Brookview Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Chambersburg, Pennsylvania.
- Location
- 1000 Northfield Drive, Chambersburg, Pennsylvania 17201
- CMS Provider Number
- 395012
- Inspections on file
- 19
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Brookview Health Care Center during CMS and state inspections, most recent first.
The facility did not follow its abuse-prevention policy requiring background and credential checks for potential employees when it hired an RN without documented verification of her professional license status. Review of the RN’s personnel file showed no evidence that her license had been checked to confirm it was current and free of disciplinary action, and the Nursing Home Administrator acknowledged that no such documentation could be found, resulting in noncompliance with state regulatory requirements.
The facility failed to follow physician's orders for three residents, leading to improper wound care for one resident, incorrect administration of a Fentanyl patch for another, and failure to monitor blood pressure for a third resident receiving Midodrine. These deficiencies were confirmed by the DON.
The facility failed to maintain sanitary conditions for an ice machine in the [NAME] House, as observed over two days. The ice machine's drain pipe extended to the floor without an air gap for back-flow prevention, confirmed by a maintenance worker.
A facility failed to update a resident's care plan following a quarterly MDS assessment. The resident, who has Alzheimer's and dementia, was observed feeding himself without the non-adherent material under his plate as specified in his care plan. The DON confirmed the care plan should have been revised to discontinue this requirement.
A facility failed to provide trauma-informed care for a resident with PTSD, as required by their policy. The resident, with a history of depression, PTSD, and anxiety, experienced crying episodes and nightmares but did not have completed assessments or identified triggers documented. An interview confirmed the lack of efforts to address these issues, resulting in a deficiency.
A facility failed to accurately document the administration of Morphine Sulfate for a resident with dementia receiving hospice care. Although doses were signed out, the MAR lacked evidence of administration, as confirmed by the DON.
The facility failed to provide written notices to the responsible parties of two residents regarding their transfers to the hospital. One resident experienced vomiting, nausea, and low blood sugar, while another complained of not feeling well and was shivering. Both were transferred to the emergency room with physician orders, but no written notices were documented for their responsible parties.
The facility failed to provide a separately-locked, permanently-affixed compartment in the refrigerator for the storage of controlled drugs. Observations revealed two multi-dose bottles of Ativan stored without a locked compartment. The RN was unaware of the requirement, and the DON confirmed the deficiency.
A facility failed to ensure timely reporting of physical abuse, allowing a nurse aide to return and mentally abuse a resident with Parkinson's disease, anxiety, and depression. The LPN who witnessed the incident did not immediately report it or protect the resident, resulting in Immediate Jeopardy to the safety of all residents.
A resident with Parkinson's disease, anxiety, and depression was subjected to physical and verbal abuse by a nurse aide during a transfer using a Hoyer lift. The nurse aide slapped the resident's hand and verbally abused her after the resident expressed discomfort. The incident was witnessed by staff and confirmed by the resident, leading to Immediate Jeopardy to the resident's health and safety.
A facility failed to address a resident's behavior of removing her feet from wheelchair footrests, leading to Immediate Jeopardy when a nurse aide repeatedly grabbed the resident's ankles, causing distress and resulting in physical and verbal altercations.
The NHA and DON failed to ensure a safe environment free from abuse, timely reporting of abuse, and proper behavior management of residents, as required by their job descriptions and regulatory requirements.
A facility failed to include instructions regarding behaviors and the use of psychotropic medications in a baseline care plan for a newly admitted resident with dementia, anxiety, and major depression. The resident exhibited significant behavioral issues, including aggression and refusal to take medications, which were not addressed in the care plan.
The facility failed to develop comprehensive care plans for a resident with Parkinson's disease, anxiety, and depression, who exhibited combative behaviors and resistance to care. Despite documented incidents of aggression, a care plan addressing these behaviors was not created until several months later.
Failure to Complete Required Licensure Check Prior to RN Hire
Penalty
Summary
The facility failed to ensure that a licensure check was completed prior to hire for one of five employee files reviewed, specifically for a registered nurse. The facility’s abuse policy dated February 27, 2026, required that potential employees be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property, and that background, reference, and credential checks be conducted on potential employees, contracted temporary staff, students, volunteers, and consultants. Review of the personnel file for the registered nurse, who was hired on December 29, 2025, showed no documented evidence that her professional license had been checked to verify it was current and free of disciplinary action. In an interview, the Nursing Home Administrator confirmed they could not locate any documentation that a licensure check had been obtained prior to the nurse’s hire, resulting in noncompliance with 28 Pa. Code 201.14(a) and 201.18(e)(1).
Failure to Follow Physician's Orders for Resident Care
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards of practice by not following physician's orders for three residents. For Resident 17, who was cognitively intact and required assistance for daily care needs, the facility did not document evidence of wound care treatment on specific dates in October 2024, as ordered by the physician. Additionally, the treatment was administered more frequently than required in February 2025, despite the resident's visit to the wound clinic. Resident 32, who was cognitively impaired and receiving hospice services, did not receive a Fentanyl patch every 72 hours as ordered by the physician. The patch was administered on December 24 and December 28, 2024, which did not comply with the prescribed schedule. This discrepancy was confirmed by the Director of Nursing during an interview. For Resident 56, who was admitted to the facility with orders to receive Midodrine for low blood pressure, the facility failed to monitor the resident's blood pressure and adjust the medication administration accordingly. The parameters for holding the medication were not added to the order, resulting in the resident receiving Midodrine when the blood pressure readings indicated it should have been withheld. This oversight was confirmed by the Director of Nursing.
Ice Machine Sanitation Deficiency
Penalty
Summary
The facility failed to ensure that ice was made and stored in sanitary conditions in one of its ice machines located in the [NAME] House. Observations on two consecutive days revealed that the drain pipe from the ice machine extended down to the floor and ran horizontally to the floor drain, lacking an air gap necessary for back-flow prevention. This deficiency was confirmed through an interview with a maintenance worker, who acknowledged the absence of an air gap between the ice machine's drain pipe and the floor drain.
Failure to Revise Care Plan for Resident with Dementia
Penalty
Summary
The facility failed to review and revise the care plan for one of the residents, identified as Resident 11, following a quarterly Minimum Data Set (MDS) assessment. The facility's policy mandates that the comprehensive care plan should be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. However, the care plan for Resident 11, which was last updated in May 2023, was not revised to reflect changes in the resident's care needs as of the quarterly MDS assessment conducted in January 2025. During an observation on February 25, 2025, it was noted that Resident 11, who has Alzheimer's disease and dementia, was feeding himself without the non-adherent material under his plate, as specified in his care plan. An interview with the Director of Nursing confirmed that the care plan should have been updated to discontinue the use of non-adherent material under the resident's plates and bowls at all meals. This oversight indicates a failure to adhere to the facility's policy on care plan revisions, potentially impacting the resident's care.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident diagnosed with Post Traumatic Stress Disorder (PTSD) received trauma-informed care to mitigate triggers. The facility's policy on Trauma Informed Care, dated April 11, 2024, mandates that care should be culturally competent and address the needs of trauma survivors by minimizing triggers. However, the facility did not adhere to this policy for one resident, as evidenced by incomplete Trauma Informed Care Assessments and a lack of documented attempts to identify specific triggers that could re-traumatize the resident. The resident in question, who has a history of depression, PTSD, crying episodes, anxiety, and nightmares, was heard screaming upon awakening since September 2023. Despite these symptoms, the facility did not complete the necessary questionnaires or consult others to identify potential triggers. An interview with the Infection Preventionist confirmed the absence of documented efforts to identify and address these triggers, leading to the deficiency noted in the report.
Failure to Document Administration of Controlled Medication
Penalty
Summary
The facility failed to maintain a complete and accurate accounting of controlled medications for a resident, identified as Resident 32. The resident, who was cognitively impaired, required assistance for daily care needs, had a diagnosis of dementia, and was receiving hospice services, was prescribed Morphine Sulfate Oral Solution for breakthrough pain. Physician's orders indicated the administration of 0.25 ml of Morphine Sulfate as needed. However, the medication accountability sheet showed that doses were signed out on specific dates, but the Medication Administration Record (MAR) lacked documented evidence of administration on those dates. An interview with the Director of Nursing confirmed the absence of documentation for the administration of the signed-out doses.
Failure to Provide Written Notice for Hospital Transfers
Penalty
Summary
The facility failed to provide a written notice to the responsible parties of two residents regarding their transfers to the hospital. Resident 2, who was cognitively intact and required assistance for daily care, experienced vomiting, nausea, and low blood sugar on January 17, 2025. The physician was notified, and an order was given to transfer the resident to the emergency room, with the resident's son present and agreeing to the transfer. However, there was no documented evidence that a written notice was provided to the resident's responsible party explaining the reason for the transfer. Similarly, Resident 13, who was also cognitively intact, complained of not feeling well and was observed shivering in bed on February 16, 2025. The physician was notified, and an order was received to transfer the resident to the emergency room, with the resident agreeing to the transfer. Again, there was no documented evidence that a written notice was provided to the resident's responsible party regarding the reason for the transfer. The Nursing Home Administrator confirmed the lack of documentation for both residents' transfers.
Failure to Secure Controlled Drugs in Locked Compartment
Penalty
Summary
The facility failed to provide a separately-locked, permanently-affixed compartment in the refrigerator for the storage of controlled drugs in the medication room at [NAME] House. Observations on March 13, 2024, revealed two multi-dose bottles of Ativan, a controlled medication used to treat anxiety, stored on the top shelf of the refrigerator without a locked compartment. Registered Nurse 1 was unaware of the requirement for a locked compartment, and the Director of Nursing confirmed the deficiency during an interview. This failure is a violation of 28 Pa. Code 211.9(a)(1) Pharmacy Services.
Failure to Report and Prevent Abuse
Penalty
Summary
The facility failed to ensure that staff reported physical abuse in a timely manner, which allowed the staff member to return to the resident and mentally abuse her. The incident involved a resident with Parkinson's disease, anxiety, and depression, who was being assisted by a nurse aide and a licensed practical nurse (LPN). The nurse aide attempted to place the resident's feet on the footrests of her wheelchair, despite the resident's resistance and vocal objections. When the resident hit the nurse aide in response, the nurse aide retaliated by slapping the resident and verbally abusing her. The LPN witnessed the incident but did not immediately report it or take steps to protect the resident from further abuse, allowing the nurse aide to return to the room and continue the abuse by making a hurtful comment while combing the resident's hair. The facility's abuse policy mandates immediate reporting and protective actions in cases of abuse, but these procedures were not followed. The LPN did not send the nurse aide off the unit or report the incident to the Director of Nursing (DON) or Nursing Home Administrator (NHA) immediately. This failure to act allowed the nurse aide to re-enter the resident's room and continue the abuse. The NHA later reviewed the incident with the LPN and confirmed that the nurse aide should have been removed from the unit and not allowed to return to the resident's room. The deficiency was identified during a review of policies, clinical records, and staff interviews. The facility's failure to ensure timely reporting and protection of the resident resulted in Immediate Jeopardy to the physical and mental safety of all residents. The incident highlighted a significant lapse in the facility's adherence to its abuse prevention policies, putting residents at risk of further harm.
Removal Plan
- Nurse Aide 2 was suspended of her duties, and her employment with the facility was terminated.
- An audit of residents was performed.
- Licensed Practical Nurse 1 was re-educated regarding abuse.
- Re-education regarding abuse to staff was started.
- Daily random audits of residents were being completed.
- The nurse aide was suspended and is no longer employed at the facility.
- An in-house audit was performed on residents, and assessments were completed along with interviews to confirm no other residents were identified.
- In-house re-education was provided to staff on abuse and reporting of abuse. The facility will not allow an employee to work unless education has been completed prior to returning to work.
- Daily random audits of care and interviews continue to ensure that no residents have been affected. The audits are going to be reviewed at Quality Assurance Performance Improvement (QAPI) meetings.
Failure to Protect Resident from Physical and Mental Abuse
Penalty
Summary
The facility failed to ensure that residents were free from physical and mental abuse, as evidenced by an incident involving a resident with Parkinson's disease, anxiety, and depression. During a transfer using a Hoyer lift, the resident expressed discomfort by removing her feet from the wheelchair footrests. Despite this, a nurse aide repeatedly attempted to place the resident's feet on the footrests, leading to the resident hitting the nurse aide. In response, the nurse aide slapped the resident's hand and verbally abused her by calling her an 'ass' and later stating, 'I hope that did hurt.' This incident was witnessed by a Licensed Practical Nurse and overheard by a student nurse, who reported the nurse aide's raised voice and abusive comments. The resident confirmed the abuse during an interview with a social worker, stating that the caregiver had chosen clothes she did not want, cussed at her, and hit her on the wrist. The Director of Nursing was informed of the incident shortly after it occurred, and the Licensed Practical Nurse corroborated the resident's account, noting that the resident appeared shaken and that the nurse aide had been insistent on placing the resident's feet on the footrests despite her resistance. The nurse aide's actions and comments were consistent with the reports from other staff members. The facility's abuse policy, dated April 13, 2023, mandates the protection of residents from abuse, neglect, exploitation, and misappropriation of property. However, the actions of the nurse aide on January 29, 2024, directly violated this policy, resulting in Immediate Jeopardy to the resident's physical and mental health and safety. The deficiency was cited as past non-compliance, and the facility was required to take corrective actions to address the issue and prevent future occurrences.
Failure to Address Resident's Behavioral Needs
Penalty
Summary
The facility failed to properly address a resident's behavior of repeatedly taking her feet off the wheelchair footrests and placing them on the ground. This resulted in Immediate Jeopardy when a nurse aide continued to grab hold of the resident's ankles, causing her to yell out and place her feet back on the ground. The resident then hit the nurse aide, who responded by slapping the resident's hand and calling her an offensive name. The resident involved had diagnoses including Parkinson's disease, anxiety, and depression. Despite the resident's clear distress and refusal to keep her feet on the footrests, the nurse aide persisted in trying to place the resident's feet back on the footrests. This escalated the situation, leading to physical and verbal altercations between the resident and the nurse aide. There was no documented evidence in the resident's clinical record indicating that the nurse aide attempted different approaches or interventions to prevent the behavior from escalating. The facility's policy on behaviors, which includes various non-pharmacological interventions, was not followed in this instance, leading to the deficiency.
Failure to Ensure Resident Safety and Proper Behavior Management
Penalty
Summary
The Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to ensure that the residents' environment remained free from abuse, as required by their job descriptions. The deficiencies cited under the Code of Federal Regulatory Groups for Long-Term Care, 483.12 Freedom from Abuse, Neglect, and Exploitation (F600), revealed that the NHA and DON did not fulfill their essential job duties. This included failing to ensure that staff reported abuse and protected residents from further abuse, as well as failing to properly address a resident's behavior. The job descriptions for both the NHA and DON outlined their responsibilities for overseeing compliance with regulatory requirements and maintaining the highest practicable well-being of each resident, which they did not meet. Additionally, the deficiencies cited under 483.12(b)(1) and 483.12(b)(5)(iii) revealed that the NHA and DON did not ensure that staff timely reported abuse and allowed staff to return to the resident. Furthermore, under 483.40(b)(2), it was found that the NHA and DON failed to ensure that staff properly addressed a resident's behavior, particularly in cases where the resident's assessment did not reveal a diagnosis of a mental or psychosocial adjustment difficulty. These failures were in direct violation of the responsibilities outlined in their job descriptions and the regulatory requirements for long-term care facilities.
Failure to Include Behavioral and Psychotropic Medication Instructions in Baseline Care Plan
Penalty
Summary
The facility failed to ensure that a baseline care plan included instructions regarding behaviors and the use of psychotropic medications for a resident admitted after February 9, 2024. The resident, who had a history of dementia with behaviors, anxiety, and major depression, was prescribed multiple psychotropic medications including Seroquel, lorazepam, and escitalopram. Upon admission, the resident exhibited significant behavioral issues such as agitation, anxiety, and refusal to take medications or undergo assessments. Despite these behaviors and the use of psychotropic medications, the baseline care plan did not include necessary instructions to manage these issues. The resident's daughter informed the facility of the resident's aggressive behaviors, including hitting, spitting, kicking, and throwing objects when upset. Staff documented multiple instances of the resident being combative and uncooperative, including refusing to remove her coat, throwing a cup of gingerale, and hitting and spitting at staff. Despite these documented behaviors and the use of psychotropic medications, the baseline care plan failed to address these critical aspects of the resident's care. The Nursing Home Administrator confirmed that the baseline care plan should have included this information.
Failure to Develop Comprehensive Care Plans for Resident with Behavioral Issues
Penalty
Summary
The facility failed to develop comprehensive care plans that included specific and individualized interventions to address the care needs of Resident 2. The resident, who had diagnoses of Parkinson's disease, anxiety, and depression, exhibited combative behaviors and resistance to care, such as refusing baths and hitting, pinching, and cursing at staff. Despite these behaviors being documented in nursing notes, there was no evidence of a comprehensive care plan addressing these behaviors until February 15, 2024. On January 29, 2024, an incident occurred where Resident 2 hit a nurse aide while being assisted into a wheelchair. The resident repeatedly removed her feet from the wheelchair footrests and became physically aggressive when the nurse aide attempted to place her feet back on the footrests. The Nursing Home Administrator later revealed that they did not believe the resident had any behaviors that warranted a care plan until February 15, 2024, indicating a delay in addressing the resident's specific needs and behaviors.
Latest citations in Pennsylvania
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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