§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and
§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
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Observations:
Based on clinical record review, review of facility documentation, and resident and staff interviews, it was determined that the facility failed to ensure each resident's environment was free of accident hazards by ensuring illegal substances were not accessible to two of six sampled residents. (Residents 1 and 2) In addition, the facility failed to ensure the safety of residents in all areas of the facility in one of two nursing units (Unit A) and first floor common areas. This failure resulted in an Immediate Jeopardy situation.
Findings include:
Clinical record review revealed that Resident 1 was admitted to the facility on December 11, 2024, with diagnoses that included alcoholic cirrhosis of the liver (liver disease linked to heavy alcohol use), major depressive disorder, and diabetes (disease that affects blood sugar). According to the Minimum Data Set (MDS) assessment (a periodic evaluation of resident care needs), dated March 19, 2025, the resident had no cognitive (ability to think, reason, and remember) impairment. According to the care plan, Resident 1 ambulated (walked) independently.
Clinical record review revealed that Resident 2 was admitted to the facility on March 17, 2023, with diagnoses that included chronic pain, alcohol abuse, and other psychoactive substance abuse (misuse of drugs that affect the brain). According to the MDS assessment, dated March 15, 2025, the resident had mild cognitive impairment. According to the care plan, Resident 2 ambulated independently.
On April 9, 2025, a nurse noted that an unknown substance was found in Resident 2's bed. Review of facility documentation revealed the police were contacted, and the unknown substance was identified as a methamphetamine. The facility documentation further indicated that Resident 2 was interviewed on April 9, 2025, by the facility and police and identified Resident 1 as the source who sold him the methamphetamine. Resident 1 was then interviewed by the facility and police and was found to have a bag of the substance in his possession. Residents 1 and 2 were drug tested on April 9, 2025, with positive results for methamphetamine. Resident 1 was then taken into police custody on April 9, 2025.
In an interview on April 11, 2025, at 11:25 a.m., Resident 2 confirmed that he purchased the illicit substance from Resident 1, used it, and maintained it's possession in his room under his bed sheets.
In an interview on April 11, 2025, at 12:00 p.m., the Administrator stated that staff had checked the unit where Resident 1 and 2 resided (Unit B) and the second floor common areas for additional illegal substances, but that the search did not included any resident areas or common areas on the first floor of the building, including Nursing Unit A.
On April 11, 2025, 2024, at 1:40 p.m., the Administrator was notified that the failure to ensure a resident's environment was free of accident hazards by ensuring illegal substances were not accessible to residents and that the facility's failure to ensure the safety of residents in all areas of the facility constituted an Immediate Jeopardy situation at F689-K, and the Immediate Jeopardy template was provided. The facility was informed that a corrective action plan was required.
The facility presented an acceptable action plan for removal of the Immediate Jeopardy on April 11, 2025, at 5:05 p.m. The facility's action plan contained the following:
1. The facility immediately removed the substance found in Resident 2's room on April 8, 2025.
2. The police were contacted on April 9, 2025, and drug screens were completed on Residents 1 and 2 on April 9, 2025.
3. Resident 1 was taken into police custody On April 9, 2025, where he remains.
4. The facility searched all resident rooms and common areas to ensure there were no additional illegal substances. Searches were completed on April 11, 2025, at 2:30 p.m..
5. The facility monitored residents for signs and symptoms of illegal drug use or a change in condition on April 9, 2025, which is ongoing.
6. The facility educated all staff on the procedure for discovery of unidentified substances, and the new procedure to check in packages and bags with the receptionist or nursing. All staff that were available on April 11, 2025, were immediately educated. Other staff will be educated prior to the start of their next shift. 92% of facility staff were educated on April 11, 2025. The remaining 8% of staff will be educated by April 12, 2025.
7. Signs were hung on April 9, 2025, in the lobby for residents to see the receptionist upon return from a leave of absence.
8. Resident 2 and his responsible party have consented to randomized drug testing and to having a limited supply of money in his possession.
The survey team validated that the Immediate Jeopardy was removed on April 11, 2025, at 5:05 p.m., through review of the facility training, and review of facility procedures following the facility's implementation of the plan for removal of the Immediate Jeopardy.
28 Pa. Code 201.14(a)(b) Responsibility of Licensee.
28 Pa. Code 201.18(b)(1)(3) Management.
28 Pa. Code 212.12(d)(1)(3)(5) Nursing services.
| | Plan of Correction - To be completed: 04/26/2025
1. The facility immediately removed substance from Resident 2's room. Police were contacted; drug screening was completed on Resident 2. Resident 1 was taken into police custody. Resident 2 was placed on monitoring for s/s of change in condition. Resident 2 and his responsible party have consented to randomized drug testing and to having limited supply of money in his possession. Facility searched all resident rooms and common areas to ensure there were no additional illegal substances, search was completed 4/11/2025.
2. Administrator/ designee conducted a sweep in facility care areas. Licensed nurses monitored current residents for signs and symptoms of a change in condition. LOA procedure updated to include a search of packages and bags upon return. Signs were hung in lobby for resident to see receptionist upon return from leave of absence.
3. Will be providing directed in service to all licensed nursing staff on WF689 Free of Accident Hazards/Supervision/ Devises on 4/25/2025. No licensed staff will be allowed to work until in-serviced. The training will be provided by Affinity Health Services, an approved provider of directed in-service training. Nursing staff will be educated on the signs and symptoms of substance abuse. Education provided to staff regarding procedure if unidentified substance found and new LOA procedure regarding checking belongings upon return.
4. Administrator/ Designee will review new admissions to identify any history of illegal substance usage. The physician and family will be notified and interventions are implemented if history of illegal substances identified. Administrator/ Designee will complete return from LOA audit weekly X 4 weeks. Administrator/Designee will complete random room audits with resident permission to identify any illegal substance weekly X 4 weeks. The audits will be reviewed by the QAPI committee and the QAPI com will determine he need for future audits.
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