Bridgeville Rehabilitation & Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bridgeville, Pennsylvania.
- Location
- 3590 Washington Pike, Bridgeville, Pennsylvania 15017
- CMS Provider Number
- 395596
- Inspections on file
- 46
- Latest survey
- April 14, 2026
- Citations (last 12 mo.)
- 33 (2 serious)
Citation history
Health deficiencies cited at Bridgeville Rehabilitation & Care Center during CMS and state inspections, most recent first.
Surveyors found that multiple residents did not receive the food items listed on their tray tickets or requested by them, despite a facility policy requiring identification and honoring of individual dining preferences. One resident did not receive a chef salad and dressings as ordered, another repeatedly received unwanted chocolate pudding and did not consistently receive a requested daily banana, and another received dry ground chicken without the ordered barbeque sauce or marinated cauliflower. A further resident did not receive a double entrée as specified, and another reported often receiving food different from what was requested, while a family member stated that undated, rotating menus made it impossible to know what meals to expect. The posted menus were labeled only by week number without dates or indication of the current week, and the NHA confirmed that resident-selected menu items were not provided for several residents.
A resident with chronic medical conditions, depression, and moderate cognitive impairment had a documented history and care plan for sexually inappropriate behavior, including repeated sexually explicit comments and physical groping of CNAs, with incidents serious enough to involve local police and psychiatric evaluation. Psychiatry and primary care notes described ongoing inappropriate sexual comments and behaviors toward female staff and documented behavioral disinhibition related to a neurocognitive disorder. Despite these repeated, documented events and an abuse prohibition policy requiring investigation of possible incidents, facility records showed no investigation into whether the resident had been sexually inappropriate with other residents, and the DON and NHA confirmed that no such investigation had been conducted.
A transportation driver delivered an individual from dialysis who shared the same first name as a newly admitted resident expected back from treatment. The receptionist directed the driver to the resident’s room based on this information. The individual had no ID band, but staff took his photo, uploaded it to the EMR, and an RN and an LPN relied on his verbal acknowledgment of the shared first name and the new photo profile to identify him. Without confirming two identifiers or recognizing that he was not the admitted resident with ESRD and Parkinson’s disease, the LPN administered scheduled medications including Flomax, Sinemet, Vitamin D, and a multivitamin that were ordered for the actual resident. Later calls from the transport company and another facility revealed that the individual was a different resident from another facility who had been transported to the wrong location, confirming that medications had been given to the wrong person.
The facility failed to ensure call lights were accessible and answered promptly, as required by its own policy, for six cognitively intact residents with significant medical and functional needs. Several residents who were dependent or required assistance for toileting hygiene and transfers reported that staff response to call lights, especially on evening and night shifts, often took 30 minutes or longer, with one resident stating a CNA discouraged frequent call light use and made her wait to use the bathroom. Other residents described frequent delays of 30–45 minutes or up to two hours when requesting help for toileting, medications, or feeling unwell, and one resident who had soiled himself reported that repeated unanswered calls led him to contact his family, who then came to the facility and reported he was not being changed. Facility leadership acknowledged that call lights were not consistently accessible or answered in a timely manner.
A resident with a history of depression, prior Seroquel overdose, psychiatric hospitalization, and documented glycol toxicity was able to obtain and keep a gallon of Peak 50/50 antifreeze in their room, likely via frequent third‑party delivery services. The resident was cognitively intact but had a care plan noting risk for self‑harm ideation related to PTSD, glycol toxicity, and hallucinations. Staff, including the RN unit manager, were unaware of the resident’s self‑harm history, and no effective monitoring or controls prevented the resident from storing a toxic chemical in a closed cupboard. After the resident developed altered mental status and was sent to the hospital, the hospital reported abnormal labs and concern for antifreeze ingestion, prompting a room search that revealed the antifreeze jug. Hospital records documented acute kidney injury and metabolic acidosis due to ethylene glycol ingestion, and the surveyors determined that the facility failed to keep the environment free of accident hazards and to provide adequate supervision, resulting in actual harm and Immediate Jeopardy.
A resident with a history of self-harm, PTSD, depression, prior Seroquel overdose, and suspected ethylene glycol ingestion was care planned as being at risk for self-harm and had orders for psych consults and psychotropic medications, yet behavior monitoring was frequently undocumented over multiple months and the record lacked behavioral health interventions addressing prior suicidal attempts/ideations. Progress notes documented serious prior events, including ICU-level care for suspected self-harm with ethylene glycol and recent psychiatric hospitalization, but the NHA and DON reported they were unaware of the resident’s self-harm history and confirmed there was no facility procedure to ensure residents with prior self-harm attempts were referred to mental health services. The resident later exhibited altered mental status, was sent to the hospital, and staff subsequently found a gallon of antifreeze in the resident’s room after the hospital reported possible antifreeze ingestion, leading surveyors to cite the facility for failure to provide appropriate mental health treatment and services and to identify and manage residents with similar needs, at the Immediate Jeopardy level.
The NHA and DON did not effectively manage the facility to protect a resident with a known history of self-harm from accessing harmful chemicals, despite job descriptions assigning them responsibility for ensuring high-quality clinical care and compliance with regulations. Their failure to implement and oversee adequate protections allowed the resident to obtain and ingest ethylene glycol (antifreeze), leading to hospitalization and creating an Immediate Jeopardy situation. Both leaders acknowledged in interviews that they did not effectively manage the facility to prevent self-harm, resulting in noncompliance with applicable state regulatory requirements.
Medications and biologicals were found unsecured in two medication rooms, with doors left unlocked and medications left on the counter. Staff with keys acknowledged the requirement to keep these rooms locked but failed to do so, as confirmed by the DON and administrator.
A resident with a history of knee replacement, sleep apnea, and morbid obesity, who was cognitively intact, experienced a loss of prescribed Oxycodone when the medication card and tracking sheet went missing from the medication cart. Only two RNs had access to the cart during the relevant period, and the missing items were not recovered, resulting in a delay in pain management for the resident. The facility was unable to determine how the medication was misappropriated.
A resident's prescribed Oxycodone went missing, and the facility failed to follow its policies for investigating misappropriation of property. Only two RNs had access to the medication cart, and key narcotic documentation was missing or incomplete. The facility did not conduct all necessary staff interviews or require drug screening, and medication rooms were found unlocked with medications unsecured. The internal investigation was incomplete, and the missing controlled substance was not recovered.
Facility staff failed to provide adequate supervision and maintain a safe environment when a courtyard exit door, not connected to the wander guard or alarm system, was found propped open. A resident was observed unattended in the courtyard, another was attempting to exit, and visitors were using the door, despite signage indicating it should remain closed. Facility leadership confirmed the lapse in supervision and security for mobile residents.
A significant medication error occurred when an LPN, after being interrupted during medication preparation, administered another patient's insulin (30 units of NovoLog) to a resident with diabetes, end stage renal disease, and hypertension. The error was identified shortly after administration, and the resident required emergency department care for monitoring and treatment.
Multiple residents reported long delays in call light response, late medication administration, and untimely assistance with daily activities due to insufficient nursing staff. Observations included residents being left in soiled conditions, missed showers, and strong urine odors in rooms. Documentation and council minutes confirmed ongoing issues with inadequate staffing, leading to unmet care needs.
A resident with neurogenic bladder and multiple sclerosis, who was cognitively intact, experienced verbal abuse and neglect from a nurse aide. The aide used profanities, refused to provide proper care, left the resident undressed, and ignored requests for assistance. The incident was reported by the resident and her son, and the facility's investigation substantiated the abuse and neglect.
A shortage of clean linens, wash cloths, and towels was observed on all nursing units, with linen carts containing insufficient supplies for the facility's census. Laundry staff reported being unable to keep up due to a broken washing machine and limited staffing, and the administrator confirmed the ongoing equipment issue.
The facility did not maintain one of its two washing machines in safe operating condition, resulting in ongoing shortages of clean linens, wash cloths, and towels as reported by two residents and observed by staff. Only one laundry staff member was available, and laundry was not completed after their shift, leading to insufficient supplies.
Surveyors observed that the facility did not maintain sanitary conditions in the kitchen, including improper dish machine temperatures, unclean cooler fans, and multiple instances of dietary staff failing to follow hand hygiene and glove protocols while handling food and equipment.
A resident with severe cognitive impairment and multiple diagnoses was left in bed with an untouched breakfast tray, as staff failed to assist with cutting food into bite-sized pieces as required by the care plan. The LPN and DON confirmed the meal was not consumed or prepared for the resident, resulting in a lack of a dignified dining experience.
The facility did not ensure that call lights were accessible and answered promptly for most residents. In multiple cases, call light cords in bathrooms were found wrapped around grab bars, making them unusable. Residents reported consistently waiting thirty minutes or more for staff to respond to call lights, and this issue was documented in resident council meetings over several months. An LPN and the DON confirmed these deficiencies.
Over a six-month period, the facility did not address or respond to repeated concerns from the resident council regarding staff response to call lights. Despite policy requirements for communication and documentation, there was no evidence of follow-up or administrative action, and most residents interviewed reported ongoing dissatisfaction with the lack of resolution.
Residents repeatedly reported that food was tasteless, mushy, and unattractive, with buns becoming soggy from contact with liquids and pureed foods served in unappealing mixtures. During meal service, some residents did not receive dinner rolls and were given bread instead, and meal delivery was delayed. The Corporate Dietary Manager confirmed the failure to provide palatable and attractive food.
Multiple resident bathrooms were found visibly soiled with debris and stains, and toilets had stains of unknown origin, despite established cleaning procedures. The DON confirmed that the facility did not maintain a clean and homelike environment on one unit.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A deficiency was cited when a facility area was not kept free from accident hazards and adequate supervision was not provided, increasing the risk of accidents for a resident.
The facility repeatedly failed to maintain state-required staffing minimums for nurse aides, LPNs, and per patient day hours, despite having QAPI plans and audits in place. Multiple surveys found the same deficiencies, and staff confirmed that corrective actions were not effectively implemented.
A resident with a right arm fracture and their family raised concerns during a care plan meeting about staff not answering call lights. The facility did not document, investigate, or resolve this grievance in a timely manner, as required by its policy, and the DON confirmed the lapse.
A resident with severe cognitive impairment was allowed to attend a medical appointment unaccompanied, despite facility policy requiring an escort for such residents. The resident was left unsupervised after the appointment, left the premises independently, and was later found at his home. Review of records showed that several other residents with severe cognitive impairment also had orders permitting them to leave unaccompanied, and care plans lacked appropriate elopement interventions. Staff confirmed that supervision protocols were not followed, resulting in an immediate jeopardy situation.
A facility failed to protect residents from misappropriation of property by not ensuring proper documentation and accountability for controlled medications. Multiple residents experienced discrepancies between narcotic logs and MARs, with missing or unaccounted-for doses of oxycodone and tramadol. Staff statements revealed confusion over medication orders and destruction procedures, and leadership confirmed the failure to safeguard residents' belongings as required.
The facility did not follow required policies and state law to report allegations of neglect for two residents. One resident experienced an injury during a Hoyer lift transfer and reported that staff did not notify a nurse or supervisor. Another resident suffered a skin tear during a transfer when agency staff used the wrong level of assistance. In both cases, the facility failed to submit required reports of possible neglect to the state field office.
The facility did not follow its policies and procedures to investigate possible abuse or neglect for three residents. One resident with multiple health conditions was injured during a Hoyer lift transfer, and staff did not report or investigate the incident properly. Another resident suffered a skin tear during a transfer performed by a single CNA instead of two, with no follow-up investigation. A third resident with dementia was found with unexplained bruises, but the facility's investigation failed to interview all relevant staff. The DON confirmed that investigations were incomplete.
A medication cart and its narcotic drawer on the first floor were found unlocked and unattended, contrary to facility policy requiring carts to be locked when out of a nurse's view. This was confirmed by the unit manager, NHA, and DON.
A resident with multiple fractures and a traumatic pneumothorax was discharged without the home health services specified in their care plan and physician orders. Although referrals to home health agencies were made, none accepted the resident, and there was no documentation confirming that services were scheduled. The resident's spouse reported not being contacted by any agency, and staff confirmed the discharge plan was not implemented as required.
The facility failed to assess the clinical appropriateness of medication self-administration for three residents, leading to a deficiency. A resident with high blood pressure and depression was observed with a medicine cup of pills without a physician's order or assessment. Another resident with diabetes and high blood pressure was similarly found with medications without proper assessment. A third resident had opened medication bottles on their table despite being hospitalized. The facility's staff confirmed the failure to assess and secure medications properly.
A resident with medical conditions requiring assistance with ADLs did not consistently receive showers as per their preference and needs. The facility's records showed gaps in shower provision, and the resident was unsure of their last shower. The DON confirmed the facility's failure to adhere to policies ensuring necessary care and respecting resident preferences.
A resident with right shoulder pain was administered Kenalog-40 and Lidocaine injections by an LPN, contrary to the physician's orders for a CRNP to perform the procedure. This resulted in a significant medication error, and the resident was sent to the emergency room for evaluation. The DON confirmed the error, and the LPN was unavailable for comment.
The facility failed to secure medication and treatment carts, as observed during a survey. The 600 hall medication cart and the 100/200 hall treatment cart were found unlocked and unattended, contrary to facility policy. RN and LPN staff confirmed the carts should have been secured, and the DON acknowledged the breach.
The facility failed to provide adequate activities for residents in the secured unit, B Hall, both on weekdays and weekends. Observations showed residents without activities in the morning, and the activity schedule revealed limited activities, especially on weekends. Interviews with staff indicated insufficient activity staff to meet the needs of B Hall residents, with only a few able to participate in main activities due to staffing constraints.
The facility failed to maintain the privacy and dignity of two residents with indwelling catheters, as their urinary bags were left uncovered and visible. Additionally, four residents expressed fear of retaliation when voicing grievances, with concerns about staff behavior and unequal care. The Nursing Home Administrator confirmed these deficiencies.
A resident experienced harm due to improper catheter care, including a penile split and traumatic insertion, as the facility failed to use a securement device and used incorrect catheter sizes. Another resident's catheter was not changed as ordered, with no documentation of attempts to revisit the change. The facility's failure to follow professional standards resulted in harm.
The facility failed to conduct annual performance evaluations for five nurse aides, as required by policy and state regulations. The nurse aides did not receive evaluations within the specified annual timeframe, with the last reviews for some aides dating back to 2022. The DON confirmed this failure during an interview.
The facility failed to provide adequate food portions to residents, as confirmed by resident interviews and observations. Several residents reported insufficient and unappetizing food portions, with examples including a hot dog with only three French fries and a small cucumber salad. Staff observations and measurements confirmed the portion sizes were smaller than indicated, leading to a violation of dietary service regulations.
The facility failed to adhere to food safety and hygiene standards in the Main Kitchen, including not verifying dish machine wash temperatures, improper food storage, and inadequate maintenance of the ice machine. Additionally, a dietary aide was observed without proper facial hair restraint. These issues were confirmed by the Dietary Manager, posing a potential risk for foodborne illness.
The facility failed to maintain a comprehensive water management program to control Legionella bacteria, lacking specific testing protocols and a flow diagram of the water system. Staff interviews revealed unawareness of necessary chlorine testing and treatment methods, leading to a significant lapse in infection control over eleven months.
The facility failed to protect residents from abuse and neglect, with incidents involving physical and verbal abuse by staff members. A resident reported being punched by a nurse aide, while another experienced inappropriate touching. An LPN verbally abused a resident, and a nurse aide attempted to kiss a resident. Additionally, a registered nurse neglected to administer medications to 16 residents. Investigations into these incidents were incomplete, lacking interviews with other residents to assess further abuse.
The facility failed to protect residents from medication misappropriation, as two LPNs were involved in incidents where narcotics were not properly managed or administered. One LPN did not place narcotics into the emergency medication machine, while another did not provide prescribed medications to two residents and was observed under the influence. These actions violated the facility's abuse prohibition policy.
The facility failed to identify and investigate potential abuse and neglect for five residents, as revealed through a review of facility policy, resident council meeting minutes, concern/grievance logs, clinical records, and interviews. The facility's policy on abuse prohibition mandates the prevention, identification, investigation, and reporting of abuse and neglect, but these procedures were not followed. For a resident, there was a failure to document the change of a suprapubic catheter, which was not identified as neglect by the facility. Another resident reported being physically abused by a nurse aide, but the investigation did not include interviews with other residents to determine if there was a pattern of abuse. Similarly, a resident reported inappropriate conduct by a night shift nurse aide, but the investigation was not comprehensive. A resident's grievance about being verbally abused by an LPN was not fully investigated, as other residents were not interviewed to assess the extent of the abuse. A resident reported unwanted physical contact from a nurse aide, but the facility did not conduct a thorough investigation to determine if other residents were affected.
The facility failed to accurately complete MDS assessments for four residents, as required by the RAI User's Manual. Despite being sometimes or usually understood, these residents did not receive necessary mental status and mood interviews due to inconsistencies in their assessments. This was confirmed by the Social Worker and RN Assessment Coordinator.
The facility failed to develop comprehensive care plans for three residents, leading to unmet care needs. One resident's care plan lacked timely updates for bed mobility, resulting in an injury. Another resident's plan did not address antipsychotic medication use, and a third resident's plan omitted tobacco use interventions. These deficiencies were confirmed by the DON.
The facility failed to provide adequate supervision during transfers for three residents, leading to safety hazards. A resident with cerebral palsy was improperly transferred using a Hoyer lift by a single nurse aide, contrary to policy. Another resident with COPD fell out of bed due to inadequate care planning and supervision. A third resident with hemiplegia was inappropriately stood during a transfer, resulting in a fall. These incidents were confirmed by the DON and Nursing Home Administrator.
The facility failed to ensure the availability of prescribed medications for two residents. One resident missed doses of Cipro and Zosyn due to delays in pharmacy delivery, while another resident did not receive a scheduled dose of Tramadol despite its availability in the Omnicell. The Director of Nursing confirmed the facility's failure to implement procedures for timely medication access.
Failure to Provide Resident-Selected Menu Items and Follow Posted Menus
Penalty
Summary
The facility failed to provide resident-selected menu items and to follow documented food preferences and diet tickets for multiple residents during a surveyed evening meal. Facility policy dated 3/15/26 stated that individual dining, food, and beverage preferences are to be identified for all residents and that tray tickets must reflect appropriate items based on diet orders, allergies, intolerances, and preferences. During an evening meal observation on 4/14/26, one resident’s tray ticket specified a chef salad with five Italian dressings, but the salad and dressings were not present on the tray delivered. Another resident’s tray ticket indicated chocolate pudding, and the resident reported having repeatedly told kitchen staff that she did not want chocolate pudding every day and that she requested a banana each morning but only received one two to three days per week. Additional residents did not receive the items listed on their meal tickets or requested by them. One resident’s tray ticket indicated ground molasses barbeque chicken and marinated cauliflower, but the resident received dry ground chicken without barbeque sauce and no cauliflower. Another resident’s tray ticket indicated a double entrée, but observation of the tray before any food was consumed confirmed that a double entrée was not provided. A further resident stated that the food often did not match what she requested, and her family member reported that they could not tell what meals to expect because the posted menu lacked dates and the meals did not follow the menu in a way that allowed them to determine the current week. The posted menu showed Week One, Week Two, and Week Three with no dates or signage indicating the current week. The Nursing Home Administrator confirmed that the facility failed to provide resident-selected menu items for five of nine residents reviewed.
Failure to Investigate Sexually Inappropriate Resident Behaviors Toward Peers
Penalty
Summary
The facility failed to investigate a resident’s known sexually inappropriate behaviors to ensure the safety of other residents. The resident, who had chronic kidney disease, diabetes, depression, and moderate cognitive impairment, was care planned for a tendency to exhibit sexually inappropriate behavior. Progress notes documented multiple incidents in which the resident made sexually explicit comments to CNAs, including asking a CNA "when are you going to let me hit that" and attempting to hit her buttocks with a shirt. A psychiatry note recorded reports from primary care that the resident had been groping staff private areas and making crude comments. Another progress note described an incident where the resident requested help scratching his back, then attempted to put his hand between a CNA’s legs and, when unsuccessful, grabbed her buttocks; the CNA was visibly upset and local police were notified due to this not being the first episode of sexual harassment toward a CNA. Subsequent psychiatry notes indicated ongoing concerning behaviors, including repeated requests for doors to be closed when female staff were present, and another incident of an inappropriate verbal remark to staff using the phrase "let me hit that." The psychiatrist documented that the resident’s presentation was consistent with a neurocognitive disorder with behavioral disinhibition and impaired judgment, possibly related to alcohol-related dementia or secondary gain, and that risk for recurrence remained. Despite these documented behaviors and the resident’s known history of sexual inappropriateness, review of facility-provided investigation documents did not show that the facility had taken steps to determine whether the resident had been sexually inappropriate with peer residents, in addition to staff. In interviews, the DON and Nursing Home Administrator confirmed that no such investigation had been completed, despite the facility’s Abuse Prohibition policy requiring identification and investigation of possible incidents or allegations.
Failure to Correctly Identify Individual Before Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to correctly identify an individual prior to medication administration, resulting in medications being given to a person who was not the resident for whom they were ordered. Facility policy required that all patients receive an identification bracelet upon admission, with any refusal documented in the medical record, and that nurses verify the right patient as part of safe medication administration. On the date of the incident, a resident with end stage renal disease and Parkinson’s disease had been admitted to the facility and was receiving outpatient dialysis three times weekly. That morning, this resident had been sent out for dialysis. Later that day, a transportation company driver arrived and told the receptionist he was returning the resident from dialysis. The receptionist, relying on the driver’s statement and the expectation that the newly admitted resident was returning, directed the driver to the resident’s room. The individual brought in by the driver was not wearing an ID band. Staff proceeded with the admission process, including taking a photograph and uploading it into the electronic medical record. A day-shift RN evaluated the individual, verified the photograph in the electronic record, and asked the individual to confirm his name; the individual verbally confirmed the first name that matched the expected resident. Based on this identification, the nurse administered scheduled medications including Flomax, Sinemet, Vitamin D, and a multivitamin, which were ordered for the actual resident with ESRD and Parkinson’s disease. Another nurse later documented that when she asked the individual to state his name, he mumbled and gestured, did not answer questions directly, but did not deny being the expected resident. The LPN who administered medications noted that the patient did not have a name band but had a picture in the profile, and that when asked his name he nodded and answered "yeah" before she gave the medications. Subsequent phone calls from the transportation company and another facility revealed that the individual was actually a resident of another facility with the same first name, who had been transported to the wrong location. Staff interviews and statements confirmed that the facility had not correctly identified the individual using required identifiers before administering medications, resulting in a significant medication error.
Failure to Ensure Timely and Accessible Call Light Response for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure call lights were accessible and answered promptly, as required by facility policy and state regulations, for six of seventeen residents. The facility’s call light policy dated 7/15/25 states that each patient will have a call light or alternative communication device at the bedside, toilet, and bathing room, and that staff will respond promptly. Despite this, multiple residents with intact cognition (BIMS scores ranging from 13 to 15) reported delays in staff response to call lights, particularly on evening and night shifts, and facility leadership confirmed that call lights were not answered in a timely manner. One resident with chronic respiratory failure, retropharyngeal and parapharyngeal abscess, and fibromyalgia, who required substantial/maximal assistance with toileting hygiene and partial/moderate assistance with toilet transfers, reported in a written statement that a nursing assistant criticized her for using the call light too much and made her wait to go to the bathroom. Another resident with spastic quadriplegic cerebral palsy, diabetes mellitus, and anxiety disorder, who was dependent for toileting hygiene and unable to perform toilet transfers due to medical condition, stated during interview that when she used the call light it often took thirty minutes or more to receive help, and that she could not care for herself and simply had to wait. Additional residents also described frequent delays in call light response. A resident with multiple sclerosis, a stage IV pressure ulcer, and malnutrition, who was independent with toileting hygiene but required partial/moderate assistance with toilet transfers, reported that it took thirty to forty-five minutes to get help, especially on evening and night shifts, occurring a couple of times each week. Another resident with COPD, diabetes mellitus, and depression, independent in toileting hygiene and toilet transfers, stated that when using the call light for needs such as medication or feeling unwell, waiting times on evenings and nights were about thirty minutes or longer. A long-stay resident with hypertension, heart failure, and depression, dependent for toileting hygiene and unable to perform toilet transfers, filed grievances on two consecutive days about daily call light wait times on evening and night shifts, later reporting that although things had improved, she still waited thirty minutes to two hours several times a week. A further resident with hypertension, diabetes mellitus, and cellulitis, requiring substantial/maximal assistance for toileting hygiene and toilet transfers, reported in a written statement that he repeatedly tried to call because he had soiled himself and no one came, leading him to call his family, who then came to the facility and reported he was not being changed. The Nursing Home Director and DON confirmed that the facility failed to ensure call lights were accessible and answered timely.
Failure to Prevent Resident Access to Antifreeze Resulting in Ethylene Glycol Ingestion
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from access to harmful chemicals, resulting in the ingestion of ethylene glycol (antifreeze) and subsequent hospitalization. Facility policy on accidents and incidents required reporting, review, and investigation of all accidents/incidents, including determining root causes and contributing factors and identifying measures to reduce further occurrences and adverse outcomes. Despite this policy, a resident with a known history of self-harm behavior and psychiatric issues was able to obtain and keep a gallon of Peak 50/50 Prediluted Antifreeze in their room without detection by staff. The resident, who was cognitively intact with a BIMS score of 15, had diagnoses including toxic effects of glycols, Parkinson’s disease, and depression. Medical documentation showed prior attempts or suspected attempts at self-harm, including a recent hospitalization for Seroquel overdose and a voluntary psychiatric admission. Hospital records further documented that the resident had been hospitalized for acute kidney injury and metabolic acidosis due to ethylene glycol ingestion, with progress notes indicating suspected self-harm with ethylene glycol requiring ICU care, intubation, and temporary dialysis. The resident also had a history of cocaine use and overuse of Seroquel, and the care plan identified potential risk for ideations of self-harm related to PTSD, glycol toxicity, and hallucinations. Following another episode of altered mental status, the resident was transferred to the emergency room, and the hospital later contacted the facility with concerns that the resident had ingested antifreeze and requested a search of the resident’s room. Staff then found a gallon jug of Peak 50/50 Prediluted Antifreeze in the resident’s closed cupboard inside a yellow dollar store bag, without a receipt. The LPN who located the jug reported that the cap still had a plastic seal around the lid, but he was able to twist the lid off without breaking the plastic seal. Staff interviews indicated that the resident frequently used third-party delivery services such as DoorDash, and that the resident was generally quiet, stayed to herself, did not use the call bell, and kept her door or privacy curtain closed. The RN Unit Manager stated he was not aware of the resident’s history of self-harm. These circumstances show that the resident was able to obtain and store a toxic chemical in her room, despite her documented psychiatric history and prior glycol toxicity, and without staff awareness or intervention, leading to ingestion of ethylene glycol and hospitalization. The survey identified this failure to ensure protection from accident hazards and to provide adequate supervision as having resulted in actual harm to one resident and constituting an Immediate Jeopardy situation. The deficiency was cited under multiple state regulatory provisions related to licensee responsibility, management, clinical records, resident care planning, and nursing services.
Removal Plan
- Complete an initial audit to identify any resident with a diagnosis of self-harm attempt or ideation and update care plans with interventions.
- DON or designee will educate staff on the accidents policy (OPS100).
- Establish a protocol related to DoorDash and other deliveries; share it at the AD HOC resident council, communicate to families via Regroup, and educate staff.
- DON or designee will complete an audit to verify residents with self-harm attempts and/or ideation are placed on psych services, have a care plan initiated, and have interventions added to the Kardex.
- Report audit results to the QAPI Committee.
Failure to Provide Appropriate Mental Health Services and Monitoring for Resident With Self-Harm History
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with a history of self-harm and significant mental health diagnoses received appropriate treatment and services to address assessed psychosocial problems. The resident was re-admitted with diagnoses including toxic effects of glycols from suspected antifreeze ingestion, Parkinson’s disease, and depression. The resident’s care plan, updated on 10/30/25, identified a potential risk for ideations of self-harm related to PTSD, glycol toxicity, and hallucinations. Physician orders from 10/25/25 through 12/3/25 included psychiatry/psychology consultation and medications for insomnia, anxiety, depression, and overdose reversal, and progress notes documented a recent voluntary psychiatric hospitalization for Seroquel overdose and a history of possible self-harm attempts, which the resident denied. Despite these identified risks and orders, the clinical record showed inconsistent behavior monitoring and a lack of documented behavioral health interventions to address the resident’s prior suicidal attempts or ideations. Behavior charting for October 2025 showed that 3 of 6 shifts lacked documented behavior monitoring, November 2025 had 24 of 90 shifts without documentation, and December 2025 had 26 of 61 shifts without documentation. The surveyor’s review of the medical records further noted a consistent lack of behavioral health interventions directed at the resident’s history of self-harm and suicidal ideation, even though the resident had a documented history of ethylene glycol toxicity, cocaine use, and Seroquel overdose, as well as recent psychiatric hospitalization. The deficiency also includes the facility’s lack of an effective system to identify and manage residents with prior self-harm attempts. On 12/21/25, the resident was noted to have altered mental status and was transferred to the emergency room. On 12/22/25, the hospital notified the facility of a possible antifreeze ingestion and requested a search of the resident’s room, where staff found a gallon of Peak 50/50 Prediluted Antifreeze. During interviews, the NHA and DON stated they were unaware of the resident’s history of self-harm and acknowledged that the facility did not have a procedure to ensure residents with prior self-harm attempts were referred to mental health services. Surveyors determined that this failure resulted in actual harm to the resident, required hospitalization for antifreeze ingestion, and that there was no system in place to ensure other residents with similar needs were receiving appropriate mental health services, constituting an Immediate Jeopardy situation.
Removal Plan
- Complete an initial audit of current and new admissions to identify any resident with a diagnosis of suicide attempt or suicidal ideation and update care plans with interventions.
- Educate the admission director and clinical liaison to attempt to identify potential needs related to suicide attempts or suicide ideations prior to admission.
- DON or designee will educate staff regarding any new admission with a history of past self-harm attempts on plan of care needs.
- DON or designee will complete a weekly audit on new admissions to determine whether any resident with a history of suicide attempt or suicidal ideation is placed on psych services, has a care plan initiated, and has interventions added to the Kardex.
- Report audit results to the Quality Assurance Performance Improvement Committee.
Failure of NHA and DON to Prevent Resident Self-Harm with Toxic Chemical
Penalty
Summary
The deficiency involves the NHA and DON failing to protect a resident with a history of self-harm from accessing harmful chemicals, resulting in an attempted self-harm incident. The facility job descriptions for the NHA and DON state that they are responsible for administering, directing, and coordinating all activities to ensure the highest quality of care, and for providing leadership and oversight of clinical care, nursing practice, and continuous improvement of nursing services. Despite these defined responsibilities, the NHA and DON did not ensure that federal and state guidelines and regulations were followed to prevent resident self-harm. Surveyors determined that this failure allowed a resident with a known history of self-harm to obtain and possess ethylene glycol, a chemical found in antifreeze. The resident ingested the ethylene glycol and required hospital admission. The incident created an Immediate Jeopardy situation for one of two residents reviewed (Resident R1). During an interview, the NHA and DON acknowledged that they failed to effectively manage the facility to protect residents from self-harm, confirming the identified deficiency under the cited Pennsylvania regulatory codes.
Failure to Secure Medications in Medication Rooms
Penalty
Summary
The facility failed to properly secure medications and biologicals in two of three medication rooms, specifically the TCU and Harmony Unit Medication Rooms. During a review of facility policy and on-site observations, it was found that the doors to these medication rooms were left unlocked, with medications designated for return sitting on the counter. The facility policy requires that medication rooms, cabinets, and supplies remain locked when not in use or attended by authorized personnel. Staff interviews confirmed that licensed nursing staff had keys to the medication rooms and were aware that the doors should be locked, yet the rooms were found unsecured during the survey. Further interviews with the DON and Nursing Home Administrator confirmed the failure to secure medications and biologicals as required. The deficiency was identified through direct observation and staff acknowledgment, with no mention of specific residents being affected or any adverse outcomes at the time of the survey. The findings were cited under relevant state pharmacy and nursing services regulations.
Failure to Protect Resident from Misappropriation of Narcotic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from misappropriation of property, specifically regarding the loss of prescribed narcotic medication. The resident, who had a history of left knee replacement, obstructive sleep apnea, and morbid obesity, was assessed as cognitively intact with a BIMS score of 13. The resident had physician orders for Oxycodone HCL and Tylenol Extra Strength for pain management. According to medication administration records, the resident received multiple doses of both medications during the review period. On the night in question, two RNs were responsible for the medication cart containing the resident's narcotic medication. The narcotic count was verified as correct during shift changes. However, during an early morning medication request, one RN was unable to locate the Oxycodone card or the associated narcotic tracking sheet in the medication cart. Further investigation revealed that the original tracking sheet had been removed and replaced with a new one, and the missing count signoff sheet was later found unsigned in the recycle bin. The missing Oxycodone and its documentation were not recovered, and the resident experienced a delay in receiving pain medication as a result. Staff interviews and documentation confirmed that only the two RNs had access to the medication cart during the relevant period. There was no evidence that the resident was interviewed regarding the missing medication, and the facility was unable to identify a perpetrator. The incident was reported to the local police department. The deficiency was confirmed by the Nursing Home Administrator and the Director of Nursing, who acknowledged the facility's failure to protect the resident from misappropriation of property.
Failure to Investigate and Secure Controlled Substances
Penalty
Summary
The facility failed to implement its policies and procedures regarding the investigation of misappropriation of resident property, specifically related to the disappearance of a controlled substance prescribed to a resident. The resident had physician orders for Oxycodone HCL and Tylenol Extra Strength for pain management. Documentation showed that the Oxycodone card and associated tracking sheet were missing from the narcotic drawer when the resident requested pain medication, resulting in a delay in administration. The shift change count sheets and narcotic records were also found to be incomplete or missing, and the original documentation was later discovered in a recycle bin, unsigned by one of the nurses involved. Staff interviews and facility documentation revealed that only two RNs had access to the medication cart during the relevant period. There was no evidence that all necessary staff interviews were conducted, including with the resident, nor was there evidence that staff drug screening was required, requested, or offered. The facility was unable to account for the missing Oxycodone or the corresponding drug count record, and the investigation did not identify a perpetrator. The facility did file a report with the local police department, but the internal investigation was incomplete as key documentation and interviews were lacking. Additionally, during a facility inspection, medication rooms were found unlocked with medications left unsecured on the counter, contrary to policy requirements for controlled substances. The Director of Nursing confirmed that original shift change count sheets were missing, and only copies were available for review. The failure to follow established procedures for handling, documenting, and investigating the loss of controlled substances resulted in a deficiency related to the misappropriation of resident property.
Failure to Supervise Residents and Secure Courtyard Exit
Penalty
Summary
The facility failed to provide adequate supervision and a safe environment for residents with unrestricted access to the outdoor courtyard area. During an observation with the DON, the Garden exit door was found propped open, despite signage instructing that the door should remain closed and indicating it was not an exit. This door, located out of view of the nursing units, was not connected to the wander guard or alarm system. During the observation, a resident was seen unattended in the courtyard, another resident was attempting to exit to the courtyard, and visitors were also observed using the door. The DON confirmed that the door should not have been propped open at that time. Interviews with the NHA, DON, and ADON confirmed that the courtyard had recently become the designated smoking area and that the unsecured door allowed any mobile resident to exit the building when propped open, as it only locks when properly closed. The facility leadership acknowledged that this situation resulted in a failure to provide adequate supervision and maintain a safe environment for mobile residents, as required by facility policy and state regulations.
Significant Medication Error: Wrong Insulin Administered
Penalty
Summary
A significant medication error occurred when a nurse administered the wrong insulin to a resident with diagnoses of diabetes mellitus, end stage renal disease, and hypertension. The resident was prescribed Lantus (glargine) and Lispro insulin at specific doses and times, as documented in the physician's orders and Medication Administration Record. However, during medication preparation, the nurse was interrupted and inadvertently gave the resident another patient's insulin, specifically 30 units of NovoLog, which was not prescribed for this resident. Following the administration of the incorrect insulin, the nurse notified the supervisor, and the resident's blood sugar was monitored, revealing a blood glucose level of 354. The resident's family and provider were informed, and the resident was subsequently sent to the emergency department, where she received intravenous D10w. The Director of Nursing confirmed that the facility failed to ensure residents are free from significant medication errors, as required by facility policy and state regulations.
Insufficient Nursing Staff Resulting in Delayed Care and Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of eight out of eleven residents, as evidenced by multiple resident interviews, observations, and documentation reviews. Residents reported long wait times for call light responses, delayed medication administration, and untimely assistance with activities of daily living such as getting in and out of bed. One resident described having to wait from early morning until late morning for assistance and reported being told by staff that they were not the only one needing help. Another resident stated that they had to call their family to get staff attention during the night. Observations included residents being malodorous, with one resident noted to have large amounts of a brown substance under their fingernails, and rooms with overpowering urine odors. Documentation showed significant gaps in incontinence care, with one resident not receiving documented care for over ten hours. Additional evidence from Resident Council meeting minutes and grievance reviews indicated ongoing concerns about insufficient staff to assist with changing soiled sheets and providing scheduled showers. Several residents reported not receiving showers on their scheduled days, with no refusals documented. One grievance detailed a resident remaining in bed without bathing assistance late into the morning. The Nursing Home Administrator confirmed that the facility did not have enough nursing staff to provide necessary care to maintain the highest practicable physical, mental, and psychosocial well-being of the affected residents.
Failure to Protect Resident from Staff-Initiated Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from staff-initiated abuse and neglect, as evidenced by the substantiated case involving a resident with neurogenic bladder and multiple sclerosis, who was cognitively intact with a BIMS score of 15. The resident reported that a nurse aide verbally abused her, used profanities, and refused to provide appropriate care, including leaving her undressed and not assisting her into her chair as requested. The resident described being left cold and upset after the aide removed all her clothing at once, ignored her requests for assistance, and made derogatory remarks. The aide's own statement confirmed a confrontation occurred, and the aide left the resident after the exchange. Facility documentation and interviews further revealed that the resident's son reported the incident, stating that the aide was verbally abusive and left his mother naked in bed. The facility's investigation substantiated the abuse, confirming that the staff member's actions constituted both verbal abuse and neglect of care. The Nursing Home Administrator acknowledged that the facility failed to protect residents from staff-initiated abuse, as required by facility policy and regulatory standards.
Failure to Maintain Adequate Clean Linens and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment across all seven nursing units due to a persistent shortage of clean linens, wash cloths, and towels available throughout the day. Observations revealed that linen carts contained only a limited number of sheets, towels, and wash cloths, which was insufficient for the current census of 168 residents. Interviews with laundry staff indicated that only one laundry employee was available, and a second washing machine had been out of service for three to four months, resulting in an inability to keep up with the facility's linen needs. The Nursing Home Administrator confirmed that the washing machine had been down for an extended period, contributing to the ongoing shortage of clean linens.
Failure to Maintain Essential Laundry Equipment
Penalty
Summary
The facility failed to ensure that all essential equipment, specifically one of two washing machines, was maintained in safe operating condition. Facility documentation and grievances from two residents, as well as concerns related to another resident, indicated a lack of clean linens, wash cloths, and towels. Observation revealed that only one washing machine had been operational for three to four months, and the sole laundry staff member was unable to keep up with the demand for clean linens. The laundry was not completed after the staff member's shift, resulting in insufficient linens. The Nursing Home Administrator confirmed that the second washing machine had been out of service for an extended period.
Failure to Maintain Sanitary Conditions in Kitchen and Food Handling
Penalty
Summary
The facility failed to maintain sanitary conditions in the main kitchen, as evidenced by multiple observations during survey visits. The dish machine's wash cycle was only reaching 142 degrees Fahrenheit, below the required 150-165 degrees, and the rinse cycle reached 160 degrees, below the required 180-194 degrees. Additionally, the walk-in cooler fans had a white fuzzy substance on them, and these fans were blowing air directly over food items. These issues were confirmed by the HCS corporate Dietary Manager during interviews. Further observations revealed that dietary staff were not following proper hand hygiene and glove use protocols. One dietary employee was seen touching the outside of a bag, pulling out buns, and then handling food items without changing gloves or washing hands. The same employee left the tray line to retrieve mashed potatoes and returned to serving without hand washing or changing gloves. Two dietary aides entered the kitchen without beard guards and had to walk through the kitchen to obtain them. Another dietary aide was observed washing dishes, handling soiled items, and then removing clean items from the dish machine without washing hands or changing gloves. These lapses in sanitary practices were also confirmed by the HCS corporate Dietary Manager.
Failure to Provide Dignified Dining Experience for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide a dignified dining experience to a resident on the secure memory care unit during breakfast meal service. The resident, who has Alzheimer's disease, morbid obesity, and a psychotic disorder, was assessed with a BIMS score of 2, indicating severe cognitive impairment, and required assistance with cutting food into bite-sized pieces prior to meals. According to the resident's care plan, staff were to assist with this task. However, during observations, the resident was found lying in bed with the breakfast tray placed within reach, but no food had been consumed, tasted, or cut into pieces. The dietary slip was accurate, and there was no evidence that the meal had been prepared or assisted as required. Staff interviews confirmed that the breakfast tray was delivered at 7:35 am and remained untouched by 10:00 am. The LPN verified that the food had not been consumed or cut, and the DON acknowledged the failure to provide a dignified dining experience for the resident. Facility policy requires treating each resident with respect and dignity, and the failure to assist the resident with their meal as outlined in the care plan resulted in the deficiency.
Failure to Ensure Accessible and Timely Call Light Response
Penalty
Summary
The facility failed to ensure that call lights were accessible and answered in a timely manner for 19 of 21 residents, as required by facility policy. Observations revealed that in at least two cases, call light cords in resident bathrooms were wrapped around grab bars, making them inoperable. Interviews with residents confirmed that some rarely used the call light, but had it available at their bedside and in the bathroom, although the bathroom call light was not functional. Staff, including an LPN, confirmed the inoperability of these call lights for the affected residents. Additionally, a group interview with residents revealed that the majority consistently experienced wait times of thirty minutes or longer for call light responses, leading to frustration. Review of six months of resident council meeting minutes showed ongoing complaints about untimely call light responses, with issues reported every month during the review period. The DON confirmed the facility's failure to ensure call lights were both accessible and answered promptly for the majority of residents identified.
Failure to Respond to Resident Council Concerns on Call Light Response
Penalty
Summary
The facility failed to respond to concerns raised by the resident council regarding staff response to call lights over a six-month period. According to the facility's Resident Council policy, a designated staff member is responsible for communicating resident concerns to the administration and ensuring responses are documented and reviewed. However, review of resident council minutes for six consecutive months showed that concerns about call light response were repeatedly documented without any evidence of follow-up actions or communication from administration. During a group interview, the majority of residents expressed ongoing dissatisfaction, stating that their concerns were not addressed or resolved. The Nursing Home Administrator confirmed that the facility did not respond to these concerns in a timely manner during the specified period.
Failure to Provide Palatable and Attractive Food
Penalty
Summary
The facility failed to provide food that was palatable and attractive to residents. Over a four-month period, resident council meeting minutes documented repeated complaints from residents about the food being tasteless, mushy, and unattractive, with specific mention of buns becoming soggy due to being placed on plates with liquids. During a resident group meeting, residents reported that the dietary department had not addressed ongoing food issues, and that food was sometimes not what was requested. Two residents interviewed also stated their only complaint was the taste and appearance of the food. Observation of tray line service revealed that, towards the end of service, some residents did not receive dinner rolls and were instead given pieces of bread. Pureed foods were served in a single glob, with mac n' cheese, stewed tomatoes, and meat mixed together, making the food unappealing. Buns for burgers, sloppy joes, or hot dogs were soaked with stewed tomato juices because the tomatoes were not served in a separate bowl. Additionally, meal delivery was delayed by 25 minutes beyond the posted time. The Corporate Dietary Manager confirmed that the facility failed to serve food that was palatable and attractive.
Failure to Maintain Clean and Homelike Resident Bathrooms
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment on one of five units, as required by its own policies and state regulations. During observation rounds with the DON, multiple resident bathrooms (rooms 507, 601, 602, 606, and 609) were found to be visibly soiled with debris and stains on the floors, and toilets had stains of unknown origin both internally and externally. Housekeeping staff described a seven-step cleaning procedure that included daily bathroom cleaning, but the observed conditions indicated that these procedures were not effectively implemented. The DON confirmed the failure to maintain a homelike environment in the affected unit.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Maintain a Hazard-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the potential for accidents to occur. The lack of appropriate supervision and the presence of hazards directly contributed to this deficiency.
Failure to Correct Staffing Deficiencies and Implement Effective QAPI
Penalty
Summary
The facility failed to correct previously cited deficiencies related to staffing and compliance with state regulations, as evidenced by repeated findings across multiple surveys. Documentation review showed that the facility's QAPI program was intended to establish and implement performance improvement projects and monitor corrective actions, but the same deficiencies were cited in several consecutive surveys. Specifically, the facility did not maintain state-required staffing minimums for nurse aides, LPNs, and per patient day hours, despite having plans of correction that included regular audits and QAPI committee reviews. During the survey process, it was confirmed through staff interview, including with the Nursing Home Administrator, that the facility did not effectively address or resolve the identified quality deficiencies. The repeated failure to meet staffing requirements and to implement effective corrective actions as outlined in their QAPI plans led to ongoing noncompliance with state regulations.
Failure to Promptly Address Resident Grievance Regarding Call Light Response
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve a resident's grievance as required by its own policy and regulatory standards. A resident who was admitted with a right arm fracture and attended a care plan meeting with family expressed concerns about staff not answering call lights. Although the facility's grievance policy requires that concerns be documented, investigated, and resolved in a timely manner, there was no evidence that a grievance form was completed or that the concern was investigated and resolved. Review of the facility's complaint log for the relevant month did not show any record of the grievance, and the Director of Nursing confirmed that the process was not followed for this resident's concern.
Failure to Supervise Severely Cognitively Impaired Resident During Offsite Appointment
Penalty
Summary
The facility failed to provide adequate supervision to prevent elopement for a resident with severe cognitive impairment, resulting in an immediate jeopardy situation for multiple residents. Specifically, a resident with a BIMS score of 6, indicating severe cognitive impairment, was allowed to leave the facility unaccompanied for a medical appointment, despite facility policy requiring an escort for residents with a BIMS score lower than 13. The resident was not identified as at risk for elopement in the care plan, and the physician's order permitted the resident to leave unaccompanied when arranged by the facility. During the appointment, the resident was left unsupervised in the lobby, was not picked up as planned, and subsequently left the premises independently by calling a ride service and returning to his home. Review of facility records revealed that several other residents with severe cognitive impairment also had orders allowing them to leave the facility unaccompanied, contrary to the established escort protocol. Staff interviews confirmed that residents with severe cognitive impairment should not be permitted to leave unaccompanied, and that new residents should not have such orders until evaluated by a provider. Despite these protocols, the facility failed to ensure that care plans and physician orders were consistent with the residents' cognitive status and supervision needs. The incident was further compounded by the lack of elopement-related goals and interventions in the affected resident's care plan, and the absence of appropriate supervision during the transfer process. The resident was reported missing after the appointment, prompting a police search and notification of emergency services. The resident was eventually located at his home, having left the appointment site without facility staff knowledge or supervision. This failure to provide adequate supervision and to follow established protocols resulted in an immediate jeopardy situation for all residents with similar cognitive impairments.
Removal Plan
- Complete AMA discharge at residence.
- Call emergency services for hospital transfer for PICC removal.
- Notify Adult Protective Services.
- Notify Ombudsman.
- Review escort protocol.
- Educate staff on sending residents to appointments with escorts.
- Update elopement book.
- Conduct wellness check on resident.
- Conduct elopement drills every shift.
- Validate appointment returns.
- Develop protocol for offices to call building or driver for return and not put residents in the lobby.
- Review upcoming appointments and determine if escorts are needed in morning meeting.
- Update care plans.
Failure to Protect Residents from Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to protect residents from the misappropriation of their property, specifically controlled medications, for 18 of 22 residents reviewed. Facility policy defines misappropriation as the deliberate misplacement, exploitation, or wrongful use of a resident's belongings or money without consent. Multiple discrepancies were identified in the handling and documentation of controlled substances, including oxycodone and tramadol, for numerous residents. In one case, a cognitively intact resident with chronic kidney disease, diabetes, and post-joint surgery care needs was found to have 27 tablets of oxycodone 10 mg missing, with no accountable documentation or explanation for their destruction or loss. Statements from staff revealed confusion and lack of clarity regarding medication orders, destruction of medication cards, and missing narcotic records. Further review of medication administration records (MARs) and controlled drug logs for other residents revealed numerous instances where narcotic medications were signed out on paper controlled drug records without corresponding documentation in the MARs. These discrepancies occurred across a range of residents and medications, including oxycodone and tramadol, with missing or inconsistent documentation of administration times and dosages. In several cases, staff statements indicated that medications were destroyed or wasted without proper documentation or clear understanding of the orders, and in some instances, medication cards were found in shred boxes or were unaccounted for entirely. Interviews with facility leadership confirmed the failure to ensure residents were free from misappropriation of property, as required by state regulations. The lack of proper documentation, inconsistent narcotic counts, and inability to account for missing medications directly contributed to the deficiency. The findings were based on a comprehensive review of facility policy, clinical records, incident investigations, and staff interviews.
Failure to Report Allegations of Neglect
Penalty
Summary
The facility failed to implement its policies and procedures for reporting allegations of neglect for two residents. For one resident with diagnoses including spinal stenosis, heart failure, and osteoarthritis, and who required a two-person assist with a Hoyer lift, there was an incident during a transfer where the resident's leg was injured. The resident reported that her leg was trapped and that she called for help, but the aides did not notify a nurse or supervisor. The Director of Nursing later interviewed the resident, who provided a slightly different account, but no report of possible neglect was submitted to the state field office as required by facility policy and state law. For another resident with chronic obstructive pulmonary disease, muscle weakness, and a history of falls, who also required a two-person assist for transfers, an incident occurred where the resident was being transferred by a nurse aide and was lowered to the floor, resulting in a skin tear. The nurse aide involved was agency staff and used an incorrect level of assistance. Despite this, the facility did not report the possible neglect to the state field office as required. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed that the facility did not follow its own policies and procedures to report allegations of abuse and neglect for these two residents. The failure to report these incidents was in violation of both state law and the facility's own abuse prohibition policy.
Failure to Investigate Possible Abuse and Neglect Incidents
Penalty
Summary
The facility failed to implement its policies and procedures to investigate possible abuse and/or neglect for three residents. For one resident with spinal stenosis, heart failure, and osteoarthritis, who required two-person Hoyer lift transfers, there was an incident where the resident's leg was injured during a transfer. The resident reported that staff did not follow her instructions, did not seek nursing assistance when requested, and did not report the incident to a nurse or supervisor. The Director of Nursing later documented conflicting accounts and determined no further investigation or reporting was necessary, and no additional information was provided when requested. Another resident with COPD, muscle weakness, and a history of falls, also requiring two-person transfers, experienced a skin tear during a transfer when an agency CNA attempted to transfer her alone. The incident report noted the incorrect level of assistance was used, but no further investigation was conducted to determine if staff were aware of proper transfer procedures. A third resident with dementia and a history of wandering was found with two large bruises of unknown origin on her arm. The facility's investigation included statements from only a few staff, some of whom were not assigned to the resident during the relevant period, and failed to interview all staff who had provided care in the 72 hours prior to the injury. The Director of Nursing confirmed that the investigation was incomplete and that the facility did not follow its own policies and procedures for investigating possible abuse or neglect.
Failure to Secure Medication Cart and Narcotic Drawer
Penalty
Summary
The facility failed to ensure that medications were properly secured in one of three medication carts, specifically the first-floor medication cart for rooms 100-117. According to the facility's policy, medication carts must be securely locked at all times when out of the nurse's view. During an observation, the medication cart was found unlocked and unattended, and the narcotic drawer within the cart was also not secured. The surveyor was able to open the cart and narcotic drawer, and this was confirmed by the First Floor Unit Manager. The Nursing Home Administrator and the Director of Nursing later acknowledged that the medications were not properly secured as required.
Failure to Provide Discharge Planning Focused on Resident's Needs
Penalty
Summary
The facility failed to provide adequate discharge planning for one resident, as required by regulation. The resident was admitted with multiple serious injuries, including fractures to the ribs, right tibia, cervical spine, and a traumatic pneumothorax. The clinical record indicated that the resident was to be discharged with home health services, including PT, OT, RN, and aide support, as per physician orders and social services assessments. However, the discharge plan documentation showed that the resident was discharged without these home health services. Facility records revealed that referrals were made to home health agencies, but these agencies were unable to accept the resident for services. There was no documentation in the progress notes confirming that home health services were scheduled or provided. Additionally, the resident's spouse contacted the facility to report that they had not been contacted by any home health agency. During staff interviews, it was confirmed that the facility did not implement the required discharge plan for the resident.
Failure to Assess Medication Self-Administration
Penalty
Summary
The facility failed to assess the clinical appropriateness of medication self-administration for three residents, leading to a deficiency. Resident R2, who was admitted with high blood pressure, congestive heart failure, and depression, was observed holding a medicine cup of pills without a physician's order or assessment for self-administration. The Licensed Practical Nurse confirmed that she should have observed Resident R2 taking her medications. Similarly, Resident R3, with diagnoses including diabetes and high blood pressure, was found with a medicine cup of pills without a physician's order or assessment for self-administration. The Registered Nurse confirmed that she did not observe Resident R3 swallow her medications. Resident R4, admitted with congestive heart failure, high blood pressure, and anxiety, had opened bottles of Fluticasone nasal suspension and Refresh artificial tears on her over-the-bed table, despite being sent to the hospital and not present in the facility. There was no physician's order or assessment for self-administration for Resident R4. The Nursing Home Administrator and the Director of Nursing confirmed that the medications should have been locked in the medication cart and acknowledged the facility's failure to assess the clinical appropriateness of medication self-administration for these residents.
Inconsistent Provision of Showers for Resident
Penalty
Summary
The facility failed to consistently provide showers and baths for a resident, identified as Resident R1, who requires assistance with activities of daily living (ADLs) due to medical conditions including diabetes, anoxic brain damage, and high blood pressure. According to the Minimum Data Set (MDS) assessment, Resident R1 needs the help of two or more helpers to complete showering. However, the clinical record review revealed significant gaps in the provision of showers, with no documented showers in September 2024 and only sporadic showers in the following months up to February 2025. Resident R1 expressed a preference for showers over bed baths and was unsure of the last time he received a shower. The Director of Nursing confirmed the facility's failure to consistently provide the necessary care, which is a violation of the facility's policy on ADLs and resident rights under federal law. This deficiency was identified during a survey, and it was determined that the facility did not adhere to its policies to maintain or improve the resident's ADL abilities, nor did it respect the resident's right to choose his care preferences.
Significant Medication Error Due to Non-compliance with Physician's Orders
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by the administration of medication by an LPN that did not follow the physician's orders. The resident, who had been admitted with diagnoses including right shoulder pain, high blood pressure, and constipation, was prescribed a one-time intra-articular injection of Kenalog-40 and Lidocaine by a CRNP. However, the medication was administered by an LPN instead, which was not in accordance with the physician's orders. Following the medication error, the resident was sent to the local emergency room for evaluation and was returned to the facility without concerns. The Director of Nursing confirmed that the nurse failed to follow the physician's order, resulting in a significant medication error. Attempts to obtain a statement from the LPN involved were unsuccessful, and the resident was unavailable for interview due to discharge from the facility.
Medication and Treatment Carts Left Unsecured
Penalty
Summary
The facility failed to properly secure medication and treatment carts, as observed during a survey. Specifically, the 600 hall medication cart and the 100/200 hall treatment cart were found unlocked and unattended. The facility's policy, reviewed in August 2024, mandates that medications and biologicals be stored properly and accessible only to authorized personnel. During observations on February 24, 2025, the 600 hall medication cart was found unlocked and unattended at 10:22 a.m., which was confirmed by RN Employee E3 as a breach of protocol. Similarly, at 10:30 a.m., the 100/200 hall treatment cart was also found unlocked and unattended, with LPN Employee E4 confirming it should have been secured. The Director of Nursing further confirmed that both carts should have been secured when unattended.
Insufficient Activities for Secured Unit Residents
Penalty
Summary
The facility failed to provide sufficient activities for residents in the secured unit, B Hall, both on weekdays and weekends. Observations on November 25, 2024, revealed that residents were left without activities in the dining room between 9:00 a.m. and 10:00 a.m. The activity schedule from June 2024 to November 2024 showed that B Hall residents were only scheduled for activities at 10:30 a.m. and 2:30 p.m. on weekdays, with limited activities on weekends. Specifically, from June to August 2024, only one activity was scheduled on Saturdays, and a movie was scheduled on Sundays. From September to November 2024, no activities were scheduled on weekends for B Hall residents. Interviews with facility staff highlighted the lack of sufficient activity staff to provide adequate activities for B Hall residents. The Activities Director stated that only three full-time activities aides were available, and they were responsible for running activities in the main activity room. Only a few residents from B Hall were able to participate in these activities, as they required staff assistance to leave the secured unit. The Activities Director also mentioned that due to other job duties and limited staffing, it was challenging to provide more activities, especially on weekends and evenings when only one activities aide was typically available.
Deficiencies in Resident Dignity and Grievance Handling
Penalty
Summary
The facility failed to uphold the privacy and dignity of two residents who were utilizing indwelling urinary catheters. Resident R1, diagnosed with high blood pressure, obstructive and reflux uropathy, and depression, was observed with a urinary collection bag on the floor under their wheelchair without a dignity cover, making the urine visible. Similarly, Resident R2, with neuromuscular dysfunction of the bladder, high blood pressure, and diabetes, was observed with a urinary bag hooked on the bed rails and resting on the floor without a privacy cover. Staff interviews confirmed the absence of dignity bags for both residents, indicating a lapse in maintaining resident dignity. Additionally, the facility failed to ensure that residents could voice grievances without fear of retaliation. Four residents expressed concerns about potential retaliation if they spoke against the facility or staff. One resident reported being afraid to speak out due to staff warnings about state surveyors being present and being told they could leave if dissatisfied. Another resident felt harassed about their belongings and perceived unequal care among residents. A third resident felt discriminated against due to their size and reported staff reluctance to provide care. The fourth resident was hesitant to speak until confirming the surveyor's independence, fearing neglect or mistreatment if they voiced complaints. The Nursing Home Administrator acknowledged these failures in upholding resident rights.
Inadequate Catheter Care Leads to Resident Harm
Penalty
Summary
The facility failed to provide appropriate care for residents with suprapubic urinary catheters, resulting in actual harm to one resident and a failure to follow physician orders for another. Resident R64 experienced a penile split and traumatic insertion and removal of a catheter due to improper catheter care. The facility's policy required the use of a catheter securement device, which was not consistently documented as being in place. Additionally, a larger catheter size than ordered was used, and the catheter tubing was improperly secured, leading to dislodgement and injury. Resident R64 had a history of neurogenic bladder and required a suprapubic catheter. Despite the care plan's instructions, the catheter securement device was not consistently used, and the catheter was not changed as ordered. The resident experienced a penile tear from the Foley catheter, and the facility's attempt to change the suprapubic catheter resulted in it being improperly advanced through the urethra. Staff interviews confirmed the lack of securement and the use of incorrect catheter sizes, contributing to the resident's injuries. Resident R2, who had a suprapubic catheter, did not have the catheter changed every 30 days as ordered. The facility's documentation did not indicate any attempts to revisit the catheter change with the resident after the initial placement. The Nursing Home Administrator confirmed the facility's failure to provide appropriate treatment and services consistent with professional standards, resulting in harm to the residents.
Failure to Conduct Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance evaluations for five nurse aides, as required by their policy and state regulations. The nurse aides, identified as Employees E1, E2, E3, E4, and E5, did not receive performance evaluations within the specified annual timeframe. Employee E1, hired on February 2, 2021, did not have an evaluation between February 2, 2023, and February 2, 2024, with the last review dated September 8, 2022. Employee E2, hired on January 4, 2022, lacked an evaluation between January 4, 2023, and January 4, 2024, with an undated review provided. Employee E3, hired on April 20, 2021, did not have an evaluation between April 20, 2023, and April 20, 2024. Employee E4, hired on March 22, 2022, was missing an evaluation between March 22, 2023, and March 22, 2024. Employee E5, hired on March 30, 2017, did not have an evaluation between March 30, 2023, and March 30, 2024, with the last review dated July 8, 2022. The Director of Nursing confirmed the facility's failure to conduct these evaluations during an interview.
Inadequate Food Portions Provided to Residents
Penalty
Summary
The facility failed to provide sufficient portions of food products for seven out of sixteen residents, as determined through resident and staff interviews and observations. Multiple residents expressed dissatisfaction with the portion sizes, stating that the food was not only insufficient but also lacked taste and was often served cold. Specific examples included a resident receiving a hot dog with only three French fries and another resident sarcastically commenting on the small size of a cucumber salad. Observations confirmed that the portion sizes, such as those of scrambled eggs and cucumber salad, were smaller than expected, with the cucumber salad not meeting the 1/2 cup measurement as indicated on the meal ticket. Staff interviews corroborated these findings, with a speech therapy employee noting that portion sizes always appeared small. The Regional Dietary Manager confirmed the discrepancy in the cucumber salad portion size during a test tray observation. The Nursing Home Administrator acknowledged the facility's failure to provide adequate food portions, which was a violation of the PA Code 211.6(a)(b) regarding dietary services. This deficiency was identified through individual and group resident interviews, as well as direct observations of meal portions.
Food Safety and Hygiene Deficiencies in Main Kitchen
Penalty
Summary
The facility was found to have several deficiencies related to food safety and hygiene practices in the Main Kitchen. During an observation, it was noted that the dish machine's wash temperature was not functioning or indicated on the valve, which is a deviation from the facility's policy that requires temperatures to be recorded after each use. Additionally, the deep freezer had ice buildup over the pipe off of cooling fans, which was over boxed food items, indicating improper food storage. The ice machine in the kitchen lacked an air gap to the drain, and a black slime-like substance was observed on the pipe sticking out of the machine, suggesting inadequate maintenance and cleaning. Furthermore, during a separate observation, a dietary aide was seen plating food on resident trays without proper facial hair restraint, which is against the facility's policy requiring all staff to have their hair and facial hair properly restrained. These failures were confirmed by the Dietary Manager, who acknowledged the facility's inability to verify the dish machine's wash temperature, maintain the ice machine's drain hose and air gap, and ensure proper food storage and staff attire, thereby creating the potential for foodborne illness.
Failure in Water Management Program for Legionella Control
Penalty
Summary
The facility failed to maintain a comprehensive water management program to monitor and control the potential development and spread of Legionella bacteria within the facility. This deficiency was identified through a review of the facility's water management policy, documentation, and staff interviews. The facility's water management plan, dated January 3, 2024, lacked specific testing protocols and acceptable ranges for control measures, as well as a description of the facility's water system using a flow diagram. Additionally, the facility did not maintain a log for Point of Use Disinfectant to measure and record chlorine concentration levels in the water, which are critical for controlling Legionella growth. The deficiency was further highlighted during interviews with facility staff. The Maintenance Director was unaware of the need to test chlorine levels or to treat the water with appropriate disinfectants such as chlorine, chlorine dioxide, copper-silver ions, and monochloramine. The Nursing Home Administrator confirmed the facility's failure to implement necessary control measures for Legionella. This oversight occurred over an eleven-month period, from September 2023 through July 2024, indicating a significant lapse in the facility's infection prevention and control program.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by multiple incidents involving various staff members and residents. Resident R47 reported being physically abused by a nurse aide, who allegedly punched and yelled at the resident during care. The facility's investigation into this incident was incomplete, as it did not include interviews with other residents to determine if they had experienced similar abuse. Additionally, Resident R58 reported being physically abused by a night shift nurse aide, who allegedly yanked the resident's sheet and touched her inappropriately. The Director of Nursing confirmed that the facility did not ensure Resident R58 was free from physical abuse. Another incident involved Resident R4, who reported verbal abuse by an LPN, who allegedly yelled at the resident and imposed punitive measures, such as denying the resident a cookie and forcing her to stay in the dining room. The investigation into this incident also lacked interviews with other residents to assess if they had been verbally abused by the same LPN. Furthermore, Resident R23 reported inappropriate behavior by a nurse aide, who attempted to kiss the resident after delivering meals. Again, the investigation did not include interviews with other residents to determine if they had been subjected to similar behavior. The facility also failed to administer medications to 16 residents, as a registered nurse neglected to provide the 6:00 a.m. medications. This oversight affected residents with various medical conditions, including high blood pressure, diabetes, and reduced mobility. The Director of Nursing acknowledged the facility's failure to protect these residents from neglect. These incidents highlight significant deficiencies in the facility's ability to prevent and investigate abuse and neglect, as well as to ensure the proper administration of medications.
Failure to Protect Residents from Medication Misappropriation
Penalty
Summary
The facility failed to protect residents from the misappropriation of medications, as evidenced by the actions of two Licensed Practical Nurses (LPNs). The facility's policy on abuse prohibition, dated January 3, 2024, clearly prohibits abuse, mistreatment, neglect, and misappropriation of property. However, on November 12, 2024, a drug diversion incident was identified when Pharmacist Employee E37 informed the Director of Nursing that narcotics, including Xanax, Oxycodone, and Morphine IR, were not placed into the emergency medication machine after being signed for by LPN Employee E38. This indicates a failure in the facility's medication management and security protocols. Additionally, on April 30, 2024, it was documented that LPN Employee E39 did not administer prescribed narcotic medications to two residents, R47 and R129. Resident R47 did not receive Ativan, and Resident R129 did not receive Tramadol. Furthermore, LPN Employee E39 was observed acting under the influence of a substance, falling asleep at her cart, and refusing a drug screen. These incidents highlight a significant lapse in ensuring residents' rights to receive their prescribed medications and to be free from misappropriation of their medications.
Failure to Investigate Abuse and Neglect Allegations
Penalty
Summary
The facility failed to identify and investigate potential abuse and neglect for five residents, as revealed through a review of facility policy, resident council meeting minutes, concern/grievance logs, clinical records, and interviews. The facility's policy on abuse prohibition mandates the prevention, identification, investigation, and reporting of abuse and neglect, but these procedures were not followed. For Resident R2, there was a failure to document the change of a suprapubic catheter, which was not identified as neglect by the facility. Resident R47 reported being physically abused by a nurse aide, but the investigation did not include interviews with other residents to determine if there was a pattern of abuse. Similarly, Resident R58 reported inappropriate conduct by a night shift nurse aide, but the investigation was not comprehensive. Resident R4's grievance about being verbally abused by an LPN was not fully investigated, as other residents were not interviewed to assess the extent of the abuse. Resident R23 reported unwanted physical contact from a nurse aide, but the facility did not conduct a thorough investigation to determine if other residents were affected. The Director of Nursing confirmed the facility's failure to identify and investigate these allegations, which is a violation of several Pennsylvania Code regulations regarding the responsibility of the licensee, management, resident care policies, and nursing services.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure that comprehensive Minimum Data Set (MDS) assessments were completed accurately for four residents. The Resident Assessment Instrument (RAI) User's Manual specifies that interviews for mental status and mood should be conducted if the resident is at least sometimes understood, with an interpreter available if needed. However, for Resident R19, the MDS indicated inconsistencies between sections, showing the resident as sometimes understood in one section but rarely understood in others, leading to incomplete Brief Interview for Mental Status (BIMS) and Resident Mood Interviews. Similarly, Residents R69, R76, and R105 had discrepancies in their MDS assessments. Each resident was noted as usually or sometimes understood in the Hearing, Speech, and Vision section, but rarely understood in the Cognitive Patterns and Mood sections, resulting in the omission of required interviews. These inconsistencies were confirmed by the Social Worker and the Registered Nurse Assessment Coordinator, indicating a failure to accurately complete the MDS assessments for these residents.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in meeting their care needs. Resident R3, who had a history of chronic obstructive pulmonary disease, high blood pressure, and falls, was not provided with a care plan addressing bed mobility until after an incident where she rolled out of bed and sustained injuries. This oversight occurred despite her admission to the facility and subsequent readmission, highlighting a lack of timely updates to her care plan. Resident R12, diagnosed with diabetes, Alzheimer's disease, and heart failure, was prescribed an antipsychotic medication, Zyprexa. However, her care plan did not include goals or interventions related to the medication's use and potential side effects. Similarly, Resident R45, who had COPD and a leg fracture and was known to smoke, did not have a care plan addressing tobacco use or smoking. These omissions were confirmed by the Director of Nursing, indicating a systemic issue in developing and implementing comprehensive care plans for residents.
Inadequate Supervision During Transfers Leads to Resident Safety Hazards
Penalty
Summary
The facility failed to provide adequate supervision during bed mobility and transfers for three residents, leading to potential safety hazards. Resident R5, diagnosed with spastic quadriplegic cerebral palsy and diabetes, was dependent on staff for all transfers. Despite the facility's policy requiring two trained persons to operate a Hoyer lift, a nurse aide used the lift alone while talking on her cell phone, leaving the resident suspended and spinning in the air. This incident was confirmed by the Director of Nursing. Resident R3, with a history of COPD, high blood pressure, and falls, did not have a care plan addressing bed mobility. During care, a nurse aide asked the resident to roll over, resulting in the resident falling out of bed and sustaining injuries. The incident was documented in a progress note and confirmed by the Director of Nursing, who acknowledged the inappropriate handling by the nurse aide. Resident R39, with hemiplegia and a history of stroke, was dependent on staff for transfers. Despite this, a nurse aide attempted to stand the resident during a transfer, resulting in a fall. The resident complained of knee pain, and the incident was confirmed by the Director of Nursing and the Nursing Home Administrator, who acknowledged the failure to provide adequate supervision.
Failure to Ensure Availability of Prescribed Medications
Penalty
Summary
The facility failed to ensure the availability of prescribed medications for two residents, R104 and R59, as required by their policy on pharmaceutical services. Resident R104, who had diagnoses of dementia, diabetes, and Parkinson's disease, was prescribed Cipro for a urinary tract infection. However, the medication was not available in the Pyxis machine, and the pharmacy did not deliver it on time, resulting in missed doses on 6/8/24 and 6/9/24. Additionally, Resident R104 was prescribed Zosyn for intravenous administration, but the medication was not delivered as expected, leading to missed doses on 7/11/24. Resident R59, diagnosed with dementia, polyneuropathy, and chronic pain, was on a scheduled pain medication regimen that included Tramadol. On 7/30/24, the 9:00 a.m. dose of Tramadol was not administered as it was documented as NN, indicating the medication was not available. Despite the medication being listed in the Omnicell inventory, it was not accessed for administration. The Director of Nursing confirmed that the facility did not implement procedures to ensure the availability of prescribed medications for these residents. This deficiency was identified during a review of clinical records and staff interviews, highlighting a failure in the facility's pharmaceutical services to provide timely and reliable access to necessary medications.
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.
Trusted data from CMS and state health departments
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.
Trusted by long-term care providers and associations.
