Initial Comments:
A focused fundamental survey survey was conducted on May 12-16, 2025, to determine compliance with the requirements of the 42 CFR Part 483, Subpart I Requirements for Intermediate Care Facilities. The census during the survey was 216, and the sample consisted of 16 individuals. Ten deficiencies were identified as a result of the survey.
Plan of Correction:
483.410(a)(1) STANDARD
GOVERNING BODY
Name - Component - 00
The governing body must exercise general policy, budget, and operating direction over the facility.
Observations:
Based on investigation review and staff interview, it was determined that the governing body failed to provide oversight and operating direction in the area of health care services. This applied to 13 individuals in the facility (Individuals #1, #3, #4, #5, #6, #7, #9, #13, #17, #18, #19, #28 and #30).
The findings included:
A) The governing body failed to ensure that Individuals #3, #5 and #13 received medical care and follow ups as recommended by specialists. Refer to W 322.
B) The governing body failed to ensure that Individuals #1, #5, #7, #9, #17 and #18 received nursing services in accordance to their needs. Refer to W 331.
C) The governing body failed to ensure that Individuals #4 and #6 received quarterly nursing physical examinations. Refer to W 336.
D) The governing body failed to ensure that Individual #9 received medications in accordance to the physician's orders. Refer to W 368.
E) The governing body failed to ensure that Individuals #19, #28, and #30 received medications without error. Refer to W 369.
An interview with the facility director on May 15, 2025, at 3:15 PM, confirmed that the governing body failed to provide direction and oversight in the area of health care services.
Plan of Correction:1. The Clinical Services Director (CSD) will notify the Governing Body (GB) when consults have been scheduled for individual:
#3 Audiology & Neurology
#5 Urology & Neurology
#13 Psychiatry
CSD (I)
GB (M)
6-27-25
2. The Quality Assurance Risk Manager (QARMD) will notify the Governing Body when the Audiologist and Psychiatrist has been trained ensuring follow-ups are completed within the specified time period.
QARMD (I)
GB (M)
6-27-25
3. The Nurse Manager (NM) will submit the revised Procedure for Medical Appointments Policy to the Governing Body for approval. The Governing Body will ensure the procedure emphasizes the timeline for medical appointments and follow ups to be completed in.
NM (I)
GB (M)
6-20-25
4. The NM will weekly report the progress of staff trained to the Governing Body. The Governing Body will ensure that all identified staff are trained
NM (I)
GB (M)
6-27-25 and ongoing
5. The NM will notify the Governing Body when the primary nurses have completed a review of their assigned caseloads to ensure consults and follow up appointments have been completed.
NM (I)
GB (M)
7-25-25
6. The CSD will submit the monthly schedule of the audiologist and psychiatrist to the Governing Body and report out on the previous months completed appointments to the Governing Body monthly.
CSD (I)
6-27-25 and ongoing
7. The QARMD will report to the Governing Body when the target staff involved in errors concerning individuals #1, 5, 7, 9, 17, & 18 have been retrained.
QARMD (I)
GB (M)
6-27-25
8. The NM will submit the following revised policies to the Governing Body for approval. The Governing Body will ensure that the policies include and emphasize the following:
1)Enteral feeding policy including directions on connection/disconnection of enteral feeding tubes (#5).
2)Medication Administration General Principals Part 1 to include:
a) Check medication labels against the Medication Administration Record (MAR) to verify dose to be administered (#7).
b) Identify each individual utilizing a three-step process prior to administering a medication (#17).
c) Following providers orders when administering enteral feedings (#1).
3)Medication Administration General Principles, Part 2 to include orders are accurately transcribed, exactly as ordered. Physician is contacted if clarification is needed (#9).
4)Selinsgrove Center System Assessment ER Visit/Hospital Admission Return Note to ensure paperwork is accurately reviewed by the accepting nurse and pertinent information is shared with the physician, ensuring signatures for accountability (#18).
5)Medication Monthly Review Policy to increase the frequency of checks for accuracy in transcription of orders.
NM (I)
GB (M)
6-20-25
9. The QARMD will report to the Governing Body weekly on the progress of the policy training. The Governing Body will ensure that all identified staff are trained.
QARMD (I)
GB (M)
6-27-25 and ongoing
10. The CSD will submit the training developed by the Occupational Therapy and Physical Therapy on how to transfer an individual without disconnecting feeding tubes safely to the Governing Body. The Governing Body will review the training and ensure it promotes the health and safety of the individual.
CSD (I)
GB (M)
6-20-25
11. The QARMD will report to the Governing Body weekly on the progress of the transfer training. The Governing Body will ensure that all identified staff are trained.
QARMD (I)
GB (M)
6-27-25 and ongoing
12. The NM will provide the Governing Body the following monitoring tools, developed for monitoring the issues causing deficiencies, for approval:
1)Ensuring enteral feeds are only reconnected by licensed nursing staff. (#5)
2)Medication Administration Competency tool monitors that medication labels are checked against the Medication Administration Record (MAR) to verify the dose being administered. (#7)
3)Medication Administration Competency tool monitors the three-step process in identifying an individual prior to administering medications. (#17)
4)Medication Administration competency tool monitors that nurses follow providers orders when administering enteral feedings. (#1)
5)Selinsgrove Center System Assessment ER Visit/Hospital Admission/Return Note monitors that all information was reviewed, and appropriate documentation was completed. (#18)
6)Medication Administration Records & Treatment Administration Records monitor compliance with new orders written and monthly accuracy checks. (#9)
NM (I)
GB (M)
6-20-25
13. The NM will report monthly to the Governing Body the result progression of the identified target staffs monitoring results. The Governing Body will ensure the monitoring fading and/or increased need to monitor are followed based on the results.
NM (I)
GB (M)
6-27-25 and ongoing
14. The NM will report monthly to the Governing Body the monitoring results for non-target staff. The Governing Body will ensure that all identified issues are immediately corrected and reported in accordance with policy.
NM (I)
GB (M)
6-27-25 and ongoing
15. The QARMD will inform the Governing Body (GB) when the targeted nursing staff have been trained on Quarterly Nursing Physical Examinations Policy.
QARMD (I)
GB (M)
6-13-25
16. The QARMD will report weekly to the Governing Body on the progress of training all nursing staff on Quarterly Nursing Physical Examinations Policy specifically that the primary nurse is to maintain a record to include the date quarterly examinations are due and completed. The Governing Body will ensure that all identified staff are trained.
QARMD (I)
GB (M)
6-20-25 and ongoing
17. The NM will submit a health tracking tool to track nursing assessments to the Governing Body for review and approval.
NM (I)
GB (M)
6-20-25
18. The NM & Director of Residential Unit Management (DRUM) will submit a policy to the Governing Body for approval that establishes a monthly community meeting for each individual. This is to foster person-centered communications related to nursing services and program services supports needed for each individual.
NM (I)
DRUM (I)
GB (M)
6-20-25
19. The Governing Body will establish living area communities and assign nursing & program services staff into them. This is to build familiarity of individuals among groups of staff.
GB (I)
6-20-25
20. The QARMD will report weekly on the progress of staff trained to the Governing Body in the following areas:
1)Approved health tracking tool for tracking nursing assessments.
2)Community Meetings and Communication Policy
The Governing Body will ensure that all identified staff are trained.
QARMD (I)
GB (M)
6-27-25 and ongoing
21. The DRUM will report to the Governing Body monthly on the meetings held for each individual. The Governing Body will ensure that monthly meetings were held for everyone and that require disciplines were in attendance.
DRUM (I)
GB (M)
6-27-25 and ongoing
22. The QARMD will inform the Governing Body (GB) when the target staff for Individual #9 has been retrained.
QARMD (I)
GB (M)
6-13-25
23. The NM will submit to the Governing Body for review the revised Medication Administration General Policies Pt. 2. The Governing Body will ensure the policy adequately covers order transcription.
NM (I)
GB (M)
6-20-25
24. The QARMD will report to the governing body weekly on the progress of the policy training. The Governing Body will ensure that all identified staff are trained.
QARMD (I)
GB (M)
6-27-25 and ongoing
25. The NM will provide the revised Medication & Treatment Record Monthly Review Policy and monitoring tool for Medication & Treatment Administration Records to the Governing Body for review and approval. The governing body will ensure that it clearly delineates the process for properly transcribing and check the monthly medication administration records and the chronic orders.
NM (I)
GB (M)
6-20-25
26. The CSD will provide a weekly report to the Governing Body of nurses trained on the revised Medication & Treatment Record Monthly Review Policy, and monitoring tool for Medication & Treatment Administration Records. The Governing Body will ensure that all identified staff are trained.
CSD (I)
GB (M)
6-27-25 and ongoing
27. The NM will report monthly to the Governing Body the results of the Medication & Treatment Administration Records monitoring. The Governing Body will ensure that all identified issues were immediately corrected and reported in accordance with policy.
NM (I)
GB (M)
6-27-25 and ongoing
28. The QARMD will notify The Governing Body (GB) when the target staff involved in the medication administration errors for Individual #19, #28, #30 have been retrained.
QARMD (I)
GB (M)
6-13-25
29. The NM will provide the Governing Body the following monitoring tools, developed for monitoring the issues causing deficiencies, for approval:
Ensuring right time and legible labels.
NM (I)
GB (M)
6-20-25
30. The NM will report monthly to the Governing Body the progression of the identified target staffs monitoring results. The Governing Body will ensure the monitoring fading and/or increased need to monitor are followed based on the results.
NM (I)
GB (M)
6-27-25 and ongoing
31. The NM will report monthly to the Governing Body the monitoring results for non-target staff. The Governing Body will ensure that all identified issues are immediately corrected and reported in accordance with policy
NM (I)
GB (M)
6-27-25 and ongoing
32. The NM will submit the new protocol to help identify and address illegible labels received from the pharmacy to the Governing body for review. The NM will submit the revised supervisor shift report communication to the Governing body for review. The Governing Body will ensure that it includes medication deliveries, assessment of medication labels to ensure labels are legible and any corrective actions taken.
NM (I)
GB (M)
6-20-25
33. The NM will report weekly to the Governing body on the progress of the training on the protocol addressing illegible labels and on the revised nurse supervisor shift report. The Governing Body will ensure that all identified staff are trained.
NM (I)
GB (M)
6-27-25 and ongoing
34. The NM will report monthly to the Governing Body on the supervisor shift report noting the illegible labels received and corrective actions taken. The Governing Body will ensure that all identified issues were immediately corrected and reported in accordance with policy.
NM (I)
GB (M)
6-27-25 and ongoing
483.420(d)(4) STANDARD
STAFF TREATMENT OF CLIENTS
Name - Component - 00
The results of all investigations must be reported to the administrator or designated representative or to other officials in accordance with State law within five working days of the incident.
Observations:
Based on a review of facility provided investigations, and interview, it was determined that the facility failed to ensure the administrator or designated representative was notified of the results of the investigations within five working days. This applied to 39 of 189 investigations of abuse, neglect, or mistreatment reviewed.
The findings included:
A) A review of 189 facility provided investigations of abuse, neglect or mistreatment were completed on May 15, 2025. This review revealed that the results for 39 of these investigations were not reported to the administrator or designated representative within the required five working days.
B) An interview was conducted with the quality assurance risk management director (QARMD) on May 15, 2025, at 10:10 AM. The QARMD confirmed that there was no documentation to indicate that the results of the above-mentioned investigations were reported to facility administration within five working days of the incident discovery date. The QARMD further confirmed that their current five day results notification process does not include verification that the administrator or designee was made aware of the results of investigations.
Plan of Correction:1. The Quality Assurance Risk Management Director (QARMD) will train the Certified Investigators that all investigations must be reported to the administrator or designated representative or to other officials in accordance with State law within 5 working days of the incident.
QARMD (I)
6-13-25
2. The QARMD will submit the training to the Facility Director (FD). The FD will ensure all investigators are trained.
QARMD (I)
FD (M)
6-20-25
3. The QARMD will update the current form to ensure all relevant information is captured on the form including instructions on how to complete, when to complete, and who to submit the form to.
QARMD (I)
6-20-25
4. The QARMD will submit the training to the FD. The FD will review the form for thoroughness and approve for training.
QARMD (I)
FD (M)
6-23-25
5. The QARMD will train all certified investigators on the updated form.
QARMD (I)
6-30-25
6. The QARMD will submit the training to the FD who will ensure all investigators are trained.
QARMD (I)
FD (M)
7-3-25
7. The QARMD will track all certified investigations and ensure the certified investigators submit the form by the due date and address any issues. The QARMD will submit the tracking form to the FD monthly to show that all investigations had a 5-day review completed and if not, corrective measures taken.
QARMD (I)
6-30-25 and ongoing
483.430(e)(2) STANDARD
STAFF TRAINING PROGRAM
Name - Component - 00
For employees who work with clients, training must focus on skills and competencies directed toward clients' health needs.
Observations:
Based on incident report review, investigation report review, record review and staff interview, it was determined that the facility failed to ensure that staff demonstrated the necessary skills and competencies directed towards the health needs for eight individuals in a sample (Individuals #20, #21, #22, #23, #24, #25, #26, and #27).
The findings included:
Review of facility incident reports and investigations was completed on May 15, 2025. This review revealed the following:
A) Individual #22
An investigation report revealed that on March 29, 2025, at 10:00 AM Individual #22 was taken off facility grounds to attend a community trip by direct care staff. During that time, Individual #22 missed his 12:00 PM dose of insulin needed for his diabetes. When the individual returned to the facility later that day, his glucose monitor test registered at 553. The doctor was contacted, who in turn ordered a covering dosage of insulin. The covering dosage of insulin was administered and was effective in reducing Individual #22's glucose level.
Further review of the investigation report revealed that the facility staff who had taken Individual #22 on the community trip had failed to inform nursing that they were taking Individual #22 off facility grounds and that he would be missing his 12:00 PM dosage of insulin. This lack of notification by staff to facility nursing resulted in the individual not receiving his prescribed 12:00 PM dosage of insulin. Staff were counseled and retrained regarding the lack of notification to nursing staff prior to taking the individual off of facility grounds on a community trip.
Interview with the quality assurance risk management director (QARMD) on May 15, 2025, at 2:45 PM confirmed that facility staff had not followed facility protocols regarding the notification of pending trips to nursing personnel. The QARMD also confirmed that this failure resulted in the individual not receiving his 12:00 PM insulin dose for his diabetes.
B) Individual #20
An investigation report revealed that on April 22, 2025, Individual #1 was being transferred via mechanical lift when she fell backwards out of the sling and hit her head on one of the legs of the lift. Individual #20 was sent to emergency department for evaluation. A CT scan of her head and brain was completed with no intracranial bleeding or skull or c-spine fractures.
Further review revealed that the mechanical lift and sling that were used during the transfer were evaluated, and no visible concerns were noted. It was determined by witness statements and evidence that the straps were not connected in the proper order per training and were not inside of the safety clip during the time of the fall.
C) Individual #21
An investigation report revealed that on April 8, 2025, Individual #21 was being transferred from his wheelchair to his recliner via stand pivot transfer by one staff. Individual #21 dropped his weight mid transfer and fell to the floor. Assessment by nurse revealed Individual #21's g-tube, with inflated balloon, was pulled out and hanging by the feeding tube and bag. This individual was sent to the emergency department for g-tube placement.
Further review revealed that Individual #21 had physician's orders for a one person stand pivot transfer for Advocate/Relief Advocate staff or two persons stand pivot transfers for all other staff. Staff completing this transfer was a floater staff and not an Advocate. In addition, Selinsgrove Center procedure for transferring an individual with a feeding tube directed staff to place the feeding on hold and disconnect the feeding tube prior to initiating the transfer.
D) Individual #23
An investigation report revealed that on February 12, 2025, Individual #23 was observed with an Applebee's To-Go container and alfredo pasta in her mouth. Individual #23 spit some noodles out when prompted by staff. She was assessed by the nurse who found no signs or symptoms of distress. Staff admitted to leaving leftover food from the night before in an unsecured drawer in the living area outside individuals' bedrooms.
Review of facility investigation also revealed that Individual #23 is ordered a pureed diet with moderately thick liquids for aspiration precautions. Individual #23's Mental Health Support Action plan (MHSA) states that that she is tracked for pica behaviors and is known to attempt to retrieve food items from trash cans if they are unlocked. The Personal Possessions on Living Area Policy indicates it is the responsibility of the staff to ensure their personal possessions are properly placed in provided lockers/cabinets while on grounds.
E) Individual #24
An investigation report revealed that on February 19, 2025, Individual #24 was found having slipped from a recliner, hanging under the arms from the seatbelt. The nurse was notified and completed a medical assessment. Individual #24 sustained redness to bilateral armpits and across the chest. Staff stated that Individual #24 was unstable in her wheelchair and behaving as if she was going to fall over. Staff then transferred the individual to a facility recliner with a seat belt. Staff stated when the individual was calm in the recliner she left to shower another individual. When the staff returned, a staff nurse was present and informed staff what had happened.
Further review revealed that the individual had human rights committee approval for pelvic support on her wheel chair. On February 20, 2025, an order was obtained for a pelvic belt and a new recliner. On the date of the incident, the individual had not received the new recliner with the appropriate seatbelt. Staff did not seek clarification prior to placing the individual into the chair.
F) Individual #25
An investigation report revealed that on December 31, 2024, Individual #25's staff found a large injury to the left hip and immediately reported the injury to medical. The individual was then transferred to the emergency room for further treatment.
Further review revealed that Individual #25 was transferred to a recliner between 10:00 AM and 10:30 AM on the day of the incident. Target staff stated that the individual was checked at 2:00 PM and 4:00 PM. Target staff stated at that time, a pillow was placed behind the individual's shoulders, which is not one of the alternate positions listed on the center's two hour repositioning flow sheet. At approximately 6:30 PM, a total of eight and one half hours later, target staff, with another staff's assistance completed a mechanical lift transfer. Individual #25 was showing signs of discomfort at this time. Once the transfer was completed, the injury was noted. The investigation report revealed that lack of repositioning and being in the same position for an extended period of time increased the likely hood of pressure injury developing due to the feeding tube being pressed on the skin for a prolonged period of time.
G) Individual #26
An investigation report revealed that on January 30, 2025, Individual #26 was sedated for a scheduled mammogram.
Further review revealed that the driver accidently picked up the wrong individual to take to the appointment. No mental, physical or emotional distress was noted. The appointment for Individual #26 was rescheduled.
H) Individual #27
An investigation report dated February 26, 2025, revealed that individual #27 received sedation for a podiatry appointment. Individual #27 missed the appointment.
Staff assigned to the individual recalled after the nurse administered the sedating medication and handed her two papers. The papers were a "Visual observation Checklist" and "Intake and Output Record. " Staff stated the nurse did not explain how to fill out the papers or what the individual was sedated for.
The shift advocate stated that no one approached him with questions about how to support the individual or how to complete the paper work. The shift advocate did not know that Individual #27 had an appointment that day.
The facility Policy and Procedure Enhanced Staff Support for Inpatient and Outpatient Sedation directs nursing staff to complete the required form and to train the staff and document the training. The forms and training record were not completed at the time the medication was administered.
Staff failed to review communication documents, 24 hour report, or complete required paper work. The nurse failed to complete required paper work and did not document that training was provided to the staff taking responsibility for Individual #27.
I) An interview was conducted with the Facility Director (FD) on May 15, 2025, at 3:00 PM. The FD confirmed above-mentioned investigations failed to ensure that staff demonstrated the skills and competencies directed towards the health needs for eight individuals in the sample.
Plan of Correction:1. For individual #22, all target staff will be trained on ensuring all required "Day of Trip" tasks that are included in the Community Trip Policy, specifically notifying the nurse, are completed prior to leaving on a community outing by the Residential Services Unit Manager (RSUM). The RSUM will submit completed training rosters to the Director of Residential Unit Management (DRUM). The DRUM will verify that all identified staff have been trained.
RSUM (I)
DRUM (M)
6-13-25
2. The Community Trip Policy will be reviewed and revised to ensure clarity and specifications of "day of trip" tasks by the DRUM. The DRUM will submit the policy to the FD for review and approval.
DRUM (I),
Facility Director (FD) (M)
6-20-25
3. All Program Services Staff and nurses will be trained on the updated and approved Community Trip Policy by the Staff Development Specialist 2 (SDS2). The QARMD will ensure that all identified staff are trained.
SDS2 (I)
Quality Assurance Risk Management Director (QARMD) (M)
7-31-25
4. For individual #20, Occupational Therapy/Physical therapy (OT/PT) staff will retrain the target staff on the proper procedures when using a mechanical lift. The OT/PT staff will submit the completed training roster to the DRUM who will verify that all identified staff have been trained.
OT/PT Staff (I)
DRUM (M)
6-13-25
5. OT/PT staff and Staff Development Specialist 2 will retrain all program services staff on the proper procedures when using a mechanical lift. The OT/PT staff and SDS1 will submit the completed training roster to the QARM Director. The QARM Director will verify that all identified staff have been trained.
OT/PT (I)
SDS2 (I)
QARMD (M)
7-31-25
6. All mechanical lift devices will be marked with a label by OT/PT staff reminding staff that the top straps (nearest the head) are to be connected to the device first to prevent the strap from sliding off. The Residential Services Supervisor (RSS) will verify that the label is on the mechanical lifts in their area.
OT/PT(I)
RSS (M)
6-20-25
7. The DRUM and Program Services Director (PSD) will develop a monitoring tool to ensure that staff are using mechanical lifts properly and that the signage is on the lift. This will be completed by the Residential Services Unit Manager (RSUM), RSS and Residential Services Worker (RSW). The monitoring tool will be submitted to the Facility Director (FD) for review and approval.
DRUM (I)
PSD (I)
FD (M)
6-13-25
8. DRUM will train all RSUM, RSS and RSW staff on the proper completion and documentation on the monitoring tool that has been approved. The DRUM will submit completed training rosters to the PSD. The PSD will verify that all identified staff have been trained.
DRUM(I)
PSD (M)
7-3-25
9. RSUM, RSS and RSW supporting living areas with individuals who utilize mechanical lifts will observe one transfer per shift every day and document on the monitoring tool. The RSUM, RSS and RSW will verify that the label is on the mechanical lift. Any areas of concern will be immediately addressed, corrected and reported in accordance with Selinsgrove Center Policy. These monitoring tools will be submitted to the DRUM at the end of each week. The DRUM will ensure that they are being completed and that all issues identified are corrected and reported in accordance with policy.
RSUM (I)
RSS (I)
RSW (I)
DRUM (M)
7-3-25 and ongoing
10. For individual # 21, the target staff will be retrained on proper transferring techniques by OT/PT. OT/PT will submit the completed training rosters to the Director of Residential Unit Management (DRUM). The DRUM will verify that all identified staff have been trained.
OT/PT (I)
DRUM (M)
6-13-25
11. The OT/PT will develop a training on safely assisting individuals in transferring without disconnecting feeding tubes. Training will be submitted to Clinical Services Director (CSD) for review and approval.
OT/PT (I)
CSD (M)
6-20-25
12. OT/PT and the SDS 2 will train all nursing and program staff on safely transferring individuals without disconnecting feeding tubes. Completed training rosters will be submitted to QARMD. The QARMD will ensure that all nursing and program services staff are trained.
LPT (I)
SDS2 (I)
QARMD (M)
7-31-25
13. For individual #23, target staff will be trained on the Personal Possessions on the Living Area Policy by the RSS. The completed training roster will be submitted to the DRUM who will ensure the staff are trained.
RSS (I)
DRUM (M)
6-13-25
14. All program services and health services staff will be trained on the Personal Possessions on the Living Area Policy. SDS2 will complete and submit the rothers to the QARMD. The QARMD will ensure that all identified staff are trained.
SDS2 (I)
QARMD (M)
7-31-25
15. All Program Services and nursing staff will be re-trained by the Staff Development Specialist 2 (SDS2) on PICA awareness and prevention. The SDS 2 will submit the training rosters to the QARMD who will ensure all designated staff are trained.
SDS2 (I)
QARMD (M)
7-31-25
16. For individual #24, staff involved will be retrained by the RSS on the proper use of safety devices. Completed training rosters will be submitted to the DRUM to ensure all identified staff have been trained.
RSS (I)
DRUM (M)
6-13-25
17. All staff will be trained to follow all safety supports as written by the physician. The SDS2 will submit the complete training rosters to the QARMD who will verify that all identified staff are trained.
SDS2(I)
QARMD (M)
7-31-25
18. The DRUM will write a policy, "Changes in Supports". This policy will state that "when a change in supports is recommended, the team must meet within 24 hours and determine what changes will be implemented to maintain the safety of the individual. All changes must be implemented immediately." The DRUM will submit the policy to the Facility Director (FD) for approval.
DRUM (I)
FD (M)
6-20-25
19. The DRUM will train RSUM, RSS and RSW on the policy. The DRUM will be responsible for collecting training rosters. The DRUM will submit completed training rosters to QARMD who will verify that all identified staff have been trained.
DRUM (I)
QARMD (M)
7-11-25
20. For individual #25, all Program Services Staff will be trained on by the SDS2 on the general supervision policy. SDS2 will complete and track the training and submit to the DRUM who will ensure that all Program Services staff have been trained.
SDS2 (I)
DRUM (M)
7-31-25
21. All Program Services Staff will be trained on following repositioning schedules as prescribed and documenting on the Repositioning Flow Sheet. SDS2 will complete and track the training to ensure that all Program Services staff have been trained. SDS2 will complete and track the training and submit to the DRUM who will ensure that all Program Services staff have been trained.
SDS2 (I)
DRUM (M)
7-31-25
22. For individual #26, all Program Services Staff will be trained to read and sign the 24-Hour Report and to complete the change of shift report at the start of each shift. SDS2 will complete and track the training and submit the training rosters to the QARMD. The QARMD will ensure that all Program Services staff have been trained.
SDS 2 (I)
QARMD (M)
7-31-25
23. The RSS will provide the NM with Info Cards and pictures of each individual. The NM will provide the Info Cards and pictures to the Registered Nurse Supervisor (RNS) to be placed in the GREEN appointment folder with other documentation needed for appointments.
RSS(I)
Nurse Manager (NM)(I)
6-20-25
24. The RNS will ensure that all Info Cards and pictures are placed in the GREEN folder. The CSD will check the GREEN folder and ensure all of the correct Info Cards and pictures are placed in the correct folder.
RNS (I)
CSD (M)
6-27-25
25. All Program Services staff will be trained to check the Info Card and picture in the GREEN folder prior to leaving for an appointment to ensure they correctly identify the individual by the SDS2. SDS2 will submit the completed training rosters to the QARMD who will verify that all identified staff are trained.
SDS2 (I)
QARMD (M)
7-31-25
26. For individual #27, all Program Services staff will be retrained to read and sign the 24-Hour Report and to complete the change of shift report at the start of each shift by the SDS2. SDS 2 will complete the training and submit the completed training rosters to the QARMD who will ensure that all Program Services staff have been trained.
SDS2 (I)
QARMD (M)
7-31-25
27. The NM will train all nurses on the sedation policy The Nurse Manager will submit all completed training rosters to the CSD to verify that all nurses are trained.
NM (I)
CSD (M)
7-7-25
483.430(e)(3) STANDARD
STAFF TRAINING PROGRAM
Name - Component - 00
Staff must be able to demonstrate the skills and techniques necessary to administer interventions to manage the inappropriate behavior of clients.
Observations:
Based on staff interview, facility incident report review and facility investigation report review, it was determined that facility staff failed to demonstrate consistent implementation of behavioral intervention techniques that were specified in two individual's Mental Health Support Action plans (MHSA) (Individuals #28 and #29).
The findings included:
Review of facility incident reports and investigations was completed on May 15, 2025. Focused record reviews were also conducted during this time. This review revealed the following:
A) Individual #29
Individual #29's record revealed the following diagnoses: Bipolar disorder (unspecified); Mood disorder; Intermittent Explosive disorder; pica behavior; and Moderate Intellectual Disability. In addition, this individual has a mental health support action plan (MHSA) dated August 15, 2024. This plan addressed various behaviors of concern, including but not limited to self-injurious behavior, physical aggression and pica behavior, and outlined steps for staff to take to keep Individual #29 safe. Padded floor mats are to be used when Individual #29 is actively engaging in the self-injurious behavior of floor headbanging. The current plan directs staff to remove the padded mats from the floor of Individual #29's room when the individual is calm and not engaging in any self-injurious behaviors.
On April 27, 2025, at 6:30 PM, Individual #29 ran into her room and tripped over a safety mat that was placed on the floor by staff. The trip resulted in a fall in which Individual #29 fell face-first to the floor. As a result of the fall, Individual #29 sustained a nasal fracture. Incident report follow up review and staff interview revealed that the staff responsible for Individual #29 at that time had failed to remove the mats from the floor in accordance with the MHSA plan and safety procedures. The target staff received counseling and retraining because of the incident.
Interview with the quality assurance risk management director (QARMD) on May 15, 2025, at 3:00 PM, confirmed that the staff responsible for Individual #29 at the time had failed to follow the Individual #29's MHSA plan and safety protocol by not ensuring that the safety mats were stored in a safe and secure area while not being utilized.
B) Individual #28
Individual #28's record revealed the following diagnoses: Intermittent Explosive Disorder, Schizoaffective Disorder Bipolar type, Unspecified Anxiety Disorder, Unspecified Personality Disorder, Pica behavior, and Mild Intellectual Disability. In addition, this individual has a mental health support action plan (MHSA) dated June 17, 2024. This plan addressed various behaviors of concern, including but not limited to self-injurious behaviors, physical and verbal aggression, property destruction, and pica behavior, and outlined steps for staff to take to keep Individual #28 safe.
On March 15, 2025, Individual #28 requested to use the remote control for his television. Assigned 1:1 staff provided this individual with the remote. Individual #28 removed the batteries from the remote and reported to staff that he swallowed one. Individual #28 was transported to the hospital where an upper GI endoscopy procedure was completed and the battery was removed with no complications. Investigation review revealed that the staff responsible for Individual #28 at that time had not been trained on this individual's MHSA or enhanced supervision plans. Staff also failed to follow Individual #28's plans by providing this individual with an item that was unsafe for him. The target staff received training on Individual #28's plans.
Interview with the quality assurance risk management director (QARMD) on May 16, 2025, at 9:30 AM confirmed that the staff responsible for Individual #28 at the time had failed to follow the Individual #28's MHSA plan and enhanced supervision expectations by providing this individual with an unsafe item leading to an ingestion of a battery.
Plan of Correction:1. For Individual #29, the Residential Services Supervisor (RSS) will train target staff on the use of safety mats when the individual is in behaviors and storage of safety mats when they are not in use. The RSS will submit the completed training rosters to the Program Services Director (PSD who will verify all that all identified staff are trained.
RSS (I)
PSD (M)
6-13-25
2. For Individual #29, the RSS will train all assigned staff on the use of safety mats when the individual is in behaviors and storage of safety mats when they are not in use. The RSS will submit the completed training rosters to the PSD who will verify all that all identified staff are trained.
RSS (I)
PSD (M)
6-13-25 and ongoing
3. The PSD will create a rounds report form to be used daily by both the RSS, Residential Services Worker (RSW) and Residential Services Unit Manager (RSUM). The rounds report will include observations of staff implementing the approved plans as written. The PSD will submit the rounds report form to the Facility Director (FD) for review and approval.
PSD (I)
FD (M)
6-20-25
4. The PSD will train the RSUM, RSS and RSW on the rounds report form. The PSD will submit the completed training roster to the Quality Assurance Risk Management Director (QARMD). The QARMD will ensure that all designated staff are trained.
PSD (I)
QARMD (M)
6-27-25
5. The RSS, RSW and RSUM will make rounds at least once per shift. These rounds will be documented on the daily rounds reports and submitted weekly to the PSD. The rounds will include any issues noted and the actions taken to immediately correct the issue.
RSS (I)
RSW (I)
RSUM (I)
6-27-25 and ongoing
6. The PSD will review the rounds report and ensure that any issues noted were corrected and reported in accordance with all reporting policies.
PSD (M)
6-27-25 and ongoing
7. For Individual #29, the Psychological Services Specialist (PSS) will review and update the Mental Health Services Action Plan (MHSA) to clearly indicate that the safety mats must be kept nearby and off the floor when not in use. The MHSA will be submitted to the PSD for review and approval.
Psychological Services Specialist (PSS) (I)
PSD (M)
6-20-25
8.For Individual #29 all staff assigned to the individual will be re-trained on the MHSA prior to their assignment by the PSS. The PSS will complete and track the training to ensure that all Program Services staff are trained and submit the completed training rosters to the PSD who will verify that all identified staff are trained.
PSS (I)
PSD (M)
6-27-25 and ongoing
9. The PSD will create a rounds report form to be used by the PSS. This rounds report will include observations by the PSS to ensure that the Mental Health Support Action is being implemented as written. The PSD will submit the rounds report form to the FD for review and approval.
PSD (I)
FD (M)
6-20-25
10. The PSD will train the PSS staff on the rounds report form. The PSD will submit the completed training roster to the QARMD who will ensure all identified staff are trained.
PSD (I)
QARMD (M)
6-27-25
11. PSS will complete a round twice per week to ensure that the MHSA is being followed. Any issues observed will be immediately corrected and documented on the weekly rounds report. (PSS) will submit the completed rounds reports at the end of each week to the Program Services Director (PSD). The PSD will review the completed rounds reports to ensure they are completed, and all issues have been corrected and reported according to all reporting policies.
PSS (I)
PSD (M)
6-27-25 and ongoing
12. All PSS will review and update, if necessary, the MHSA on their caseloads to ensure that the language is clear and concise in regard to implementation of behavioral interventions. They will submit the reviewed/revised MHSA to the PSD for review and approval.
PSS (I)
PSD (M)
7-11-25
13. All PSS will re-train Program Services staff assigned to their caseloads on the MHSA. The PSS will complete and track the training to ensure that all Program Services staff are trained and submit the completed training rosters to the PSD. The PSD will verify all that all identified staff are trained.
PSS (I)
PSD (M)
7-11-25 and ongoing
14. For Individual #28, target staff will be re-trained by the RSS on the individuals enhanced supervision plan. The RSS will submit the completed training roster to the QARMD who will ensure identified staff have been trained.
RSS (I)
QARMD (M)
6-13-25
15. For Individual #28 all staff assigned to the individual will be re-trained on the Enhanced Supervision Plan prior to their assignment by the RSS. The RSS will complete and track the training to ensure that all Program Services staff are trained and submit the completed training rosters to the PSD. The PSD will verify all that all identified staff are trained.
RSS (I)
PSD (M)
6-13-25 and ongoing
16. For Individual #28, the RSS will write and implement a Safety Support Action to ensure his safety while watching TV, movies and listening to music. This Support Action will include staff protocol upon arriving to his room and remote-control usage which includes that the remote was epoxied for his safety. The RSUM will review the completed Support Action for approval.
RSS (I)
RSUM (M)
6-20-25
17. For Individual #28, the RSS will train all assigned staff on the approved Support Action to ensure his safety while watching TV, movies and listening to music. The RSS will submit the completed training rosters to the PSD who will verify all that all identified staff are trained.
RSS (I)
PSD (M)
6-20-25 and ongoing
18. The PSD will create a rounds report form to be used daily by the RSUM. RSS and RSW. The PSD will submit the rounds report form to the FD for review and approval.
PSD (I)
FD (M)
6-20-25
19. The PSD will train the RSUM, RSS and RSW on the rounds report form. The PSD will submit the completed training roster to the QARMD who will verify all identified staff have been trained.
PSD (I)
QARMD (M)
6-27-25
20. The RSUM, RSS and RSW will make rounds at last once per shift to ensure that the details of the MHSA and Enhanced Supervision Plan are being followed. Any issues observed will be immediately corrected and documented on the rounds report. These rounds will be submitted weekly to the PSD. The PSD will ensure that all identified issues are corrected and reported in accordance with policy.
RSUM (I)
RSS (I)
RSW (I)
PSD (M)
6-27-25 and ongoing
21.
All RSS will re-train staff assigned to their caseloads on the Enhanced Supervision Plans and submit the completed training rosters to the PSD who will verify all that all identified staff have been trained.
RSS (I)
PSD (M)
6-13-25 and ongoing
22. All Program Services and nursing staff will be re-trained by the SDS2 on PICA awareness and prevention. and submit the completed training rosters to the QARMD. The QARMD will ensure that all identified staff have been trained.
SDS2 (I)
QARMD (M)
7-31-25
23. All Program Services staff will be re-trained on the Enhanced Supervision Policy by the SDS2 and submit the completed training rosters to the QARMD. The QARMD will ensure that all identified staff have been trained.
SDS2 (I)
QARMD (M)
7-31-25
483.460(a)(3) STANDARD
PHYSICIAN SERVICES
Name - Component - 00
The facility must provide or obtain preventive and general medical care.
Observations:
Based on documentation review and staff interview, it was determined that the facility failed to ensure that preventative and general medical care was received in accordance with recommendations from the provider. This was noted for three individuals in the sample (Individual #3, Individual #5 and Individual #13).
The findings included:
A) Individual #3:
Review of Individual #3's record revealed medical diagnoses, which included but were not limited to: hearing loss. Individual #3 had an audiology appointment on September 6, 2024, with a recommended follow-up in one week. There was no documentation to support that this follow-up appointment was completed to date.
Additional review of Individual #3's record revealed medical diagnoses that included but were not limited to: chronic migraine. Individual #3 had a neurology appointment in 2015 with a recommended follow-up in one year. There was no documentation to support that this follow-up appointment was completed, or that this individual was seen by a neurologist to date.
The Qualified Intellectual Disability Professional (QIDP) was interviewed on May 14, 2025, at 1:00 PM, May 15, 2025, at 2:00 PM and May 16, 2025, at 8:30 AM. The QIDP confirmed that the above-mentioned recommendations for follow-up medical care were not completed to date.
B) Individual #5
Review of Individual #5's record revealed medical diagnoses, which included but were not limited to: seizure disorder. Individual #5 had a neurology appointment on February 15, 2024, with a recommended follow-up in one year. There was no documentation to support that this follow-up appointment was completed to date.
Additional review of Individual #5's record revealed medical diagnoses that included but were not limited to: permanent urinary catheterization. Individual #5 had an urology appointment on January 9, 2024, a recommended follow-up in one year. There was no documentation to support that this follow-up appointment was completed to date.
The Qualified Intellectual Disability Professional (QIDP) was interviewed on May 15, 2025, at 1:00 PM and May 16, 2025, at 10:00 PM. The QIDP confirmed that the above-mentioned recommendations for follow-up medical care were not completed to date.
C) Individual #13
Review of Individual #13's record was completed on May 15, 2025. This review revealed Individual #13 had a psychiatric consultation on March 14, 2024, with a recommended follow-up in three to six months. This review also revealed that Individual #13 had a psychiatric consultation on April 29, 2025. This review failed to reveal any psychiatric consultations within three to six months as recommended by the psychiatrist.
An interview was completed with the director of clinical services (DCS) on May 16, 2025, at 9:10 AM. The DCS confirmed there was no documentation that Individual #13 received a follow up psychiatric consultation in three to six months as recommended by the psychiatrist on March 14, 2024.
Plan of Correction:1. For Individual #3, audiology will complete a screening. Documentation will be forwarded to the Clinical Services Director (CSD) to ensure that the follow up screening has been completed.
Audiologist (I)
CSD (M)
6-13-25
2. For Individual #3, audiologist will be trained by the CSD to ensure follow up appointments are completed. The CSD will submit the training record to the Quality Assurance Risk Management Director (QARMD).
CSD (I)
QARMD (M)
6-13-25
3. All Physicians, Nursing, Audiology, Speech and Hearing Staff will be trained by the Nurse Manager (NM) that all audiology orders including but not limited to drops and consults will be faxed to audiology to assist with follow up. The NM will submit the completed training record to the CSD.
NM (I)
CSD (M)
6-20-25
4. Audiology will create and track initial appointments. Audiology will provide the follow up consult to the Health Services Secretary within 72 hours. Follow up appointments will be scheduled by the Health Services Secretary in accordance with the recommended follow up. The Health Services Secretary will send the audiologist's schedule to the CSD. The CSD will ensure that the schedule is being completed and followed by the above-mentioned staff.
Audiologist (I)
Health Services Secretary (M)
CSD (M)
6-13-25 and ongoing
5. For Individual # 3, the prescribing physician will complete a consult for neurology, the primary nurse will make a copy of the consult and fax to the appointment coordinator. The appointment coordinator will schedule and notify the CSD when appointment has been scheduled.
Physician (I)
Primary Nurse (I)
CSD (M)
6-13-25
6. All Primary Nurses will review their assigned caseloads to ensure that consults for follow up appointments have been completed. If any appointments or follow-up appointments have been missed, they will be reported, and appropriate follow-up taken. This will be documented and submitted to the NM for review to ensure everyone has been reviewed and any missed appointments have been reported, and appropriate follow-up has been completed.
Primary Nurse (I)
NM (M)
6-27-25
7. For Individual # 5, the prescribing physician will complete a consult for urology and neurology, the primary nurse will make a copy of the consult and fax to the appointment coordinator. The appointment coordinator will schedule and notify the CSD when appointment has been scheduled.
Physician (I)
Primary Nurse (I)
CSD (M)
6-13-25
8. For Individual #13, the psychiatrist will be trained by the CSD on ensuring follows up are completed within the specified time period. The CSD will submit the training record to the QARMD.
CSD (I)
QARMD (M)
6-13-25
9. For Individual #13, psychiatry will follow up to ensure a recent screening has been completed and submit a copy the CSD who will verify it has been completed.
Psychiatry (I)
CSD (M)
6-13-25
10. Psychiatry will create and track initial appointments. Psychiatry will provide the follow up consult to the Health Services Secretary within 72 hours of the completed appointment. Follow up appointments will be scheduled by the Health Services Secretary in accordance with the recommended follow up. The Health Services Secretary will send the psychiatrist's schedule to the CSD. The CSD will ensure that the schedule is being completed and followed by the above-mentioned staff.
Psychiatrist (I)
Health Services Secretary (M)
CSD (M)
6-13-25 and ongoing
11. The NM will review and clarify the Procedure for Medical Appointments Policy to emphasize the procedure and timeline for ensuring medical appointments and follow ups are completed in the time frame recommended and submit to the Governing Body (GB) for review and approval.
NM (I)
GB (M)
6-20-25
12. All Nursing Staff, Physicians, Residential Services Supervisors (RSS) and appointment coordinator will be trained on the approved revised Medical Appointments Policy by the NM. The NM will submit the training rosters to the QARMD who will ensure that all identified staff have been trained.
NM (I)
QARMD (M)
7-31-25
483.460(c) STANDARD
NURSING SERVICES
Name - Component - 00
The facility must provide clients with nursing services in accordance with their needs.
Observations:
Based on review of facility investigations, incident reports, facility health documentation, and interview, it was determined that the facility failed to ensure that nursing services were provided to the individuals in accordance with their healthcare needs. This applied to six individuals in the facility (Individuals #1, #5, #7, #9, #17, and #18).
The findings included:
Review of facility incident reports and investigations was completed on May 15, 2025. This review revealed the following:
A) Individual #5
A review of a facility investigation report revealed that on December 07, 2024, the nurse connected Individual #5's feeding to the wrong port. Record review revealed that Individual #5 has a g-j tube. Physician's orders stated that all Individual #5's enteral feedings are to be administered through the j-port of the g-j tube. The investigation revealed that at 2:05 PM, staff realized the feeding tube was connected to the g-port and not the j-port and immediately reported the concern to nursing. The nurse addressed the issue and notified the physician. No new orders were given. There were no negative outcomes reported from this incident. No external medical assessment was necessary.
B) Individual #7
Individual #7 is diagnosed with schizoaffective disorder, depression with psychosis, and anxiety. A review of a facility investigation report for Individual #7 was completed on May 14, 2025. This review revealed that from January 12, 2025, to February 9, 2025, Individual #7 received the wrong dosage of the medication Clonazepam. On February 10, 2025, while completing a routine narcotics count and ordering refill medications it was discovered that Individual #7 had received one tablet of one milligram (mg) of Clonazepam when he was prescribed two tablets for two mg dose.
A review of a psychiatric report for Individual #7 was completed on May 14, 2025. This review revealed that Individual #7 had an increase in physical aggression during the time of the reduced medication. The investigation report indicated that five nurses failed to administer the correct dosage of Clonazepam to Individual #7.
C) Individual #17
A review of a facility investigation report revealed that on December 14, 2024, Individual #17 was found to be unresponsive at 6:00 AM. The nurse was notified and Individual #17 was taken to the hospital via 911 ambulance. The first responders evaluated Individual #17 and suspected he may have been over-medicated.
Individual #17 was admitted to the hospital with a diagnosis of altered mental status on December 14, 2024. Readmission to the facility on December 16, 2024, revealed a toxicology report that was positive for benzodiazepine. Individual #17 is not prescribed benzodiazepine medications. Hospital discharge diagnosis was drug ingestion.
Individual #17 receives one medication at 8:00 PM, (Flomax) and he is not prescribed any psychotropic medications. Four of Individual #17 peers receive benzodiazepines at 8:00 PM. Staff interview in the investigation stated that one of the peers was observed to be unusually anxious and active the morning of December 14, 2024. The specific peer is one of four individuals receiving benzodiazepines. The investigation determined the preponderance of evidence suggested that the individual in question (Individual #17's peer) did not receive his anti-anxiety medications.
D) Individual #1
A review of a facility investigation report revealed that on January 25, 2025, Individual #1 was noted to have an emesis at 2:20 PM. The nurse noted that this individual had a gravity bag next to him to deliver the feeding. Individual #1 was found to be in respiratory distress at 2:35 PM. At this time, oxygen and albuterol were administered and this individual was sent to the hospital for evaluation.
Individual #1 was admitted to the hospital with a diagnosis of acute respiratory failure with hypoxia. A chest x-ray and CT scan were performed with concerns for bilateral pneumonia.
Further review of the investigation report revealed a feeding order that outlined the protocol for administering Individual #1's daily feedings. This order indicated that Individual #1 uses a pump to administer the feedings with a combination of feeding and water flushes that are administered at a specific rate and amount over a period of time. In addition, the order gave specific instructions for how to administer the feedings should the specified equipment not be available. Use of a gravity bag was not included as part of the feeding order.
According to the witness statement, the nurse who administered Individual #1's feeding reported that the decision to administer the feeding via gravity bag was made based on nursing background and knowledge and that she did not consult other medical professionals prior to this decision. Additionally, it was stated that this nurse used the gravity bag for Individual #1's feedings three times during the same shift with slow drips.
E) Individual #18
Individual #18 is diagnosed with Mild Intellectual Disability, Intermittent Explosive Disorder, and Bipolar Disorder and has a Mental Health Support Action (MHSA) to address the following behaviors, including but not limited to: physical and verbal aggression, actual and attempted self-abuse, and attempted and actual pica.
Review of an investigation dated April 4, 2025, revealed Individual #18 was in the emergency room for a prior behavioral issue on March 31, 2025. When this individual was told he was being discharged from the hospital, he became physically aggressive with staff and pulled off tape and gauze from his arm and put it in his mouth. One staff immediately intervened and was able to retrieve the medical tape but was unable to retrieve the gauze. Three (3) Selinsgrove Center staff, as well as hospital staff, witnessed Individual #18 ingest medical gauze but were unsuccessful in their intervention.
Individual #18 was discharged from the emergency room and returned to Selinsgrove Center on March 31, 2025, at 5:30 PM. Nurse assessed this individual upon his return and collected discharge paperwork. The three Selinsgrove Center staff present at the hospital for the ingestion of the gauze did not report it to appropriate staff.
On April 4, 2025, Quality Assurance Risk Management Director (QARMD) was reviewing hospital discharge paperwork for Indivdual #18 that revealed the following discharge instructions: "On the way to his vehicle, patient ate a small piece of gauze. This will likely pass through the GI tract, but if he develops severe abdominal pain or inability to pass a bowel movement he should return for evaluation."
Interview with the QARMD on May 16, 2025, at 9:30 AM, confirmed that it is the nurse's responsibility to collect and review all information returned with the individual upon return from the hospital/emergency room. The nurse did not fully read Individual #18's discharge paperwork stating that he ingested a piece of gauze while in the hospital.
F) Individual #9
A record review was completed for Individual #9 on May 14, 2025. This review revealed current physician's orders dated March 24, 2025, for the use of risperidone as follows:
- "Risperidone Tab 0.5 mg Take 1 tablet orally along with 0.25 mg and 1 mg = 1.75 mg daily at 2000."
- "Risperidone Tab 1 mg Take 1 tablet orally along with 0.75 mg = 1.75 mg daily at 2000."
Review of the above orders revealed the total dose of risperidone received at 8:00 PM was 1.50 mg. These physician's orders failed to reveal enough milligrams of risperidone in the order to total 1.75 mg at 8:00 PM.
Interview with the day shift nurse on May 14, 2025, at 1:35 PM confirmed the current medication administration record (MAR) for the month of May 2025, matched the current physician's orders. At this time, when reviewing the medication blister packs in the medication cart with the nurse, there were two blister packs for risperidone; one pack with 1 mg tablets and one pack with 0.5 mg tablets that matched the above physician's orders and MARs. The day shift nurse confirmed that Individual #9 had been receiving risperidone 1.50 mg at 8:00 PM instead of the ordered 1.75 mg. The nurse further stated it was unable to be determined how long Individual #9 had not been receiving the risperidone according to physician's orders.
A review of the consecutive physician's orders for the past year revealed the risperidone was ordered the same as the current physician's orders dated March 24, 2025, as follows:
- "Risperidone Tab 0.5 mg Take 1 tablet orally along with 0.25 mg and 1 mg = 1.75 mg daily at 2000."
- "Risperidone Tab 1 mg Take 1 tablet orally along with 0.75 mg = 1.75 mg daily at 2000."
A review of the available MARs for the past year (May, June, July 2024, and April and May 2025) revealed the MARs matched those physician's orders. Therefore, according to the MARs, Individual #9 received risperidone 1.5 mg at 8:00 PM. The MARs for the months of August, September, October, November, and December 2024, and January, February, and March 2025, were not available for review.
An interview with the nurse manager (NM) was conducted on May 15, 2025, at 3:55 PM. The NM stated that these physician's orders are to be reviewed by two nurses each 90-day cycle. She confirmed that according to the current and past years physician's orders, Individual #9 should have been receiving risperidone 1.75 mg at 8:00 PM, but received 1.5 mg in error. At this time the NM stated that the above identified months of missing MARs were lost by facility. The NM further confirmed these medication errors should have been identified by the nurses and by failing to do so did not meet the needs of Individual #9.
G) An interview with the QARMD on May 15, 2025, at 3:00 PM confirmed that the facility failed to ensure nursing services were provided in accordance to the needs of six individuals in the facility.
Plan of Correction:1. For Individual #5 the Nurse Manager (NM) will train the target nurse that some individuals have enteral feeding tubes that have dual port (G-tube/J-tube), and the nurse is responsible to check the Medication Administration Record (MAR) to verify which port medications and feeding are administered through. Completed Training rosters will be submitted to Quality Assurance Risk Management Director (QARMD). The QARMD will ensure that target nurse is trained.
NM (I)
QARMD (M)
6-13-25
2. The NM will review and update the enteral feeding policy to specify direction on connection/disconnection of enteral feeding tubes and submit to the Governing Body for review and approval.
NM (I)
GB (M)
6-20-25
3. The Staff Development Specialist 2 (SDS2) will ensure that all Nursing and Program services are trained on the updated enteral feeding Policy. SDS2 will track the training to ensure that all above mentioned staff are trained and submit the completed training rosters to the QARMD. The QARMD will ensure that all nursing and program services staff are trained.
SDS2 (I)
QARMD (M)
7-31-25
4. The Occupational Therapy and Physical Therapy (OT/PT) will develop a training on safely assisting individuals in transferring without disconnecting feeding tubes. Training will be submitted to Clinical Services Director (CSD) for review and approval.
OT/PT (I)
CSD (M)
6-20-25
5. OT/PT will train all nursing and program staff on safely transferring individuals without disconnecting feeding tubes. SDS2 will ensure that all staff are trained. Completed training rosters will be submitted to QARMD. The QARMD will ensure that all nursing and program services staff are trained.
OT/PT(I)
SDS2 (I)
QARMD (M)
7-31-25
6. NM and Director of Residential Unit Management (DRUM) will develop a monitoring tool for ensuring that enteral feedings are only reconnected by licensed nursing staff. The monitoring tool will be submitted to the Governing Body for review and approval.
NM (I)
DRUM (I)
GB (M)
6-20-25
7. DRUM will train all Residential Services Aide Supervisors (RSAS), Residential Services Worker (RSW), Residential Services Supervisors (RSS) and Residential Services Unit Manager (RSUM) on enteral feeding monitoring tool. Completed training rosters will be submitted to the QARMD. The QARMD will ensure that identified staff are trained.
DRUM (I)
QARMD (M)
6-27-25
8. Each RSUM, RSS, RSW and RSAS will compete a training monitor each shift they work, if applicable, to any persons in their assigned living areas to ensure that enteral feeding was connected only be licensed nursing staff. Completed monitoring's will be submitted to the DRUM weekly. The DRUM will review completed monitoring tool and ensure that they were completed as assigned and any concerns, discrepancies or errors were corrected and reported in accordance with policy.
RSS (I)
RSW (I)
RSAS (I)
RSUM (I)
DRUM (M)
6-27-25 and ongoing
9. For individual #7 the Nurse Manager (NM) will train target nursing staff identified on the medication Administration General Principles Pt 1 Policy specifically that the nurse is responsible check medication labels against the Medication Administration Record (MAR) to verify the dose to be administered. Completed training roster will be submitted to QARMD. The QARMD will ensure that targeted nursing staff is trained.
NM (I)
QARMD (M)
6-13-25
10. The NM will retrain all nursing staff on the Medication Administration, General Principles Pt 1 specifically that the nurse is responsible check medication labels against the Medication Administration Record (MAR) to verify the dose to be administered. Completed Training rosters are to be submitted to the QARMD. The QARMD will ensure that all nursing staff is trained.
NM (I)
QARMD (M)
7-31-25
11. The NM and DRUM will develop a Medication Administration Competency tool to be used to do observations of medication passes. The medication monitoring tool is to be used by Registered Nurse Supervisors (RNS), RSUM, RSS and RSW. The NM and DRUM will submit the monitoring tool to the Governing Body (GB) for review and approval. The GB will ensure that the monitoring tool targets any issues that contributed to the medication error.
NM (I)
DRUM (I)
GB (M)
6-20-25
12. The NM will train the RNS team on the approved tool and submit completed training rosters to the CSD. The CSD will ensure that all RNS staff have been trained. The DRUM will train all RSUM, RSS and RSW on the approved tool and submit the completed training rosters to the CSD. The CSD will ensure identified staff are trained.
NM (I)
CSD (M)
6-27-25
13. The NM will assign an RNS to complete random medication administration monitoring on the target nurse once a week for thirty days. If within 30 days no errors are noted the NM will assign monitoring of the target nurses twice a month for 30 days. If within thirty days no errors are found the NM will assign monitoring of the target nurse once a month for 60 days. If at any time an error is noted, then the monitoring will start over and return to the highest frequency and follow progression. If there are any concerns, discrepancies or errors noted during the monitoring they will be corrected immediately, reported to the NM as well as adhering to all policies and procedures.
RNS (I)
NM (M)
6-27-25 and ongoing
14. The RSUM, RSS, and RSW will be assigned one medication administration per week to monitor. The NM will make these weekly random assignments. RSUM, RSS and RSW will submit the completed medication administration monitoring forms to the NM weekly. The NM will ensure that any concerns or errors noted during the monitoring are corrected and reported in accordance with policy.
RSUM (I)
RSS (I)
RSW (I)
NM (M)
6-27-25 and ongoing
15. For individual #17 the Nurse Manager (NM) will train target nursing staff identified on the medication Administration General Principles Pt 1 Policy specifically that the nurse is responsible to accurately identify each individual before administering medications, utilizing a three-step process as outlined in the policy. Completed training roster will be submitted to QARMD. QARMD will ensure target nursing staff is trained.
NM (I)
QARMD (M)
6-13-25
16. The NM will retrain all nursing staff on the Medication Administration, General Principles Pt 1 specifically that the nurse is responsible to accurately identify each individual before administering medications, utilizing a three-step process outlined in the policy. Completed training rosters are to be submitted to the QARMD. QARMD will ensure that all nursing staff are trained.
Nurse Manager (I)
QARMD (M)
7-31-25
17. The NM and DRUM will develop a Medication Administration Competency tool to be used to do observations of medication passes. The medication monitoring tool is to be used by Registered Nurse Supervisors (RNS), RSUM, RSS and RSW. The NM and DRUM will submit the monitoring tool to the Governing Body (GB) for review and approval. The GB will ensure that the monitoring tool targets any issues that contributed to the medication error.
NM (I)
DRUM (I)
GB (M)
6-20-25
18. The NM will train the RNS team on the approved tool and submit completed training rosters to the CSD. The CSD will ensure that all RNS have been trained. The DRUM will train all RSUM, RSS and RSW on the approved tool and submit the completed training rosters to the CSD. The CSD will ensure all RSUM, RSS And RSW are trained.
NM (I)
CSD (M)
6-27-25
19. The NM will assign an RNS to complete random medication administration monitoring on the target nurse once a week for thirty days. If within 30 days no errors are noted the NM will assign monitoring of the target nurses twice a month for 30 days. If within thirty days no errors are found the NM will assign monitoring of the target nurse once a month for 60 days. If at any time an error is noted, then the monitoring will start over and return to the highest frequency and follow progression. If there are any concerns, discrepancies or errors noted during the monitoring they will be corrected immediately, reported to the NM as well as adhering to all policies and procedures.
RNS (I)
NM (M)
6-27-25 and ongoing
20. The RSUM, RSS, and RSW will be assigned one medication administration per week to monitor. The NM will make these weekly random assignments. RSUM, RSS and RSW will submit the completed medication administration monitoring forms to the NM weekly. The NM will ensure that any concerns or errors noted during the monitoring are corrected and reported in accordance with policy.
RSUM (I)
RSS (I)
RSW (I)
NM (M)
6-27-25 and ongoing
21. For Individual #1 the Nurse Manager (NM) will train target nurse on the Medication Administration General Principles, Pt. 1 policy and the Enteral Feeding Policy specially the nurse is to follow provider orders when administering enteral feeding. Completed training rosters will be submitted to QARMD. QARMD will ensure that target nurse is trained.
NM (I)
QARMD (M)
6-13-25
22. The NM will retrain all nursing staff on the Medication Administration General Principles, Pt. 1 policy and the Enteral Feeding Policy specially the nurse is to follow provider orders when administering enteral feeding. Completed training rosters will be submitted to QARMD. QARMD will ensure that all nursing staff is trained.
NM (I)
QARMD (M)
7-31-25
23. The NM and DRUM will develop a Medication Administration Competency tool to be used to do observations of medication passes. The medication monitoring tool is to be used by Registered Nurse Supervisors (RNS), RSUM, RSS and RSW. The NM and DRUM will submit the monitoring tool to the Governing Body (GB) for review and approval. The GB will ensure that the monitoring tool targets any issues that contributed to the medication error.
NM (I)
DRUM (I)
GB (M)
6-20-25
24. The NM will train the RNS team on the approved tool and submit completed training rosters to the CSD. The CSD will ensure that all RNS have been trained. The DRUM will train all RSUM, RSS and RSW on the approved tool and submit the completed training rosters to the CSD. The CSD will ensure all RSUM, RSS And RSW are trained.
NM (I)
CSD (M)
6-27-25
25. The NM will assign an RNS to complete random medication administration monitoring on the target nurse once a week for thirty days. If within 30 days no errors are noted the NM will assign monitoring of the target nurses twice a month for 30 days. If within thirty days no errors are found the NM will assign monitoring of the target nurse once a month for 60 days. If at any time an error is noted, then the monitoring will start over and return to the highest frequency and follow progression. If there are any concerns, discrepancies or errors noted during the monitoring they will be corrected immediately, reported to the NM as well as adhering to all policies and procedures.
RNS (I)
NM (M)
6-27-25 and ongoing
26. The RSUM, RSS, and RSW will be assigned one medication administration per week to monitor. The NM will make these weekly random assignments. RSUM, RSS and RSW will submit the completed medication administration monitoring forms to the NM weekly. The NM will ensure that any concerns or errors noted during the monitoring are corrected and reported in accordance with policy.
RSUM (I)
RSS (I)
RSW (I)
NM (M)
6-27-25 and ongoing
27. For Individual #18 the Nurse Manager (NM) will train target nursing staff on the Hospitalization, Hospital Return and ER Visits Policy, specifically that information accompanying an individual upon return from the hospitalization/ER returns must be reviewed for follow up. The NM will submit the completed training roster to the QARMD. QARMD will ensure that target nursing staff is trained. For Individual #18 the DRUM will train target program services staff on the Incident Management policy for report incidents specifically ensuring that incidents are reported appropriately following facility reporting structure. The DRUM will submit the completed training roster to the QARMD. QARMD will ensure that target staff is trained.
NM (I)
QARMD (M)
6-13-25
28. The NM will update the Selinsgrove Center Systems Assessment ER Visit/Hospital Admission/Return Note to identify that hospital/ER visit return paperwork is to be accurately reviewed by the accepting nurse and the nurse reviewed pertinent information with the provider, ensuring signatures for accountability. Updated form will be submitted to the Governing Body for review and approval.
NM (I)
GB (M)
6-20-25
29. The Nurse Manager will train the RNS team on the approved Selinsgrove Center System Assessment ER Visit/Hospital Admission/Return Note to identify that hospital/ER visit return paperwork is to be accurately reviewed by the accepting nurse and the nurse reviewed pertinent information with the provider, ensuring signatures for accountability. The NM will submit the completed training rosters to the CSD.CSD Will ensure that all RNS staff are trained.
NM (I)
CSD (M)
6-27-25
30. RNS will training on nursing staff on the updated Selinsgrove Center System Assessment ER Visit/Hospital Admission/Return Note to identify that hospital/ER visit return paperwork is to be accurately reviewed by the accepting nurse and the nurse reviewed pertinent information with the provider, ensuring signatures for accountability. Completed training rosters will be submitted to the NM. NM will ensure that all nursing staff are trained.
RNS (I)
NM (M)
7-18-25
31. NM will develop a monitoring tool for reviewing Selinsgrove Center System Assessment ER Visit/Hospital Admission/Return Note to identify that all information was reviewed, and appropriate documentation was completed. Monitoring tool will be submitted to the Governing Body for review and approval.
NM (I)
GB (M)
6-20-25
32. NM will train all RNS staff on the approved monitoring tool of the Selinsgrove Center System Assessment ER Visit/Hospital Admission/Return Note to identify that all information was reviewed, and appropriate documentation was completed. Completed training roster will be submitted to the CSD. CDS will ensure that all RNS staff are trained.
NM (I)
CSD(M)
6-27-25
33. The NM will assign the RNS to complete random reviews or hospital return notes/documentation from their assigned living area, utilizing the monitoring tool, to ensure that information was reviewed and documented on appropriately. Completed monitoring tool will be submitted to the NM weekly. The NM will review completed audits to ensure that they were completed as assigned and any concerns were corrected.
RNS (I)
NM(M)
6-27-25 and ongoing
34. For individual #9 the Nurse Manager (NM) will train target nursing staff on the importance of accurately Medication Administration General Principles Pt 2 ensuring that worders are accurately transcribed, exactly as the order if clarification is needed the provider is notified. Completed training rosters will be submitted to the QARMD. QARMD Will ensure that target nursing staff are trained.
NM (I)
QARMD (M)
6-13-25
35. The NM will update the Medication Administration and Treatment Record Monthly Review Policy to increase the frequency of checks for accuracy in transcription of orders and submit to the Governing Body for review and approval.
NM (I)
GB (M)
6-20-25
36. NM will train the RNS on the approved Medication Administration and Treatment Record Monthly Review Policy to increase the frequency of checks for accuracy in transcription of orders. The NM will submit completed training rosters to the CSD. CSD will ensure that all RNS staff are trained.
NM (I)
CSD (M)
6-27-25
37. RNS staff will train all nurses on the revised Medication Administration and Treatment Record Monthly Review Policy. The RNS will submit completed training rosters to the NM. NM will ensure that all nursing staff are trained.
RNS (I)
NM (M)
7-18-25
38. NM develop a monitoring tool for ensuring that Medication Administration Records and Treatment Administration Records are checked in compliance with new orders written and monthly accuracy checks. Completed monitoring tool will be submitted to the CSD for review and approval.
NM (I)
CSD (M)
6-20-25
39. NM will train the RNS staff on the approved monitoring tool. Completed Training rosters will be submitted to the CSD. CSD will ensure that all RNS staff are trained.
NM (I)
CSD (M)
6-27-25
40. Each RNS will complete one monitoring tool weekly and submit to the NM. The NM will review and ensure that they were completed as assigned and any concerns, discrepancies or errors were corrected and reported in accordance with policy
RNS (I)
NM (M)
6-27-25 and ongoing.
483.460(c)(3)(iii) STANDARD
NURSING SERVICES
Name - Component - 00
Nursing services must include, for those clients certified as not needing a medical care plan, a review of their health status which must be on a quarterly or more frequent basis depending on client need.
Observations:
Based on record review and staff interview, it was determined that the facility failed to ensure that nursing direct physical examinations were completed on a quarterly basis. This applied to two individuals in the sample (Individuals #4 and #6).
The findings included:
A) Individual #4
Record review for Individual #4 was completed on May 15, 2025. This review revealed that Individual #4's last nursing quarterly exam was January 13, 2024. Individual #4 received an annual physical exam on January 21, 2025.
B) Individual #6
Record review for Individual #6 was completed on May 15, 2025. This review revealed that Individual #6's last nursing quarterly exam was July 12, 2023. Individual #6 received an annual physical exam on Feburary 5, 2025.
C) Interview with the nurse manager on May 16, 2025, at 7:45 AM, confirmed there was no medical documentation of nursing quarterlies for Individual #4 since January 13, 2024, and Individual #6 since July 12, 2023.
Plan of Correction:1. For individuals #4 and #6 will have a Quarterly Nursing Physical Exam completed. The Nurse Manager (NM) will train target nursing staff on the Quarterly Nursing Physical Examination Policy specifically that the primary nurse is to maintain a record to include date quarterly examinations are due and completed. Completed training roster will be submitted to Quality Assurance Risk Management Director (QARMD). QARMD will ensure that target nursing staff are trained. The NM will ensure that a Quarterly Nursing Physical Exam is completed on Individual #4 and #6 and submit to the QARMD for review.
NM (I)
Nurse (I)
QARMD (M)
6-13-25
2. The NM will retrain all nursing staff on Quarterly Nursing Physical Examination Policy specifically that the primary nurse is to maintain a record to include date quarterly examinations are due and completed. Completed training roster will be submitted to QARMD. QARMD will ensure that target nursing staff are trained.
NM (I)
QARMD (M)
6-20-25
3. The NM will develop a Health tracking tool for tracking nursing assessments. Monitoring tool will be submitted to the governing body for review and approval.
NM (I)
GB (M)
6-20-25
4. The NM will train all nursing staff on the approved Health tracking tool for tracking of nursing assessments are completed as per policy. Completed training rosters will be submitted to the QARMD. QARMD will ensure that all nursing staff are training
NM (I)
QARMD (M)
7-11-25
5. The NM and Director of Unit Management (DRUM) will develop a policy to encompass monthly community meetings for each individual to foster person centered communication related to nursing services and program services. Policy will be submitted to the governing body for review and approval.
NM (I)
DRUM (I)
GB (M)
6-20-25
6. Staff development Specialist 2 (SDS2) will train all nursing and program services staff on the community meetings and communication policy. SDS2 will submit training rosters to the QARMD. QARMD will ensure that all nursing and program services are trained.
SDS2 (I)
QARMD (M)
7-31-25
7. The Governing Body (GB) will group living areas into communities. All health services and program services staff will be assigned to work in a specific community to build familiarity.
Governing Body (GB)
6-20-25
8. The Residential Services Supervisor (RSS) will coordinate with the other team members assigned to their community to schedule monthly meetings for each individual they are responsible for. The RSS will submit completed monthly meeting notes to the DRUM. DRUM will ensure that monthly meetings are completed for each individual.
Residential Services Supervisor (RSS) (I)
Director of Residential Unit Management (DRUM) (M)
7-31-25 and ongoing
9. The primary nurse will submit a Health tracking tool for each assigned individual in their area to the RSS prior to the monthly meeting. RSS will ensure that nursing documentation is reflected in the individual record. The RSS will verify the receipt of the monthly tracker on the Monthly Meeting notes. The RSS will submit a copy of the monthly meeting notes to the DRUM. The DRUM will verify that a meeting was held for each individual and all required disciplines attended the meeting.
Primary Nurse (I)
RSS (I), DRUM (M)
7-31-25 and ongoing
10. The RSS will ensure the Quarterly Nursing Physical is present in the chart and submit documentation to the Registered Nurse Supervisor. The RNS will track and monitor to ensure that all Quarterly Nursing Physicals are completed.
RSS (I)
RNS (M)
7-31-25 and ongoing
483.460(k)(1) STANDARD
DRUG ADMINISTRATION
Name - Component - 00
The system for drug administration must assure that all drugs are administered in compliance with the physician's orders.
Observations:
Based on record review and staff interview, it was determined that the facility failed to ensure that all medications were administered according to physician's orders. This applied to one of 16 individuals in the original sample (Individual #9).
The findings included:
A) Individual #9
A record review was completed for Individual #9 on May 14, 2025. This review revealed current physician's orders dated March 24, 2025, for the use of risperidone as follows:
- "Risperidone Tab 0.5 mg Take 1 tablet orally along with 0.25 mg and 1 mg = 1.75 mg daily at 2000."
- "Risperidone Tab 1 mg Take 1 tablet orally along with 0.75 mg = 1.75 mg daily at 2000."
Review of the above orders revealed the total dose of risperidone received at 8:00 PM was 1.50 mg. These physician's orders failed to reveal enough milligrams of risperidone in the order to total 1.75 mg at 8:00 PM.
Interview with the day shift nurse on May 14, 2025, at 1:35 PM, confirmed the current medication administration record (MAR) for the month of May 2025, matched the current physician's orders. At this time, when reviewing the medication blister packs in the medication cart with the nurse, there were two blister packs for risperidone; one pack with 1 mg tablets and one pack with 0.5 mg tablets that matched the above physician's orders and MARs. The day shift nurse confirmed that Individual #9 had been receiving risperidone 1.50 mg at 8:00 PM instead of the ordered 1.75 mg. The nurse further stated it was unable to be determined how long Individual #9 had not been receiving the risperidone according to physician's orders.
A review of the consecutive physician's orders for the past year revealed the risperidone was ordered the same as the current physician's orders dated March 24, 2025, as follows:
- "Risperidone Tab 0.5 mg Take 1 tablet orally along with 0.25 mg and 1 mg = 1.75 mg daily at 2000."
- "Risperidone Tab 1 mg Take 1 tablet orally along with 0.75 mg = 1.75 mg daily at 2000."
A review of the available MARs for the past year (May, June, July 2024, and April and May 2025) revealed the MARs matched those physician's orders. Therefore, according to the MARs, Individual #9 received risperidone 1.5 mg at 8:00 PM. The MARs for the months of August, September, October, November, and December 2024, and January, February, and March 2025, were not available for review.
An interview with the nurse manager (NM) was conducted on May 15, 2025, at 3:55 PM. The NM confirmed that according to the current and past years physician's orders, Individual #9 should have been receiving risperidone 1.75 mg at 8:00 PM, but received 1.5 mg in error. At this time the NM stated that the above identified months of missing MARs were lost by facility. The NM further confirmed these medication errors should have been identified by the nurses and by failing to do so this individual received over a years worth of risperidone not in accordance with physician's orders.
Plan of Correction:1. For individual #9 the Nurse Manager (NM) will train target nursing staff on the Medication Administration General Principles Pt 2. Specifically, that orders are accurately transcribed, and if clarification is needed the provider is notified. Completed training rosters will be submitted to the Quality Assurance Risk Management Director (QARMD). QARMD Will ensure that target nursing staff are trained.
NM (I)
QARMD (M)
6-13-25
2. The NM will update the Medication Administration and Treatment Record Monthly Review Policy to increase the frequency of checks for accuracy in transcription of orders and submit to the Governing Body (GB) for review and approval.
NM (I)
GB (M)
6-20-25
3. NM will train the Registered Nurse Supervisor (RNS) on the approved Medication Administration and Treatment Record Monthly Review Policy to increase the frequency of checks for accuracy in transcription of orders. The NM will submit completed training rosters to the Clinical Services Director (CSD). CSD will ensure that all RNS staff are trained.
NM (I)
CSD (M)
6-27-25
4. RNS staff will train all nurses on the revised Medication Administration and Treatment Record Monthly Review Policy. The RNS will submit completed training rosters to the NM. NM will ensure that all nursing staff are trained.
RNS (I)
NM (M)
7-11-25
5. NM develop a monitoring tool for ensuring that Medication Administration Records and Treatment Administration Records are checked in compliance with new orders written and monthly accuracy checks. Completed monitoring tool will be submitted to the CSD for review and approval.
NM (I)
CSD (M)
6-20-25
6. NM will train the RNS staff on the approved monitoring tool. Completed Training rosters will be submitted to the CSD. CSD will ensure that all RNS staff are trained.
NM (I)
CSD (M)
6-27-25
7. Completed monitoring tools will be submitted to the NM weekly. The NM will review and ensure that they were completed as assigned and any concerns, discrepancies or errors were corrected and reported in accordance with policy
RNS (I)
NM (M)
6-27-25 and ongoing
483.460(k)(2) STANDARD
DRUG ADMINISTRATION
Name - Component - 00
The system for drug administration must assure that all drugs, including those that are self-administered, are administered without error.
Observations:
Based on observation, record review, and staff interview, it was determined that the facility failed to ensure medications were administered without error. This was noted for three individuals in the facility (Individuals #19, #28 and #30).
The findings included:
A) Individual #28
Afternoon medication administration was observed on May 13, 2025, between 3:00 PM and 4:30 PM. Individual #28 received his medications, including Colesevelam 3.75 grams (gm).
Physician's orders, dated April 21, 2025, were reviewed on May 14, 2025. This review revealed that Individual #28 was prescribed Colesevelam 3.75 gm, dissolve one packet in glass of water or juice and drink orally at bedtime.
Interview with the Quality Assurance Risk Management Director (QARMD) on May 16, 2025, at 9:30 AM confirmed the nurse committed a medication error by administering Colesevelam 3.75 mg at the wrong time.
B) Individual #19
Observations of the morning medication administration were completed on May 14, 2025, from 7:06 AM to 7:19 AM.
At 7:06 AM, the nurse was observed to prepare 19 medications for Individual #19, which included the medication Polyethylene glycol 3350. This surveyor questioned the nurse about the label being illegible. The nurse stated, "I can read the label." The nurse administered the medication to Individual #19 according to physician orders dated March 1, 2025.
An interview was conducted with the nurse manager on May 15, 2025, at 10:13 AM and confirmed the labeled Polyethylene glycol 3350 for Individual #19 was illegible.
C) Individual #30
At 7:16 AM, the nurse was observed to prepare seven medications for Individual #30, which included the medication Polyethylene glycol 3350. This surveyor questioned the nurse about the label being illegible. The nurse stated, "I can read the label." The nurse administered the medication to Individual #30 according to physician orders dated March 1, 2025.
An interview was conducted with the nurse manager on May 15, 2025, at 10:13 AM and confirmed the labeled Polyethylene glycol 3350 for Individual #30 was illegible.
An interview was conducted with day shift nurse supervisor on May 15, 2025, at 4:07 PM and confirmed that the nurse committed a medication error by giving the medication with illegible labels.
Plan of Correction:1. For individual 28, the Nurse Manager (NM) will train the involved nurse that all medications are to be given as ordered within the allotted time frame. The NM will submit the completed training roster to the Quality Assurance Risk Management Director (QARMD).
NM (I)
QARMD (M)
6-13-25
2. The NM will train all nurses that all medications are to be given within the allotted time frames. The NM will submit the completed training rosters to the QARMD will ensure that all nurses are trained.
NM (I)
QARMD (M)
6-27-25
3. The NM and Director of Residential Unit Managers (DRUM) will develop a Medication Administration Competency tool to be used to do observations of medication passes. The medication monitoring tool is to be used by Registered Nurse Supervisors (RNS), Residential Services Unit Managers (RSUM), Residential Services Supervisor (RSS) and Residential Service Worker (RSW). The NM and DRUM will submit the monitoring tool to the Governing Body (GB) for review and approval. The GB will ensure that the monitoring tool targets any issues that contributed to the medication error.
NM (I)
DRUM (I)
GB (M)
6-20-25
4. The NM will train the RNS team on the approved tool and submit completed training rosters to the CSD. The CSD will ensure that all RNS have been trained. The DRUM will train all RSUM, RSS and RSW on the approved tool and submit the completed training rosters to the CSD. The CSD will ensure all RSUM, RSS And RSW are trained.
NM (I)
DRUM (I)
CSD (M)
7-11-25
5. The NM will assign an RNS to complete random medication administration monitoring on the target nurse once a week for thirty days. If within 30 days no errors are noted the NM will assign monitoring of the target nurses twice a month for 30 days. If within thirty days no errors are found the NM will assign monitoring of the target nurse once a month for 60 days. If at any time an error is noted, then the monitoring will start over and return to the highest frequency and follow progression. If there are any concerns, discrepancies or errors noted during the monitoring they will be corrected immediately, reported to the NM as well as adhering to all policies and procedures.
RNS (I)
NM (M)
7-11-25 and ongoing
6. The RSUM, RSS, and RSW will be assigned one medication administration per week to monitor. The NM will make these weekly random assignments. This monitoring will be conducted for 60 days. If no errors are noted in these 60 days, then the NM will randomly select one medication administration per community twice a month for monitoring by a RSUM, RSS and an RSW. This monitoring will be conducted for 60 days. If no errors are noted in these 60 days, then the NM will randomly select one medication administration per community monthly for monitoring by a RSUM, RSS and an RSW. This monitoring will be conducted for 60 days. If at any time an error is noted, then the monitoring will start over and return to the highest frequency and follow the progression. If there are any concerns, discrepancies or errors noted during the monitoring they will be corrected immediately, reported to the NM as well as adhering to all policies and procedures. RSUM, RSS and RSW will submit the completed medication administration monitoring forms to the NM weekly.
RSUM (I)
RSS (I)
RSW (I)
NM (I)
7-11-25 and ongoing
7. For individuals 19 and 30, the NM will train the involved nurse that at no time is a medication to be administered where the label is not clear or has a label that may be inaccurately read. The NM will submit the completed training roster to the QARMD.
NM(I)
QARMD (M)
6-13-25
8. The NM will train all nurses that at no time is a medication to be administered where the label is not clear or has a label that may be inaccurately read. The NM will submit the completed training rosters to the QARMD. The QARMD will ensure that all nurses are trained.
NM(I)
QARMD (M)
6-27-25
9. The NM will establish a protocol to help identify and address illegible labels received from the pharmacy. The NM will revise the RNS shift report communication to include medication deliveries, assessment of medication labels to ensure labels are legible and any corrective actions taken. RNS shift report and protocol will be submitted to the CSD for review and approval.
NM (I)
CSD (M)
6-20-25
10. The NM will train all the RNS on the new shift report and the protocol. The NM will submit the completed training rosters to the CSD. The CSD will ensure that all RNS were trained.
NM (I)
CSD(M)
6-27-25
11. The RNS will send the shift report daily to the NM ensuring that documentation of medication labels was reviewed, and any concerns or discrepancies were corrected and reported in accordance with protocol. The NM will ensure that all identified issues are handled in accordance with policy and protocol.
RNS (I)
NM (M)
6-27-25 and ongoing
483.470(i)(2)(iv) STANDARD
EVACUATION DRILLS
Name - Component - 00
The facility must investigate all problems with evacuation drills, including accidents.
Observations:
Based on documentation review and staff interview, it was determined that the facility failed to identify and address all problems with evacuation drills. This applied to all drills for all locations in the past 12 months.
The findings included:
A) A review of facility evacuation drills for the past 12 months was completed on May 13, 2025. This review revealed that all evacuation drills completed for all locations during the past year did not identify the locations of the hypothetical fire or the exits used for safe evacuation.
B) This review also revealed that a drill completed in building CM 9 on June 11, 2024, at 9:00 AM, indicated four individuals did not evacuate. The reasons identified for three of the individuals were they were in "bed" and one was in a "recliner". The record did not provide an explanation for why these individuals did not evacuate.
C) An interview with the Quality Assurance Risk Management Director (QARMD) on May 14, 2025, at 10:30 AM, confirmed that the facility failed to identify and address all problems with evacuation drills.
Plan of Correction:1. The Quality Assurance Risk Management Director (QARMD) will train the Facility Safety Manager (FSM) and Fire Marshall (FM) that when conducting evacuation drills the evacuation routes taken must lead away from an established hypothetical fire. The QARMD will submit the completed training rosters to the Facility Chief Operating Officer (FCOO). The FCOO will ensure that identified staff are trained.
QARMD (I)
FCOO (M)
6-13-25
2. The QARMD will train the FSM and FM that when conducting fire drill all individuals must be evacuated. Any individual not evacuated, due to extenuating circumstances, must have a valid explanation documented on the Living Area Fire Evacuation Roster. The QARMD will submit the completed training rosters to the FCOO. FCOO will ensure that identified staff are trained.
QARMD (I)
FCOO (M)
6-13-25
3. The FM will revise the Fire Drill Report to include a location of the hypothetical fire and the evacuation route. The FSM will review the revised report and ensure that the necessary items are included.
FM (I)
FSM (M)
6-20-25
4. The FM will revise the Living Area Fire Drill Roster to include an explanation section for any individual present in the living area but not evacuated during a fire drill due to extenuating circumstances. The FSM will review the revised roster to ensure that it includes are necessary information.
FM (I)
FSM (M)
6-20-25
5. The Staff Development Specialist 2 (SDS2) will train all staff that they must evacuate away from the fire and all individuals present in an area must be evacuated during an evacuation drill. Extenuating circumstances must be documented on the Living Area Fire Drill Roster. The SDS2 will submit a report to the QARMD indicating the staff that have been trained. The QARMD will ensure that all staff are trained.
SDS2 (I)
QARMD (M)
7-31-25
6. The FM will submit all fire drill documentation for review to the FSM after each evacuation drill is conducted. The documentation will be submitted the following business day following the evacuation drill. The FSM will review all completed evacuation drill documentation and assure that all problems associated with evacuation drill are investigated and corrective action taken. The FSM will assure that all evacuation routes taken for each drill lead away from the hypothetical fire. If the FSM finds any issue with the documentation that is reviewed, they will immediate re-train those involved with the drill and a repeat evacuation drill will occur.
FM (I)
FSM (M)
6-20-25 and ongoing
7. The FSM will submit a monthly report to the QARMD indicating the number of fire drills, locations of hypothetical fires, all present individuals not evacuated with explanation, problems with associated with the evacuations, and corrective actions taken.
FSM (I)
QARMD (M)
7-1-25 and ongoing.
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