Citations in Pennsylvania
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Pennsylvania.
Statistics for Pennsylvania (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Pennsylvania
The facility did not maintain its fire alarm system in proper working order, as the fire alarm panel was observed to be in trouble mode during both the initial survey and a follow-up revisit. This issue was confirmed by facility leadership on both occasions.
Surveyors identified deficiencies in electrical system maintenance, including an open junction box with exposed wiring and electrical panels blocked by storage or with a broken latch, which remained unresolved upon revisit.
Surveyors identified that fire-rated doors in the basement elevator lobby area had multiple penetrations and extensive damage, compromising the required fire resistance rating for common wall separations. Facility leadership confirmed these deficiencies during interviews.
A resident did not consistently receive the prescribed range of motion (ROM) program after discharge from therapy due to a communication breakdown between therapy and nursing. Documentation showed gaps in the delivery of both active and passive ROM exercises, with multiple days missed despite daily scheduling. The DON confirmed the failure to implement the recommended program as ordered.
A resident with severe protein-calorie malnutrition experienced significant weight loss and consistently low intake of meals and supplements. Facility staff did not follow policy for reweighing after significant weight changes, failed to document attempts to reweigh, and did not implement or update interventions in response to the resident's ongoing nutritional decline. The physician did not assess the severe weight loss until much later, and staff confirmed these lapses in care.
Surveyors found that the facility did not complete required annual performance evaluations for three nurse aides, as confirmed by personnel record review and interview with the administrator. Documentation was lacking to show that evaluations were performed at least once every 12 months, resulting in noncompliance with regulatory requirements.
The facility did not develop or implement individualized, person-centered care plans for dementia and cognitive loss for three residents with a diagnosis of dementia. Despite assessments indicating the need for such plans, documentation and staff interviews confirmed that these care plans were not in place prior to surveyor review.
Three residents who were transferred to the hospital did not receive required written notices of transfer or the facility's bed-hold policy at the time of transfer. Clinical record reviews and staff interviews confirmed that neither the residents nor their representatives were provided with these documents, as mandated by federal regulations.
Surveyors found that food items in the kitchen were not properly labeled or dated, with some stored in unsanitary conditions such as a walk-in freezer with ice accumulation and a dry goods area with significant debris. Equipment, including a dough cutter, was found with build-up and rust, and partially used containers lacked open dates. Additionally, required food temperature documentation was missing for several meal services, with no explanation provided by the Director of Dining Services.
Surveyors found that the facility did not offer updated pneumococcal immunizations to several residents, despite previous vaccinations and current CDC recommendations. Clinical records lacked documentation that residents or their representatives were engaged regarding updated vaccine options, resulting in a failure to meet immunization requirements.
Failure to Maintain Fire Alarm System in Proper Operating Condition
Penalty
Summary
The facility failed to maintain its fire alarm system in proper operating condition, as evidenced by the fire alarm panel being in trouble mode during both the initial survey and a subsequent onsite revisit. On May 28, 2025, observation revealed that the fire alarm panel, located in the front lobby office area, was in trouble mode at the time of the survey. This condition was confirmed during the exit interview with the Administrator and Maintenance Director. During a follow-up onsite revisit on July 16, 2025, the fire alarm panel remained in trouble mode, and this was again confirmed by the Administrator and Maintenance Director during the exit interview. No information regarding residents or their medical conditions was provided in the report.
Plan Of Correction
The facility fire panel has been repaired so that it is not in trouble mode. The facility will call our fire protection company to repair if the panel should go into trouble mode. The Maintenance Director and/or designee will perform audits weekly, for four weeks and monthly for two months to ensure that the fire panels are not in trouble. Results of the audits will be reported to QAPI.
Electrical System Deficiencies: Exposed Wiring and Inaccessible Panels
Penalty
Summary
Surveyors observed that the facility failed to maintain proper protection of electrical wiring in multiple areas. Specifically, an open junction box with exposed wiring was found in the basement phone room. Additionally, in the storage room across from the Health Care Administrator's office, two electrical panels (DP 2 and DP 4) were blocked by storage items within three feet, and one of the panels (DP 4) had a broken latch, making it difficult to open. During a follow-up onsite revisit, it was determined that the issue with the missing latch on the DP 4 electrical panel door had not been corrected, and the panel was still not secured properly. These deficiencies were confirmed during exit interviews with the Administrator and Maintenance Director. No information about residents or their medical conditions was included in the report.
Plan Of Correction
1) The electrical panel labeled DP 4 has been repaired so that it can latch and be easily opened. Storage has been removed from in front of electrical panel DP 2 and DP 4. 2) Other electrical panels have been checked to ensure that there is no storage and that the latch can close and be easily opened. 3) The Maintenance Director and/or designee will perform audits weekly, for four weeks and monthly for two months to ensure that the electrical panels can latch and easily open, and that there is no storage within three feet of the panels. Results of the audits will be reported to QAPI.
Failure to Maintain Fire-Resistant Door Barriers
Penalty
Summary
Surveyors observed that the facility failed to maintain the required fire resistance rating for common wall fire separations in one of three levels. Specifically, during an inspection, deficiencies were identified with fire-rated doors in the basement elevator lobby area. One double fire door had several penetrations on the door leaf and in the metal door frame, and another fire door showed penetrations and extensive damage at each hinge location. These conditions were directly observed by surveyors during their walkthrough. The deficiencies were confirmed in interviews with the Administrator and Maintenance Director, who acknowledged the issues with the fire doors. The report does not mention any specific patients or residents affected, nor does it provide details about their medical history or condition at the time of the deficiency. The focus of the findings is on the physical environment and the failure to maintain fire-resistant barriers as required by NFPA 101 standards.
Plan Of Correction
The fire door with penetrations has been replaced. Other fire doors in the center will be checked to ensure that they are free of penetrations. The Maintenance Director and/or designee will perform audits weekly, for four weeks and monthly for two months to ensure that the fire doors are free from penetrations. Results of the audits will be reported to QAPI.
Failure to Provide Consistent Range of Motion Services
Penalty
Summary
A deficiency was identified when a resident with a physician-ordered range of motion (ROM) program did not consistently receive the prescribed services following discharge from physical therapy. The resident reported that after therapy ended, staff either did not perform the recommended exercises or did so inconsistently. Clinical records confirmed that the resident was to receive both active and passive ROM programs to the lower extremities, but documentation showed that these services were not provided from May 16 to May 31. This lapse was attributed to a communication issue between therapy and nursing, resulting in the ROM program not being initiated until June 1. Further review of documentation for June revealed that the resident did not receive the required active ROM exercises on multiple days throughout the month, despite being scheduled for daily sessions. The Director of Nursing acknowledged the communication breakdown and the resulting failure to implement the ROM program as recommended. The deficiency was based on the facility's failure to ensure that the resident received appropriate treatment and services to maintain or improve range of motion as required.
Plan Of Correction
The facility completed a review of resident #19's ROM/Mobility tasks in PointClickCare. Tasks were updated and staff implemented said tasks. No evidence or actual ill effects exist on any resident in our community due to lack of adherence to the requirements of increase/prevent decreases in ROM/mobility. A report was generated to indicate residents with range of motion or mobility issues, and those identified were reviewed individually. Any related issues were updated, and staff were instructed to implement said tasks. An education session was completed by the director of nursing or designee with clinical and therapy staff to ensure proper communication between nursing and therapy disciplines, documentation on Point of Care, and tasks being initiated on PointClickCare. A review of 10 records will be completed weekly for one month for any identified residents with ROM/Mobility tasks and bi-weekly for 3 months. Findings will be presented to the Quality Assurance Performance Improvement committee for recommendations, including an explanation of any identified variance infractions.
Failure to Address Severe Weight Loss and Poor Nutritional Intake
Penalty
Summary
The facility failed to implement interventions to promote acceptable parameters of nutritional status for a resident with severe protein-calorie malnutrition. The resident was admitted with this diagnosis and had documented low meal and supplement intake over several months. Staff recorded that the resident consumed zero to 25 percent of meals and less than 25 percent of prescribed nutritional supplements on numerous occasions. Despite these findings, there was no evidence that the facility took timely action to address the resident's poor intake or significant weight loss. Weight assessments for the resident showed a marked decline, with a loss of 28 pounds (over 24 percent of body weight) in two months. The facility's policy required reweighing residents after significant weight changes and evaluating undesirable weight changes, but there were gaps in weight documentation and no evidence of reweighing as required. Some weights were crossed out by the registered dietitian, who believed them to be inaccurate, but no reweighs or further assessments were documented for an extended period. There was also no documentation that the resident refused weights during this time. Additionally, the resident's physician did not assess the severe weight loss until much later, and there was no update to the nutrition plan of care or implementation of new interventions in response to the ongoing weight loss and poor intake. Staff interviews confirmed these findings, and the lack of timely intervention and documentation was acknowledged by the registered dietitian.
Plan Of Correction
Upon identification of noted issue re: resident #28, IDT members, including the PA were notified of weight loss. Facility Physician Assistant assessed resident noting dx of Adult FTT and Severe Protein-Calorie Malnutrition. The provider discussed potential use of enteral/tube feedings to support resident nutrition status. Resident declined tube feeding/nutritional enteral support. Continue to assist resident #28 with feeding, continue to encourage meal, fluid, and supplement intake, and encourage oral fluids q 1hours. Comfort measures were orders by provider on July 17, 2025. Residents are weighed upon admission and at intervals determined by the IDT. Any weight change of 5# or more since the last assessed weight is retaken the next day for confirmation. The facility EMR notifies staff of significant changes in weight status as well. The weight alerts are reviewed and assessed by the facility Registered Dietitian along with other members of the IDT. If a significant change in weight is confirmed, the IDT including the resident physician and/or physician assistant will be notified. The current nutrition plan of care will be reviewed and adjusted as necessary. The facility Registered Nurse Assessment Coordinator will determine if resident qualifies for a significant change assessment and notify IDT members. Education and training was provided to clinical staff regarding the facility's weight program, and the need for timely resident reweighs was emphasized as part of this training. Weight reviews and trends will continue to be a part of the facility's Quality Assurance and Performance Improvement program. Audits will be completed on 5 charts weekly for one month and biweekly for 3 months in regard to the appropriate weights for monitoring and reporting purposes. Findings will be presented to the Quality Assurance Performance Improvement committee for recommendations, an explanation of any identified variance infractions.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
Surveyors determined that the facility failed to complete annual performance evaluations for three nurse aides, as required by federal and state regulations. Personnel record reviews showed that for three employees, there was no documented evidence of a performance evaluation being completed at least once every 12 months. The specific employees had hire dates ranging from 1991 to 2017, and their last recorded evaluations did not meet the annual requirement. During an interview, the Nursing Home Administrator confirmed that annual performance evaluations were not completed for the three nurse aides in question. This deficiency was identified through a review of employee records and direct confirmation from facility leadership, with no evidence provided to show compliance with the required evaluation schedule.
Plan Of Correction
No evidence of any actual ill effect exists on any residence in our community due to the lack of adherence to the requirements of completion of performance evaluations for staff members identified as #7, 8, and 9. Performance evaluations were completed on these staff members to ensure they meet such requirements. Performance evaluations are being conducted/completed on the current CNA staff. Information on a deficiency basis on these evaluations will be utilized for future training purposes. In addition, performance evaluations will be scheduled with staff on their original anniversary date. Management staff have been educated about the need for annual performance evaluations, and a system of tracking and scheduling is created to ensure human resources send out monthly reminders of those required. A tracking tool will be reviewed monthly for six months to ensure performance evaluations are completed and filed in the individual staff records. Findings will be presented to the Quality Assurance Performance Improvement committee for recommendations, an explanation of any identified variance infractions.
Failure to Develop Individualized Dementia Care Plans
Penalty
Summary
The facility failed to develop and implement individualized, person-centered care plans to address dementia and cognitive loss for three residents who had been admitted with a diagnosis of dementia. Clinical record reviews for these residents showed that, although the facility assessed each resident as having dementia and determined that a care plan would be developed, there was no evidence in the care plans that such individualized plans addressing dementia and cognitive loss were actually created or implemented. This lack of documentation was confirmed by both the Nursing Home Administrator and the Director of Nursing during interviews, who acknowledged that no further documentation existed to show that appropriate care plans had been developed prior to surveyor inquiry. For one resident, the care plan was only developed after the surveyor raised concerns, and it was noted that the plan should have included family involvement in its development. The findings were confirmed through interviews with facility staff, including a social worker, who acknowledged that the individualized dementia care plan was created only after the issue was brought to their attention by the surveyor. The deficiency centers on the facility's failure to provide appropriate, individualized treatment and services for residents with dementia as required.
Plan Of Correction
Newly completed individualized dementia care plans were developed for residents #33, #52, and #61 by the facility's social worker. No evidence of any actual ill effect exists on any of the residents in our community due to the lack of adherence to the requirements of said individualized care plans. A review of the residents admitted within the past six (6) months was conducted to ensure all residents with a current diagnosis of dementia have individualized care plans in place. Future admissions or residents with newly diagnosed dementia will have a new care plan completed within 72 hours. An education session was completed by the director of nursing or designee with social services on the importance of accuracy of diagnosis on care plans and ensuring that they are individualized to each resident. Audits will be completed on five (5) charts weekly for one month and biweekly for three (3) months relating to the residents with a diagnosis of dementia and ensure the care plan has been appropriately annotated. Findings will be presented to the Quality Assurance Performance Improvement committee for recommendations, an explanation of any identified variance infractions.
Failure to Provide Written Transfer and Bed-Hold Notices During Hospitalization
Penalty
Summary
The facility failed to provide required written notices of transfer and bed-hold policies to residents and/or their representatives at the time of transfer for three residents who were hospitalized. For one resident, documentation showed a change in condition that led to a 911 call and subsequent hospital admission for a urinary tract infection. The resident returned to the facility several days later, but there was no documentation that the resident or their representative received written notice of the transfer or the facility's bed-hold policy. This lack of documentation was confirmed by the Director of Nursing during an interview. Another resident was transferred to the emergency room for evaluation due to mental status changes, weakness, and frequent falls, and was admitted to the hospital for weakness and pneumonia. Again, there was no documentation that the resident or their representative received the required written notices at the time of transfer. The surveyor requested this documentation during meetings with facility leadership, but it was not provided. A third resident was transferred to the hospital for a change in condition and returned after a short stay. Review of the clinical record revealed no documentation that the resident's representative received written notice of transfer or the facility's bed-hold policy. Interviews with facility staff confirmed that these notices were not provided as required. The deficiency was identified through clinical record review and staff interviews, which consistently showed a lack of compliance with federal requirements for written notification during resident transfers.
Plan Of Correction
The facility provides a written Bed Hold Acknowledgment and Notice of Transfer document containing all the required elements, including the date of transfer, specific reason for discharge/transfer, location to be transferred, right to appeal process information, and the information pertaining to the Office of the Long-Term Care Ombudsman to the responsible party for those residents identified (#28, 59, and 65). A copy of the Bed Hold Acknowledgment and the Notice of Transfer Document was sent to residents #28, #59, and #65. Once a copy of the signed documents is returned, they will be filed in the resident's medical chart. A review of the facility's resident records, who were transferred over the past six (6) months, will be completed, and corrective actions will be taken if necessary. Education was provided by Social Services and the Admissions Director on the Notice Requirements before Transfer/Discharge Notification Program and the process to be completed upon each transfer. Education was provided to all Nursing Staff. Any future transfers will be reviewed by the Admission Director at the morning meeting (five days per week) to ensure proper procedures were followed for the Notice Requirements before Transfer/Discharge process, including the initial notification verification, and the written notification of the transfer/discharge and the reasons for the move. Audits will be completed on all transfers weekly for two months and bi-weekly for three months. Findings will be presented to the Quality Assurance Performance Improvement committee for recommendations, including an explanation of any identified variance infractions.
Deficient Food Storage, Sanitation, and Documentation in Kitchen
Penalty
Summary
Surveyors observed multiple failures in food storage, equipment sanitation, and food preparation practices in the facility's main kitchen. During an initial tour, a walk-in freezer was found to contain a cardboard box with several items in slide lock plastic bags, including baked beans and peeled bananas, none of which were labeled or dated. The Director of Dining Services was unable to clarify when these items were packaged or their intended use-by dates. Additionally, several packages of sliced flavored bread stored on a shelf under circulating fans in the freezer had significant ice accumulation. In the dry goods storage area, the floor beneath four shelving units was found to have a significant accumulation of debris, including dust, unopened soda cans, discarded paper products, condiment packets, a butter packet, and several plastic spoons. A kitchen shelf held two partially used vinegar containers and a partially used syrup container, all lacking open dates. An expandable dough cutter in a drawer was found with extensive build-up of a batter-like substance and multiple areas of rust. A review of tray line food temperature logs revealed missing documentation for dinner temperatures on several dates. The Director of Dining Services confirmed that food temperatures should be documented for each meal service but was unable to explain the missing records. These findings were discussed with the Nursing Home Administrator and Director of Nursing. The report also notes that similar deficiencies had been previously cited.
Plan Of Correction
The facility dietary department conducted a thorough cleaning of the entire department to include the dry storage area and under the walk-in freezer fan. In addition, all areas such as the freezer, refrigerators, coolers, and storage areas were inspected, and any corrections needed to labels, etc., were made at that time. No action could be taken on the failure to document the tray line food temperatures. The expandable dough cutter was removed and disposed of. If needed, a new cutter will be ordered for use in the kitchen. Corrective actions were taken in the areas identified, and education was provided at a mandatory meeting with staff to address the importance and necessity of proper cleaning techniques. In addition, the session included the sanitary and safe operations of the kitchen to include all documentation requirements and temperature recordings. Audits of the kitchen area's
Failure to Offer Updated Pneumococcal Immunizations per CDC Guidance
Penalty
Summary
Surveyors determined that the facility failed to offer recommended pneumococcal immunizations to five residents who were reviewed for immunizations. The facility's policy required that residents be assessed for eligibility to receive the pneumococcal vaccine upon admission and, when indicated, be offered the vaccine within 30 days. The policy also stated that administration of the vaccine should follow current CDC recommendations. However, clinical record reviews revealed that several residents had received previous pneumococcal vaccines prior to admission, but there was no documentation that the facility offered updated pneumococcal vaccinations in accordance with the latest CDC guidance. Specifically, the records for five residents showed that although they had received earlier versions of the pneumococcal vaccine (such as Prevnar 13 and PPSV23), there was no evidence that the facility assessed or offered updated vaccines as recommended by the CDC's October 2024 guidance. For example, one resident had received Prevnar 13 in 2016 and PPSV23 in 2001, but there was no documentation of an offer for an updated vaccine. Another resident had received Prevnar 13 in 2022, but the record did not show that the facility offered the required follow-up vaccine (PCV20 or PCV21) one year later. The lack of documentation extended to all five residents reviewed, with no evidence that the facility engaged with the residents or their representatives to decide on updated pneumococcal vaccination, as required. This deficiency was identified through clinical record review, policy review, and staff interviews, and it was noted that the facility had previously been cited for a similar issue.
Plan Of Correction
Residents 11, 18, 19, and 29 (or their resident representative) have been contacted by the facility's medical records representative and provided education and handouts, as well as an offer for the updated vaccine. As the resident or representative's decision is conveyed, the outcome was/will be annotated in the medical chart on the Pneumococcal Consent, in the administration record, and under the immunization tab in each resident's chart. Resident #23 has ceased to breathe on July 21, 2025. A facility audit was completed on 7/22/25 to identify all residents who are due for Pneumococcal Immunization. Residents due for the vaccine will be offered a Prevnar 20 per the recommendation of the Medical Director. Resident education will be provided with each resident's consent. Education was provided to clinical staff and the admissions director, ensuring they are familiar with and aware of the Prevnar 20 vaccine and the need to offer the vaccine to incoming residents or their responsible parties. Weekly audits will be conducted for one month and bi-weekly for three months on all new residents to assure compliance with the requirements set forth in the vaccine program. Findings will be presented to the Quality Assurance Performance Improvement committee for recommendations, including an explanation of any identified variance infractions.
Some of the Latest Corrective Actions taken by Facilities in Pennsylvania
Policy & System Changes
- Reviewed and revised the facility elopement policy to strengthen prevention measures (J - F0689 - PA)
- Updated resident‐escort procedures and created an office-to-facility return protocol to ensure residents are not left unattended after appointments (K - F0689 - PA)
- Implemented a staffing ratio of one staff member for every eight resident smokers to provide adequate supervision during smoking times (J - F0689 - PA)
- Placed lists of residents at risk for elopement at each nursing station to keep staff continuously aware of high-risk individuals (J - F0689 - PA)
- Installed elopement binders with resident photos at all nurses’ stations and reception areas for rapid identification of at-risk residents (J - F0689 - PA) (J - F0689 - PA)
- Added a protective cover over the exit-door release button to limit unauthorized resident egress (J - F0689 - PA)
- Established daily door-alarm functionality audits by maintenance to ensure exit alarms remain operable (J - F0689 - PA)
- Instituted validation checks of resident returns from off-site appointments before closing transportation logs (K - F0689 - PA)
- Started head counts of all residents each shift against census to detect missing residents promptly (J - F0689 - PA)
- Integrated elopement-risk screening into admission, quarterly reviews, and daily stand-up audits to keep care plans and interventions current (J - F0689 - PA) (J - F0689 - PA)
Staff Education & Drills
- Trained staff on escort requirements for off-site appointments to prevent unsupervised outings (K - F0689 - PA)
- Educated all staff, including agency personnel, on revised elopement policies, documentation of exit-seeking behaviors, reporting protocols, and intervention implementation (J - F0689 - PA)
- Provided comprehensive training on dementia behaviors, elopement-risk mitigation, alarm response, resident re-orientation, lobby monitoring, code 10 procedures, and safety checks (J - F0689 - PA)
- Educated staff on the facility’s smoking prohibition and supervision requirements to reduce unsupervised exits for smoking (J - F0689 - PA)
- Incorporated elopement-risk, missing-person, and visitor-badge procedures into new-employee orientation to sustain competence in future staff cohorts (J - F0689 - PA)
- Conducted elopement drills every shift and instituted monthly drills on all shifts to reinforce rapid response skills (K - F0689 - PA) (J - F0689 - PA)
- Educated reception and security staff on enforcing visitor-badge return prior to door release to control building egress (J - F0689 - PA)
- Held interdisciplinary huddles to review residents with frequent leave-of-absence orders and early signs of elopement risk to enhance proactive monitoring (J - F0689 - PA)
Failure to Educate Staff on Safe Food Heating Results in Resident Burn
Penalty
Summary
The facility failed to ensure that direct care staff were educated on the safe process for heating and reheating food, as required by facility policy. The policy specified that food and beverages must be heated, stirred, temperature-checked, stirred again, and re-checked before being served to residents, with temperatures maintained between 140°F and 165°F to minimize the risk of burns. However, a licensed nurse who had not received this education prepared instant ramen soup for a resident and did not check the temperature before serving it. The resident involved had diagnoses of diabetes and peripheral vascular disease, was cognitively intact, and required set-up assistance with feeding. After the soup was served, the resident spilled it on their chest, resulting in a second-degree burn. Observations and clinical documentation confirmed the presence of a significant burn area on the resident's chest and abdomen, and the resident reported pain following the incident. Progress notes and wound care consults documented the extent and treatment of the burn. Interviews and facility documentation revealed that the nurse did not follow the required procedure for checking food temperature, and there was no evidence of temperature documentation for the soup. The Nursing Home Administrator confirmed that the staff member had not been trained on the safe food heating policy, and further acknowledged that all direct care staff, including nurses and nursing assistants, had not received this education. This lack of staff education and failure to follow policy led to an Immediate Jeopardy situation when the resident sustained a burn from overheated food.
Removal Plan
- Education was provided to the staff
- A whole house audit was conducted to check all microwaves in the facility had thermometers attached to it
- All residents were assessed to ensure no other residents received a burn from re-heated food items
- Process signage for re-heating food in the microwave were attached to the microwaves
- House-wide education developed and implemented for all facility staff on re-heating process, education was implemented and presented during the new hire and agency orientation
- Dietary performed audits to ensure thermometers are present and functioning on all microwaves in resident areas
- Audits were completed and ongoing
- The outcome of audits will be reviewed at the QA meeting
Failure to Supervise Severely Cognitively Impaired Resident During Offsite Appointment
Penalty
Summary
The facility failed to provide adequate supervision to prevent elopement for a resident with severe cognitive impairment, resulting in an immediate jeopardy situation for multiple residents. Specifically, a resident with a BIMS score of 6, indicating severe cognitive impairment, was allowed to leave the facility unaccompanied for a medical appointment, despite facility policy requiring an escort for residents with a BIMS score lower than 13. The resident was not identified as at risk for elopement in the care plan, and the physician's order permitted the resident to leave unaccompanied when arranged by the facility. During the appointment, the resident was left unsupervised in the lobby, was not picked up as planned, and subsequently left the premises independently by calling a ride service and returning to his home. Review of facility records revealed that several other residents with severe cognitive impairment also had orders allowing them to leave the facility unaccompanied, contrary to the established escort protocol. Staff interviews confirmed that residents with severe cognitive impairment should not be permitted to leave unaccompanied, and that new residents should not have such orders until evaluated by a provider. Despite these protocols, the facility failed to ensure that care plans and physician orders were consistent with the residents' cognitive status and supervision needs. The incident was further compounded by the lack of elopement-related goals and interventions in the affected resident's care plan, and the absence of appropriate supervision during the transfer process. The resident was reported missing after the appointment, prompting a police search and notification of emergency services. The resident was eventually located at his home, having left the appointment site without facility staff knowledge or supervision. This failure to provide adequate supervision and to follow established protocols resulted in an immediate jeopardy situation for all residents with similar cognitive impairments.
Removal Plan
- Complete AMA discharge at residence.
- Call emergency services for hospital transfer for PICC removal.
- Notify Adult Protective Services.
- Notify Ombudsman.
- Review escort protocol.
- Educate staff on sending residents to appointments with escorts.
- Update elopement book.
- Conduct wellness check on resident.
- Conduct elopement drills every shift.
- Validate appointment returns.
- Develop protocol for offices to call building or driver for return and not put residents in the lobby.
- Review upcoming appointments and determine if escorts are needed in morning meeting.
- Update care plans.
Failure to Ensure Nursing Staff Competency with Insulin Pump Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies and skill sets to care for a resident using an insulin pump, resulting in immediate jeopardy to the resident's health and safety. The Director of Nursing confirmed that there was no policy in place for insulin pumps, and the facility's policy on competent nursing staff was not followed in this case. Clinical record review showed that a resident with multiple diagnoses, including diabetes, was admitted with an insulin pump, but the nursing admission evaluation did not document the presence of the pump, and the care plan did not address its management. Multiple interviews with RNs and LPNs revealed that none of the nursing staff, including agency staff, had received education or training on insulin pumps. Staff members were unfamiliar with the device, its maintenance, and its operation, with some only having personal knowledge from outside the facility. One LPN, who was working her first shift at the facility, transcribed hospital discharge orders incorrectly, entering the wrong insulin type and route of administration due to lack of training and orientation. This error led to the administration of insulin subcutaneously instead of refilling the pump, resulting in the resident experiencing hypoglycemia and requiring hospital transfer for an accidental insulin overdose. The employee file for the LPN who made the error did not contain evidence of facility orientation or training on the admission process, order transcription, or insulin pump management. The Director of Nursing and Nursing Home Administrator confirmed that staff were not trained on insulin pumps or related processes, and that this lack of training and competency directly resulted in a negative outcome for the resident.
Removal Plan
- Audit residents to identify specialty equipment. If specialty equipment is identified, obtain physician orders. Update care plans to include specialty equipment if applicable.
- Audit admission assessments for residents for special equipment specifically insulin pumps and/or continuous glucose monitors.
- Audit physician orders from discharge paperwork for residents for accuracy.
- Conduct pre-admission resident screening to identify any special equipment. Communicate special equipment needs to the nursing team prior to resident admission. Educate Admissions Director on this process.
- Educate licensed nursing staff (including agency) on conducting pre-admission resident screening to identify any special equipment and communicating special equipment needs to the nursing team prior to resident admission.
- Educate licensed nursing staff (including agency) on assessing residents upon admission for special equipment including insulin pumps/continuous glucose monitors.
- Educate licensed nursing staff (including agency) on obtaining physician orders for specialty equipment.
- Educate licensed nursing staff (including agency) on accurate order transcription and admission red lining processes.
- Educate licensed nursing staff (including agency) on care plan updates on specialty equipment.
- Educate licensed nursing staff (including agency) on updated processes.
- Update and review facility policy on medication administration to include specialty equipment, obtaining physician orders, and updating care plans.
- Conduct audits of new resident admission assessments to ensure assessments, redlining, and orders are completed and accurate.
- Submit findings of audits through facility Quality Assurance and Performance Improvement program.
Failure to Prevent Elopement and Identify At-Risk Residents
Penalty
Summary
The facility failed to provide adequate supervision and monitoring to prevent accidents, specifically elopement, for two residents. One resident, who was assessed as being at risk for elopement due to cognitive impairment, poor decision-making skills, and exit-seeking behavior, was able to leave the facility unsupervised. This resident exited the building when a CNA was assisting other residents to a smoking area, and the door was opened using a code that temporarily disabled the Wanderguard alarm system. The resident was not identified as a smoker and was not being directly supervised at the time, allowing him to leave unnoticed until another resident alerted staff. Another resident, also with cognitive impairment and a history of exit-seeking behavior, was not properly identified as an elopement risk. Although this resident had previously been assessed as at risk and had a Wanderguard device ordered, the device was discontinued after one week without documented evidence of ongoing risk assessment or justification. Staff interviews revealed that this resident had managed to exit the building with visitors and had to be redirected frequently due to continued exit-seeking behaviors. However, the resident was not included in the facility's elopement risk binder, and key staff, including the NHA, were unaware of her risk status or previous incidents. Observations and staff interviews indicated a lack of consistent documentation and communication regarding which residents were at risk for elopement and who required supervision during high-risk activities such as smoking breaks. Staff relied on informal knowledge rather than documented lists, and there was insufficient supervision during these times. The facility's failure to identify and supervise residents at risk for elopement resulted in one resident leaving the premises without staff knowledge and another resident's risk not being properly managed or communicated.
Removal Plan
- The facility reviewed and revised the elopement policy.
- The Director of Nursing or designee will complete assessments on all residents to identify their risk for elopement, and care plans will be updated to reflect the residents' current condition, risk for elopement and resident centered interventions.
- A list of residents at risk for elopement will be placed at each nursing station to inform staff of residents at risk.
- The Nursing Home Administrator or Designee will educate all staff, including agency staff, on elopement policies and procedures, documenting residents with exit seeking behaviors, reporting exit seeking behaviors to administration and implementing proper interventions for these residents prior to staff's next scheduled shift.
- The facility will allocate additional staff members to supervise smokers to ensure appropriate supervision is available to meet residents.
- The facility will have one staff member for every eight residents who smoke.
- The Facility will complete a head count of all residents each shift to ensure residents are safe and provided adequate supervision.
- The Director of Nursing of Designee will review progress notes daily to identify any residents with new exit seeking behaviors to ensure appropriate interventions are in place.
- The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for frequency of audits.
Failure to Prevent Elopement Due to Inadequate Supervision and Care Planning
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident who was identified as being at risk for wandering and exit-seeking behaviors. The resident had a history of cognitive impairment, poor decision-making skills, and demonstrated wandering and exit-seeking behaviors, as documented in an Elopement Risk Assessment. Despite these findings, the resident's care plan did not include any interventions to address elopement risk, and there were no physician orders for elopement prevention measures. On the day of the incident, the resident was last seen by staff in a recliner in the community room and later in another resident's room before being returned to his own room around 7:30 p.m. The resident was left unsupervised, and staff failed to monitor the front door, which allowed the resident to exit the facility without detection. The absence of supervision at the front desk was confirmed by video footage, contradicting an initial staff statement. The facility did not document the resident's wandering behaviors in the progress notes, and there was no immediate notification to local authorities by the facility when the resident was discovered missing. The resident was found by police in a nearby residential area without shoes and with no memory of how he arrived there. The police were alerted by a passer-by, not the facility, and the resident was subsequently taken to the emergency department for evaluation. The incident revealed gaps in supervision, documentation, and adherence to elopement prevention protocols, resulting in an immediate jeopardy situation for the resident.
Removal Plan
- Complete a root cause analysis to validate the cause of the resident elopement.
- Complete a head count to ensure all residents are accounted for.
- Reassess the resident upon return from the hospital and implement frequent checks.
- Audit all elopement books to ensure accuracy.
- Review and assess all residents for elopement risk, wandering, and update care plans and orders to include appropriate interventions.
- Assess all residents in house for elopement risk by the Director of Nursing or designee.
- Review and update care plans for residents identified with elopement risks with interventions to prevent elopement by the Director of Nursing or designee.
- Add all residents identified to be elopement risk to Elopement Binder per protocol.
- Conduct a house audit on all doors and exit points to ensure that facility is secure and alarms are functional by Maintenance.
- Conduct education to all facility staff regarding dementia/behavior in LTC residents, elopement risk and mitigation, and elopement policy and procedures to include keeping doors secure.
- Educate all staff on elopement interventions such as responding to alarms, reorienting wandering patients, encouraging activities, monitoring the front lobby and sign in sheet, code 10, and safety checks.
- Educate staff that all residents assessed as an elopement risk will have their picture and face sheet in the elopement book.
- Place elopement books with identified resident photos on all nurses' stations in addition to the current one at the receptionist's desk by the Administrator or designee.
- Screen newly admitted residents for elopement risk on admission, quarterly and as needed, and update care plans appropriately.
- Place new admissions and any resident assessed as an elopement risk in the elopement book that includes photograph and face sheets. Book is available for staff to review and monitor at all times.
- Investigate all incidents, perform root cause analysis and follow up with appropriate interventions by the DON or designee.
- Review elopement interventions and update as required by the QAPI team.
- Ensure the front door is monitored 24 hours 7 days a week by the RN supervisor until the wander guard system is installed.
- Review the lobby monitoring sign in sheet regularly.
- Audit door alarms daily by maintenance.
- Conduct elopement drills monthly on all shifts.
- Monitor the plan of correction by QAPI including all door audits, elopement book, elopement drills and all new admissions will be audited for elopement risk.
- Monitor the plan of correction at the Quality Assurance and Process Improvement meeting until consistent substantial compliance has been met.
Failure to Prevent Elopement and Ensure Smoking Safety
Penalty
Summary
The facility failed to implement sufficient monitoring interventions and supervision to prevent an elopement incident involving a resident. The resident, who had a history of traumatic subdural hemorrhage, mild cognitive impairment, COPD, type 2 diabetes, repeated falls, anxiety, depression, and nicotine dependence, was able to exit the facility without staff awareness. The resident left the premises by unlocking the door and leaving the property to purchase cigarettes, despite the facility's status as a tobacco-free, non-smoking environment. Staff interviews and documentation confirmed that the resident was able to access the door release button and leave the facility unsupervised. Prior to the elopement, there was no evidence that the facility had conducted a safe smoking assessment or implemented any safety interventions related to the resident's smoking habits. Progress notes indicated that the resident had previously been caught smoking inside the facility and had expressed frustration about not being able to smoke, but no additional safety measures or care plan updates were documented. The resident's care plan and progress notes lacked any interventions or updates addressing elopement risk or smoking safety from the time of the incident until the investigation several days later. Staff interviews revealed that the resident's cigarettes and lighter were kept in a locked medication cart, and when the resident requested a cigarette, staff would provide them and allow the resident to smoke on the porch. However, there was no supervision or monitoring in place to prevent the resident from leaving the property. The facility was unable to provide a smoking policy when requested, and there was no documentation of the elopement in the progress notes until the investigation began. At the time of the investigation, no elopement prevention interventions had been implemented for the resident.
Removal Plan
- Resident will have a smoking assessment completed. Resident will have supervised smoking three times per day until discharged to a smoking facility, or until discharged to his residence.
- All residents will be assessed for elopement risk by the director of nursing or designee.
- All care plans for residents identified with elopement risks will be reviewed and updated if needed with interventions to prevent elopement by the Director of Nursing or designee.
- A facility care feed message will be sent to families reminding them that the facility is a non-smoking facility and resident smoking is prohibited.
- Education will be completed by all staff on elopement risks, assessments, and supervision of residents by the director of nursing or designee.
- Education will be provided to all staff on facility smoking policy. Facility is a non-smoking facility for residents.
- Elopement books with identified resident photos will be placed on all nurses stations in addition to the current one at the receptionist's desk by the Administrator or designee.
- A protective device will be placed over the exit door button to prevent residents from access.
- Audits will be implemented to ensure residents are adhering to the facility smoking policy by the Director of nursing or designee.
- New admissions will be audited for elopement and smoking risks at morning stand up meeting by the director of nursing or designee to ensure appropriate interventions are in place as needed.
- An Ad Hoc Quality Assurance and Process Improvement Meeting will be held by the Administrator or designee.
- This part of correction will be monitored at the Quality Assurance and Process Improvement meeting until such time consistent substantial compliance has been met.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Protocol Lapses
Penalty
Summary
A deficiency occurred when a resident with a history of repeated falls, difficulty walking, pelvic fracture, and cognitive impairment was able to leave the facility without a physician's order for a leave of absence (LOA) and without staff supervision. The resident, who required one-person assistance for ambulation and had a moderately impaired cognitive status as indicated by a BIMS score of 10, exited the third floor via elevator and walked out the front entrance using a walker. The resident was not identified as having an LOA order in the clinical records, and there was no documentation of staff being notified or a sign-out process being followed. Facility policy required that residents at risk for wandering or elopement have care plans with specific interventions and that staff intervene if a resident attempts to leave. However, the receptionist on duty did not recognize the resident as a facility resident, mistaking her for a visitor due to her appearance. The receptionist was distracted by personal computer use and failed to follow the protocol of ensuring all residents and visitors sign out and wear visitor badges. Surveillance footage confirmed that the receptionist opened the door for the resident, who then left the premises unchallenged. Staff interviews revealed that the assigned nursing assistant was aware the resident wanted to walk but did not clarify the resident's intentions or monitor her whereabouts. The resident was later found approximately 1.2 miles away in a busy area after being missing for about two hours. The failure to provide adequate supervision and to follow established LOA and visitation protocols resulted in the resident leaving the facility unsupervised, placing her at high risk for injury.
Removal Plan
- Resident was assisted back to the Center and assessed by RN Supervisor for injuries.
- The Center completed a headcount of all residents and compared it to the midnight census to ensure all residents were accounted for.
- The Nursing Administration held huddles with staff to discuss residents who go on frequent LOAs and signs and symptoms that may indicate risk for leaving the Center without staff notification.
- Shift RN Supervisor provided immediate education to receptionist on duty.
- RN Supervisors were educated on the completion of headcount of all residents compared to midnight census and the immediate reporting of any discrepancy to the Director of Nursing/designee.
- Staff were educated on signs and symptoms that may indicate a risk of elopement.
- Reception/security staff were educated on the process of each visitor receiving a badge that must be returned prior to door being opened and visitor leaving the premise.
- Staff educated on elopement/missing person policy and procedure including code yellow announcement to notify staff in Center, search both on the premises and the surrounding areas, notification processes including local police department.
- Staff educated on elopement drills including how often and expected response.
- All the training above will be added to our general orientation schedule for all new future employees.
- Residents with a current unsupervised LOA order were re-educated on the LOA policy/agreement and understood the sign out process with both the nursing staff on the unit.
- Auditing census compared to headcount every 4 hours for 3 days then every shift for 14 days then daily. All variances will be reported to the QAPI Committee monthly.
- Random audit of five visitors to ensure compliance with the visitor pass system two times daily for 14 days then daily for two months. All variances will be reported to the QAPI Committee monthly.
- Daily audit of LOA log to ensure reception/security staff are checking for clearance to leave the Center. The audit will be completed daily for three weeks with all variances reported during the clinical meeting.
- The QAPI Committee will make recommendations to ensure continued compliance. Upon sustained compliance, the QAPI Committee will recommend the reduction or resolution of the audits and the reception/security staff.
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