Crosslands

In the surveyor’s words

From the most serious findings on record at Crosslands, in the surveyor’s own words.

• Actual harm, isolatedF656Jan 9, 2025

  Based upon review of clinical records, review of facility documentation, and staff interview it was determined the facility failed to follow a resident's care plan resulting in fall with subsequent actual harm of a hematoma requiring transportation to the emergency room for evaluation and treatment of a hematoma for one of three residents reviewed (Resident 52). Findings include: Review of Resident 52's care plan for continence at the time of the fall revealed Toileting program: check and change upon awake, before bed, before and after meals, at midnight, 3 a.m. and 6 a.m. Review of Resident 52's progress notes dated December 28, 2024, at 11:30 a.m. […]

• No harm, potential for more than minimal, patternF684Jan 22, 2024

  Based on clinical record review, staff interviews, and facility policies it was determined that the facility failed to notify the physician in a timely manner of multiple medication errors experienced for 15 of 15 residents reviewed. (Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14 and Resident R15). Findings include: Review of information dated January 8, 2024 submitted by the facility to Department of Health revealed the facility has been facing substantial frequency of medication errors (failure to administer a medication as prescribed by their provider). These errors stem from inaccuracies originating within their contracted pharmacy. Interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on January 22, 2024, at 9:10 a.m. […]

• No harm, potential for more than minimal, patternF755Jan 22, 2024

  Based on clinical record review, staff interviews, and facility policies it was determined that the facility failed to identify pharmacy delivery errors that in turn caused multiple medication errors experienced by 15 of 15 residents reviewed. (Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14 and Resident R15). This deficient practice has been determined to be past non compliance. Findings include: Review of information dated January 8, 2024 submitted by the facility to Department of Health revealed the facility has been facing substantial frequency of medication errors (failure to administer a medication as prescribed by their provider). […]

• No harm, potential for more than minimal, patternF839Sep 27, 2022

  Based on review of facility documentation, personnel records, and staff interview it was determined that the facility failed to ensure nursing staff maintained active licensure for five of five personnel records reviewed (Employee E2, E3, E4, E5, E6). Findings include: Review of documentation submitted by the facility on [DATE] revealed that Employees E2, E3, E4, E5, E6 worked at the facility as a nurses after their license expired. Interview conducted with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on [DATE]th, 2022, at 9:30 a.m. revealed that Licensed Practical Nurses (LPN) E2, E3, E4, E5, and E6 failed to renew their LPN license by [DATE]th, 2022, working a total of 48 shifts with an expired license from [DATE]st, 2022, through [DATE]th, 2022. […]

• No harm, potential for more than minimal, isolatedF606Feb 20, 2026

  Based on review of facility policy, review of facility documentation, and interview with staff, it was determined that the facility failed to thoroughly screen individuals prior to hire for one of five employee records reviewed (Employee E3).Findings include:Review of facility policy, Criminal Record/FBI Check Policy, revised March 14, 2022, indicated that a criminal record check and an FBI national check (if applicable) will be processed for all staff members upon hire. If the staff member is not a current resident of Pennsylvania or has not been a state resident for two years preceding his/her application, FBI national check will be required.Review of Employee E3's personnel record revealed that Employee E3 was hired on December 18, 2025. […]