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
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Facility staff failed to follow dialysis care policies and the care plan for a resident with diabetes mellitus, chronic kidney disease, and an upper extremity hemodialysis fistula. Despite clear directions to avoid using the arm with the dialysis access for any treatment, including blood pressure measurement, staff repeatedly documented taking blood pressure on that arm over multiple months. The DON later confirmed that the resident’s blood pressure had been measured on the arm containing the dialysis access.
A resident admitted with PTSD, depression, polyneuropathy, and insomnia, and assessed as having no cognitive impairment but needing substantial assistance with ADLs, was not evaluated for PTSD-related symptoms or triggers. The care plan did not address the resident’s trauma history, identify triggers, or include specific interventions to minimize triggers or re-traumatization. The DON confirmed that no PTSD assessment or related care planning had been completed, resulting in a deficiency in required nursing services.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Improper Blood Pressure Measurement on Dialysis Access Arm
Penalty
Summary
Facility staff failed to provide appropriate dialysis-related care by not adhering to policy and the resident’s care plan regarding protection of a hemodialysis access site. The facility’s policy on hemodialysis external catheter evaluation and maintenance, last reviewed February 24, 2026, directed staff to avoid taking blood pressure from an arm with a dialysis access device. The resident, who had diabetes mellitus with chronic kidney disease and required ongoing hemodialysis, had a care plan initiated November 11, 2021 and last reviewed December 17, 2025 that instructed staff to monitor the left upper extremity fistula for bleeding and to avoid using that arm for any treatment to prevent complications related to dialysis access. Despite these directives, clinical record review showed that staff documented taking the resident’s blood pressure on the left arm 10 times in January 2026, 10 times in February 2026, 14 times in March 2026, and four times in April 2026. In an interview on April 17, 2026, the Director of Nursing confirmed that the documentation showed the resident’s blood pressure had been measured on the left arm containing the dialysis access. These findings were cited under 28 Pa. Code 211.10(d) Resident care policies and 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
Failure to Assess and Care Plan for Resident with PTSD
Penalty
Summary
Surveyors identified that the facility failed to provide trauma-informed, person-centered care for a resident with a documented diagnosis of post-traumatic stress disorder (PTSD). The resident was admitted with PTSD, depression, polyneuropathy, and insomnia, and a Minimum Data Set assessment showed no cognitive impairment, a need for substantial assistance with activities of daily living, and a confirmed PTSD diagnosis. Despite this, the clinical record contained no documentation that the resident had been assessed for PTSD-related symptoms or triggers, and the resident’s care plan lacked any measures addressing the history of trauma, identifying triggers, or specifying interventions to minimize triggers or re-traumatization. In an interview, the Director of Nursing confirmed that the resident had not been assessed or care planned for PTSD, in violation of 28 Pa. Code 211.12(d)(3)(5) regarding nursing services.
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.
Explore Popular Searches
