Aventura At Prospect
Inspection history, citations, penalties and survey trends for this long-term care facility in Prospect Park, Pennsylvania.
- Location
- 815 Chester Pike, Prospect Park, Pennsylvania 19076
- CMS Provider Number
- 395203
- Inspections on file
- 38
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Aventura At Prospect during CMS and state inspections, most recent first.
The facility failed to ensure that meals were served at a palatable taste and appropriate temperature during a test tray evaluation of a lunch meal. Review of the facility’s test tray standards showed that starches and vegetables should be delivered at 135–165°F, but three pureed items—intended to be mac and cheese, mashed potatoes, and mixed vegetables—were served at 110°F. The food was described as bland with an unfamiliar taste, and the pureed vegetables tasted more like pureed meat. The NHA participated in the tasting and agreed with the surveyor’s findings regarding the substandard temperature and taste.
Missing State Survey Agency Posting: The facility failed to display the State Survey Agency phone number and contact information in prominent, readily accessible locations on two nursing units. During a tour, the DOSS was unsure where the postings were located, and the required complaint/reporting information could not be found in the nursing units or common areas. The NHA later confirmed the postings were not up and may have been removed during painting.
Meal service did not follow the planned menu: soup, crackers, and other listed items were missing or substituted, portioning did not match the production sheet, and a cook served items not on the menu. Residents with nectar-thick liquid orders were not offered the planned tomato soup, and cognitively intact residents reported the always available menu was limited and often left them without an acceptable alternative.
Failure to Maintain Effective Antibiotic Stewardship Program: The facility did not maintain an effective antibiotic stewardship program with ongoing tracking, analysis, and reporting of antibiotic use for 11 months. The Infection Surveillance Report showed no evidence of interventions to optimize antibiotic use, including review of antibiotic orders for appropriateness, empiric therapy protocols, de-escalation based on culture results, or avoiding unnecessary antibiotics for viral infections, and there was no evidence of tracking, monitoring, staff education, analysis, or feedback, as confirmed by the DON/IPC.
The facility did not maintain an effective antibiotic stewardship program with a system to monitor antibiotic use for 11 of 11 months reviewed. Policy review found no evidence that facility-acquired infections were reported to the PA Patient Safety Authority through PA-PSRS as required by Act 52, and the DON/Infection Preventionist was unable to provide evidence of compliance during interview.
Pest Control Program Not Maintained: Residents on both nursing floors reported mice and roaches in their rooms, including mice entering through wall and bathroom openings and roaches seen at night. Surveyors observed unfilled voids, a hole in a resident room wall, roaches in traps, open snacks stored on the floor, and half-eaten meal trays left on top of an ice machine, while pest control logs documented repeated mice activity, droppings, and a rat in resident areas.
Incomplete Investigation of Unwitnessed Fall: A resident with stroke-related mobility limits, hemiplegia, and visual field deficits sustained an unwitnessed fall from bed after reaching for a cell phone and reported severe pain. The facility gathered statements from the RN supervisor, two LPNs, and two nurse aides, but did not obtain written or signed statements from the resident or the roommate; both residents later reported that staff did not respond right away and that the roommate had to call for help.
A facility failed to develop person-centered comprehensive care plans with measurable goals for two residents. One resident with pulmonary HTN and acute/chronic respiratory failure had PT restorative recommendations for OOB activity, sitting tolerance, and wheelchair mobility, but no restorative nursing care plan was in place. Another resident with quadriplegia and acute/chronic respiratory failure had physician orders for bilateral hand mitts to prevent trach dislodgement, but no restraint care plan was documented; the DON confirmed both omissions.
Failure to provide and accurately document hygiene assistance: A resident with hemiplegia/hemiparesis, PTSD, cardiomyopathy, and other medical conditions was observed disheveled with dandruff on clothing. The resident stated he/she had not been offered a shower, did not know the shower schedule or location, and had been using the sink for hygiene. Although the chart showed a completed shower, an aide later confirmed the shower was falsely documented.
Failure to Provide Restorative Nursing and Passive ROM: The facility failed to ensure rehabilitative nursing care was carried out for two residents. One resident with pulmonary hypertension had PT discharge recommendations for a home exercise program, restorative nursing, and out-of-bed-to-chair activity via hoyer lift, but there was no documented evidence these interventions were implemented in the nursing tasks or care plan. Another resident with functional quadriplegia had a care plan and Kardex directing daily passive ROM to all extremities, yet the record showed multiple instances where the task was marked not applicable with no explanation documented.
A resident with malnutrition, left-sided hemiplegia, a right-hand contracture, and visual field defects required partial/moderate assistance for bed mobility and therapy focused on log rolling and use of handrails. The resident later rolled out of bed while reaching for a cell phone and sustained an unwitnessed fall; the resident reported no bed handrails were in place, and the DON and DOR confirmed the rails were absent at the time of the fall.
Failure to reassess residents with significant weight loss led to a nutrition care deficiency for multiple residents. Facility policy required weights to be monitored and any 5% or greater loss in one month to be reported to the RD and reweighed, but one resident with DM and malnutrition had ongoing rapid weight loss that was not formally assessed in a timely manner, and another resident with fractures lost 7.5 lbs in one month with no documented nutritional assessment; the RD confirmed no assessment was completed.
Medication was not administered accurately for a resident with schizophrenia, schizoaffective disorder, bipolar disorder, and other psychiatric diagnoses. The resident had acute worsening psychosis with agitation, paranoia, and refusal of care, and orders were entered for Haloperidol 0.25 mg and Ingrezza 60 mg. However, the orders remained pending confirmation, the e-MAR showed missed doses, and an LPN administered Ingrezza 40 mg instead of the ordered 60 mg.
The facility failed to provide a resident and the resident’s representative with timely and reasonably priced access to the resident’s medical records. Despite a written HIPAA-compliant authorization and a policy requiring records to be available within 48 hours, the facility issued a high-cost invoice for over 1,400 pages and conditioned release of the records on payment. A later request for a complete electronic copy resulted instead in an incomplete paper set missing key portions of the chart, including MDS and CNA flow sheets, and the records were still being compiled weeks later. The Director of Medical Records reported difficulty providing electronic records, while the NHA confirmed that records could be sent electronically and that the resident’s records were not released as requested in a timely manner or at a reasonable cost.
A resident with multiple chronic conditions reported new symptoms, including body aches, cold symptoms, and vomiting, but did not receive timely or adequate monitoring and assessment by nursing staff. Only one set of vital signs was documented despite ongoing symptoms, and communication lapses occurred during shift changes. The resident was later found unresponsive and could not be resuscitated.
A resident with severe mobility limitations was not given the required two-person assistance during bed repositioning, as specified in their care plan and nursing Kardex. A nurse aide attempted to roll the resident alone while changing bed sheets, resulting in the resident rolling off the bed. Facility staff confirmed that proper procedures and care plan instructions were not followed.
Aventura at Prospect was found non-compliant with the Life Safety Code due to staff's lack of access to keys or knowledge of codes for egress doors, affecting emergency exits and potentially hindering safe evacuation.
The facility's fire alarm system was found to be deficient and non-operational, affecting the entire facility. The system had been out of operation since March 21, 2025, as confirmed during an exit interview with the administrator and maintenance director.
The facility's pest control program was ineffective, leading to a persistent infestation of rodents and other pests. Residents reported rodents entering through air conditioning units, and observations confirmed entry points and pest activity in the kitchen and other areas. Despite repeated treatments, structural issues remained unaddressed, allowing pests to enter.
The facility failed to maintain a safe environment and provide adequate supervision for residents, as evidenced by unlocked storage rooms with cleaning supplies, unsecured razors in a cognitively impaired resident's bathroom, and improperly stored medications in residents' rooms. These deficiencies indicate a lack of adherence to facility policies on hazardous materials and resident supervision.
The facility failed to maintain nutritional care for two residents, leading to significant weight loss and inadequate dietary management. One resident did not receive prescribed double protein portions or low phosphorus foods due to staff unawareness, while another resident's weights were not recorded for two months, despite being at risk for malnutrition.
A resident with heart failure, end-stage renal disease, and diabetes did not receive insulin as ordered on days scheduled for dialysis. The nursing staff failed to administer insulin at 12:30 p.m. on multiple occasions, and there was no documentation of communication with the physician. The DON confirmed the lack of coordination with the dialysis center and meal service.
A facility was found to have a medication error rate of 35.8%, significantly above the acceptable threshold. Errors included incorrect dosages of Gabapentin and Vitamin D3 administered by licensed nurses, contributing to the high error rate.
The facility did not consider the food preferences of several residents, as evidenced by meal observations, resident interviews, and council meeting minutes. Despite a policy requiring comprehensive assessments of food preferences, residents repeatedly requested changes to the menu, which were not implemented. Interviews with dietary staff confirmed a lack of coordination to meet residents' dietary needs.
The facility failed to meet professional standards for food service safety, with deficiencies in food storage, preparation, and sanitation. Observations revealed outdated and unlabeled food items in the refrigerator and freezer, rodent infestation in the dry storage room, and inadequate sanitation practices in the dishwashing area. These issues were confirmed by the food service director and registered dietitian.
The facility failed to implement a comprehensive infection prevention and control program, lacking evidence of measures to prevent Legionella and other waterborne bacteria. Additionally, the facility did not demonstrate ongoing analysis of infection surveillance data or proper documentation when residents returned from acute care hospitals.
The facility did not designate a qualified infection preventionist for its infection prevention and control program. A review of the facility's policy indicated the need for an Infection Preventionist to conduct surveillance for HAIs. However, the Director of Nursing could not provide documentation of employing an Infection Preventionist with specialized training, resulting in non-compliance with training requirements.
A facility failed to protect a resident's personal property, as their belongings were not accounted for upon discharge. The resident's inventory was completed at admission, but after their death, a note stated no belongings were present, and the discharge inventory was not used. Staff interviews revealed that the discharge inventory process was not followed, leading to the deficiency.
A facility failed to thoroughly investigate the misappropriation of a resident's property, involving missing funds from the resident's bank account. The resident identified two employees as alleged perpetrators, but the facility could not substantiate the claims. The investigation report lacked documentation of agency involvement and police notification, and did not review bank charges with the resident.
The facility did not ensure that the Infection Preventionist and Medical Director attended the QAPI meetings for one quarter. There were no sign-in sheets for February, March, April, or June 2024, and the May 2024 sheet lacked signatures from these key members. The facility has not employed an Infection Preventionist since February 2024, and the Medical Director has not attended or designated a representative for the meetings.
A resident reported verbal abuse by a nursing aide after requesting a TV channel change. The administration met with the resident and reported the incident to the State Survey Agency, but failed to process the complaint as a grievance, violating resident rights regulations.
The facility failed to respond to resident council concerns about meal portion sizes for four consecutive months. Despite repeated requests for larger portions, there was no documented follow-up or communication from the administration. During a resident group meeting, all residents present expressed dissatisfaction with the administration's lack of response. The Nursing Home Administrator confirmed this failure.
The facility failed to provide the required advanced notice of Medicare Non-Coverage (CMS 10123) for three residents, as the notices were not delivered at least two calendar days before the termination of Medicare services. This was confirmed through a review of clinical records and an interview with the Nursing Home Administrator.
The PASRR assessments for three residents were found to be incomplete or incorrect, failing to document mental health and neurocognitive conditions accurately. This was confirmed through clinical record reviews and staff interviews, indicating a failure in the facility's process for completing PASRR assessments as required by policy.
The facility failed to develop a comprehensive care plan for a resident with heart failure, high blood pressure, schizophrenia, and a history of ileus. The care plan did not address the resident's history of ileus, constipation, or schizophrenia, despite documented complaints and psychiatric notes.
The facility failed to ensure that nurse aides demonstrated competency in skills and techniques necessary to care for residents requiring intravenous therapy and tracheostomy care. Documentation of staff competencies and skill sets was not provided, and an interview confirmed the lack of evaluation for these competencies.
The facility failed to provide necessary pharmaceutical services for two residents, resulting in missed doses of Debrox Otic solution and Zaditor ophthalmic solution. The residents reported that the facility often ran out of medications due to staff not ordering them on time and insufficient supply from the pharmacy.
A resident, diagnosed with heart failure, high blood pressure, schizophrenia, and a history of ileus, was not informed of the results of an abdominal x-ray ordered to rule out an ileus. The resident indicated that no one had informed him of the results, and review of the records confirmed this lack of communication.
The facility failed to post the complaint hotline number for the State Survey Agency on three nursing units. Observations and interviews confirmed the absence of the required postings in the main lobby and on the First and Second floors.
The facility failed to promptly resolve resident complaints and grievances. During a resident council meeting, eight residents, including one who had not received medications and Ensure as ordered by his physician for several months, expressed concerns about the administration's failure to address their grievances. The social service director confirmed that no follow-up or immediate interventions were implemented.
The facility failed to monitor bowel movements for a resident with a history of ileus and did not ensure another resident wore an Aspen Collar as prescribed. The Director of Nursing confirmed these lapses, which led to discomfort and improper treatment for the residents.
A cognitively impaired resident experienced multiple falls due to inadequate supervision, despite being completely dependent on staff for all activities of daily living. The resident's falls included incidents where the resident fell from a Geri-chair and was found on the floor in the dining room and hallway. The Director of Nursing confirmed that the resident was not properly supervised according to the facility's 1:1 supervision policy.
The facility failed to ensure that a resident with a history of depression, bipolar disorder, and suicidal attempts received timely behavioral health services. Despite a recommendation for a psychology consult on January 29, 2024, the resident was not seen by a psychologist. Additionally, the social service director did not follow up on the resident's concerns after the resident expressed frustration and made a statement about harming himself.
The facility failed to ensure a resident's medication regimen was free from unnecessary medications. A physician's order for Clonazepam was renewed without proper documentation or justification, and a psychiatric consult did not specify the expected duration of the medication trial.
The facility failed to ensure that laboratory studies were promptly obtained and communicated as ordered by the physician for a resident. A valproic acid level test conducted on one occasion showed a low level, but the result was not notified to the physician until three days later. A follow-up test was ordered but not completed, and another test conducted months later also showed a low level, with the result not promptly communicated to the physician.
The facility failed to ensure a resident with moderate cognitive impairment and altered mental status had the capacity to understand a binding arbitration agreement. The Admission Director signed the agreement without verifying the resident's mental status.
The facility failed to ensure safe oxygen storage on the first floor nursing unit. Approximately 12 oxygen cylinders were stored in an open hallway area without proper signage. A Nursing Assistant was unaware of the protocol requiring storage in a locked room. The Nursing Home Administrator confirmed the unsafe practice and admitted to not educating staff about safe handling procedures.
The facility failed to ensure its nurse aide staff received the required 12 hours of annual in-service training, affecting five employees. The facility could not provide the necessary training records during the survey, and the Nursing Home Administrator confirmed the lack of documentation.
A facility failed to follow its discharge procedures for a resident with short-term memory problems and hepatic encephalopathy, leading to the resident exiting against medical advice without proper documentation or notification to the physician, family, or State authorities. The resident, who required supervision for safety due to confusion and unsteady gait, was discharged without identification documents, creating an Immediate Jeopardy situation. Staff interviews revealed lapses in consulting psychiatry, notifying the State Long Term Care Ombudsman, and ensuring proper documentation for discharge against medical advice.
A facility failed to ensure that a resident with hepatic encephalopathy and moderately impaired cognition received psychiatric consultations as ordered by the physician. Despite multiple orders for psychiatric and psychological consults, the facility did not carry out these consultations, as confirmed by the Director of Nursing.
Failure to Provide Palatable Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food was served at a palatable taste and appropriate temperature, as identified during a test tray evaluation of a lunch meal. Review of the facility’s undated Test Tray Evaluation form showed that acceptable delivery temperatures for starches and vegetables should be 135–165°F. During a lunch meal service test tray conducted on March 18, 2026, at 12:25 p.m. with the food service employee and the Nursing Home Administrator, three pureed items—intended to be pureed mac and cheese, mashed potatoes, and mixed vegetables—were evaluated. The measured temperature of the food was 110°F, which was below the facility’s stated standard, and the items were described as bland with an unfamiliar taste; the pureed vegetables in particular tasted more like pureed meat. The Nursing Home Administrator also tasted the food and agreed with the surveyor’s findings regarding the temperature and taste deficiencies.
Missing State Survey Agency Posting
Penalty
Summary
The facility failed to post the State Survey Agency phone number and contact information in readily accessible locations on two nursing floors, including the 1st Floor and 2nd Nursing Units. During a tour with the Director of Social Services, the employee stated she was new to the facility and was unsure where the State Survey Agency postings were located. A review of the nursing units and common areas did not locate the required State Survey Agency phone number, contact information, or reporting information. The Nursing Home Administrator later confirmed that the required postings were not up and may have been taken down during painting. The report states that the facility did not ensure the required postings, including the name, address, and telephone number for the State Survey Agency, were displayed in prominent places throughout the facility, along with a statement that residents may file a complaint with the State Survey Agency regarding abuse, neglect, exploitation, or misappropriation of resident property.
Meal Service Did Not Follow Planned Menu
Penalty
Summary
The facility failed to ensure food was served in accordance with the planned menus for one of four days observed during the lunch meal service. The main menu for lunch listed tomato soup, grilled American cheese sandwich, mixed vegetables, crackers, chilled peaches, and a beverage, and the facility also maintained an always available menu with items such as cottage cheese, fresh fruit, chicken salad sandwich, grilled cheese sandwich, hot dog, turkey hoagie, and cheeseburger. However, observations in the main kitchen and on the second-floor nursing unit showed that the meal service did not match the planned menu: only one type of soup was prepared and it was observed as thin consistency, crackers were not available with the grilled cheese and tomato soup, and pureed diets were being given mashed potatoes that were not part of the planned meal. The cook was observed using a #16 scoop to plate pureed mac and cheese and mixed vegetables even though the production sheet called for larger portions, and the Food Service Director was unsure whether residents ordered nectar thick liquids received thickened soup. Residents with specific diet needs were affected during the meal service. Review of the diet type report showed two residents had physician orders for nectar thick liquids, yet one licensed nurse confirmed one resident was not offered tomato soup and another resident was also not offered tomato soup, despite the resident stating he or she enjoyed it and would have eaten it. A resident with end stage renal failure and osteomyelitis of the left femur, who was cognitively intact with a BIMS score of 15, reported that the always available menu was limited and that there was not always an alternative, so the resident sometimes did not eat. Another cognitively intact resident with vertebral and patella fractures stated the always available menu was a joke, that available choices kept being reduced, and that if a resident did not like the meal, the only option was a hot dog or hamburger, leading the resident to often not eat. The Food Service Director also confirmed that crackers were unavailable and that meatloaf was served to a resident even though it was not on the menu.
Failure to Maintain Effective Antibiotic Stewardship Program
Penalty
Summary
The facility did not ensure an effective antibiotic stewardship program that included ongoing tracking, analysis, and reporting of antibiotic use for 11 of 11 months reviewed, from May 2025 through March 2026. Review of the facility’s policies showed that the antibiotic stewardship and infection prevention and control program were intended to monitor antibiotic use, evaluate antibiotic usage, and provide feedback to practitioners, with surveillance activities including culture reports, sensitivity data, and antibiotic usage reviews. Review of the facility’s Infection Surveillance Report for the same period revealed no evidence of implemented interventions to optimize antibiotic use, including review of antibiotic prescriptions for appropriateness, setting protocols for empiric therapy, de-escalation based on culture results, or avoiding unnecessary antibiotics for viral infections. During the infection prevention and control program review, the report also showed no evidence of tracking, monitoring, or staff education upon request, and no evidence of analysis and feedback for the months reviewed. These findings were confirmed with the DON/IPC, Employee E2.
Failure to Monitor Antibiotic Use and Report Infections
Penalty
Summary
The facility did not ensure an effective antibiotic stewardship program that included a system to effectively monitor antibiotic usage for 11 of 11 months of antibiotic stewardship program data reviewed, covering May 2026 through March 2026. Review of the facility’s policy titled "Infection Prevention and Control Program," revised December 2025, and the policy titled "Antibiotic Stewardship," revised December 2016, revealed no evidence that facility-acquired infections were reported to the Pennsylvania Patient Safety Authority through the Pennsylvania Patient Safety Reporting System as required by Act 52. During an interview on Thursday, March 19, 2026 at 3:00 pm, the DON/Infection Preventionist, employee E2, was unable to provide evidence of compliance with Act 52. The cited regulations were 28 Pa Code 211.10(d) and 28 Pa Code 211.12(d)(1)(5).
Pest Control Program Not Maintained
Penalty
Summary
The facility did not maintain an effective pest control program to keep the building free of insects and rodents on the first and second nursing floors. The facility’s pest control policy stated that it shall maintain an effective pest control program and that the building is kept free of insects and rodents, but resident interviews on March 18, 2026 identified ongoing mouse and roach activity in rooms on both floors. Residents reported mice in rooms and hallways, roaches at night, and one resident stated the mouse problem had worsened over time and had damaged the bottom drawer of a dresser by chewing holes through it. Another resident on the first floor reported mice entering and leaving through a hole near the toilet and seeing roaches in the bathroom. Facility observations and record review confirmed pest activity and structural openings. On the second floor, a void under an air conditioning unit had been filled, but a roach trap nearby contained one dead roach and one roach actively dying. On the first floor, a bathroom wall beside the toilet had peeling baseboard and an unfilled void in the corner, and approximately ten baby roaches were observed in a trap behind the toilet. Pest control reports documented treatment of multiple areas and noted mice activity in hallways and rooms, open voids in baseboard heaters, baiting and sealing of voids, and repeated reports of mice, droppings, and a rat in a resident room. Additional observations found a hole in a resident room wall, snacks stored open on the floor along the wall, and two half-eaten resident breakfast trays left on top of the ice machine in the nursing unit pantry.
Incomplete Investigation of Unwitnessed Fall
Penalty
Summary
The facility failed to conduct a complete and thorough investigation to rule out neglect for one resident after an unwitnessed fall from bed. The resident had diagnoses including malnutrition, left-sided hemiplegia, contracture of the right hand, and homonymous bilateral field defects, and was documented as cognitively intact and independent for rolling left and right. The resident’s care plan noted limited physical mobility related to stroke. On the day of the incident, the resident rolled out of bed while reaching for a cell phone, landed hard on the left hip and abdomen, reported pain as 10 out of 10, and requested transfer to the emergency room. Facility documentation showed the incident report and witness statements were obtained from the RN supervisor, two LPNs, and two nurse aides, but there was no documented written or signed statement from the resident or the roommate. During interviews, the resident stated staff did not respond right away and that the roommate had to ring the call bell to alert staff that the resident had fallen out of bed. The roommate confirmed needing to call for nursing assistance, and the DON confirmed that written or signed statements were not obtained from either resident regarding the fall.
Missing Care Plans for Restorative Nursing and Restraints
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan with measurable objectives and timetables for two residents related to restorative nursing and restraints. Facility policy stated that care plans are to include measurable objectives and timetables to meet each resident’s physical, psychosocial, and functional needs. Resident R1’s quarterly MDS dated February 1, 2026, showed diagnoses including pulmonary hypertension and acute and chronic respiratory failure. R1’s physical therapy discharge summary included restorative program recommendations for the resident to be out of bed in a chair via hoyer lift 1-3 times per week to encourage socialization, increase sitting tolerance, and perform wheelchair mobility, but the comprehensive care plan contained no restorative nursing program care plan. The DON confirmed this absence during interview on March 19, 2026. Resident R13’s quarterly MDS dated February 5, 2026, showed diagnoses including quadriplegia and acute and chronic respiratory failure. Physician orders dated January 9, 2026, directed bilateral hand mitts to prevent dislodgement of the trach, with mitts to be released every 2 hours and skin integrity checked. However, the comprehensive care plan contained no restraint care plan for R13. The DON confirmed during interview on March 19, 2026, that no care plan was in place for restraints for this resident.
Failure to Provide and Accurately Document Hygiene Assistance
Penalty
Summary
Facility did not ensure that Resident R86 received necessary assistance with activities of daily living related to bathing, grooming, and personal hygiene. The resident’s clinical record showed a history of hemiplegia and hemiparesis affecting the right dominant side, unsheltered homelessness, PTSD, cardiomyopathy, urogenital candidiasis, adrenocortical insufficiency, urinary retention, high blood pressure, and psychoactive substance abuse. The resident’s MDS completed on March 5, 2026, showed a BIMS score of 15, and the functional abilities assessment completed on March 4, 2026, indicated the resident was independent with shower/bath tasks and tub/shower transfers. During observation on the day shift, Resident R86 was seen with a disheveled appearance and visible flakes from dandruff on clothing. In interview, the resident stated that he/she was not aware of the location of the common shower room, had not been offered a shower, did not know the scheduled shower days, and had been using the sink in the room for hygiene care. The clinical record documented by nurse aide E13 stated that the resident completed a shower that morning, but E13 later confirmed that the shower/bath was falsely documented as completed. The facility policy defined neglect as failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress, including failure to meet basic needs such as hygiene.
Failure to Provide Restorative Nursing and Passive ROM
Penalty
Summary
The facility failed to ensure rehabilitative nursing care was provided to two residents. For one resident, the clinical record showed admission with pulmonary hypertension, and a PT discharge summary included recommendations for a supine and seated home exercise program, restorative nursing training, and out-of-bed-to-chair activity via hoyer lift 1 to 3 times per week to promote socialization, sitting tolerance, and wheelchair mobility. However, the resident’s nursing tasks contained no documented evidence that these recommendations were implemented, and the comprehensive care plan also contained no documented evidence of a restorative nursing program being implemented. For another resident, the quarterly MDS showed the resident was rarely or never understood and had a diagnosis of functional quadriplegia. The care plan identified limited physical mobility related to neurological deficits and included an intervention for skilled PT/OT services as indicated. The nursing Kardex included a task for nursing rehab to provide passive ROM daily to both upper and lower extremities with morning and evening care, but documentation from February 18, 2026 through March 19, 2026 showed passive ROM was marked not applicable on 39 occasions, with no supporting evidence explaining why it was not provided or why it was marked not applicable.
Missing Bed Handrails for Resident Needing Bed Mobility Assistance
Penalty
Summary
The facility failed to provide assistance devices necessary to prevent an avoidable accident for Resident R24. The resident’s quarterly MDS dated December 9, 2025, showed diagnoses of malnutrition, left-sided hemiplegia, contracture of the right hand, and homonymous bilateral field defects, and a later MDS indicated the resident was cognitively intact. Physical therapy treatment notes dated January 24, 2026, documented that Resident R24 required partial/moderate assistance for bed mobility, with skilled interventions focused on log rolling techniques and use of handrails to increase independence in bed mobility tasks. On January 26, 2026, Resident R24 sustained an unwitnessed fall at 5:45 a.m. after rolling out of bed while reaching for a cell phone and landing hard on the left hip and abdomen. The resident reported pain at a level of 10 out of 10 and requested transfer to the emergency room. The incident report stated the call light was within reach and no known predisposing environmental, psychological, or situational factors were identified. During interviews, Resident R24 stated there were no handrails on the bed at the time of the fall, and the Director of Rehabilitation confirmed the resident should have had bed handrails to assist with bed mobility. The DON also confirmed the bed rails were not in place at the time of the fall and were applied afterward.
Failure to Reassess Residents With Significant Weight Loss
Penalty
Summary
The facility failed to ensure adequate monitoring and timely reassessment of residents with significant weight loss to maintain acceptable nutrition status for 3 of 9 residents reviewed. Facility policy required residents to be weighed on admission, weekly for four weeks, then monthly, and any weight change of 5% or more in one month to be reported to the Registered Dietitian and reweighed. The facility’s Clinical Dietitian job description stated the Registered Dietitian would develop individualized nutrition care plans based on assessments and use clinical judgment, including nutrition-focused physical exams as needed. Resident R1 had diagnoses of diabetes mellitus and malnutrition and was identified in the MDS as having lost 5% or more in the last month or 10% or more in the last 6 months without a physician-prescribed weight loss regimen. The resident’s weight history showed a significant downward trend beginning January 14, 2026, with a 20-pound loss from January 2, 2026, followed by an additional 12-pound loss to 237 pounds on January 20, 2026, and then 234 pounds on February 18, 2026. A nutrition weight note on February 20, 2026 documented a 6.4% weight loss over one month and noted the resident was at potential risk for malnutrition, but the ongoing significant weight loss was not addressed by the Registered Dietitian until March 12, 2026, when the note stated there was no formal documented assessment/outcome to determine whether the resident met criteria for malnutrition. Resident R11, who had diagnoses of thoracic vertebrae fracture and left patella fracture and a BIMS score of 15 indicating cognitive intactness, weighed 161.0 pounds on February 4, 2026 and 153.5 pounds on March 3, 2026, a loss of 7.5 pounds in one month. The record contained no documented nutritional assessment related to the significant weight change, and the Registered Dietitian confirmed no nutritional assessment was completed.
Medication Administered at Incorrect Dose
Penalty
Summary
Medication was not administered accurately for one resident with a complex psychiatric history that included bipolar disorder, schizoaffective disorder, drug induced parkinsonism, generalized anxiety disorder, psychosis, drug induced subacute dyskinesis, recurrent depressive disorders, and schizophrenia. A psychiatric progress note documented acute worsening of psychosis with escalating agitation, aggression, paranoia, refusal of care, disorganized behavior, poor reality testing, and persistent delusions. The note stated urgent medication intervention was needed and that the resident's granddaughter agreed to start Haloperidol. Physician orders later included Haloperidol at a decreased dose of 0.25 mg and Ingrezza increased to 60 mg, but both orders remained pending confirmation for several days. During medication administration observation, the resident received Ingrezza 40 mg instead of the ordered 60 mg. Review of the e-MAR showed Ingrezza 60 mg was not administered for several days, and Haloperidol 0.25 mg was also not administered during the same period. Nursing documentation stated the provider ordered Haloperidol reduced from 0.5 mg twice daily to 0.25 mg twice daily due to tremors and Ingrezza increased to 60 mg daily, but also noted to give 40 mg temporarily until the 60 mg dose arrived from the pharmacy. The unit manager confirmed the orders were not timely confirmed, resulting in the lower dose of Ingrezza being administered than prescribed.
Failure to Provide Timely, Reasonably Priced Access to Medical Records
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident’s medical records in a timely manner and at a reasonable cost, as required by regulation and the facility’s own policy. The facility policy on Release of Information, revised November 2009, states that residents may obtain photocopies of their records with at least 48 hours’ notice (excluding weekends and holidays), and that a fee may be charged for copying services. For one resident, a written, HIPAA-compliant authorization signed by the resident’s Power of Attorney was submitted on October 13, 2025. The facility generated an invoice on October 23, 2025, billing $732.08 for 1,424 pages of records. The Director of Medical Records (Employee E12) stated that the resident’s son was told he would have to pay this amount to receive the records, in accordance with facility policy, and that he declined to pay. A subsequent written request for “any and all records” with a HIPAA-compliant authorization, dated January 3, 2026, was submitted through a third party on behalf of the resident. On February 9, 2026, that party emailed Employee E12, warning that regulatory agencies would be notified if the records were not provided without further delay. E12 responded on February 10, 2026, that the records would be prepared that week, and later reported that the resident’s son picked up a paper copy on February 17, 2026. On February 22, 2026, the requesting party reported that the resident had requested an electronic version via an electronic form but instead received an incomplete paper copy missing multiple important parts of the chart, and requested a PDF copy of the PCC chart. E12 replied on February 25, 2026, that the missing records would be provided as soon as possible, and on March 3, 2026, stated that MDS documents and nine more months of CNA flow sheets were still being compiled and would be scanned by the end of the week. By March 10, 2026, the requester was still following up, and on March 19, 2026, E12 stated she had been printing and scanning as fast as she could and did not know how to send the chart electronically. The Nursing Home Administrator confirmed that records can be sent electronically via a link and confirmed that the resident’s records were not released upon request in a timely manner or at a reasonable cost.
Failure to Timely Monitor and Assess Resident with Acute Symptoms
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical conditions, including chronic kidney disease, heart failure, COPD, anemia, and schizophrenia, was not timely or adequately monitored and assessed after reporting new symptoms. The resident, who was cognitively intact, complained of generalized body aches and cold symptoms during the overnight shift and was given Tylenol per orders. Despite these complaints and the resident being observed in the bathroom at unusual times, there was no documented evidence that the nurse checked the resident's vital signs or performed further assessment during the shift. On the following day, the resident was found with a bucket and reported nausea and vomiting that began early in the morning. The nurse aide promptly informed the charge nurse, noting that this was not typical for the resident and requested immediate attention. The resident continued to vomit throughout the morning and after lunch, and was later observed undressed, rocking back and forth, and expressing feeling neither hot nor cold. Despite these ongoing symptoms, only one set of vital signs was documented for the entire day, and the resident's status was not effectively communicated during the change of shift report. The lack of timely and thorough assessment, including failure to monitor vital signs after the onset of new symptoms and inadequate communication between staff, contributed to the deficiency. The resident was ultimately found unresponsive in the evening, and resuscitation efforts were unsuccessful. The survey identified that the facility failed to ensure prompt and adequate monitoring and assessment of the resident's changing medical condition.
Failure to Provide Required Two-Person Assistance During Bed Mobility
Penalty
Summary
A deficiency occurred when a resident with significant mobility impairments, including hemiplegia, functional quadriplegia, and functional limitations in both upper extremities, was not provided with the required level of assistance during bed mobility. The resident's care plan and nursing Kardex specified that two staff members were needed to assist with bed mobility and repositioning. Despite these documented requirements, a nurse aide attempted to roll the resident alone while changing bed sheets, resulting in the resident rolling off the bed. Facility documentation and staff interviews confirmed that the nurse aide did not follow the resident's care plan, which mandated two-person assistance for bed mobility. The Director of Nursing stated that residents should always be rolled toward the caregiver, and the Nursing Home Administrator confirmed that the care plan was not followed. This failure to provide adequate supervision and assistance directly led to the accident involving the resident.
Egress Door Deficiency at Aventura at Prospect
Penalty
Summary
Aventura at Prospect was found to be non-compliant with the National Fire Protection Association's Life Safety Code during a complaint survey. The facility, a two-story, fully sprinklered, wood frame building, failed to maintain egress doors with special locking arrangements. Observations made on April 2, 2025, revealed that staff members did not have access to keys or knowledge of the codes necessary for the rapid removal of occupants. This deficiency affected several key exit points, including the emergency exit door at the 1 north entrance, exit doors #3 and #4 in the first-floor corridor, and the front lobby door on the first floor. During an exit interview with the facility's administrator and maintenance director, it was confirmed that the staff's inability to access or operate the egress doors was a deficiency. The lack of access to keys or knowledge of the codes for these doors could potentially hinder the safe and efficient evacuation of residents in an emergency. The survey findings highlight a critical lapse in the facility's adherence to safety protocols required for the protection of its occupants.
Plan Of Correction
1. Current staff will be educated on the door codes for emergent exits and location of egress doors. 2. Emergency evacuation policy will be updated to identify designated egress doors and mechanisms for use. Staff will be educated on hire and during the monthly fire drills on the door codes for emergent exits and location of egress doors. 3. NHA/Designee will conduct random audits of staff awareness of door codes and location of egress doors weekly for four weeks and monthly for two months.
Fire Alarm System Deficiency
Penalty
Summary
The facility failed to maintain its fire alarm system, which was found to be deficient and non-operational during a document review and observation conducted on April 2, 2025. The fire alarm system had been out of operation since March 21, 2025, affecting the entire facility. This deficiency was confirmed during an exit interview with the administrator and maintenance director on the same day.
Plan Of Correction
1. There was a malfunction of the fire panel on 3/21/2025. Facility was on fire watch as per policy when the fire panel is malfunctioning. Vendor was contacted to correct the problem. Fire alarm system was restored to full function on 4/3/2025. 2. Maintenance department will maintain a fully functioning fire alarm system. 3. NHA/designee will conduct audits of fire alarm system weekly for eight weeks and monthly for one month.
Ineffective Pest Control Program Leads to Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a persistent infestation of rodents and other pests. Residents expressed dissatisfaction with the pest control measures, reporting a rodent problem in the building, particularly through air conditioning and heating units in their rooms. Observations confirmed the presence of entry points for pests, such as voids and holes around air conditioning units and an unsealed doorway threshold leading to the trash area. Mice droppings were found in the dry food storage area of the main kitchen, indicating a vermin infestation. The pest control operator's reports from May to July 2024 documented repeated treatments for common household pests, including rodents and roaches, in various areas of the facility such as the main kitchen, nursing units, lobby, and employee break rooms. Despite these treatments, the reports noted ongoing pest activity and structural issues that facilitated pest entry. The nursing home administrator acknowledged the persistent pest problems and the need for maintenance to address structural deficiencies, such as sealing holes in air conditioning units and ensuring doors close properly to prevent pest access.
Failure to Ensure Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for three residents. The facility's policy on hazardous areas, devices, and equipment was not adhered to, as evidenced by unlocked housekeeping storage rooms containing cleaning supplies on two units. Additionally, a storage cabinet in a central hall bathroom was found open, containing nail clippers and razors, which should have been double locked for resident safety. The maintenance log showed no evidence of work orders related to these unlocked storage rooms. Resident R51, who was severely cognitively impaired and required supervision with activities of daily living, was found to have five razors in their bathroom, contrary to the facility's policy on shaving and hazardous materials. The resident's medical record lacked documentation of supervision during shaving procedures. Interviews with staff confirmed that razors were provided to the resident by a nurse aide, but the required documentation and safety measures were not followed. Resident R126 was observed with a cup containing several types of pills in their room, which they claimed were obtained from the nurses. The pills included Acetaminophen and Trazadone, and were not properly secured or documented. Additionally, Resident R446 had multiple bottles of eye drops in a biohazard bag on their bedside table, with new bottles on the nurse's cart, indicating a lack of proper supervision and storage of medications. These findings highlight the facility's failure to maintain a safe environment and provide adequate supervision to prevent accidents and ensure resident safety.
Failure to Maintain Nutritional Care for Residents
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for two residents, R113 and R118, as observed through care and services, clinical record reviews, and interviews. Resident R113, who was cognitively intact and diagnosed with heart failure, end-stage renal disease, and diabetes mellitus, experienced a significant weight loss of 7.5% over three months and a continuous weight loss of 15 pounds over four months. Despite a nutritional supplement being ordered, there was no documentation of its consumption, and the resident expressed a preference for chocolate-flavored supplements. Observations revealed that Resident R113 did not receive the prescribed double protein portions or low phosphorus foods, as dietary staff were unaware of the care plan requirements. Resident R118, admitted with diagnoses including GERD, dysphagia, gastrostomy status, and aphasia, was at risk for malnutrition. The care plan indicated the need to maintain adequate nutritional status without significant weight changes. However, no weights were recorded for June and July 2024, and the dietitian confirmed these findings. The lack of recorded weights and adherence to dietary plans for both residents highlights the facility's failure to ensure proper nutritional care.
Failure to Administer Insulin as Ordered for Dialysis Resident
Penalty
Summary
The facility failed to ensure that a resident received medications consistent with professional standards of practice due to a lack of ongoing communication and collaboration with the dialysis care center. The resident, identified as R113, had diagnoses of heart failure, end-stage renal disease, and diabetes mellitus, requiring insulin administration in conjunction with meals. However, the nursing staff omitted the administration of insulin at 12:30 p.m. on multiple days when the resident was scheduled for hemodialysis treatments, without any documentation of communication with the attending physician regarding these omissions. The Director of Nursing confirmed the lack of coordination between the facility's meal service and the dialysis center visits, acknowledging that the nursing staff did not follow the physician's orders for insulin administration. This deficiency was identified through clinical record reviews and staff interviews, highlighting the failure to adhere to the facility's medication administration policy and the standards of nursing practice.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by a 35.8% error rate identified during a survey. This deficiency was observed in the administration of medications to residents, where errors were noted in the dosages given. Specifically, a licensed nurse administered 600 mg of Gabapentin to a resident instead of the prescribed 300 mg. This error was confirmed by the nurse at the time of observation. Additionally, another licensed nurse was observed administering medications to a different resident at an incorrect time, with discrepancies in the dosage of Vitamin D3. The nurse gave two 1000 mg tablets instead of the prescribed 2000 mg tablet. These errors contributed to the high medication error rate, which was significantly above the acceptable threshold, indicating a failure in the facility's medication administration process.
Failure to Consider Resident Food Preferences
Penalty
Summary
The facility failed to consider the food preferences of seven residents, as determined through reviews of policies, procedures, staff interviews, meal observations, resident interviews, and resident council meeting minutes. The policy required the dietitian and multidisciplinary team to conduct comprehensive assessments of each resident's food preferences and dislikes, but this was not adhered to. Observations during meal services revealed that several residents requested substitute food items instead of the planned menu entrees. A group meeting with residents further highlighted dissatisfaction with the meals served, as residents reported that their dietary preferences were repeatedly ignored by the dietary department. The resident council meeting minutes from April, May, and June 2024 showed ongoing concerns about the lack of variety and preference in the menu, with specific requests for different breakfast items, fresh fruits, and alternative milk options. Despite these repeated requests, there was no documented follow-through on the residents' menu suggestions. Interviews with the director of dietary services and the registered dietitian confirmed a lack of coordination among staff to meet the residents' nutritional and dietary needs and preferences.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple deficiencies in food storage, preparation, and sanitation practices. Observations revealed that the walk-in refrigerator contained numerous food items that were outdated or beyond their use-by dates, including cottage cheese, mozzarella cheese, parmesan cheese, and cream cheese with visible mold. Additionally, fresh strawberries and a prepared lasagna were not discarded according to policy, and various food items were found unlabeled and undated. The walk-in freezer also contained unlabeled and undated items, such as a bag of French fries and jars of sauce. The dry food storage room was found to be in poor condition, with inadequate lighting and evidence of rodent infestation, including pest droppings, rubbings, and nesting materials. Opened food packages were improperly stored on the floor, and the room had structural issues such as voids and holes that could facilitate pest entry. The floor was sticky and tacky, further complicating the storage environment. Unlabeled and undated food items, such as cake mixes, cereal, and rice, were also observed in this area. Sanitation practices were inadequate, as the three-compartment sink lacked the necessary chemical sanitizer, and the mechanical dish machine was not functioning properly to sanitize dishware effectively. The litmus paper used to test the sanitizer concentration did not register acceptable levels, and the garbage area outside the food and nutrition services department had doors that did not seal properly, allowing potential pest entry. These deficiencies were confirmed through interviews with the director of food service and the registered dietitian.
Inadequate Infection Prevention and Control Program
Penalty
Summary
The facility failed to maintain and implement a comprehensive infection prevention and control program, as evidenced by the lack of adherence to their own 'Legionella Water Management Program' policy. This policy, revised in July 2017, outlines the need for identifying areas in the water system that could promote the growth and spread of Legionella or other waterborne bacteria. The policy specifies the need for control measures, monitoring of control limits, and documentation of the program. However, the facility was unable to provide evidence of established measures for the prevention of Legionella and other waterborne bacteria, nor could they demonstrate ongoing analysis of surveillance data or documentation of follow-up activities in response to identified issues. Additionally, the facility's 'Surveillance for Infections' policy, revised in September 2017, requires the gathering of surveillance data, documentation, calculation of infection rates, and interpretation of this data. The facility was unable to provide evidence of a process for obtaining pertinent information such as discharge summaries, lab results, current diagnoses, treatment, and infection or multi-drug resistant organism colonization status when residents were transferred back from acute care hospitals. This lack of evidence indicates a failure to effectively monitor and prevent infections within the facility, as required by the policies in place.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified infection preventionist responsible for the infection prevention and control program, as required by regulations. A review of the facility's policy on infection surveillance, revised in September 2017, indicated that an Infection Preventionist should conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other significant infections. However, during an interview with the Director of Nursing, it was revealed that the facility did not provide documentation showing that an Infection Preventionist with specialized training in infection prevention and control was employed. This lack of documentation and designation led to the facility not meeting the requirement for professional and specialized training in infection prevention and control.
Failure to Account for Resident's Personal Belongings
Penalty
Summary
The facility failed to protect a resident from the misappropriation of personal property, as evidenced by the case of a resident whose belongings were not accounted for upon discharge. The facility's policy on personal property requires that residents' belongings be inventoried and documented upon admission and updated as necessary. In this case, the resident's inventory sheet was completed upon admission, listing several personal items. However, after the resident's death, a progress note indicated that the resident did not have personal belongings, and there was no discharge inventory completed. Interviews with facility staff revealed a lack of adherence to the policy regarding the inventory of personal belongings. The Director of Nursing indicated that nursing staff are responsible for taking inventory at discharge, while an activities employee confirmed that she completed the admission inventory but noted that the discharge inventory section of the form is never utilized. This failure to properly document and account for the resident's belongings at discharge led to the deficiency identified by the surveyors.
Failure to Investigate Misappropriation of Resident Property
Penalty
Summary
The facility failed to conduct a thorough investigation regarding the misappropriation of a resident's property, specifically involving Resident R70. The resident, who had a Brief Interview of Mental Status (BIMS) score of 14, reported missing funds from their personal bank account. Resident R70 identified two employees, a housekeeper and an activities aide, as the alleged perpetrators who accepted the resident's debit card to purchase cigarettes. Despite the termination of both employees, the facility was unable to substantiate the misappropriation of funds. The investigation report lacked critical information, such as involvement of another state agency and notification of the local police department. Although verbal information about the incident number and the officer's last name was provided, there was no evidence of follow-up after the investigation was initiated. Additionally, the report included a printout of the resident's bank statements but did not indicate whether the facility reviewed the charges with the resident to identify fraudulent transactions. This lack of thorough investigation and documentation led to the deficiency.
Failure to Ensure Required Attendance at QAPI Meetings
Penalty
Summary
The facility failed to ensure that the required members attended the Quality Assurance Process Improvement (QAPI) committee meetings for one of the four quarters from February 2024 through June 2024. A review of the QAPI committee meeting sign-in sheets revealed that there were no sign-in sheets for February, March, April, or June 2024. The sign-in sheet for May 2024 lacked signatures from the Infection Preventionist and the Medical Director. An interview with the Director of Nursing and the interim Nursing Home Administrator revealed that there has not been an Infection Preventionist employed at the facility since February 2024. Additionally, the Medical Director has been invited to the QAPI meetings but has not attended or designated someone to attend since their employment in 2024.
Failure to Initiate Grievance Process for Resident Complaint
Penalty
Summary
The facility failed to initiate the grievance process for a resident who reported an incident of alleged verbal abuse. The resident, identified as R2, reported to the administration that a nursing aide yelled at them when they requested a change in the TV channel. This incident occurred on May 9, 2024. Although the Nursing Home Administrator and the Director of Nursing met with the resident to discuss the concern and reported the allegation to the State Survey Agency, the complaint was not processed as a grievance, which is a requirement under the resident rights regulation 28 Pa. Code 201.29(a)(d)(k).
Failure to Address Resident Council Concerns on Meal Portions
Penalty
Summary
The facility failed to respond to concerns from the resident council regarding meal portion sizes for four consecutive months (November 2023, December 2023, January 2024, and February 2024). This deficiency was identified through a review of resident council minutes, resident council group interviews, individual resident interviews, and staff interviews. The resident council had repeatedly requested larger meal portions, but there was no documentation indicating follow-up actions or communication from the nursing home administration to address these concerns. During a resident group meeting on March 13, 2024, all eight residents present expressed dissatisfaction with the administration's lack of response to their requests for larger meal portions. The Nursing Home Administrator confirmed the facility's failure to address these concerns in a timely manner.
Failure to Provide Timely Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide the required advanced notice, through a Notice of Medicare Non-Coverage (CMS 10123), regarding the termination of Medicare services for three residents. The Notice of Medicare Non-Coverage (NOMNC) CMS-10123 is intended to inform recipients when care received from the skilled nursing facility is ending and how to contact a Quality Improvement Organization to appeal. The Medicare provider must ensure that the notice is delivered at least two calendar days before covered services end. However, the review of the clinical records and facility documentation revealed that the notices for three residents were not delivered within the required timeframe. Specifically, the notices for the residents indicated that their Medicare skilled A services would end on specific dates, but the facility did not ensure the notices were delivered at least two calendar days before these dates. This was confirmed during an interview with the Nursing Home Administrator.
Deficiencies in PASRR Assessments
Penalty
Summary
The PASRR (Preadmission Screening and Resident Review) assessments were not appropriately completed for three residents, leading to deficiencies in identifying and documenting their mental health and neurocognitive conditions. Resident R83, who was diagnosed with schizophrenia, had a PASRR Level I assessment that failed to include schizophrenia as a mental disorder. This omission was confirmed by the Social Service Director. Resident R148, diagnosed with a neurological traumatic brain injury, had a PASRR assessment that did not accurately reflect the resident's neurocognitive disorder, which was also confirmed by the Social Service Director. Resident R13, with multiple mental health diagnoses including psychotic disorder and PTSD, had a PASRR screen that contained another resident's name, and the facility could not provide evidence of a completed PASRR for this resident, as confirmed by the Director of Nursing. The facility's Admission policy, revised in August 2022, states that all new admissions are to be screened for mental disorders, intellectual disabilities, or related disorders per the Medicaid PASRR process. However, the review of clinical records and staff interviews revealed that the PASRR assessments for the three residents were either incomplete or incorrect, failing to meet the requirements set forth by the policy and the Omnibus Budget Reconciliation Act (OBRA) of 1987. These deficiencies indicate a failure in the facility's process for accurately completing and documenting PASRR assessments, which are crucial for ensuring appropriate placement and services for residents with mental illness or intellectual disabilities.
Failure to Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. Specifically, the care plan for a resident diagnosed with heart failure, high blood pressure, schizophrenia, and a history of ileus did not address the resident's history of ileus and constipation. The resident had complained of nausea, abdominal discomfort, and constipation, and had an episode of vomiting, but these issues were not included in the care plan. Additionally, the resident's care plan did not address the diagnosis of schizophrenia, despite a psychiatric note indicating the need to re-evaluate the diagnosis and psychotropic drug use due to episodes of the resident eating cardboard and experiencing auditory and visual hallucinations. This deficiency was confirmed by the Director of Nursing.
Failure to Ensure Nurse Aide Competency
Penalty
Summary
The facility failed to ensure that nurse aides demonstrated competency in skills and techniques necessary to care for residents. This deficiency was identified for five nursing staff members (Employees E13, E14, E15, E16, and E17). The review of personnel files and staff interviews revealed that the facility provided care to residents requiring intravenous therapy and tracheostomy care. However, the facility did not submit documentation of staff competencies and skill sets related to the management of residents with tracheostomy, intravenous therapy, and medication administration. An interview with the Nursing Home Administrator and Regional staff confirmed that there was no documentation available to show that licensed nursing staff had been evaluated for these competencies.
Failure to Provide Necessary Pharmaceutical Services
Penalty
Summary
The facility failed to provide necessary pharmaceutical services for two residents, resulting in missed medication doses. Resident R66 did not receive six doses of Debrox Otic solution as ordered by the physician, with the Medication Administration Record indicating that the medication was not available on multiple occasions in February and March 2024. Resident R66 confirmed in an interview that the facility often ran out of his medications due to staff not ordering them on time and the pharmacy not delivering enough supply. Similarly, Resident R68 did not receive 13 doses of Zaditor ophthalmic solution for allergic conjunctivitis as ordered by the physician. The Medication Administration Record for Resident R68 showed missed doses in February and March 2024, with the resident stating that staff did not order the medication appropriately and the facility frequently ran out of supplies. These deficiencies were identified through a review of facility documentation, clinical records, and staff interviews.
Failure to Inform Resident of Medical Condition
Penalty
Summary
The facility failed to ensure that a resident was informed of his medical condition. Resident R83, who is cognitively intact and diagnosed with heart failure, high blood pressure, schizophrenia, and a history of ileus, complained of nausea, vomiting, and abdominal discomfort. An abdominal x-ray was ordered to rule out an ileus. However, during an interview, the resident indicated that no one had informed him of the x-ray results, which were available almost two weeks prior. Review of the records confirmed that there was no documented evidence that the resident was informed of the results.
Failure to Post Complaint Hotline Number
Penalty
Summary
The facility failed to post the complaint hotline number for the State Survey Agency as required on three nursing units: the First, Second, and Third floors. This deficiency was identified through observations and interviews conducted on March 13, 2024. During the observation at 1:18 p.m., it was noted that the main lobby area, as well as the First and Second floor nursing units, did not have the complaint hotline number posted. The Nursing Home Administrator confirmed during an interview at the same time that the complaint hotline number was not posted.
Failure to Resolve Resident Grievances Promptly
Penalty
Summary
The facility failed to promptly resolve resident complaints and grievances as required by their policy. During a resident council group meeting, eight residents, including Resident R66, expressed concerns about the administration's failure to address their grievances in a timely manner. Resident R66 specifically mentioned that he had raised concerns about not receiving medications and Ensure as ordered by his physician for several months, but these issues were not resolved, and he did not receive any response from the staff. An interview with the social service director confirmed that Resident R66 had raised his concerns on March 8, 2024, and was given a grievance form to fill out. However, the social service director admitted that she did not follow up with the resident about his grievance, nor did she implement any immediate interventions to address the issues. This lack of follow-up and resolution of grievances is a violation of the residents' rights as outlined in the facility's policy and state regulations.
Failure to Monitor Bowel Movements and Follow Physician Orders
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for two residents. Resident R83, who has a history of heart failure, high blood pressure, and ileus, complained of nausea, abdominal discomfort, and constipation. Despite the facility's bowel protocol requiring daily monitoring of bowel movements, there was no documentation of Resident R83's bowel habits. The Director of Nursing confirmed that nursing staff failed to monitor and document the resident's daily bowel habits, leading to the resident experiencing discomfort and requesting medication for constipation after two days without a bowel movement. Resident R146, who had a care plan intervention to wear an Aspen Collar at all times due to chronic progressive disease, mobility deficit, and spinal fusion, was observed without the collar. The clinical record showed an order for the collar to be worn at all times, but documentation indicated multiple instances where the collar was not in place. The Director of Nursing confirmed that the collar was not on order and that the resident had been pulling at it. The collar should have been discontinued by hospice, but this was not done, resulting in the resident not receiving the prescribed treatment.
Failure to Provide Adequate Supervision for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure adequate supervision for a cognitively impaired resident, identified as Resident R148, leading to multiple falls. The resident, who was completely dependent on staff for all activities of daily living and had a history of neurological conditions, experienced three falls that required emergency room evaluations. Despite the facility's policy to implement additional or different interventions after reoccurring falls, the resident continued to fall, including an incident where the resident fell from a Geri-chair while a nursing assistant turned away to prepare a meal. Another fall occurred when the resident was found on the floor in the dining room having a seizure, and yet another when the resident was found lying face down in the hallway, despite being assigned 1:1 supervision at the time. During an interview, the Director of Nursing confirmed that the resident was not properly supervised during the fall on February 19, 2024. The unit clerk assigned to supervise the resident was working on the computer at the nurse station when the resident fell. The facility's policy for 1:1 supervision requires that the assigned staff have no other job assignments other than supervising the resident. The failure to adhere to this policy resulted in the resident's fall and subsequent transfer to the hospital.
Failure to Provide Timely Behavioral Health Services
Penalty
Summary
The facility failed to ensure that Resident 66 received the necessary behavioral health services in a timely manner. The resident, who had a history of depression, bipolar disorder, suicidal attempts, and multiple psychiatric hospitalizations, was re-evaluated on January 29, 2024, and a recommendation was made for a psychology consult. However, there was no evidence in the clinical record that the resident was seen by a psychologist as recommended. The psychology practitioner, who visited the facility weekly, was not aware of the consult made on January 29, 2024, and did not see Resident 66. Additionally, the social service director did not follow up on the resident's concerns raised on March 8, 2024, after the resident expressed frustration and made a statement about harming himself. The social service progress note indicated that the department was in the process of addressing the resident's concerns, but it did not specify the actual concerns or any plans or interventions to address them. This lack of timely and appropriate behavioral health care and follow-up contributed to the deficiency in ensuring the resident's highest practicable mental and psychosocial well-being.
Failure to Ensure Medication Regimen Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from potential unnecessary medications. Clinical record review for Resident R138 revealed a physician's order for Clonazepam 1 mg to be given every 8 hours as needed for anxiety, initially prescribed for 14 days. This order was renewed without proper documentation or justification for its continuation. A psychiatric consult report indicated a short trial of Clonazepam but did not specify the expected duration. Additionally, a physician progress note ordered the continuation of Clonazepam twice daily without providing a reason for extending the as-needed order beyond the initial 14 days.
Failure to Promptly Obtain and Communicate Laboratory Results
Penalty
Summary
The facility failed to ensure that laboratory studies were promptly obtained and communicated as ordered by the physician for Resident R66. On October 27, 2023, a valproic acid level test was conducted, and the result, which showed the level was below the therapeutic range, was reported on the same day. However, the clinical record revealed no evidence that the result was notified to the physician until October 30, 2023. The physician then recommended rechecking the valproic acid level in one week, but there was no evidence that this follow-up test was completed as ordered. On March 8, 2024, another valproic acid level test was conducted for Resident R66, and the result again showed a low level. The clinical record indicated that the facility staff did not obtain the result from the laboratory system and notify the physician in a timely manner. This deficiency was confirmed during an interview with the Assistant Director of Nursing on March 15, 2024.
Failure to Ensure Resident Capacity for Binding Arbitration Agreement
Penalty
Summary
The facility failed to ensure that a resident had the capacity to understand the terms of a binding arbitration agreement. Resident R99, who was admitted with a diagnosis of altered mental status and cocaine abuse, showed signs of moderate cognitive impairment. The resident scored a 9 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. Additionally, physician progress notes and a psychiatric consultation revealed that the resident was a poor historian, forgetful, and exhibited confused and agitated behavior, including urinating in a Styrofoam cup and drinking the urine. Despite these indicators, the resident signed a binding arbitration agreement on September 28, 2023. The facility's Admission Director, Employee 19, also signed the binding arbitration agreement but later confirmed in an interview that he was not aware of the resident's mental status. Employee 19 admitted that he usually asks the staff about residents' mental status but was unsure if he received any response regarding Resident R99's mental status. This lack of awareness and verification led to the resident signing a legally binding document without the capacity to understand its terms, violating the resident's rights and the facility's policies.
Unsafe Oxygen Storage on First Floor Nursing Unit
Penalty
Summary
The facility failed to ensure a safe environment related to oxygen storage on the first floor nursing unit. On March 11, 2024, at 11:00 a.m., it was observed that approximately 12 oxygen cylinders were stored in an open hallway area between resident rooms [ROOM NUMBER] and 101, without any signage indicating oxygen storage. During an interview on March 13, 2024, at 1:00 p.m., a Nursing Assistant (Employee E20) stated that staff stored oxygen in the hallway space and was unaware of the facility protocol requiring storage in a locked oxygen storage room. The Nursing Home Administrator confirmed the unsafe storage practice and acknowledged awareness of the problem but admitted to not implementing or educating staff about safe oxygen handling procedures. The Administrator stated that staff were expected to store oxygen cylinders in a locked room with appropriate signage outside the room.
Failure to Provide Required In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure its nurse aide staff received the required in-service training to be proficient and competent, specifically not meeting the minimum of 12 hours of annual training. This deficiency was identified for five nurse aides (Employees E21, E22, E23, E24, and E25) based on a review of facility documentation and staff interviews. The facility was unable to provide the requested training records for these employees during the survey conducted on March 13, 14, and 15, 2024. The Nursing Home Administrator confirmed the absence of documentation proving that the required training hours were met for the specified employees.
Improper Discharge of Resident with Cognitive Impairments
Penalty
Summary
The facility failed to properly discharge Resident Cl1, who had short term memory problems and required guidance for safety awareness. Despite having policies in place regarding discharge procedures, the facility did not follow them in this case. Resident Cl1, who had a history of delirium and confusion due to hepatic encephalopathy, was allowed to exit the building against medical advice without proper documentation, notification to the resident's physician, family, or State authorities. The resident's safety device was removed, and he was discharged to an unknown location without his identification documents, creating an Immediate Jeopardy situation. Clinical documentation revealed that Resident Cl1 exhibited symptoms of unsteady gait, confusion, and incontinence, requiring supervision and assistance for daily activities. The resident's care plan included interventions for safety risks related to confusion, delirium, and elopement behavior. Despite these documented needs, the facility did not adequately address Resident Cl1's discharge process, leading to the resident leaving the facility without proper support or supervision. The failure to involve the resident's physician, family, and State authorities in the discharge process resulted in a breach of regulatory requirements and put Resident Cl1 at risk. Interviews with staff members confirmed that essential steps in the discharge process were overlooked, including consulting psychiatry or psychology for assessment and treatment, notifying the State Long Term Care Ombudsman, and ensuring proper documentation and witness signatures for discharge against medical advice. The facility's lack of coordination and communication regarding Resident Cl1's discharge highlights systemic deficiencies in ensuring the safety and well-being of residents with cognitive impairments. The events leading to Resident Cl1's improper discharge underscore the importance of thorough assessment, planning, and communication in facilitating safe transitions for vulnerable residents in long-term care facilities.
Failure to Provide Psychiatric Consultations as Ordered
Penalty
Summary
The facility failed to ensure that a resident with a history of delirium and confusion due to hepatic encephalopathy received psychiatric consultations as ordered by the physician. The resident, who was admitted with moderately impaired cognition, exhibited behaviors of inattention, disorganized thinking, increased anxiety, and pacing. The resident also had several elopement attempts and expressed a desire to punch someone. The physician had ordered psychiatric and psychological consults on multiple occasions, but these consultations were not carried out by the facility. The Director of Nursing confirmed that the facility did not consult the psychiatry or psychology departments to assess, evaluate, and treat the resident as ordered by the attending physician. This failure to follow through on the physician's orders for psychiatric consultations was identified during a clinical record review and staff interview, highlighting a significant lapse in patient care policies and nursing services as per the relevant state codes.
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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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