Observations:
Based on review of clinical record and facility job descriptions, and staff interview, it was determined that the facility failed to ensure that nursing services met professional standards of quality as required by the Pennsylvania Code Title 49, Professional and Vocational Standards by failing to ensure that a Registered Nurse (RN) conducted assessments for seven of 17 sampled residents requiring transfer to the hospital (Residents R10-R16).
Findings include:
Review of Title 49, Professional and Vocational Standards, Department of State Chapter 21, State Board of Nursing, indicated that under Responsibilities of the RN, 21.11, "General Functions. (a) The registered nurse [RN] assesses human responses and plans, implements and evaluates nursing care for individuals or families for whom the nurse is responsible", and "(b) The registered nurse is fully responsible for all actions as a licensed nurse and is accountable to clients for the quality of care delivered."
The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals.
21.145 "Functions of the LPN [Licensed Practical Nurse], (a) ... The LPN participates in the planning, implementation and evaluation of nursing care using the focused assessment in settings where nursing takes place."
Review of the facility Job Description for LPNs indicated that the LPN will "Administer resident care under the supervision of a RN and/or physician to maintain the highest level of resident care; function within the scope of practice according to the State Board of Nursing; and observe, evaluate, and report any abnormal findings .... and any significant changes in condition."
Review of the facility Job Description for RNs indicated that the RN will "Administer resident care under the supervision of a the Director of Nursing [DON] and/or physician to maintain the highest level of resident care; function within the scope of practice according to the State Board of Nursing; and observe, assess, and report any abnormal findings ..... and any significant changes in condition."
Resident R10's clinical record revealed an admission date of 5/07/24, with diagnoses including arthropathy (any disease or disorder affecting the joints, which can cause pain, swelling, stiffness, and reduced function), sacroiliitis (inflammation in the joints where your spine meets your pelvis), Type 2 Diabetes (condition in which the body cannot use insulin correctly and sugar builds up in the blood) and stroke. On 2/11/26, at 12:45 a.m. Resident R10 fell from his/her bed, sustained injury, and was transferred to the hospital for emergency evaluation and treatment.
Resident R11's clinical record revealed an admission date of 1/27/24, with diagnoses including irregular heartbeat, depression, heart disease, and fibromyalgia (long-term condition that involves widespread body pain, fatigue, issues with sleep, memory and mood). On 2/14/26, at 5:12 a.m. Resident R11 fell in the hallway, sustained injury, and was transferred to the hospital for emergency evaluation and treatment.
Resident R12's clinical record revealed an admission date of 1/10/26, with diagnoses including kidney stones, displacement of kidney drainage tube, urinary tract infection, and heart failure. On 1/14/26, at 5:22 p.m. Resident R12's kidney drainage tube became displaced and he/she required emergency transfer to the hospital to replace the tube.
Resident R13's clinical record revealed an admission date of 6/26/19, with diagnoses including bacterial infection in the blood, heart failure, Type 2 Diabetes, and irregular heartbeat. On 1/14/26, at 12:43 a.m. Resident R13 experienced a change in condition and required transfer to the hospital for emergency evaluation and treatment.
Resident R14's clinical record revealed an admission date of 1/20/26, with diagnoses including high blood pressure, emphysema (long term lung condition that causes shortness of breath due to damaged air sacs in the lungs), Type 2 Diabetes, and stroke. On 1/11/26, at 12:45 p.m. Resident R13 experienced a change in condition and required transfer to the hospital for emergency evaluation and treatment.
Resident R15's clinical record revealed an admission date of 9/30/25, with diagnoses including stroke, heart attack, fainting, and heart disease. On 2/17/26, at 7:11 p.m. Resident R15 experienced a change in condition and required transfer to the hospital for emergency evaluation and treatment.
Resident R16's clinical record revealed an admission date of 5/25/25, with diagnoses including bacterial infection in the blood, skin infection of the right leg, chronic obstructive pulmonary disease (COPD- lung disease that causes airflow blockage and breathing problems). On 2/09/26, at 10:49 p.m. Resident R16 experienced a change in condition and required transfer to the hospital for emergency evaluation and treatment.
During interviews on 2/23/26, between 6:00 p.m. and 8:00 p.m. and 2/24/26, between 8:45 a.m. and 3:15 p.m. with LPN Employees E1 through E5 confirmed they are expected to complete their own assessments on residents newly admitted to the facility, residents sustaining injuries, and residents experiencing change in condition, and are responsible for obtaining provider's orders for emergency transfer to the hospital based on their assessments. LPN Employees E1 through E5 also confirmed that there are many times that there is not an RN available to complete the assessments on residents.
Review of clinical records for Residents R10-R16 lacked evidence that they were assessed for injuries and/or change of condition by an RN prior to being transferred to the hospital for emergency evaluation and treatment.
During an interview on 2/24/26, at 12:10 p.m. the DON confirmed that the assessments for the above residents were conducted by an LPN, without the oversight or assistance of an RN and that he/she was not aware that an RN was required to perform assessments for residents experiencing a change in condition.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1)(3) Management
28 Pa. Code 201.18(e)(1) Management
28 Pa. Code 211.10(d) Resident care policies
28 Pa. Code 211.12(d)(1)(5) Nursing services
| | Plan of Correction - To be completed: 04/15/2026
F 658 Comprehensive Care Plans
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice.
The director of nursing or designee reviewed the records of residents R10, R11, R12, R13, R14, R15 and R16 following their transfers to the hospital. Each residents assessment, provider communication and transfer documents were reviewed for completeness and adherence to professional standards of quality.
How the care community will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken.
The director of nursing of designee completed a facility-wide audit of all residents transferred to the hospital over the past 2 weeks to determine whether any transfers occurred without proper documentation meeting standards of quality. Any resident identified during the audit had their assessments and care plans reviewed and updated.
What measures will be put into place or what systemic changes will you make to ensure that the deficient practice does not recur?
Director of nursing or designee will educate licensed nursing staff on federal requirements under F658 ensuring all services meet the professional standards of quality. The Director of nursing or designee will educate licensed nursing staff on the standards of practice for a licensed practical nurse/LPN including the Licensed practical nurses ability to participate in the planning, implementation and evaluation of nursing care using focused assessment in settings where nursing takes place, and that they shall communicate with a licensed professional nurse and the patients' health care team members to seek guidance in all areas of the code but specifically, when the patient's condition deteriorates of there is a significant change in condition the patient is not responding to therapy, the patient becomes unstable or the patient needs immediate assistance. Registered Nurses will be educated on assessments and the need to ensure that they: collect complete and analyze ongoing data to determine nursing care needs, analyze the health status of the individuals and compare the data with the norm when possible in determining nursing care needs, and carry out nursing actions that promote, maintain and restore the well-being of individuals in accordance with Title 49, Professional Vocational Standards 21.11(a)(1)(2) and (4).
A standardized notification and escalation protocol has been implemented. Education was provided on the definition of a focused assessment to ensure documentation aligns with accepted professional standards.
How will the corrective action(s) be monitored to ensure that deficient practice will not recur, i.e., what quality assurance program will be put into place; and
Director of nursing or designee will audit all residents with change in condition resulting in a transfer to the hospital, licensed practical nurse documentation and registered nurses assessments, as appropriate, to ensure there was communication to the licensed professional nurse and patients health care team members in accordance with Pennsylvania Code Section Title 49 21.145 related to changes in condition. All residents with a change in condition resulting in transfer to the hospital will be audited for 3 weeks and one resident transfer a week for 3 weeks randomly thereafter to ensure sustained compliance.
All audits will be reviewed through the monthly quality assurance and performance improvement committee,
Dates when corrective action will be completed.
April 15, 2026
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