Aventura At Pembrooke
Inspection history, citations, penalties and survey trends for this long-term care facility in West Chester, Pennsylvania.
- Location
- 1130 West Chester Pike, West Chester, Pennsylvania 19380
- CMS Provider Number
- 395166
- Inspections on file
- 29
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 28 (1 serious)
Citation history
Health deficiencies cited at Aventura At Pembrooke during CMS and state inspections, most recent first.
Surveyors found that residents on all three floors were not consistently provided with fresh water and ice during the day shift. Observations showed many rooms lacked water cups or contained undated, warm water, and residents reported that fresh water was not offered every shift and sometimes not daily, despite ice being available on each unit. When informed of these findings, the DON stated that residents receive fresh water every shift, which conflicted with the observed conditions and resident reports.
Surveyors found that the facility failed to maintain safe water temperatures in multiple resident care areas, with several locations registering dangerously high temperatures. Staff were unaware of the issue, lacked documentation of temperature monitoring, and had no policies or procedures in place to ensure water safety. Inconsistent practices were observed among nursing and agency staff, and administrative leadership was not present during critical follow-up visits.
The NHA and DON did not ensure a system was in place to monitor hot water temperatures, nor did staff consistently check water safety before care, resulting in unsafe conditions for residents.
A resident with anemia and chronic kidney disease did not receive prescribed Aranesp injections on multiple scheduled dates due to pharmacy approval delays and lack of follow-up by staff. The DON reported giving verbal approval for the medication but could not provide documentation, and the physician was not notified of the missed doses.
Two residents with tracheostomies were observed with oxygen and suction tubing, as well as disposable suction canisters, that were not labeled or dated to indicate when they were last changed. The DON confirmed that this labeling should have occurred.
A resident with acute kidney failure did not receive a timely urinalysis, culture, and sensitivity test after the initial specimen was rejected by the lab due to improper labeling. Staff failed to follow up or notify the physician promptly, resulting in a delay in identifying and treating a UTI caused by Klebsiella Pneumoniae ESBL.
The facility did not provide required signage for Enhanced Barrier Precautions (EBP) outside four resident rooms where PPE was available, and failed to supply both PPE and signage for a resident with a tracheostomy and tube feeding, contrary to facility infection control policy.
Two residents did not receive physician-ordered wound care and IV antibiotics as prescribed. One resident with chronic leg ulcers experienced missed and undocumented wound treatments, leading to wound deterioration and increased wound size. Another resident with a wound infection missed two doses of IV antibiotics due to lack of IV access, with no documentation that the physician was notified of the missed doses. The DON confirmed these failures in care and documentation.
A resident with paraplegia and total dependence on staff for bed mobility was not provided with the required two-person assistance during care. Instead, a single staff member attempted to reposition the resident, leading to a fall and an acute subarachnoid hemorrhage that required ICU admission. The resident's care plan did not reflect the documented need for two-person assistance, and staff interviews confirmed the resident's dependency.
A resident with a Stage 4 pressure ulcer and MASD did not receive wound care as ordered, with observations revealing undated or outdated dressings and a sacral wound left open to air. An LPN documented wound treatments as completed when they had not been performed, and could not confirm care on previous dates, resulting in a failure to meet professional standards of nursing practice.
A resident with a Stage 4 sacral pressure ulcer did not receive wound care as ordered by the physician, with documentation indicating care was completed when it was not. The wound was found without a dressing and with a large bowel movement present, and the DON could not explain the missed treatment.
Multiple residents receiving tube feedings did not consistently receive the physician-ordered volume of enteral nutrition, with medication administration records showing frequent discrepancies and no documentation explaining the variances. Licensed staff and the DON confirmed the inconsistencies in the amounts administered.
A resident with chronic congestive heart failure was enrolled in hospice care, but the facility did not create a comprehensive hospice care plan with measurable interventions and timetables, as confirmed by clinical record review and staff interviews.
Two residents with ESRD and CHF who were on hemodialysis had physician-ordered fluid restrictions that were not accurately followed or documented by staff. Clinical records lacked evidence of proper fluid intake tracking as required by the orders, and a licensed employee confirmed the failure to comply with these directives.
A resident with a urinary catheter did not have physician orders or required documentation for catheter care, including input and output, during the period the catheter was in place. Facility policy required detailed documentation and assessment, but staff confirmed that no such records were maintained.
A resident with complex medical needs, including tube feeding and dysphagia, did not have an accurate admission weight obtained, and subsequent weights were also incorrect and later struck from the record. This led to the resident's nutritional status and tube feeding being managed based on inaccurate data for nearly a month, with the error only identified after a hospital weight was received.
A resident received PRN Roxicodone for pain multiple times without evidence that non-pharmacological interventions were attempted or documented beforehand, as required by facility policy. Review of clinical records and staff interview confirmed this deficiency.
A resident with complex medical needs, including severe malnutrition and dysphagia, had physician orders for enteral feedings at specific times. The MAR lacked options for staff to document tube feedings set up and taken down in the afternoon, preventing proper documentation of the prescribed feeding schedule. A nurse confirmed the MAR was not configured for accurate documentation.
Surveyors found that the facility did not have documentation verifying completion of a required full-scale emergency preparedness exercise within the past year, and facility leadership confirmed the absence of this documentation during interviews.
Surveyors found that an exit sign above the door leading to grade from the stairtower near the Elevator Lobby was not illuminated as required. This lack of illumination was confirmed by facility leadership during the inspection.
Surveyors found that the facility did not properly maintain its sprinkler system, with open areas in the walls behind beds on multiple floors and a sprinkler head covered in paint overspray. These issues were confirmed by facility leadership during the survey exit conference.
Surveyors identified several corridor door deficiencies, including doors that failed to latch, lacked smoke tight integrity, and had missing locksets, across multiple floors. These issues were confirmed by facility leadership during the exit conference.
Smoke barrier doors near the Laundry Area did not fully close when released from hold-open devices, resulting in a failure to maintain smoke-tight conditions as required. Facility leadership confirmed the deficiency during the survey.
A portable air conditioning unit in a large common area near the Nurses' Station was observed to be vented directly into the ceiling's interstitial space instead of to the outside, contrary to NFPA 101 and manufacturer requirements. This was confirmed by facility leadership during the survey.
Surveyors found that a receptacle near an A-bed was missing a cover and a reading light over another A-bed had exposed, non-terminated wiring hanging from the underside of the cover. These electrical system deficiencies were confirmed by facility leadership during the inspection.
Surveyors found that extension cords and surge protectors were being used in multiple rooms to power phone chargers and medical devices, in violation of NFPA 101 and related standards. Facility leadership confirmed these unauthorized devices were in use during the survey.
Surveyors found that the facility is a four-story, Type II (000) unprotected noncombustible structure that is fully sprinklered, which exceeds the maximum number of stories allowed by the 2012 Life Safety Code for this construction type. Facility leadership confirmed the building's structure does not meet code requirements.
Surveyors found that the facility did not have documentation of a required semi-annual visual inspection of the fire alarm system for all smoke compartments, as confirmed during interviews with facility leadership.
A cognitively intact resident, diagnosed with unspecified dementia and major depressive disorder, was not allowed to transfer from the memory care unit despite multiple requests and a grievance. The resident, with a BIMS score indicating intact cognition, could not interact with others at the same cognitive level. Staff confirmed the resident's high functioning status and lack of participation in unit activities. The DON and NHA acknowledged the resident's inappropriate placement, yet no transfer occurred.
The facility failed to follow physician orders for two residents. One resident did not receive prescribed referrals for physical and occupational therapy and a DBS Clinic, despite having multiple medical conditions. Another resident received Midodrine HCI outside the prescribed parameters for hypertension management, as confirmed by staff.
A facility failed to accurately monitor and document a resident's side effects from antipsychotic medication. Despite orders to monitor every shift, records showed inconsistent documentation, often indicating no side effects. Observations confirmed the presence of involuntary movements, which were not properly recorded. The Nursing Home Administrator and DON acknowledged the documentation inaccuracies.
A resident with multiple medical conditions, including Parkinson's disease and rheumatoid arthritis, did not receive prescribed physical and occupational therapy after being discharged from occupational therapy. Despite referrals from a neurologist, the facility failed to provide the necessary therapy services, as confirmed by staff interviews.
A facility failed to develop a comprehensive care plan, including discharge planning, for a resident admitted after seizure treatment. The resident, with diagnoses of depression, epilepsy, and anxiety, had no housing plan and expressed readiness to leave. Despite this, the care plan lacked a discharge goal, as confirmed by the DON. This was a violation of 28 Pa Code 211.11(d).
A facility failed to comprehensively assess a wound upon admission and delayed placing a treatment order for a resident with a sacral wound. The initial wound assessment lacked details, and the treatment order was not transcribed due to an oversight. The wound physician's treatment recommendation was delayed by two days, resulting in a three-day delay in implementing the treatment.
Failure to Provide Fresh Hydration on All Units
Penalty
Summary
The facility failed to provide adequate hydration to residents on all three floors during the survey period. On March 26, 2026, observations of resident rooms on the 1st, 2nd, and 3rd floors showed that most rooms either had no cups with water available for hydration or contained cups of warm water. The cups present were not dated, so there was no way to determine when the water had been provided. Resident interviews revealed that multiple residents reported fresh water was not provided every shift and sometimes not even daily, despite the presence of functioning ice machines on each unit. Observations were made throughout the day shift and showed that residents were not provided with fresh water and/or ice during that shift. When surveyors presented these findings to the Nursing Home Administrator and the DON on March 26, 2025, at 3:10 p.m., the DON stated that residents are provided with fresh water during every shift, which conflicted with the observations and resident reports. These findings were cited under 28 Pa. Code 211.12(d)(1)(5) Nursing Services and 28 Pa. Code 211.10(c) Resident care policies.
Failure to Maintain Safe Water Temperatures in Resident Care Areas
Penalty
Summary
Surveyors identified a deficiency in the facility's failure to maintain safe water temperatures in resident care areas across all three units. During an observation, a surveyor experienced excessively hot water in a staff and visitor bathroom, resulting in visible redness on their hands after brief exposure. Subsequent temperature checks throughout the facility revealed multiple locations with water temperatures significantly exceeding safe limits, with some readings as high as 132.9 degrees Fahrenheit. The Maintenance Director was unaware of these high temperatures and could not provide documentation or logs verifying regular monitoring of water temperatures. Further investigation revealed that maintenance staff only monitored the temperature at the mixing valve daily and performed random room checks weekly, but there was no documentation to support these practices. Nursing staff reported using their wrists to test water temperature before resident use, and there were no working thermometers or temperature logs in the shower rooms. Interviews with the Nursing Home Administrator confirmed the absence of policies and procedures for monitoring water temperatures or ensuring safe water temperatures prior to resident care. Additional observations showed inconsistent practices among staff, with some using hot water for bed baths despite instructions to use disposable washcloths due to the ongoing water issue. Agency staff were not informed about the situation, and key administrative personnel were not present in the facility during follow-up visits. There was no evidence of ongoing temperature monitoring or staff education during the period when the water system remained uncorrected.
Removal Plan
- Maintenance responded onsite.
- Hot water was turned off.
- All resident-accessible sinks and shower rooms with hot water temperatures were audited. Any exceeding 110 F were immediately addressed.
- Nursing staff provided direct supervision and assistance with all bathing and hygiene needs as needed.
- Education was initiated to all staff regarding water temperatures and safety requirements.
- Skin assessments on all residents were initiated.
- Hot water temperatures are in the process of being re-tested using a calibrated thermometer at all resident accessible sinks and shower rooms on all nursing floors.
- Any affected outlets will be returned to resident use only after verification and documentation of compliant temperatures.
- All bathing and showering occurred only at outlets verified to be within the acceptable temperature range, with staff supervision provided as indicated.
- The facility implemented a hot water temperature monitoring process requiring: daily random water temperature checks in resident rooms, shower rooms, and common areas for 7 days; then weekly water temperature checks in resident rooms and shower rooms and common areas for 4 weeks; then ongoing monthly water temperature checks in resident rooms and shower rooms and common areas.
- Use of a thermometer, not hand tested.
- Documentation on a Water Temperature Monitoring Log.
- The facility clearly defined the requirement to include: maximum allowable temperature of 110 F, monitoring frequency, immediate corrective action for out-of-range temperatures.
- Facility staff education was initiated and to be provided to staff prior to start of their shift: acceptable hot water temperature ranges, with maximum water temperature not to exceed 110 F; proper use of thermometers to accurately measure water temperature (thermometers will be located at each nursing station, every shower room, and the receptionist desk); prohibition of hand-testing water temperature due to risk of injury and inaccuracy; immediate reporting of any water temperatures found to be outside the acceptable range to administrative staff and/or Maintenance Director for prompt corrective action.
Failure to Monitor Hot Water Temperatures Creates Immediate Jeopardy
Penalty
Summary
The facility failed to ensure resident safety by not maintaining a system to monitor hot water temperatures, resulting in an Immediate Jeopardy situation. Review of job descriptions and facility documentation, as well as staff interviews, revealed that both the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage or oversee the facility's operations to prevent unsafe water temperatures. Specifically, there was no system in place to regularly check water temperatures, nor did staff consistently verify that water was at a safe temperature before providing care to residents.
Failure to Administer Physician-Ordered Medication for Anemia
Penalty
Summary
The facility failed to administer a physician-ordered medication, Aranesp, to a resident diagnosed with anemia and chronic kidney disease. The resident had a documented history of low hemoglobin levels requiring blood transfusions and was prescribed Aranesp 200 mcg intramuscularly every Thursday. Review of the Medication Administration Record showed that the medication was not given on three scheduled dates. Nursing progress notes indicated that the medication was not available because it was awaiting delivery from the pharmacy, and there were delays due to the need for cost approval. Despite the missed doses, there was no documentation that the physician was notified about the missed administration of Aranesp. The DON reported giving verbal approval to the pharmacy for the medication but could not provide documentation or the name of the person contacted. Additionally, there was no follow-up when the medication was still not received after approval was reportedly given. The resident was later discharged home, and the clinical records did not reflect any physician notification regarding the missed medication doses.
Failure to Label and Date Respiratory Tubing for Residents with Tracheostomies
Penalty
Summary
Facility staff failed to label and date oxygen and suction tubing for two residents who both had tracheostomies and required respiratory care. During observations, both residents were found with trach collars in place and suctioning equipment set up at their bedsides. The tubing for both oxygen and suction, as well as the disposable canisters for suctioning, were not labeled with the date they were last changed. An interview with the DON confirmed that the tubing should have been dated to indicate when it was last replaced.
Failure to Timely Complete and Follow Up on Physician-Ordered Urinalysis
Penalty
Summary
The facility failed to ensure that a physician-ordered urinalysis, culture, and sensitivity test for a resident with acute kidney failure was completed in a timely manner. The initial urine specimen collected on October 13, 2025, was not tested by the laboratory due to improper labeling, as indicated by the laboratory report dated October 14, 2025. There was no documentation that the urine test was completed, and no follow-up was conducted to recollect the specimen after the initial error. Additionally, the physician was not notified of the missed test until October 20, 2025, at which point a new order for the urine test was made. As a result, the resident's urine was not tested until October 21, 2025, when the laboratory report revealed a urinary tract infection caused by Klebsiella Pneumoniae ESBL. The delay in testing led to a delay in the resident receiving appropriate antibiotic treatment. The Director of Nursing confirmed that the lack of follow-up and delayed notification to the physician contributed to the delay in addressing the resident's infection.
Failure to Provide PPE and Signage for Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement its infection prevention and control policy regarding Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling medical devices. Observations revealed that while PPE such as gowns, gloves, and masks were available outside the doors of rooms 102, 104, 108, and 115, there were no signs posted to notify staff or visitors of the need for EBP as required by facility policy. Additionally, a resident with a tracheostomy and tube feeding did not have PPE available in the room, nor was there any signage indicating the need for EBP. These deficiencies were identified during observations and confirmed through policy review and staff interviews.
Failure to Follow Physician Orders for Wound Care and Medication Administration
Penalty
Summary
The facility failed to follow physician orders for wound care and medication administration for two residents, resulting in deficiencies. For one resident with diabetes, peripheral venous insufficiency, and chronic leg ulcers, the facility did not transcribe a new wound care order for Medihoney to the Treatment Administration Record (TAR) after a physician consult indicated wound deterioration and ordered a change in treatment. As a result, the resident's right leg venous ulcer was not treated from October 30 to November 2, and the left leg wound treatment was inconsistently documented and not performed as recorded. Observations confirmed that wound dressings were loose and not dated appropriately, and wound measurements showed significant increases in size, indicating actual harm and further deterioration. Staff interviews revealed that wound treatments were documented as completed when they had not been performed, and the nurse responsible was unable to explain discrepancies between documentation and actual care provided. The Director of Nursing confirmed that wound treatments were missed for several days, and both wounds had increased in size with surrounding redness upon assessment. For another resident readmitted with a wound infection, the facility failed to administer ordered intravenous antibiotics (Ertapenem and Daptomycin) on two consecutive days due to lack of IV access. Although the physician was notified about the need for new IV access, there was no documentation that the physician was informed of the missed antibiotic doses. The resident ultimately received only six out of eight ordered doses. The DON confirmed the missed medication doses, indicating a failure to follow the physician's medication orders for wound infection treatment.
Failure to Provide Required Two-Person Assistance During Care Results in Resident Fall and Harm
Penalty
Summary
A deficiency occurred when a resident with paraplegia and significant impairment in both upper and lower extremities, who was dependent on staff for all activities of daily living including bed mobility, was not provided with the required two-person assistance during care. The resident's care plan did not reflect the need for two-person assistance with bed mobility, despite this requirement being documented in multiple MDS assessments and confirmed by several staff members. During a sheet change, a single unlicensed staff member attempted to turn the resident, resulting in the mattress lifting and the resident falling to the floor. The fall resulted in the resident sustaining an acute subarachnoid hemorrhage, requiring hospitalization and ICU admission. Interviews with the resident and multiple staff confirmed that the resident was unable to roll independently and typically required two staff for bed mobility. The incident was attributed to inadequate supervision and failure to follow the documented care needs, as only one staff member was present during the incident, contrary to the resident's assessed requirements.
Failure to Provide and Document Wound Care per Professional Standards
Penalty
Summary
The facility failed to maintain professional standards of practice in providing wound care for a resident with a Stage 4 pressure ulcer to the sacrum and moisture-associated skin damage (MASD) to the left medial thigh. Physician orders specified wound care regimens for both the sacral wound and the left lower leg, including cleansing, application of specific dressings, and covering with appropriate materials. Review of the Treatment Administration Record (TAR) indicated that wound treatments were documented as completed on several dates by a licensed nurse. However, during an observation, the resident was found with loose dressings on both legs, one of which was dated several days prior, and the sacral wound was left open to air without a dressing, contrary to physician orders. In an interview, the nurse responsible for the resident's care admitted to documenting that wound treatments had been performed when, in fact, they had not been completed for the day. The nurse was unable to confirm whether treatments had been performed on the dates documented, as the dressing dates did not correspond with the recorded entries. This failure to provide wound care as ordered and to accurately document care provided resulted in noncompliance with professional standards and facility policy.
Failure to Follow Wound Care Orders for Sacral Pressure Ulcer
Penalty
Summary
A resident with a Stage 4 pressure ulcer on the sacrum, measuring 1.2 x 0.8 x 0.2 cm with moderate serous drainage, had a physician's order for daily wound care. The order specified cleansing the wound with normal saline, applying nickel-thick Santyl ointment, and covering with a dry dressing. Review of clinical records showed that the wound treatment was not performed on one of the ordered days, and on another day, the wound was observed without a dressing and with a large bowel movement present when the resident's incontinence brief was opened. During staff interviews, the nurse assigned to the resident admitted to documenting that the wound care had been completed for the day, despite not having performed the treatment. The Director of Nursing was unable to provide an explanation for the missed treatment. The facility failed to follow the physician's wound care orders for the resident's sacral pressure ulcer as required.
Failure to Administer Ordered Enteral Nutrition Volumes
Penalty
Summary
The facility failed to ensure that residents receiving enteral (tube) feeding received the amount of nutrition ordered by their physicians. For five of eight residents reviewed, the recorded daily total volume of tube feeding administered did not match the physician's orders on multiple occasions. For example, one resident with an order for Glucerna 1.5 at 63 mL/hour for 20 hours (totaling 1260 mL per day) received amounts ranging from 316 mL to 2382 mL, with discrepancies noted on numerous days in both July and August. There was no documentation in the clinical records addressing these discrepancies. Another resident with a history of stroke, dysphagia, and tracheostomy dependence had an order for Osmolite 1.5 at 60 mL/hour for 20 hours (totaling 1200 mL per day), but failed to receive the prescribed amount on several days in both July and August. The care plan identified a risk for malnutrition, but the clinical record did not provide evidence that the ordered volume was consistently administered. Similar discrepancies were found for other residents, including those with orders for Jevity 1.5 at various rates and volumes, with the actual amounts received often falling short of the prescribed totals. Interviews with licensed staff and the Director of Nursing confirmed that the residents did not receive the ordered amounts of enteral nutrition and that there was a lack of documentation explaining the variances. The facility's failure to provide the prescribed volume of tube feeding and to document reasons for discrepancies was identified through review of physician orders, medication administration records, and staff interviews.
Failure to Develop Hospice Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive hospice care plan for a resident with chronic congestive heart failure who was enrolled in hospice care. Clinical record review showed that the resident had physician orders for hospice evaluation and treatment, and was documented as being on hospice services for a defined period. Despite this, there was no hospice care plan with measurable interventions and timetables found in the resident's clinical records. Staff interviews confirmed that the resident had been receiving hospice care, but no corresponding care plan was created to address the resident's hospice needs.
Failure to Follow and Document Fluid Restriction Orders for Dialysis Residents
Penalty
Summary
The facility failed to ensure that physician orders for fluid restrictions were followed and accurately documented for two residents with end stage renal disease (ESRD) and congestive heart failure (CHF) who were receiving hemodialysis. Both residents had care plans and physician orders specifying a daily fluid restriction of 1500 ml, with detailed allocations for nursing and dietary staff across different shifts and meals. However, clinical record reviews for both residents did not show evidence that their fluid intake was being accurately tracked or documented in accordance with these orders. An interview with a licensed employee confirmed that the facility did not accurately follow or document the daily fluid consumption for these residents as prescribed. The deficiency was cited under regulations related to clinical records and nursing services, with previous citations noted for the same areas.
Failure to Document and Provide Appropriate Catheter Care
Penalty
Summary
A deficiency was identified when a resident with a urinary catheter did not receive appropriate catheter care and documentation as required by facility policy. Observation revealed the resident had a urinary catheter, and review of the clinical record showed that after the resident was readmitted from the hospital with a Foley catheter, there were no physician's orders for catheter care. Additionally, there was no documentation of input and output or catheter care provided during the period the catheter was in place. Facility policy required that catheter care, including assessment data, problems noted, and resident tolerance, be documented in the medical record, along with the date, time, and staff involved. An interview with licensed staff confirmed the absence of documentation regarding the catheter from the time of readmission until the catheter was removed. This lack of documentation and absence of physician orders for catheter care constituted a failure to provide appropriate catheter treatment and services for the resident.
Failure to Obtain and Monitor Accurate Admission Weight
Penalty
Summary
The facility failed to obtain an accurate admission weight and did not ensure ongoing accurate weight monitoring for one resident. According to facility policy, new and re-admission residents are to have their weight and height obtained within 24 hours of admission, and significant weight changes are to be reported to the Registered Dietitian and the physician. For one resident with diagnoses including stroke, dysphagia, tracheostomy dependence, and PEG tube feeding, the admission weight was inaccurately documented, and subsequent weights were also incorrect and later struck from the record. As a result, the resident's nutritional status and tube feeding regimen were based on inaccurate weight data for nearly a month, making it impossible to determine if there was a significant weight loss during that period or if the tube feeding was adequate. The issue was confirmed through clinical record review and staff interview, which revealed that the initial and subsequent weights were not accurate, and the error was only identified after receiving a hospital weight.
Failure to Attempt Non-Pharmacological Pain Interventions Before PRN Opioid Administration
Penalty
Summary
The facility failed to implement non-pharmacological interventions prior to administering pain medication for one of two residents reviewed. According to the facility's policy on administering pain medications, non-pharmacologic interventions such as positioning or warm/cold compresses should be evaluated and their effectiveness documented before administering pain medication. For the resident in question, physician's orders included Roxicodone 5 mg every four hours as needed for pain, which was administered 28 times in July and three times in August. However, review of the clinical record showed no evidence that non-pharmacological interventions were attempted or documented prior to the administration of the as-needed pain medication. This was confirmed by interview with licensed staff, who acknowledged the lack of evidence for such interventions.
Failure to Provide Accurate MAR Documentation for Tube Feeding Schedule
Penalty
Summary
The facility failed to ensure accurate documentation of a resident's tube feeding schedule on the Medication Administration Report (MAR). Review of the clinical records for a resident with multiple complex medical diagnoses, including severe protein calorie malnutrition, adult failure to thrive, Wernicke's encephalopathy, dysphagia, and achalasia of the cardia, revealed physician orders for enteral feedings at specific times throughout the day. However, the MAR only provided options for staff to document the tube feedings being set up and taken down during the day and evening shifts, with no option for the afternoon. This omission resulted in the inability of staff to properly document the administration of tube feedings according to the prescribed schedule. A registered nurse confirmed that the MAR was not set up to allow for proper documentation of the resident's tube feeding schedule.
Failure to Document Annual Full-Scale Emergency Exercise
Penalty
Summary
A deficiency was identified when the facility failed to maintain its Emergency Preparedness Program as required by federal regulations. During a Medicare/Medicaid Recertification Survey, surveyors reviewed documentation and conducted interviews to assess compliance with emergency preparedness testing requirements. The review, conducted on August 5, 2025, between 8:35 AM and 10:45 AM, revealed that the facility did not have documentation verifying that a full-scale emergency exercise had been conducted within the last twelve months. This documentation is necessary to demonstrate that the facility has tested its emergency plan as required by regulation §483.73(d)(2). During the exit conference, the Administrator, Regional Director, Regional Maintenance Director, and Environmental Services Director confirmed that the facility lacked documentation of a full-scale exercise. This absence of documentation substantiated the finding that the facility was not in compliance with the emergency preparedness testing requirements.
Plan Of Correction
The facility lacked documentation verifying a full-scale exercise had been conducted in the last twelve months. No residents were affected. All residents have the potential to be affected. A full-scale exercise will be completed within 30 days by the Emergency Preparedness Plan Committee as required. The facility will reach out to the healthcare coalition and will participate in a full-scale exercise if available. The Director of Maintenance and maintenance staff were educated by the Administrator on the requirement. The Maintenance Director/Designee will conduct a semi-annual audit on an ongoing basis to ensure compliance with conducting a full-scale exercise as required. Results of audits will be reviewed at the Quarterly Quality Assurance and Improvement Committee Meeting over the duration of the audit process. Based on the results of the audits, a decision will be made regarding the need for continued submission and reporting.
Failure to Maintain Continuous Illumination of Exit Sign
Penalty
Summary
Surveyors observed that the facility failed to maintain continuous illumination of an exit sign as required by NFPA 101 standards. Specifically, during an inspection, the exit sign located above the door leading to grade from the stairtower near the Elevator Lobby on one of the four floors was found to be unlit. This deficiency was confirmed during an interview with the Administrator, Regional Director, Regional Maintenance Director, and the Environmental Services Director, who acknowledged that the exit sign was not illuminated at the time of the survey. No information regarding residents or their medical conditions was provided in relation to this deficiency.
Plan Of Correction
The facility failed to maintain exit signs to be continuously illuminated, on one of four floors. No residents were identified. All residents have the potential to be affected. The exit sign, above the door leading to grade from the stair tower near the Elevator Lobby, was repaired to ensure it is continuously illuminated as required. Facility-wide audit was completed by the Maintenance Director to ensure that there are no other open areas in walls. The Maintenance Director was educated on the requirement by the Administrator. The Maintenance Director/Designee will conduct compliance audits to ensure that exit signs meet the requirement. The audits will be weekly for four weeks, then monthly ongoing thereafter. The administrator will conduct quarterly random audits thereafter to spot check. The results of the audits will be discussed monthly and quarterly by the Quality Assurance and Performance Improvement Committee for the duration of the audit process (3 months). Based on the results of these audits, a decision will be made regarding the need for continued submissions and reporting.
Failure to Maintain Sprinkler System Integrity and Function
Penalty
Summary
The facility failed to maintain the sprinkler system as required, as evidenced by observations on three of four floors. On the 3rd and 2nd floors, there were open areas in the walls behind beds in two resident rooms, each measuring approximately 12 inches by 2 inches, which could cause a delay in sprinkler activation. Additionally, on the 1st floor, a sprinkler located over a bed in one room was found to be covered in paint overspray. These deficiencies were confirmed during an exit conference with facility leadership, including the Administrator, Regional Director, Regional Maintenance Director, and Environmental Services Director. No information about the medical history or condition of residents in the affected rooms was provided in the report.
Plan Of Correction
The facility failed to maintain the sprinkler system on three of four floors. No residents were affected. All residents have the potential to be affected. The open area in the wall behind the A bed in room 315 on the 3rd floor was repaired. The open area in the wall behind the B bed in room 204 on the 2nd floor was repaired. The sprinkler over the B bed in room 102 on the 1st floor was repaired and paint was removed. A facility-wide audit was completed to ensure that there are no other open areas in walls. An audit of the facility's remaining sprinklers was completed by the Director of Maintenance to assure that they meet the requirement. The Director of Maintenance and maintenance staff were educated by the Administrator on the requirement to maintain the sprinkler system according to the regulation. They were also educated on sprinkler head inspection to ensure that they meet the requirement. The Maintenance Director/Designee will conduct one random weekly audit to ensure that there are no open areas in walls for four weeks, then monthly for two months and quarterly thereafter. They will also conduct one random weekly audit of all sprinklers for four weeks, then monthly for two months and then quarterly thereafter. Results of audits will be reviewed at the Quarterly Quality Assurance and Improvement Committee Meeting over the duration of the audit process. Based on the results of the audits, a decision will be made regarding the need for continued submission and reporting.
Multiple Corridor Door Deficiencies Impacting Smoke and Fire Protection
Penalty
Summary
Surveyors observed multiple deficiencies related to corridor doors on three of four floors within the facility. Specifically, one door on the 3rd floor (Room 315) failed to latch properly in its frame. On the 2nd floor, Room 220's door did not maintain smoke tight integrity even when latched, and the Clean Utility door near the Nurses' Station had an open hole where the lockset was removed. On the 1st floor, doors to Rooms 128 and 107 also lacked smoke tight integrity while latched in their frames. These deficiencies were confirmed during an exit conference with facility leadership, including the Administrator, Regional Director, Regional Maintenance Director, and Environmental Services Director. The report does not mention any specific residents or their medical conditions in relation to these deficiencies.
Plan Of Correction
The facility failed to maintain corridor doors on three of four floors. No residents were affected. All residents have the potential to be affected. The corridor door on the 3rd floor, Room 315 was repaired to meet the regulation and latch in the corresponding frame. The corridor door on the 2nd floor, Room 220 was repaired to ensure smoke tight integrity. The 2nd floor, the hole noted in the clean utility door near the nurses' station was repaired. The corridor door on the 1st floor, Room 128 was repaired to ensure smoke tight integrity. The corridor door on the 1st floor, Room 107 was repaired to ensure smoke tight integrity. An audit of the facility's remaining resident corridor doors was completed by the Director of Maintenance to ensure that all doors meet the requirement. Director of Maintenance and maintenance staff were educated by the Administrator on maintaining corridor doors to meet the requirement of smoke tight integrity and latch properly. The Maintenance Director/Designee will conduct one weekly audit of corridor doors to check function and integrity for four weeks. The audits will continue monthly thereafter. Results of audits will be reviewed at the Quarterly Quality Assurance and Improvement Committee Meeting over the duration of the audit process. Based on the results of the audits, a decision will be made regarding the need for continued submission and reporting.
Smoke Barrier Doors Failed to Close Smoke-Tight
Penalty
Summary
Surveyors observed that the facility failed to maintain smoke barrier doors in a manner that ensured they were smoke-tight. Specifically, on the ground floor near the Laundry Area, the smoke barrier doors did not fully close when released from their hold-open devices. This deficiency was identified during an observation and was confirmed in an interview with facility leadership, including the Administrator, Regional Director, Regional Maintenance Director, and Environmental Services Director. The report does not mention any residents or specific patient involvement in this deficiency.
Plan Of Correction
The facility failed to maintain smoke barrier doors to be smoke tight, on one of four floors. No residents were affected. All residents have the potential to be affected. The smoke barrier doors, near the Laundry Area on the ground floor, were repaired to close smoke-tight, when released from the hold-open devices. An audit of the facility's remaining smoke barrier doors was completed by the Director of Maintenance to ensure that all smoke barrier doors were smoke-tight when released from the hold-open devices and closed. The Director of Maintenance and maintenance staff were educated by the Administrator on the requirement. The Maintenance Director/Designee will conduct one weekly audit of smoke barrier doors for four weeks, then monthly for two months and then quarterly thereafter. Results of audits will be reviewed at the Quarterly Quality Assurance and Improvement Committee Meeting over the duration of the audit process. Based on the results of the audits, a decision will be made regarding the need for continued submission and reporting.
Improper Venting of Portable Air Conditioning Unit
Penalty
Summary
A deficiency was identified when, during an observation, a portable air conditioning unit was found in a large common area near the Nurses' Station on one of four floors. The unit was vented directly into the interstitial space of the ceiling rather than being vented to the outside, as required. This was confirmed during an interview with the Administrator, Regional Director, Regional Maintenance Director, and the Environmental Services Director. The facility did not maintain the air conditioning system in accordance with NFPA 101 and the manufacturer's specifications.
Plan Of Correction
The facility failed to maintain air conditioning systems on one of four floors. No residents were affected. All residents have the potential to be affected. The portable air conditioning unit, located in a large common area near the Nurses' Station, was removed so it is not vented directly into the interstitial space of the ceiling. The expected date for HVAC repair is September 30th, 2025, with the portable air conditioners removed before October 31st, 2025. An audit was completed by the Maintenance Director to ensure that no portable air conditioning units were vented directly into the interstitial space of the ceiling, with no concerns found and compliance confirmed. The Director of Maintenance and maintenance staff were educated by the Administrator on the requirement. The Maintenance Director/Designee will conduct one weekly audit of the portable air conditioner for four weeks, then monthly for two months. Results of audits will be reviewed at the Quarterly Quality Assurance and Improvement Committee Meeting over the duration of the audit process. Based on the results of the audits, a decision will be made regarding the need for continued submission and reporting.
Electrical System Maintenance Deficiencies Identified
Penalty
Summary
Surveyors observed that the facility failed to maintain components of the electrical system on one of four floors. Specifically, on the 2nd floor in Room 224, a receptacle near the A-bed was missing a cover, and in Room 226, the reading light over the A-bed had non-terminated, exposed wiring hanging from the underside of the cover. These deficiencies were identified during an inspection and confirmed in an interview with the Administrator, Regional Director, Regional Maintenance Director, and the Environmental Services Director.
Plan Of Correction
0911 The facility failed to maintain components of the electrical system, on one of four floors. No residents were affected. All residents have the potential to be affected. The 2nd floor Room 224, a receptacle near the A-bed was repaired and a cover was installed as required. 2nd floor Room 226, the reading light over the A-bed had non-terminated, exposed wiring hanging from the underside of the cover. An audit was completed by the Maintenance Director to ensure that all receptacles are installed as required and that all lights are installed as required. Director of Maintenance and maintenance staff were educated by the Administrator on the requirement. Also, maintenance director and maintenance staff were educated on the requirement to audit the receptacles when installed. They were also educated that bedside lights must be inspected frequently for physical integrity. Education of floor staff (Certified nursing assistants, professional nurses, housekeepers) was initiated to report any damaged receptacles and overhead lights to maintenance for repair. The Maintenance Director/Designee will conduct one weekly audit of random receptacles for four weeks, then monthly for two months and then quarterly thereafter. In addition, auditing will occur for any newly installed receptacles and during room deep cleaning. The Maintenance Director/Designee will conduct one weekly audit for overhead lamps for four weeks and then monthly for two months. Additionally, overhead lamps will be audited when a repair or replacement is put in place. Results of audits will be reviewed at the Quarterly Quality Assurance and Improvement Committee Meeting over the duration of the audit process. Based on the results of the audits, a decision will be made regarding the need for continued submission and reporting.
Unauthorized Use of Extension Cords and Surge Protectors
Penalty
Summary
Surveyors observed that the facility failed to monitor and prevent the unauthorized use of surge protectors and extension cords on two of four floors. Specifically, on the 2nd floor in Room 204, an extension cord was used to power a phone charger at the B-bed, and in Room 214, various medical devices near the A-bed were powered by a surge protector. On the 1st floor in Room 104, an extension cord was also used to power a phone charger at the A-bed. These findings were made during observations conducted between 11:34 AM and 12:03 PM. During the exit conference, facility leadership, including the Administrator, Regional Director, Regional Maintenance Director, and Environmental Services Director, confirmed that the surge protector and extension cords were in use at the time of the survey. The use of these devices did not comply with NFPA 101 and related standards, which restrict the use of extension cords and power strips in patient care areas and specify the types of equipment and conditions under which they may be used.
Plan Of Correction
The facility failed to monitor for the unauthorized use of surge protectors and extension cords on two of four floors. No residents were affected. All residents have the potential to be affected. The extension cord in Room 204 at B-bed on the 2nd floor was removed to meet the requirement. The surge protector in Room 214 A-bed on the 2nd floor was removed to meet the requirement. The extension cord in Room 104 A-bed on the 1st floor was removed to meet the requirement. An audit was completed by the Maintenance Director to ensure that no unauthorized surge protectors or extension cords are in use. The Director of Maintenance and maintenance staff were educated by the Administrator on the requirement. The Maintenance Director/Designee will conduct one weekly audit to ensure compliance with unauthorized use of surge protectors and extension cords for 4 weeks, then monthly thereafter. The audits will include new residents, decorated areas, and new equipment. Results of audits will be reviewed at the Quarterly Quality Assurance and Improvement Committee Meeting over the duration of the audit process. Based on the results of the audits, a decision will be made regarding the need for continued submission and reporting.
Noncompliance with Building Construction Type and Height Requirements
Penalty
Summary
Surveyors determined that the facility failed to comply with building construction requirements as outlined in the 2012 Edition of the Life Safety Code. During a document review and on-site observation, it was found that the facility is a four-story, Type II (000) unprotected noncombustible structure that is fully sprinklered. According to the Life Safety Code, this type of construction is not permitted to exceed two stories for an existing sprinklered health care occupancy. The deficiency was confirmed during an exit conference with facility leadership, including the Administrator, Regional Director, Regional Maintenance Director, and Environmental Services Director. The facility's documentation and physical structure did not meet the required standards for the number of stories allowed for its construction type, as specified by the applicable code.
Plan Of Correction
Facility is requesting DOH complete an FSES for us. Center will submit life safety drawings that were requested.
Failure to Maintain Fire Alarm System Documentation
Penalty
Summary
The facility failed to maintain the fire alarm system in accordance with NFPA 70 and NFPA 72 requirements, as evidenced by the absence of documentation for a semi-annual visual inspection of the fire alarm system. During a document review and interviews, it was determined that the facility could not provide records of the required inspection for all seven smoke compartments. This lack of documentation was confirmed during interviews with the Administrator, Regional Director, Regional Maintenance Director, and Environmental Services Director at the time of the survey exit conference. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
The facility failed to maintain the fire alarm system, for seven of seven smoke compartments. No residents were affected by this deficient practice. All residents have the potential to be affected. On 8/12/2025, the Maintenance Director was educated by the Administrator on the requirement that a semi-annual visual inspection of the fire alarm system is required. A semi-annual visual inspection of the fire alarm system was completed. Fire alarm system was audited to ensure compliance with the requirement. The Maintenance Director/Designee will conduct compliance audits semi-annually on an ongoing basis to ensure that a semi-annual visual inspection of the fire alarm system is completed. Results of audits will be reviewed at Quarterly Quality Assurance and Performance Improvement Committee Meeting over the duration of the audit process. Based on the results of these audits, a decision will be made regarding the need for continued submission and reporting.
Failure to Transfer Cognitively Intact Resident from Memory Care Unit
Penalty
Summary
The facility failed to honor the resident's right to a dignified existence by not allowing Resident 98, who is cognitively intact, to transfer from the memory care unit to a more appropriate unit. Resident 98, diagnosed with unspecified dementia and major depressive disorder, has a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Despite multiple requests and a filed grievance to move off the memory care unit due to the inability to interact with residents of similar cognitive levels, the facility did not accommodate the resident's request. Interviews with staff, including an LPN and other employees, confirmed that Resident 98 is a high-functioning resident who does not participate in activities designed for residents with impaired cognition. The Director of Nursing and Nursing Home Administrator acknowledged that Resident 98 does not belong in the memory care unit, yet the resident remained there, highlighting the facility's failure to provide a dignified existence and self-determination for the resident.
Failure to Follow Physician Orders for Referrals and Medication Administration
Penalty
Summary
The facility failed to adhere to physician orders for two residents, leading to deficiencies in care. For Resident 29, who has multiple medical diagnoses including pleural effusion, acute kidney failure, Parkinson's disease, and rheumatoid arthritis, the facility did not follow through with referrals for physical therapy, occupational therapy, and a Deep Brain Stimulation (DBS) Clinic as prescribed by a neurologist. Despite the after-visit summary and progress notes indicating these referrals were necessary, a review of the resident's clinical records on July 25, 2024, showed that these referrals had not been made, which was confirmed by the Nursing Home Administrator (NHA), Director of Nursing (DON), and Employee E7 during an interview. For Resident 69, who has conditions such as cellulitis, hypertension, atherosclerotic heart disease, end-stage renal disease, congestive heart failure, diabetes, and chronic kidney disease, the facility failed to administer medication according to the prescribed parameters. The physician's order for Midodrine HCI Oral Tablets 5MG specified administration three times a day with a condition to hold if blood pressure exceeded 100/60. However, the Medication Administration Report (MAR) for June and July 2024 revealed that the medication was given outside these parameters on multiple occasions. Employee E7 confirmed this discrepancy, acknowledging that the resident received the medication incorrectly.
Failure to Monitor Antipsychotic Side Effects
Penalty
Summary
The facility failed to accurately monitor and assess a resident for side effects of antipsychotic medications. Resident 6 was prescribed Rexulti, an antipsychotic medication, with an order to monitor for side effects every shift. However, the clinical record review and observations revealed discrepancies in the documentation of side effects. The Abnormal Involuntary Movement Scale (AIMS) assessment on June 3, 2024, indicated mild to moderate involuntary movements, yet the Medication Administration Record (MAR) for May, June, and July 2024 showed inconsistent documentation, often marked as 0 or N/A, indicating no side effects, except for one instance on May 30, 2024, where a stiff neck was noted. An observation on July 25, 2024, confirmed the presence of tremors and lip puckering in Resident 6, which were not accurately documented in the MAR. An interview with the Nursing Home Administrator and Director of Nursing corroborated the failure to document the resident's side effects accurately. This deficiency highlights a lapse in the facility's adherence to monitoring protocols for antipsychotic medication side effects, as required by the relevant Pennsylvania codes.
Failure to Provide Required Therapy Services
Penalty
Summary
The facility failed to provide necessary therapy services to prevent a decline in the Activity of Daily Living (ADL) performance for a resident. The resident, identified as Resident 29, has a medical history that includes pleural effusion, acute kidney failure, Parkinson's disease, and rheumatoid arthritis. On July 1, 2024, the resident returned from a neurologist appointment with a prescription for physical and occupational therapy. The clinical records also included an after-visit summary from a neurology consultation, documenting referrals for physical and occupational therapy. Despite these referrals, the resident did not receive any physical or occupational therapy after being discharged from occupational therapy on June 6, 2024. The discharge recommendations included specific exercises and activities to maintain the resident's current level of function. However, the facility did not follow through with the prescribed therapy services, as confirmed during an interview with the Nursing Home Administrator, Director of Nursing, and another staff member on July 25, 2024. This lack of action resulted in a deficiency as the facility did not provide the specialized rehabilitative services required for the resident.
Failure to Include Discharge Planning in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan, including discharge planning, for a resident who was admitted following treatment for seizure activity. The resident, who has diagnoses of depression, epilepsy, and anxiety, was admitted to the facility after being discharged from a local hospital. The resident had been living in a homeless shelter prior to the hospital admission. Despite the resident's expressed readiness to go home and the absence of a housing plan, the care plan did not include a goal for discharge. The deficiency was identified during a review of the resident's clinical records, which included progress notes from a CRNP and a social worker. The notes indicated that the resident had no seizure activity since admission and was anxious about discharge planning. An interview with the Director of Nursing confirmed the absence of a discharge goal in the care plan. The facility's failure to include discharge planning in the care plan was a violation of 28 Pa Code 211.11(d) Resident Care Plans.
Failure to Timely Assess and Treat Wound
Penalty
Summary
The facility failed to comprehensively assess a wound identified upon admission and did not place a treatment order timely for Resident CL1. Upon admission, Resident CL1 was found to have a sacral wound measuring 5.0 x 3.0 x 3.0 cm, but the wound assessment lacked details regarding the wound's appearance. Although a treatment plan involving Medihoney was noted, it was not transcribed into the resident's Treatment Administration Record. An interview with a licensed nurse revealed that the initial wound assessment was incomplete and the treatment order was not placed due to an agency nurse's oversight. Further review showed that the wound physician assessed the wound the following day and recommended a treatment plan involving Leptospermum Honey. However, this treatment order was not implemented until two days later, as the consultation form with the treatment recommendation was not received by the facility until then. This delay resulted in the treatment order being placed three days after the wound was initially identified. The deficiency was discussed with the Nursing Home Administrator and Director of Nursing.
Latest citations in Pennsylvania
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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