resident care needs to ensure no abuse/neglect is identified.
- Review nursing documentation to ensure no incidents occurred that were unreported to administration by Mobile DON or designee.
- Review all audits and policy changes related to the Immediate Jeopardy at an ad hoc QA meeting.
- Have the QAPI committee review all findings.
Repeated Hand Sanitizer Ingestion Due to Inadequate Hazard Control and Supervision
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free of accident hazards and to provide adequate supervision for a resident with known alcohol abuse and cognitive impairment, resulting in repeated ingestion of alcohol-based hand sanitizer. The facility’s Accident & Injury Prevention and Response Policy stated that residents were to be protected from avoidable accidents and injuries through proactive assessment, environmental safety, staff training, and timely response. The Safety Data Sheet for the ProCure Alcohol Gel Hand Sanitizer 70% identified the product as containing 70–75% ethyl alcohol and directed that a physician or poison control center be contacted immediately if ingested. Despite this information, the resident, who had a BIMS score of 10 indicating moderately impaired cognition and documented diagnoses including alcohol abuse, bipolar disorder, COPD, heart failure, and dementia, was able to obtain and ingest hand sanitizer on multiple occasions. The resident’s history included prior discharge from another LTC facility for alcohol abuse, insurance issues, and behavioral issues, and psychologist notes over several months documented alcohol and cocaine abuse, as well as the resident’s statements that they currently drink, do not plan to stop, and had drunk at a previous nursing home. On one date in January, a nurse observed the resident drinking hand sanitizer during rounds, removed the substance, completed an assessment, and documented stable vital signs. However, the clinical record did not show that the physician was notified of this ingestion or that any interventions were implemented to monitor or supervise the resident specifically related to hand sanitizer consumption. This lack of notification and absence of documented follow-up interventions occurred despite the known hazardous nature of the product and the resident’s substance use history. In late February, the unit manager documented finding the resident drinking a cup of hand sanitizer, discarding the cup, educating the resident on the dangers of ingestion, and notifying the physician and responsible party. A care plan was then documented indicating that the resident drinks hand sanitizer, with interventions focused on administering medications, analyzing triggers, assessing coping skills and support systems, providing re-education, and encouraging the resident to discuss feelings. Nevertheless, on a subsequent date in March, a nurse again observed the resident in their room with a bottle of hand sanitizer and a cup containing hand sanitizer, and both items were removed. A psychologist note also recorded that the resident was observed drinking hand sanitizer from a cup, with no further documentation of additional interventions to prevent recurrence. Staff interviews confirmed that the resident walked throughout the building unrestricted, could obtain more sanitizer without staff knowledge, and that the unit manager did not ask where the resident had obtained the sanitizer. The DON and NHA acknowledged that the resident drank or was observed with hand sanitizer in a cup on three separate occasions, had a history of alcohol abuse, and continued to have access to hand sanitizer in the facility, leading surveyors to identify an Immediate Jeopardy situation related to hazardous substance access and inadequate supervision.
Removal Plan
- Audit Resident R1's personal environment to ensure no hazardous substances are in the resident's possession or within reach.
- Update Resident R1's care plan to include history of alcohol and substance use.
- Initiate facility-wide staff in-service on signs and symptoms of alcohol/substance consumption and the requirement to report to a direct supervisor; supervisor to notify physician and family in the event of consumption.
- Notify and in-service staff regarding Resident R1's behaviors and educate staff to monitor when Resident R1 comes into view.
- Remove all alcohol-based hand sanitizer products potentially accessible to Resident R1 from units, including removing refills from wall dispensers, removing the dispensers, and removing other self-standing bottles.
- Provide staff with pocket hand sanitizers; ensure no hand sanitizer is available in the facility aside from these pocket sanitizers.
- Educate staff to keep pocket sanitizers on their person at all times.
- Conduct an audit to identify all residents with a history of alcohol and substance abuse; update care plans to include this history and appropriate interventions.
- Audit units every shift for audits.
- Continue audits and report results to QAPI.
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