Bonham Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Stillwater, Pennsylvania.
- Location
- 477 Bonnieville Road, Stillwater, Pennsylvania 17878
- CMS Provider Number
- 395654
- Inspections on file
- 17
- Latest survey
- August 13, 2024
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Bonham Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident who experienced a change in condition and was transferred to the hospital did not have official documentation of the event in their clinical record, as required by facility policy and federal regulations. The Assistant DON confirmed the absence of this documentation, noting it may have been sent with the ambulance during transfer.
The facility failed to maintain its automatic sprinkler system components, affecting the entire facility. An inspection report identified that sprinklers in the 'old part' of the building, dated 1974, were due for UL-Testing, and the FDC needed hydrotesting. A revisit confirmed that the sprinkler issue remained unresolved.
The facility failed to maintain its automatic sprinkler system components, affecting the entire facility. A document review revealed that the sprinklers in the 'old part' of the building were dated 1974 and required UL-Testing, and the FDC needed to be hydrotested. These deficiencies were confirmed during an exit interview with the Administrator and Maintenance Director.
The facility failed to document the monthly conductance testing of its generator's maintenance-free batteries, as required by NFPA standards. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director, highlighting a lapse in maintaining essential emergency power system protocols.
The facility failed to maintain unobstructed means of egress on the first floor. The music room's emergency exit door was inoperable due to a screw in its panic bar, and even after removal, it failed to open. Additionally, the stair tower D emergency exit door required excessive force to open. These issues were confirmed by the Administrator and Maintenance Director.
The facility did not maintain smoke barrier doors according to NFPA 101 standards. An observation revealed that the smoke doors near a resident room had a broken magnetically held fire door device, affecting one of the two levels. This was confirmed in an exit interview with the Administrator and Maintenance Director.
A smoke detector in the kitchen wash room on the first floor was found obstructed with a plastic cover and tape, failing to meet NFPA 101 standards. This was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility failed to maintain the fire resistance rating of linen chutes, affecting two levels. Observations revealed that linen chute doors on the third and second floors of the South Wing did not close and latch properly. This was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility was found to be in violation of building construction requirements, as it was classified as a four-story, Type II (000), unprotected non-combustible construction, which is fully sprinklered. This classification exceeds the maximum allowable height for unprotected non-combustible construction by two stories. The deficiency was confirmed in an exit interview with the Administrator and Maintenance Director.
Cheltenham Nursing and Rehabilitation Center failed to protect a resident from abuse, resulting in physical harm. A resident with a history of verbal aggression physically assaulted another resident, causing a closed head injury and a fractured finger. Despite previous altercations, the facility did not prevent the escalation to violence.
The facility failed to provide suitable and nourishing snacks to several residents who wanted to eat at non-traditional times, outside of scheduled meal service. Despite the facility's policy requiring bedtime snacks to be accessible and assistance provided as needed, residents reported not being routinely offered these snacks. Observations and records indicated a lack of consistent documentation and assurance that staff were completing this task, with concerns also noted in food committee meeting minutes.
The facility failed to follow professional standards for food service safety, particularly in the dishwashing process. Dietary staff did not conduct a test load or use sanitizer testing strips to verify the concentration of the final rinse water. Additionally, incorrect test strips were used, leading to inaccurate measurements of chlorine concentration. The Food Service Director confirmed these lapses in proper sanitation practices.
The facility failed to develop comprehensive care plans for two residents. One resident, diagnosed with physical aggression, paranoia, and insomnia, was involved in altercations without a care plan addressing these issues. Another resident, requiring oxygen therapy for shortness of breath, also lacked a care plan. These deficiencies highlight a significant oversight in meeting residents' medical and psychosocial needs.
A facility failed to conduct routine testing for therapeutic levels of Depakote for a resident with epilepsy, leading to an incorrect dosage change. Additionally, the facility did not inform the physician of a recommended increase in Risperdal for the resident, resulting in a lapse in communication and adherence to professional standards.
The facility failed to provide necessary treatment and services for two residents with limited range of motion. One resident with paraplegia and multiple sclerosis was not receiving prescribed passive range of motion exercises and splinting. Another resident with a history of stroke and hemiplegia was not receiving the recommended splint and brace program. Observations and interviews confirmed the lack of implementation of these restorative nursing programs.
A resident with a history of opioid dependence and suicidal ideation was found holding razors, which were accidentally left accessible by a nursing assistant. The resident's care plan included measures to prevent self-harm, but the oversight led to a breach in maintaining a safe environment.
The facility failed to ensure medications were administered with adequate indications and monitoring for two residents. One resident was prescribed medications for insomnia without a diagnosis, while another was given Lorazepam without documented rationale for extended use and Depakote without adequate indication. Additionally, a blood level test for Depakote was below normal, with no evidence of physician review.
A facility failed to obtain necessary lab tests for a resident with obesity and high risk for pressure sores. The physician ordered blood tests to assess albumin and thyroid function, but there was no documentation of completion. This was confirmed by an LPN.
A facility failed to maintain enhanced barrier precautions for a resident requiring enteral nutrition. Despite clear instructions and signage, a nurse aide provided incontinence care without wearing a gown, violating infection control protocols. The resident had multiple diagnoses, including Parkinson's disease and dysphasia, necessitating strict adherence to infection prevention measures.
The facility failed to implement timely and effective safety interventions for residents with known fall risks, resulting in serious injuries and a fatality. A resident with a history of falls and assessed as high risk was not adequately supervised, leading to multiple falls and a fatal subdural hematoma. Another resident with Parkinson's Disease experienced repeated falls despite increased supervision, resulting in a hematoma. The facility's inaction and insufficient response to known fall risks led to significant harm.
The facility failed to develop comprehensive care plans for two residents, neglecting to address specific medical needs such as pacemaker monitoring for a resident with a cardiac condition and denture care for a resident with Alzheimer's. These deficiencies were confirmed through clinical record reviews and staff interviews.
Two residents in an LTC facility did not receive timely physician action on pharmacy recommendations regarding their medication regimens. One resident, with major depressive disorder, continued on Trazodone 300 mg daily without physician review for several months despite pharmacy advice. Another resident, with Alzheimer's, was on Divalproex Sodium 375 mg three times daily, with no physician response to pharmacy recommendations for months. The facility policy requires physician action or documented rationale, which was not followed.
A resident with a history of falls and Parkinson's Disease experienced multiple falls in an LTC facility due to ineffective implementation of a QAPI program. Despite being identified as a high fall risk, the facility failed to investigate and analyze the root cause of the falls, particularly in the dining room during the evening shift. The lack of systematic approach and documentation of corrective actions contributed to the deficiency.
A facility failed to provide person-centered care for a resident with a pacemaker, lacking documented physician orders for necessary care, monitoring, and battery checks. This deficiency was confirmed through clinical record reviews and an interview with the DON, resulting in a citation under F656.
A resident developed an avoidable pressure sore due to the facility's failure to monitor a therapeutic device effectively. Despite physician orders for two-hourly skin checks, the facility did not document these checks, leading to a suspected deep tissue injury on the resident's ankle. The resident's care plan lacked necessary interventions for the immobilizer, contributing to the deficiency.
A facility failed to attempt non-pharmacological interventions before administering as-needed pain medication to a resident with multiple fractures and diabetes. The resident received Acetaminophen and Oxycodone HCL without documented non-pharmacological attempts, and the care plan lacked individualized non-pharmacological interventions. The DON confirmed the absence of such documentation.
A facility failed to implement a hospice plan of care for a resident with end-stage chronic kidney disease and stroke. Despite hospice services being triggered in the resident's MDS, the facility's care plan lacked specific goals and interventions for hospice care, as confirmed by the DON.
A facility failed to provide written notice of its bed-hold policy to a resident and their representative upon hospital transfer. A review of records showed no documentation of notification, and during an interview, the NHA and DON could not provide evidence of compliance, violating resident rights.
Incomplete Documentation of Change in Condition
Penalty
Summary
The facility failed to ensure complete and accurate documentation for one resident, as required by federal regulations and the facility's own policy. Specifically, a review of the clinical record for one resident who experienced a change in condition and was transferred to the hospital did not contain official documentation of the change in condition. The facility's policy requires that all change in condition documentation include the date, time, assessment findings, actions taken, notifications, and resident response, and that this documentation be timely, accurate, and complete. During an interview, the Assistant Director of Nursing confirmed that the resident experienced a change in condition and was transferred to the hospital, but the required documentation was not present in the clinical record. It was suggested that the documentation may have been sent with the ambulance during the transfer, but it was not retained in the facility's records as required.
Failure to Maintain Sprinkler System Components
Penalty
Summary
The facility failed to maintain its automatic sprinkler system components, which affected the entire facility. During a document review on December 23, 2024, it was found that the sprinkler inspection report from November 8, 2024, identified deficiencies. Specifically, the sprinklers in the 'old part' of the building, dated 1974, were due for UL-Testing, and the Fire Department Connection (FDC) required hydrotesting. An exit interview with the Administrator and Maintenance Director confirmed these deficiencies. A subsequent onsite revisit on February 11, 2025, revealed that the issue with the sprinklers in the 'old part' of the building remained unresolved, as confirmed by the Administrator during the exit interview.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement by this provider of the facts alleged, or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and/or state law. The plan of correction constitutes our credible allegation of compliance. 1. On 1/6/2025 the Maintenance Director contacted The Tustin Group to schedule UL testing for the sprinklers in the "old part" of the building. 2. On 1/31/2025 the Tustin Group gathered the make and model for heads on the "old part" of the building to order replacement parts for the upcoming UL testing. 3. On 2/11/2024 the Maintenance Director checked the most recent sprinkler inspection report for cited deficiencies. There were no other deficiencies. 4. On 2/11/2025 the NHA re-educated the maintenance team on correcting deficiencies cited following a sprinkler inspection. 5. The Maintenance Director/designee will conduct weekly audits for 4 weeks to verify that the deficiencies cited following an inspection are corrected timely. Results of the audits will be reviewed at the QAPI meeting held monthly.
Failure to Maintain Sprinkler System Components
Penalty
Summary
The facility failed to maintain its automatic sprinkler system components, which affected the entire facility. During a document review on December 23, 2024, it was found that the sprinkler inspection report from November 8, 2024, identified specific deficiencies. The sprinklers in the 'old part' of the building were dated 1974 and required UL-Testing. Additionally, the Fire Department Connection (FDC) needed to be hydrotested. These deficiencies were confirmed during an exit interview with the Administrator and Maintenance Director on the same day.
Plan Of Correction
1. On 1/6/2025 the Maintenance Director contacted The Tustin Group to schedule UL testing for the sprinklers in the "old part" of the building. 2. On 1/6/2025 the Maintenance Director contacted The Tustin Group to have the FDC hydrotested. Testing is scheduled for 2/2/2025. 3. On 12/24/2024 the Maintenance Director checked all sprinkler inspection reports for cited deficiencies. There were no other deficiencies. 4. On 12/30/2024 the NHA educated the maintenance team on correcting deficiencies cited following a sprinkler inspection. 5. The Maintenance Director/designee will conduct weekly audits for 4 weeks to verify that the deficiencies cited following an inspection are corrected timely. Results of the audits will be reviewed at the QAPI meeting held monthly.
Failure to Document Monthly Generator Battery Testing
Penalty
Summary
The facility failed to maintain the required testing of emergency generator components, specifically the monthly conductance testing of the generator's maintenance-free batteries. This deficiency was identified during a document review conducted on December 23, 2024, at 9:30 a.m., which revealed the absence of verifying documentation for the monthly testing. The lack of documentation indicates that the facility did not adhere to the necessary maintenance protocols for the emergency generator, which is crucial for ensuring the generator's reliability in providing essential power during emergencies. During the exit interview with the Administrator and Maintenance Director on the same day at 12:15 p.m., it was confirmed that the documentation for the monthly conductance testing was missing. This oversight affects the facility's ability to demonstrate compliance with the National Fire Protection Association (NFPA) standards, specifically NFPA 101, NFPA 110, and NFPA 111, which outline the requirements for maintaining and testing emergency power systems in healthcare facilities.
Plan Of Correction
1. On 1/3/2025 the Maintenance Supervisor completed conductance testing of the generator's maintenance free batteries. 2. On (Insert Date) the Maintenance Director revised the generator testing documentation to include monthly conductance testing. 3. On 12/30/2024 the NHA educated the maintenance team on maintaining the required testing of emergency generator components in accordance with NFPA 101 requirements. 4. The Maintenance Director/designee will conduct audits monthly for 3 months to verify proper documentation for generator testing is present. Results of the audits will be reviewed at the QAPI meeting held monthly.
Obstructed Means of Egress on First Floor
Penalty
Summary
The facility failed to maintain the means of egress free of obstructions, affecting one of two levels. On December 23, 2024, at 10:45 a.m., an observation revealed that the emergency exit door in the music room on the first floor was inoperable due to a screw inserted into its panic bar. Even after the screw was removed, the door still failed to open. Additionally, at 10:55 a.m., it was observed that the emergency exit door in stair tower D on the first floor required excessive force to open. These findings were confirmed during an exit interview with the Administrator and Maintenance Director on the same day at 12:15 p.m.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement by this provider of the facts alleged, or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and/or state law. The plan of correction constitutes our credible allegation of compliance. 1. On 12/23/2024 the Maintenance immediately removed the screw from the panic bar on the emergency exit door in the music room. The door was tested and opened without restriction. 2. On 12/26/2024 the maintenance team adjusted the stair tower D emergency exit door. The door opens without the use of excessive force. 3. On 12/26/2024 the maintenance team inspected all emergency exit doors to verify that there were no obstructions to egress. 4. On 12/30/2024 the NHA educated the maintenance team on maintaining that the means of egress are free of obstructions. 5. The Maintenance Director/designee will conduct weekly audits for 4 weeks to verify the proper functionality of all emergency exit doors in accordance with NFPA 101 requirements. Results of the audits will be reviewed at the QAPI meeting held monthly.
Failure to Maintain Smoke Barrier Doors
Penalty
Summary
The facility failed to maintain smoke barrier doors as required by NFPA 101 standards. During an observation on December 23, 2024, it was noted that the smoke doors near resident room B-1 had a magnetically held fire door device with a broken housing. This deficiency affected one of the two levels in the facility. The issue was confirmed during an exit interview with the Administrator and Maintenance Director on the same day.
Plan Of Correction
1. On 12/26/2024 the Maintenance Director repaired the magnetic housing device. 2. On 12/23/2024 the Maintenance Director inspected all smoke doors to verify that the magnetic housing devices were secure. 3. On 12/30/2024 the NHA educated the maintenance team on maintaining smoke barrier doors in accordance with NFPA 101 requirements. 4. The Maintenance Director/designee will conduct weekly audits for 4 weeks to verify that smoke barrier doors are in accordance with NFPA 101 requirements. Results of the audits will be reviewed at the QAPI meeting held monthly.
Smoke Detector Obstruction in Kitchen Wash Room
Penalty
Summary
The facility failed to maintain smoke detectors as required by NFPA 101 standards. During an observation on December 23, 2024, at 11:20 a.m., it was found that a smoke detector in the kitchen wash room on the first floor was obstructed with a plastic cover and tape. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director on the same day at 12:15 p.m.
Plan Of Correction
1. On 12/23/2024 the Maintenance Director removed the plastic cover and tape from the obstructed smoke detector in the kitchen washroom. 2. On 12/23/2024 the maintenance team inspected all smoke detectors in the building to verify there were no obstructions. 3. On 12/30/2024 the NHA educated the Maintenance team on properly maintaining the smoke detection system in accordance with NFPA 101 requirements. 4. The Maintenance Director/designee will conduct weekly audits for 4 weeks to verify that smoke detectors are not obstructed. Results of the audits will be reviewed at the QAPI meeting held monthly.
Failure to Maintain Fire Resistance of Linen Chutes
Penalty
Summary
The facility failed to maintain the fire resistance rating of linen chutes and discharge rooms, affecting two of four levels. During an observation on December 23, 2024, between 11:45 a.m. and 12:05 p.m., it was noted that the linen chute doors on the third and second floors of the South Wing did not close and latch properly when tested. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director on the same day at 12:15 p.m.
Plan Of Correction
1. On 1/3/2025 the Maintenance team replaced the existing hardware on the 2nd and 3rd floor South Wing linen chutes. 2. On 12/23/24 the Maintenance Director inspected the linen chutes on the other units and verified the proper functionality. 3. On 12/30/2024 the NHA educated the maintenance team on maintaining the fire resistance rating of the linen chutes in accordance with NFPA 101 requirements. 4. The Maintenance Director/designee will conduct weekly audits for 4 weeks to verify positive latching and the proper functionality of the linen chute doors. Results of the audits will be reviewed at the QAPI meeting held monthly.
Building Construction Type Violation
Penalty
Summary
The facility was found to be in violation of building construction requirements as it was classified as a four-story, Type II (000), unprotected non-combustible construction, which is fully sprinklered. This classification exceeds the maximum allowable height for unprotected non-combustible construction by two stories. The deficiency was identified during a document review and confirmed in an exit interview with the Administrator and Maintenance Director.
Plan Of Correction
The facility will be engaging a certified external auditor to conduct a comprehensive Fire Safety Evaluation System (FSES) audit. This audit will evaluate the facility's fire safety measures across all designated zones, ensuring that each area meets or exceeds the rigorous standards set forth by the FSES. A passing score for each zone is a critical requirement, as it will demonstrate the facility's commitment to maintaining a safe environment for all residents, staff, and visitors. Upon successfully achieving a passing score in all zones, the facility will become eligible for the Centers for Medicare & Medicaid Services (CMS) approved time-limited waiver. This waiver will grant the facility an extension to comply with any remaining fire safety requirements that may need additional time or adjustments, while ensuring that essential safety measures are already in place to safeguard occupants in the interim. The FSES audit will cover a range of critical fire safety aspects, including but not limited to: fire detection and alarm systems, emergency evacuation plans, fire suppression systems, staff training and preparedness, and overall compliance with both local fire codes and CMS regulations. Each zone will be meticulously assessed to identify potential vulnerabilities and areas for improvement, and the results will be used to implement necessary corrective actions. Achieving a passing score not only ensures eligibility for the CMS time-limited waiver but also reflects the facility's proactive approach to maintaining a high standard of fire safety, protecting both the health and safety of all those within the facility and mitigating the risk of fire-related incidents.
Failure to Protect Resident from Abuse
Penalty
Summary
Cheltenham Nursing and Rehabilitation Center was found to be non-compliant with federal and state regulations due to a failure to protect a resident from abuse. Resident R46, who had a history of verbal aggression, physically assaulted Resident R112, resulting in actual harm. The incident involved Resident R46 becoming physically violent, leading to Resident R112 sustaining a closed head injury and a fractured right finger. Resident R46 was assessed as alert, oriented, and independent in activities of daily living, with a history of verbal aggression towards Resident R112. Despite this, the facility did not take adequate measures to prevent further altercations. Resident R112, who had severe cognitive impairment and required supervision for daily activities, was left vulnerable to the aggression of Resident R46. The facility's documentation revealed multiple instances of verbal altercations between the two residents, including a significant incident where Resident R46 threatened Resident R112. The situation escalated to physical violence, witnessed by another resident, resulting in injuries to Resident R112. The facility's failure to address the ongoing aggression and protect Resident R112 from harm was substantiated as abuse.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement by this provider of the facts alleged, or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and/or state law. The plan of correction constitutes our credible allegation of compliance. 1. Resident R112 was immediately moved to another unit on October 12, 2024, following the resident-to-resident altercation. Resident R112 and R46 remain on separate units. 2. On 12/26/2024 the nurse management team reviewed the Electronic Health Record (EHR) of residents with a history of verbal or physical aggression towards other residents to identify those that were at high risk. 3. On 12/26/2024 The Social Services Director and Nurse Managers reviewed those residents identified at high risk for verbal and physical aggression. Those identified were referred to psych. The care plans were updated, and medications were reviewed. 4. On 12/26/24 the NHA/designee started education for all staff on the facility's abuse policy and supervision of residents. The education was completed by 12/31/2024. 5. The DON and/or designee will conduct audits of residents at high risk for verbal or physical aggression. Audits will be completed weekly for 4 weeks and monthly for 3 months. Results of the audits will be reviewed at the Quality Assurance Performance Improvement meeting held monthly.
Failure to Provide Nourishing Snacks at Non-Traditional Times
Penalty
Summary
The facility failed to provide suitable and nourishing snacks to eight out of nine residents who expressed a desire to eat at non-traditional times, outside of the scheduled meal service. This deficiency was identified through clinical record reviews, interviews with residents and staff, and reviews of policies and procedures. The facility's policy required that bedtime snacks be placed within reach of each resident and that nursing staff assist residents with eating these snacks as necessary. However, during a group meeting, residents reported that they were not routinely offered nourishing snacks at bedtime, despite being able to express their nutritional preferences and needs. Observations revealed that bulk snacks were provided by the dietary department at 6:00 a.m. for use during the 7-3 shift, but there was no consistent documentation or assurance that the 3-11 shift staff offered bedtime snacks to all residents. Clinical records for the involved residents, who were mostly cognitively intact, showed a lack of consistent documentation indicating that staff were completing the task of offering and assisting with bedtime snacks. Additionally, food committee meeting minutes noted a resident's concern about not being frequently offered between meals and bedtime snacks as care planned.
Plan Of Correction
1. On 12/19/2024 the DON assessed Residents R111, R23, R476, R95, R145, R133, R162 and R167 and there were no negative outcomes. On 12/19/2024 the Dietary department delivered HS snacks to all units. 2. On 12/19/2024 the dietician reviewed the electronic records of residents identified as "at risk" for weight loss to verify that nourishment orders were in place if necessary. 3. The dietary department will deliver nourishments 3 times per day for residents with orders and re-stock the units with nourishments for all other residents daily. A nourishment log will be utilized to verify the nourishment delivery. 4. On 12/19/2025 the NHA and Dietary Manager educated the dietary staff, providing nourishments between meals. 5. The NHA/designee will conduct audits of nourishment delivery 3x per week for 4 weeks and monthly for 3 months.
Improper Dishwashing Practices and Testing in Facility
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, specifically in the operation and monitoring of their dishwashing process. During an inspection, it was observed that dietary staff members, Employees E13 and E14, did not conduct a test load of dishes nor use sanitizer testing strips to verify the concentration of the final rinse water when operating the dish machine. This machine operates as a low-temperature unit, relying on chemical sanitation, which necessitates precise monitoring to ensure effective sanitation. Further investigation revealed that the Dietary Assistant, Employee E12, used incorrect test strips, specifically 'QAC QR' test strips, which are intended for measuring Quaternary Ammonium Compounds, rather than the required chlorine test strips. This error resulted in the test strips not changing color, indicating a failure to measure the chlorine concentration accurately. The Food Service Director confirmed that the correct procedure was not followed, highlighting a lapse in proper sanitation practices within the facility.
Plan Of Correction
1. There were no negative outcomes to residents of Cheltenham Nursing and Rehab as a result of not utilizing correct sanitation test strips for the dish machine. 2. On 12/19/2024, the Dietary Manager obtained the proper sanitation levels of the dish machine using the correct test strip. 3. On 12/19/2024, the Dietary Manager educated the dietary staff on the proper method of testing the dish machine sanitation levels, utilizing the proper test strips and accurately completing the sanitation log. 4. The Dietary Manager will label the test strips to make certain that the proper strips are being utilized. 5. The NHA/designee will conduct audits of sanitation logs 3x per week for 4 weeks and monthly for 3 months.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for Resident R46, who was diagnosed with physical aggression, paranoia, insomnia, and was taking antipsychotic medication for psychosis. Despite being alert and oriented, Resident R46 was involved in multiple altercations, including a verbal altercation on May 2, 2024, and a physical altercation on October 12, 2024, which resulted in injuries to another resident. The facility's documentation did not include a care plan addressing these behaviors or the resident's insomnia and medication needs. Additionally, the facility did not create a care plan for Resident R170, who required oxygen therapy. Resident R170 was admitted with diagnoses of anemia and acute myeloblastic leukemia and had a physician's order for oxygen use as needed for shortness of breath. However, there was no care plan developed to address the resident's respiratory needs or the use of oxygen, as confirmed by the Assistant Director of Nursing. These deficiencies indicate a failure to adhere to the facility's policy of developing comprehensive, person-centered care plans that address the medical, nursing, and psychosocial needs of residents. The lack of care plans for both residents R46 and R170 highlights a significant oversight in ensuring the well-being and safety of residents, as required by regulatory standards.
Plan Of Correction
1. On 12/18/2024 the nurse management team developed a care plan for Resident R46 addressing physical aggression, paranoia, suspicious behaviors and insomnia. Resident R170 is no longer in the facility. 2. On 12/26/2024 the nurse management team reviewed the Electronic Health Record of residents with a history of physical or verbal aggression, paranoia and suspicious behaviors. Care plans for those residents were reviewed and revised as needed. 3. During the morning clinical meeting the Interdisciplinary Team will review all admissions and notes from the most recent psych visit to develop a comprehensive care plan that includes resident specific behaviors including physical aggression, paranoia, suspicious behaviors and insomnia. 4. Education on the development of comprehensive care plans to address resident specific behaviors including physical aggression, paranoia, suspicious behaviors and insomnia will be presented by the DON/designee to nursing staff and the Interdisciplinary Team members by 01/16/2025. 5. Audits of comprehensive care plans that include resident specific behaviors for residents physical or verbal aggression, paranoia and suspicious behaviors will be completed weekly for 1 month and then monthly for 1 quarter. Audits will be forwarded to the monthly Quality Assurance Performance Improvement Meeting and evaluated by the Quality Assurance Committee.
Failure to Monitor Medication Levels and Communicate Dosage Changes
Penalty
Summary
The facility failed to provide treatment and services in accordance with professional standards of practice by not conducting routine testing to verify therapeutic levels of a seizure medication for a resident diagnosed with epilepsy. The resident, who was alert, oriented, and capable of making independent decisions, was initially prescribed Depakote at a daily total of 750 mg. However, due to a miscommunication, the dose was incorrectly decreased to 500 mg daily instead of being increased as intended. This error persisted for two weeks before the dose was corrected. Additionally, the facility did not perform routine Depakote level testing after the initial admission test, which was contrary to the care plan that required monitoring of therapeutic levels. Furthermore, the facility failed to inform the physician of a recommended increase in the dose of Risperdal, an antipsychotic medication, for the same resident who was experiencing increased paranoia and aggression. The psychiatrist confirmed that the Depakote dose should not have been changed and that therapeutic levels should be checked every six months. The psychiatrist also confirmed that the recommended increase in Risperdal was not completed, indicating a lapse in communication and adherence to professional standards of practice.
Plan Of Correction
1. On 1/10/2025 the Nurse manager obtained Depakote levels for Resident R46. Medications were at a therapeutic level. Additional Labs will be obtained every 6 months to monitor therapeutic levels. 2. A review of the medical record for Resident R46 identified that there was no physician order to increase Risperdal based on the Psychiatrist's recommendation. Resident R46 remains on the current dose of Risperdal and there is no order to increase. This was verified by the DON on 1/10/2025. 3. On 12/26/2025 the nurse management team completed an audit of all residents receiving Depakote. The nurse management team verified that residents receiving Depakote have laboratory orders in place to monitor therapeutic levels. 4. During morning clinical meeting, the IDT team will review any resident that has an order for Depakote for residents with medications that require routine testing and verify that orders for routine monitoring are present. 5. Education on conducting routine testing to verify therapeutic levels of seizures medication will be presented by the DON/designee to all licensed nursing staff by 1/16/2025. 6. The DON/designee will conduct audits of residents with medications requiring routine monitoring weekly for 4 weeks and monthly for 3 months.
Failure to Provide Restorative Nursing Programs for Residents with Limited Range of Motion
Penalty
Summary
The facility failed to provide necessary treatment and services to maintain or improve the range of motion and mobility for two residents with limited range of motion. Resident R7, who was admitted with conditions including paraplegia, multiple sclerosis, and muscle contractures, was observed with his left arm in a fixed position on his chest. Despite having a restorative nursing program in place, which included passive range of motion exercises and splinting, there was no documented evidence that these interventions were provided to Resident R7. This was confirmed by an interview with the Assistant Director of Nursing. Similarly, Resident R37, who was admitted with a history of cerebrovascular accident and hemiplegia, was not receiving the recommended restorative nursing program. The occupational therapy discharge summary recommended a splint and brace program, but there was no documentation that this was implemented. Observations revealed that Resident R37's left upper and lower extremities were limp, and interviews confirmed that the resident was not receiving the necessary splinting as prescribed. The lack of documentation and implementation of the restorative nursing programs for both residents indicates a failure by the facility to ensure that residents with limited range of motion receive appropriate treatment and services. This deficiency was identified through observations, clinical record reviews, and staff and resident interviews, highlighting a significant oversight in the care provided to these residents.
Plan Of Correction
1. On 12/26/2024 the nurse management team reviewed all residents that have nurse maintenance programs for splinting and implemented sign off sheets for the nurse maintenance programs for Resident R7 and Resident R37. 2. On 12/26/2024 the nursing management team reviewed the electronic health record of residents on a nurse maintenance program for splinting program and verified that proper documentation was present. 3. The IDT team will review new residents on a maintenance program for splinting during clinical meetings to verify documentation is present for maintenance programs. 4. Education on maintaining complete documentation for nursing maintenance programs will be presented by the DON/designee to all CNA staff by 1/16/2025. 5. The DON/designee will conduct audits on nursing maintenance nursing program for splinting documentation for 4 weeks and monthly for 3 months. Results of the audits will be reviewed at the QAPI meeting held monthly.
Resident Access to Hazardous Materials Due to Staff Oversight
Penalty
Summary
The facility failed to ensure that the resident environment was free of accident hazards, specifically by allowing a resident access to hazardous materials. Resident R575, who was admitted with a history of opioid dependence, homicidal ideations, and a previous suicide attempt, was observed holding two razors in the doorway of their room. The resident's care plan included interventions to prevent self-harm, such as removing harmful items from the room and maintaining hourly checks. The incident occurred when Employee E4, a nursing assistant, accidentally left the razors in the bathroom, making them accessible to the resident. Interviews with the Director of Nursing and other staff confirmed that the resident should not have had access to razors, given their history of behaviors and the existing care interventions. This oversight highlights a lapse in maintaining a safe environment for the resident, as required by the facility's policies.
Plan Of Correction
1. On 12/18/2024 the razors were immediately discarded by the CNA. There were no negative outcomes or injuries noted for Resident R575. 2. On 12/18/2024 the nursing staff checked resident rooms to verify that there were no razors left in the room and/or bathrooms. None were identified. 3. On 12/26/2024 the NHA educated the nursing staff on maintaining safety measures for residents regarding razors. 4. The DON/designee will conduct audits 2 times a week for 4 weeks and monthly for 3 months verifying that residents' rooms are free of razors. Results of the audits will be reviewed at the QAPI meeting held monthly.
Inadequate Medication Indication and Monitoring
Penalty
Summary
The facility failed to ensure that medications were administered with adequate indications for use and monitoring for two residents. For Resident R46, the clinical record showed that the resident was prescribed Melatonin and Trazodone for insomnia, despite not having a diagnosis of insomnia. This indicates a lack of adequate indication for the use of these medications. For Resident R83, the facility did not document the rationale for the continued use of Lorazepam beyond 14 days, as required for psychotropic medications. Additionally, the resident was prescribed Depakote without adequate indication for its use, as the medication is typically used for bipolar disorder, epilepsy, or migraines, none of which were documented as diagnoses for the resident. Furthermore, a blood level test for Depakote showed a below-normal range, but there was no documentation that this was reviewed with the physician to ensure proper monitoring.
Plan Of Correction
1. On 12/19/24 the DON assessed Resident R46 and Resident R83 and there were no negative outcomes. 2. On 12/20/2024 the DON obtained an order and added the insomnia diagnosis for Resident R46. On 1/5/2025 he attending physician discontinued the order for Lorazepam for Resident R83. 3. On 12/26/24 the nurse managers reviewed the electronic health records for residents with a PRN order for a psychotropic medication to verify that documentation indicating continued use past 14 days is present. 4. During the morning clinical meeting the IDT team will review new and existing PRN orders for psychotropic medications to verify diagnosis and supporting documentation by the physician for continued use. 5. Education on administering medications with the proper diagnosis and physician documentation for continued psychotropic medications will be presented by the DON/designee to licensed nurses by 1/16/2025. 6. The DON/designee will conduct audits on administering medications with proper diagnosis and documentation for continued use and monitoring weekly for 4 weeks and monthly for 3 months.
Failure to Obtain Ordered Laboratory Services
Penalty
Summary
The facility failed to obtain necessary laboratory studies as ordered by a physician for Resident R158, who was identified as being at high risk for pressure sore development and had moisture-associated skin damage. Resident R158, diagnosed with obesity, was 68 inches tall and weighed 231 pounds, which is 25% above the ideal body weight. The physician had ordered blood tests to assess the metabolism of albumin and thyroid function on November 13 and 15, 2024. However, there was no documentation in the clinical records to indicate that these tests were completed as ordered. This deficiency was confirmed during an interview with a licensed nurse, Employee E17, on December 19, 2024.
Plan Of Correction
1. On 12/19/2024 the DON assessed Resident R158 and there were no negative outcomes for failure to obtain laboratory studies of blood. 2. On 1/5/2025 and 1/16/2025 the Nurse Manager obtained laboratory studies per physician's order. The results are pending review by attending physician. 3. On 12/26/2024 the nurse management team reviewed lab orders for the last 3 months to verify the completion of lab orders per physician orders. 4. The IDT team will review lab binders during morning clinical meetings to verify the completion of labs request from the previous day. 5. Education on obtaining laboratory studies as ordered by the physician will be presented to the licensed nurses by 1/16/2025. 6. The DON/designee will conduct audits of lab binders weekly for 4 weeks and monthly for 3 months. Results of the audits will be reviewed at the QAPI meeting held monthly.
Failure to Maintain Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain enhanced barrier precautions for Resident R15, as required by infection prevention and control regulations. Resident R15, who was admitted with multiple diagnoses including Parkinson's disease, dyskinesia, anxiety, bipolar disorder, muscle wasting, and dysphasia, required enteral nutrition through a gastrostomy tube. The care plan for Resident R15 included goals to keep the tube insertion site free of infection and interventions to monitor and report any signs of aspiration or fever. Despite these precautions, an observation on December 18, 2024, revealed that a nurse aide, Employee E6, was providing incontinence care to Resident R15 while only wearing gloves and not a gown, as mandated by the enhanced barrier precautions. The enhanced barrier precautions, as outlined by the CDC, require the use of gowns and gloves during high-contact resident care activities to prevent the spread of multi-drug resistant organisms. A sign posted outside Resident R15's room clearly indicated the need for such precautions during activities like dressing, bathing, transferring, and providing hygiene. However, during the observation, Employee E6 confirmed awareness of the enhanced barrier precautions but failed to adhere to the proper procedure by not wearing a gown. This lapse in following the infection control protocol contributed to the facility's failure to meet the infection prevention and control requirements.
Plan Of Correction
1. On 12/18/24 the Nurse Manager assessed resident R15 and there were no negative outcomes. The CNA, Employee E6 was immediately educated by the DON on 12/18/24. 2. On 12/18/24 the managers assessed all residents with Enhanced Barrier Precautions to verify that proper PPE was available. 3. The NHA started education for all staff on 12/26/2024 on infection control and prevention. The DON/designee will educate the remainder of the staff by 1/16/2025. 4. The DON/designee will conduct audits on Enhanced Barrier Precautions 3x a week for 4 weeks and monthly for 3 months.
Failure to Implement Effective Fall Prevention Measures
Penalty
Summary
The facility failed to implement timely and effective safety interventions for residents with known fall risks, resulting in serious injuries and a fatality. Resident 195, who had a history of frequent falls and was assessed as high risk, was admitted to the facility with recommendations for 100% supervision. Despite this, the facility did not adequately address the resident's fall risk in the initial care plan, leading to multiple falls, including one that resulted in a fatal subdural hematoma. The facility's failure to provide necessary supervision and timely interventions contributed to the resident's death. Resident 9, also identified as high risk for falls due to Parkinson's Disease and other conditions, experienced multiple falls within the facility. Despite being on increased supervision with 15-minute safety checks, the resident continued to fall, including an incident that resulted in a hematoma requiring hospital evaluation. The facility did not adequately revise the resident's fall prevention measures or supervision frequency, leading to repeated falls and injury. The Director of Nursing confirmed the facility's responsibility to ensure adequate supervision and fall prevention measures, acknowledging the failure to prevent falls for both residents. The facility's inaction and insufficient response to known fall risks and unsafe behaviors resulted in significant harm, highlighting deficiencies in their fall prevention program and supervision protocols.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for two residents, leading to deficiencies in addressing their specific medical needs. Resident 17, who was admitted with sick sinus syndrome and a pacemaker, did not have a care plan that included monitoring or evaluating the pacemaker's function. This oversight was confirmed by the Director of Nursing during an interview, indicating a lack of proper documentation and planning for the resident's cardiac condition. Similarly, Resident 3, who had chronic obstructive pulmonary disease and Alzheimer's disease, did not have a care plan that addressed her need for denture care. Despite being dependent on staff for personal hygiene, including denture care, there was no documentation or evidence that such care was consistently provided. Interviews with nursing aides revealed that denture care was not included in the resident's Kardex, and the Director of Nursing confirmed the absence of a care plan for the resident's oral hygiene needs.
Physician Inaction on Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that the physician timely acted upon irregularities identified by pharmacy services during drug regimen reviews for two residents. Resident 30, diagnosed with major depressive disorder, was prescribed Trazodone 300 mg daily since July 2023. A pharmacy recommendation in January 2024 suggested evaluating the medication for side effects, dose changes, or continued use. However, no action was taken by the physician until April 15, 2024, when the Trazodone dosage was adjusted to 275 mg. Similarly, Resident 38, diagnosed with Alzheimer's disease, was prescribed Divalproex Sodium 375 mg three times a day since June 2023. A pharmacy recommendation in December 2023 advised evaluating the medication for side effects, dose changes, or continued use. The physician did not respond until April 16, 2024, when the dosage was reduced to 125 mg twice a day. The facility's policy requires the physician to either accept and act upon pharmacy recommendations or document the rationale for rejection, which was not demonstrated in these cases.
Failure to Implement Effective QAPI Program for Fall Prevention
Penalty
Summary
The facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) program, as evidenced by multiple falls experienced by a resident identified as Resident 9. The resident, who was admitted with a history of falls and diagnosed with Parkinson's Disease, muscle weakness, and tremors, experienced seven falls between December 2023 and August 2024. Despite being identified as a high fall risk, the facility did not demonstrate the use of systems for investigating and analyzing the root cause of these adverse events. Resident 9's care plan included various interventions to mitigate fall risks, such as the use of a walker, wheelchair, and scoot-n-go chair, as well as safety checks and alarms. However, the facility's documentation and incident reports revealed that the interventions were not effectively preventing falls, particularly in the dining room during the evening shift. The facility's failure to identify patterns in the falls and adjust staff supervision accordingly contributed to the ongoing issue. The Director of Nursing confirmed the lack of additional documentation regarding efforts to investigate and analyze the falls to determine their root cause. The facility did not provide evidence of a systematic approach to addressing the resident's unsafe behaviors, such as self-transfers and unassisted walking, which resulted in multiple falls and an injury. This lack of effective QAPI program implementation and documentation of corrective actions led to the deficiency cited in the report.
Failure to Provide Person-Centered Care for Pacemaker Management
Penalty
Summary
The facility failed to provide person-centered care for a resident with a pacemaker, as revealed through a review of clinical records and staff interviews. The resident, who was admitted with a diagnosis of sick sinus syndrome and had a pacemaker implanted, did not have documented evidence of current physician orders for the care, monitoring, and battery checks necessary for the pacemaker's proper functioning. An interview with the Director of Nursing on August 1, 2024, confirmed the absence of documented person-centered care and physician orders related to the pacemaker, leading to a deficiency citation under F656 and relevant Pennsylvania codes.
Failure to Monitor Therapeutic Device Leads to Pressure Sore
Penalty
Summary
The facility failed to effectively monitor a resident's use of a therapeutic device, leading to the development of an avoidable pressure sore. Resident 2, who was admitted with multiple diagnoses including diabetes and fractures, was noted to have an immobilizer on the left lower extremity. The physician's orders required skin checks every two hours to prevent pressure sores, but the facility did not document these checks. The resident's baseline care plan did not include the necessary interventions for the immobilizer, such as the required skin checks. A Braden Scale assessment indicated the resident was at moderate risk for pressure ulcer development. Despite this, the facility did not implement consistent skin integrity checks, resulting in the development of a suspected deep tissue injury (DTI) on the resident's left lateral ankle. The facility's failure to conduct timely and consistent skin checks was confirmed by the Director of Nursing. The lack of documentation and adherence to the care plan and physician's orders contributed to the development of the pressure ulcer, which was later observed as a reddened area on the resident's ankle.
Failure to Attempt Non-Pharmacological Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident by not attempting non-pharmacological interventions before administering as-needed pain medication. The clinical record review and staff interviews revealed that Resident 2, who was admitted with multiple diagnoses including diabetes and fractures, received Acetaminophen and Oxycodone HCL without any documented evidence of non-pharmacological interventions being attempted first. The resident's Medication Administration Record showed that Acetaminophen was administered 14 times for pain levels between 2 to 6, and Oxycodone HCL was administered 26 times for pain levels between 7 to 10, all without prior non-pharmacological attempts. The resident's care plan, which was reviewed, included goals and interventions related to pain management but failed to identify individualized non-pharmacological interventions to be attempted before administering medication. The Director of Nursing confirmed the lack of documentation for non-pharmacological interventions prior to the administration of pain medication. This deficiency was noted under the Pennsylvania Code regulations for medical records and nursing services.
Failure to Implement Hospice Plan of Care
Penalty
Summary
The facility failed to fully implement a hospice plan of care for a resident under hospice care. The clinical record review and staff interview revealed that the resident, who was admitted with diagnoses including cerebral infarction, right-sided hemiplegia, chronic kidney disease, and gastro-esophageal reflux disease, was receiving hospice services for end-stage chronic kidney disease and stroke. Despite the hospice care being triggered in the resident's Significant Change MDS, the facility's plan of care did not include specific goals and interventions for hospice care. This deficiency was confirmed during an interview with the Director of Nursing.
Failure to Notify Resident of Bed-Hold Policy
Penalty
Summary
The facility failed to provide written notice of its bed-hold policy to a resident and the resident's representative upon the resident's transfer to the hospital. This deficiency was identified during a review of clinical records and staff interviews, which revealed that Resident 30 was transferred to the hospital on March 11, 2024, and subsequently readmitted to the facility. However, there was no documentation indicating that the resident or their representative was informed of the facility's bed-hold and reserve bed payment policy at the time of transfer. During an interview on August 1, 2024, the Nursing Home Administrator and Director of Nursing were unable to provide evidence that such notification had been given, resulting in a violation of resident rights as per 28 Pa Code 201.18 (e)(1) Management and 28 Pa Code 201.29 (b) Resident rights.
Latest citations in Pennsylvania
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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