Bradford Manor Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Bradford, Pennsylvania.
- Location
- 50 Lang Maid Lane, Bradford, Pennsylvania 16701
- CMS Provider Number
- 395700
- Inspections on file
- 17
- Latest survey
- August 5, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Bradford Manor Nursing And Rehab during CMS and state inspections, most recent first.
Heat tape installed on the building was found plugged into outlet multipliers outside the main entrance, which was confirmed as a deficiency by the maintenance supervisor during the survey.
Surveyors found two full oxygen cylinders unsecured in the oxygen storage room near the generator, in violation of NFPA gas equipment storage requirements. The maintenance supervisor confirmed the deficiency during the inspection.
Surveyors identified that three electrical receptacles in the facility were not GFCI protected as required, including those near a sink in the café, a water fountain near the nurse station, and a juice machine in the kitchen. These deficiencies were confirmed by the maintenance supervisor.
Three residents with complex medical conditions were transferred to the hospital without documentation that their necessary clinical information was communicated to the receiving health care provider, as required by federal and state regulations. The DON confirmed that the clinical records lacked evidence of this communication at the time of transfer.
The facility did not develop required person-centered care plans for two residents: one with PTSD and another requiring oxygen therapy. The absence of these care plans was confirmed by facility leadership, despite both residents having clear medical needs documented in their records.
Four residents with complex medical conditions, including COPD, hypertension, hyperlipidemia, hypothyroidism, type II diabetes, and heart failure, had care plans that were not reviewed or revised by the required target dates. The DON confirmed that these care plans were overdue and should have been updated as per facility policy.
A resident with COPD, hypertension, and heart failure did not have their oxygen tubing and humidifier bottle changed or dated as required by facility policy and physician orders. Observations showed the nasal cannula was undated and the humidifier bottle had not been changed for over a month, despite frequent oxygen use. An LPN confirmed these items should have been changed according to protocol.
Surveyors observed that a LPN did not wear a gown while providing wound care to a resident under enhanced barrier precautions, and a urinary drainage bag for another resident was repeatedly found lying on the floor with the spout touching the surface. Both staff and facility policies confirmed these actions did not meet required infection control standards.
The facility failed to implement Enhanced Barrier Precautions (EBPs) for residents with indwelling medical devices, such as gastric feeding tubes and urinary catheters, during high contact care activities. Despite physician orders for daily care, observations revealed that EBPs were not in place, and the Director of Nursing confirmed that staff should have been using gloves and gowns. This deficiency affected multiple residents with various medical conditions.
A facility failed to ensure consistency between a resident's physician's orders, POLST, and care plan. The resident, with conditions including end-stage renal disease and Parkinson's disease, had a DNR order, but the POLST requested CPR and comfort measures only. The care plan also indicated DNR, leading to a discrepancy confirmed by the Nursing Home Administrator.
A facility failed to accurately complete the MDS for a resident with hemiplegia and other conditions. The Quarterly MDS incorrectly coded a fall with a major injury, despite the resident being found on the floor with a bruise and not requiring hospital treatment. This error was confirmed by the Nursing Home Administrator.
A resident with hemiplegia did not receive physician-ordered treatment for range of motion maintenance, as their hand splint was repeatedly observed off the resident and on the nightstand. An LPN confirmed the splint should have been worn except during hygiene, indicating a failure to follow the care plan.
A resident with a history of pneumonia, anxiety, COPD, and chronic respiratory failure was observed receiving oxygen at 4 lpm, contrary to the physician's order of 3 lpm PRN. This discrepancy was confirmed by an LPN, indicating a failure to follow the care plan and physician's orders for respiratory care.
A facility failed to document a clinical rationale and duration for a PRN psychotropic medication beyond 14 days for a resident with anxiety and other health issues. The medication order for Hydroxyzine lacked a required stop date or justification for continued use, as confirmed by a registered nurse.
Improper Use of Outlet Multipliers for Heat Tape
Penalty
Summary
The facility failed to maintain electrical system requirements in one of four smoke compartments. During an observation, heat tape installed on the building was found to be plugged into outlet multipliers located outside the main entrance. This setup was directly observed by surveyors, and the maintenance supervisor confirmed the deficiency at the time of the survey. No information regarding residents or their medical conditions was provided in relation to this deficiency.
Plan Of Correction
This plan of correction has been prepared and executed because the law requires it. This plan does not constitute an admission that any of the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract obligation or position. Bradford Manor reserves the right to raise all possible contestations and defenses in any civil, criminal, claim, action or proceeding. Please accept this plan of correction as Bradford Manor's credible allegation of compliance. Education was provided to the Maintenance department by the Nursing Home Administrator regarding safety concerns with using outlet multipliers and its unacceptable practice. Heat tape was unplugged from outlet multiplier on day of survey. All other areas where heat tape is used were checked to ensure that no outlet multipliers were being used, none were identified. Ongoing compliance will be monitored through daily rounding by the Environmental Service Supervisor or designee 3x weekly for 2 weeks.
Unsecured Oxygen Cylinders in Storage Room
Penalty
Summary
During an inspection, surveyors observed that the oxygen storage room, located near the generator, contained two full oxygen cylinders that were not properly secured. This observation was made on August 5, 2025, at 11:02 a.m. The facility is required to maintain gas equipment in accordance with NFPA 101 and NFPA 99 standards, which include securing cylinders to prevent them from falling or being damaged. The maintenance supervisor was present during the observation and confirmed that the two full cylinders were unsecured at the time of the survey. The deficiency was identified based on the direct observation of the unsecured cylinders in the designated storage area. No additional details regarding patient involvement or medical history were provided in the report.
Plan Of Correction
Education was provided to all staff regarding the requirements of storing gas equipment. The two unsecured tanks identified during survey were immediately placed in a secured storage holder at the time of survey. Ongoing compliance will be maintained by observations during daily rounding by the Environmental Service Supervisor or designee, 3 times weekly for 2 weeks, then once weekly for 1 month.
Failure to Maintain GFCI Protection for Electrical Receptacles
Penalty
Summary
Surveyors observed that the facility failed to maintain electrical receptacles in accordance with NFPA 101 and NFPA 99 standards. Specifically, three deficiencies were identified: a receptacle in the main floor Sweet Shop café was not GFCI protected within six feet of a sink basin; a water fountain near the main floor center core nurse station was not connected to a GFCI protected receptacle; and a juice machine in the main floor kitchen was not connected to a GFCI protected receptacle. These deficiencies were confirmed during an interview with the maintenance supervisor. No information regarding residents' medical history or condition at the time of the deficiency was provided in the report.
Plan Of Correction
Education was provided to the Maintenance department by the Nursing Home Administrator regarding the requirement of having power receptacles to have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. All identified outlets were changed over to GFCI outlets on day of survey. A whole house observation of all outlets near water sources was inspected with no others identified. Ongoing compliance will be maintained through daily rounding by the Environmental Service Supervisor or designee 3x weekly for 2 weeks. K 0912
Failure to Communicate Required Clinical Information During Resident Transfers
Penalty
Summary
Bradford Manor was found to be noncompliant with federal and state regulations regarding the discharge process, specifically the communication of necessary clinical information to receiving health care providers when residents were transferred to the hospital. The facility's policy requires sufficient preparation to ensure safe and orderly transfers, with documentation in the residents' clinical records. However, for three residents reviewed, the required information was not communicated as mandated. One resident with diabetes and chronic obstructive pulmonary disease (COPD) was transferred to the hospital, but the clinical record did not show that necessary clinical information was provided to the receiving provider. Another resident with peripheral vascular disease, hyperlipidemia, and hypertension was transferred to the hospital on two occasions, and in both instances, the clinical record lacked evidence of communication of essential clinical information to the hospital. A third resident with COPD, hypertension, and heart failure was also transferred to the hospital, and again, the clinical record did not contain documentation that the required information was shared with the receiving provider. During an interview, the Director of Nursing confirmed that the clinical records for these residents did not contain evidence that the necessary clinical information was provided to the receiving health care provider upon transfer. The facility failed to meet the requirements for ensuring that all pertinent information was communicated during resident transfers, as outlined in both federal and state regulations.
Plan Of Correction
This plan of correction has been prepared and executed because the law requires it. This plan does not constitute an admission that any of the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract obligation or position. Bradford Manor reserves the right to raise all possible contestations and defenses in any civil, criminal, claim, action or proceeding. Please accept this plan of correction as Bradford Manor's credible allegation of compliance. Contacted the hospital that a current resident is admitted to and confirmed that they have received all of the resident's medical record information as required. For the identified residents, we interviewed the nurses that transferred them out and confirmed that all required information was communicated and sent with the resident at time of transfer. Those nurses were immediately educated. The E-interact (transfer document used in our electronic health records) is processed and it includes all of the resident's medical records as well as a checklist of all required documents that are to be sent when resident is transferred. This checklist will be signed by the nurse completing the transfer and then placed in the resident's chart. Director of Nursing or designee will provide education to all registered nurses on the requirements of providing and documenting that all necessary resident information sent and communicated with the receiving healthcare provider upon transfer by 8/30/2025. DON will audit 100% of transfers for the past one month, then 50% of transfers for the past one month, and then 25% of transfers for the past one month. All findings will be reviewed at monthly Quality Assurance and Performance Improvement meetings.
Failure to Develop Comprehensive Care Plans for PTSD and Oxygen Therapy
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents as required by federal regulations. For one resident with a diagnosis of Parkinson's disease, PTSD, anxiety, and depression, the clinical record review showed that there was no care plan addressing PTSD. This omission was confirmed by the Nursing Home Administrator during an interview. For another resident with chronic obstructive pulmonary disease, hypertension, and heart failure, the review of the clinical record revealed that there was no care plan for respiratory care involving the use of oxygen, which was also confirmed by the Director of Nursing. The facility's own policy requires the development of comprehensive care plans that include measurable objectives and timetables to address each resident's medical, nursing, and psychosocial needs as identified in the comprehensive assessment. The care plans are to be developed by the interdisciplinary team and periodically reviewed and revised. In these two cases, the required care plans for PTSD and for respiratory care with oxygen were not developed, despite the residents' documented needs and diagnoses.
Plan Of Correction
Director of Nursing or Designee will provide education to the Interdisciplinary Team on the requirements of developing and implementing a comprehensive person-centered care plan for each resident reflecting their specific needs by 08/30/2025. R8's care plan was updated to reflect that he has PTSD, goals and interventions specific to him. R84's care plan was updated to reflect her respiratory plan of care. An audit of all current residents with an order for oxygen will be conducted to ensure that they have a respiratory care plan. An audit of all current residents with a diagnosis of PTSD will be reviewed to ensure that they have a person-centered care plan completed. Ongoing compliance will be maintained by the Director of Nursing or designee checking 10% of current residents' care plans weekly for one month and then 5% weekly for one month to ensure that the care plans are person-centered for each resident, including measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs. Findings of these audits will be reviewed in monthly Quality Assurance and Performance Improvement meetings.
Failure to Timely Review and Revise Comprehensive Care Plans
Penalty
Summary
The facility failed to review and revise comprehensive care plans by the required target dates for four residents. According to the facility's own Care Plan Policy, care plans are to be periodically reviewed and revised to ensure they reflect the current necessary care and services. However, for four residents with various diagnoses including COPD, hypertension, hyperlipidemia, hypothyroidism, type II diabetes, and heart failure, their care plans were not updated by the specified target dates. For example, one resident with a catheter had a care plan with a target date that was missed, and other residents had all their care plans overdue for revision. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the care plans for these residents were beyond their target dates and should have been updated accordingly. The failure to update care plans as required was identified through review of facility policy, clinical records, and staff interviews.
Plan Of Correction
Director of Nursing or Designee will provide education to the Interdisciplinary Team on the requirements of developing a comprehensive person-centered care plan within 7 days after completion of the comprehensive assessment and then ongoing review/revise after each assessment including comprehensive and quarterly reviews by 08/30/2025. Residents R4, R11, R78, and R84 had completed care plan reviews. All other residents, triggering with late review dates, will be reviewed and updated by 09/15/2025. Ongoing compliance will be maintained by the Director of Nursing or designee checking 10% of current residents' care plans weekly for one month and then 5% weekly for one month to ensure that care plans have been reviewed/revised within the target date. All findings will be reviewed in monthly Quality Assurance and Performance Improvement meetings.
Failure to Change and Date Oxygen Tubing and Humidifier Bottle per Policy and Orders
Penalty
Summary
The facility failed to provide respiratory care in accordance with physician's orders and facility policy for a resident requiring oxygen therapy. Specifically, the facility did not change or date the oxygen tubing and humidifier bottle as required. Facility policy stated that oxygen cannulas and prefilled humidifier bottles should be changed weekly or as needed, and physician's orders directed that oxygen tubing, supply bag, and water jug be changed weekly. Review of the resident's clinical record showed frequent use of oxygen, yet observations revealed that the nasal cannula attached to the resident's oxygen tank was not dated, and the humidifier water bottle attached to the oxygen concentrator was last dated over a month prior. Further observations on multiple occasions confirmed that the nasal cannula remained undated and the humidifier water bottle had not been changed according to the required schedule. During an interview, an LPN confirmed that both the nasal cannula and humidifier water bottle should have been changed and that the current practice did not meet the facility's policy or the physician's orders. The resident involved had a history of chronic obstructive pulmonary disease, hypertension, and heart failure, and had used oxygen therapy multiple times during the review period.
Plan Of Correction
Director of Nursing or designee will provide education to all nurses on the policy of providing oxygen and changing and dating oxygen tubing and humidifier bottles according to physician's orders by 08/30/2025. The identified resident, R84, oxygen tubing and humidifier water bottle was replaced immediately. All other residents with oxygen orders had their tubing and bottles checked to ensure we were in compliance with the required changing date. Ongoing compliance will be monitored by the Director of Nursing or designee by ensuring that all residents with oxygen orders have tubing and humidifier bottles changed weekly per policy and physician order, one time per day weekly for one month, one time per day every other week for one month and then monthly for two months. All findings will be reviewed in monthly Quality Assurance and Performance Improvement meetings.
Failure to Follow Infection Control Protocols for Wound Care and Catheter Management
Penalty
Summary
Surveyors identified deficiencies in infection control practices related to enhanced barrier precautions (EBP) and urinary catheter care. For one resident with a diabetic foot ulcer and chronic kidney disease, a LPN performed wound care without donning a gown, despite a posted EBP sign and the availability of gloves and gowns in the room. Facility policy required the use of gloves and gowns for high-contact care activities such as wound care, but this protocol was not followed during the observed event. The LPN confirmed not wearing a gown prior to entering the resident's room. Additionally, another resident with an indwelling urinary catheter was observed multiple times with the urinary drainage bag lying flat on the floor, with the drainage spout touching the floor. Facility staff confirmed that the urinary drainage bag should not be on the floor, as per infection control standards. Both incidents were confirmed through staff interviews and direct observation, indicating a failure to adhere to established infection prevention and control policies.
Plan Of Correction
Director of Nursing or designee will provide education to all nursing staff on Infection Control and Enhanced Barrier Precautions. Education will include catheter care and placement. All education will be completed by 08/30/2025. Identified resident's, R4, catheter bag was removed from the floor immediately and staff working the hall were educated. All residents with a catheter were checked to ensure that their catheter bag was properly placed. Nurse that provided wound care was immediately educated. Resident R9 was monitored for signs and symptoms of infection for five days. Ongoing compliance will be monitored by Director of Nursing or designee by observing nursing staff following enhanced barrier requirements on 10% of residents with orders for enhanced barrier precautions one time per day 3x week for 2 weeks, one time per day weekly for 2 weeks and one time per day monthly for 2 months. Audits shall cover all shifts and all residents with orders for enhanced barrier precautions. Director of Nursing or designee will do an audit all residents with catheters will be checked to ensure the catheter bags are not placed on the floor one time per day 3x week for 2 weeks, one time per day weekly for 2 weeks and then one time per day monthly for 2 months. Audits shall cover all shifts and all residents with orders for a catheter. Findings will be reviewed in monthly Quality Assurance and Performance Improvement meetings.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement infection control practices regarding Enhanced Barrier Precautions (EBPs) for residents with indwelling medical devices, such as gastric feeding tubes and urinary catheters. This deficiency was identified for six residents who required high contact care activities, which include device care. The facility's policy on EBPs, dated December 7, 2023, specifies that such precautions should be considered for residents with wounds or indwelling medical devices, regardless of MDRO colonization status. However, observations on August 28, 2024, revealed that EBPs were not in place for any of the residents reviewed, despite their need for high contact care activities. The residents involved had various medical conditions, including sepsis, hypertension, chronic kidney disease, hemiplegia, neuromuscular dysfunction of the bladder, and multiple sclerosis. Physician orders for these residents included daily gastric tube site care and indwelling catheter care every shift, which are considered high contact care activities. During an interview, the Director of Nursing confirmed that employees should have been wearing gloves and gowns during these activities, but EBPs were not being followed. This oversight was noted for all six residents reviewed, indicating a systemic failure to adhere to the facility's infection control policy.
Inconsistency in Resident's Life-Sustaining Treatment Orders
Penalty
Summary
The facility failed to ensure consistency between a resident's physician's orders, Pennsylvania Order for Life Sustaining Treatment (POLST), and care plan. The resident, who was admitted with diagnoses including end-stage renal disease, Parkinson's disease, and adult failure to thrive, had a physician's order indicating Do Not Resuscitate (DNR) status. However, the POLST for the same resident requested Cardiopulmonary Resuscitation (CPR) and comfort measures only. The care plan also indicated a DNR status, creating a discrepancy between the documents. This inconsistency was confirmed during an interview with the Nursing Home Administrator.
Inaccurate MDS Completion for Resident
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for a resident, identified as Resident R15, which led to a deficiency. Resident R15, who was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, depression, heart failure, and high blood pressure, was involved in this incident. The Quarterly MDS inaccurately reflected the resident's status by incorrectly coding a fall with a major injury. The resident's progress notes indicated that on June 30, 2024, the resident was found on the floor with a bruise to the mid-back but did not require hospital treatment. This discrepancy was confirmed during an interview with the Nursing Home Administrator, who acknowledged the incorrect coding in Section J1900 of the MDS.
Failure to Implement Physician-Ordered Splint Use
Penalty
Summary
The facility failed to provide appropriate care for a resident, identified as Resident R59, who had limited range of motion due to hemiplegia. The resident's clinical record included a physician's order for a hand splint to be worn on the left hand, which could be removed only for hygiene purposes. The care plan also specified the use of the left hand splint for contracture management. However, observations on multiple occasions revealed that the resident's left hand splint was not being used as prescribed, as it was found laying on the nightstand instead of being worn by the resident. During an interview, an LPN confirmed that the splint was not on the resident's hand and acknowledged that it should have been, except during hygiene. This oversight indicates a failure to adhere to the physician's orders and the resident's care plan, potentially leading to a further decrease in the resident's range of motion. The deficiency was identified through a review of facility policies, clinical records, and staff interviews, highlighting a lapse in the implementation of restorative care services for the resident.
Failure to Adhere to Physician's Orders for Oxygen Therapy
Penalty
Summary
The facility failed to provide oxygen therapy according to the physician's orders for a resident identified as R65. The resident's clinical record indicated a physician's order for oxygen via nasal cannula at 3 liters per minute (lpm) as needed (PRN). However, observations on multiple occasions revealed that the resident was receiving oxygen at a flow rate of 4 lpm, which was not in accordance with the prescribed order. This discrepancy was confirmed during an interview with a Licensed Practical Nurse (LPN), who acknowledged that the oxygen concentrator was set incorrectly. Resident R65 had a medical history that included pneumonia, anxiety, chronic obstructive pulmonary disease (COPD), and chronic respiratory failure, conditions that necessitate careful management of oxygen therapy. Despite the care plan specifying the correct oxygen flow rate, the facility's staff did not adhere to the physician's orders, resulting in the resident receiving a higher oxygen flow than prescribed. This failure to follow the care plan and physician's orders constitutes a deficiency in the facility's provision of respiratory care services.
Failure to Document PRN Psychotropic Medication Duration
Penalty
Summary
The facility failed to provide a clinical rationale and duration for the continued use of a PRN psychotropic medication beyond 14 days for a resident. The resident, identified as R65, was admitted with diagnoses including pneumonia, anxiety, chronic obstructive pulmonary disease, and chronic respiratory failure. A review of the resident's medication orders revealed a physician's order for Hydroxyzine, an anti-anxiety medication, to be administered every 12 hours as needed for anxiety. This order, dated 8/21/24, lacked the required stop date within 14 days or a clinical rationale for its continuation beyond this period. During an interview, a registered nurse confirmed that the Hydroxyzine order for Resident R65 did not include the necessary stop date or clinical rationale for use beyond 14 days, acknowledging that such documentation is required.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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