Burgh Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pittsburgh, Pennsylvania.
- Location
- 909 West Street, Pittsburgh, Pennsylvania 15221
- CMS Provider Number
- 395883
- Inspections on file
- 44
- Latest survey
- April 10, 2026
- Citations (last 12 mo.)
- 47
Citation history
Health deficiencies cited at Burgh Care Center during CMS and state inspections, most recent first.
The facility failed to employ a qualified Dietary Manager to oversee daily Dietary Dept operations for six months. The Dietary Manager stated that the RD came to the facility once weekly and that he was not a Certified Dietary Manager, and the NHA confirmed there was no documented evidence that he met the position qualifications.
Failure to monitor food and refrigerator temperatures: The facility had missing tray line temperature documentation for multiple meals in the main kitchen, and a receptionist removed a prepared, bagged lunch for a dialysis resident from a unit refrigerator that had no thermometer or Temperature Log. The Dietary Manager and NHA confirmed the monitoring failures.
Unaddressed MRRs for Psychotropic and Antidepressant Medications: The facility failed to ensure monthly MRRs were completed and reviewed by the attending physician for three residents receiving psychotropic or antidepressant medications. Records showed missing physician responses to pharmacist recommendations involving Zyprexa, Remeron, Seroquel, and Effexor, while CRNPs documented decisions such as no GDR or contraindication to GDR. The residents had diagnoses including psychotic disorders, dementia with agitation, stroke, anxiety, hypertension, repeated falls, and depression.
Failure to Communicate Transfer Information and Required Notifications: The facility did not document that required transfer information was sent to the receiving provider for four residents who were hospitalized, including care plan goals, advance directive info, ongoing care instructions, and resident representative info. The facility also did not provide bed-hold policy info to one resident or representative at transfer, and did not notify the State LTC Ombudsman for four hospital transfers. The DON and SW confirmed the missing documentation and notifications.
Failure to Follow Ordered Treatments and Neuro Checks: The facility did not carry out ordered care for two residents. One resident with a recent RLE amputation and frostbite did not have the prescribed dressing treatment entered into the MD order set until 10 days after hospital discharge orders directed daily wound care. Another resident with Alzheimer’s disease and repeated falls was found on the floor after tripping, and although neuro checks were ordered at set intervals, only the first assessment was documented; the DON confirmed the missing follow-up assessments.
Failure to provide proper nebulizer care for three residents. Residents with orders for nebulizer treatments were observed with tubing that was not dated or was overdue for change, tubing and masks not stored in bags when not in use, and one nebulizer machine with dried debris on it. An LPN confirmed the tubing should be changed weekly and acknowledged the storage and equipment concerns.
The facility failed to complete annual performance evaluations for three NA personnel records as required by policy. Review of the files for three NAs showed no evaluations completed at least every 12 months, and the NHA stated the issue was discovered after prior HR staff were not completing staff education correctly.
Missing Physician Review of Monthly MRRs: The facility failed to document that monthly MRRs were completed and reviewed by the attending physician for five residents. Records showed missing June MRRs for several residents and pharmacist recommendations for psychotropic and other medications that were instead addressed by the CRNP or NP, with no attending physician response documented. Residents involved had diagnoses including CAD, DM, psychotic disorders, HTN, bipolar disorder, schizophrenia, depression, and repeated falls.
A dietary services deficiency occurred when meal trays did not match the planned menu for multiple residents. During meal observations, residents received missing or incorrect items such as no milk, the wrong breakfast foods, and a sandwich substitution because the kitchen was out of listed ingredients; staff confirmed several of the tray errors.
The facility failed to maintain an infection control surveillance system for several months, failed to properly monitor a resident’s personal refrigerator temperature, and failed to prevent cross contamination during a medication pass. A resident with anemia, HTN, and DM used the refrigerator daily, but the temperature log was outdated, and an LPN touched medication with an ungloved hand before administering it to a resident.
Failure to implement antibiotic stewardship monitoring: Facility policy required the IP or designee to review antibiotic utilization and identify use inconsistent with appropriate antibiotic use, but Order Listing Reports for multiple months did not show evidence that monitoring was completed. The DON confirmed the facility failed to implement the program for seven months, and stated the previous IP had handed her papers in December to place in the infection control binder.
The facility failed to provide required Effective Communication in-service training for an LPN, an RN, and three NAs. Facility policy required regular in-service education for direct care staff, but personnel file review showed no annual training documentation for the five staff members, and the NHA stated there was no employee education for the prior year and that the previous HR process had not been done correctly.
Failure to Provide Resident Rights Training: The facility did not provide required Resident Rights in-service education for an LPN, an RN, and three NAs. Personnel files lacked annual training documentation, and some education packets were undated or incomplete. The NHA stated the facility could not locate 2025 education records and later confirmed there was no employee education for that year.
Failure to Provide Required Abuse, Neglect, and Exploitation Training: The facility failed to document annual in-service education on abuse, neglect, exploitation, and dementia care for an LPN, an RN, and three NAs. Facility policy required regular staff training on these topics, but personnel files did not show the required annual education, and the NHA confirmed there was no employee education for the year reviewed.
Failure to provide required QAPI training for five staff members, including an LPN, an RN, and three NAs. Facility policy required all staff to complete regular in-service education on QAPI, but personnel files showed no annual QAPI training for the review period, and the NHA confirmed there was no employee education for the year reviewed.
Failure to Provide Required Infection Control Training: The facility did not provide required Infection Control in-service training for an LPN, an RN, and three NAs. The facility’s policy required regular staff education on infection prevention and control, but personnel files showed no annual Infection Control training for the affected staff, and the NHA stated there was no employee education for the prior year.
Failure to provide required Compliance and Ethics training for an LPN, an RN, and three NAs. Facility policy required regular in-service education for all staff, including annual compliance and ethics training documented with the date, topic, competency assessment, and hours completed. Personnel files did not show the required annual training for the five staff members, and the NHA stated there was no employee education for the year and confirmed the lapse.
Failure to Provide Required Staff In-Service Training: The facility did not provide required in-service education on dementia management and resident abuse prevention for an LPN, an RN, and three NAs. Records also showed that the three sampled NAs did not receive the minimum 12 hours of annual in-service education. The NHA and DON confirmed that education records were missing or incomplete, and that only the NAs received certain training packets.
Failure to Provide Required Behavioral Health Staff Training: The facility did not provide required Behavioral health in-service training for an LPN, an RN, and three NAs. Facility policy required regular staff education on Behavioral health, but personnel files did not show annual training for the required period, and the NHA confirmed that no 2025 employee education records were available.
Failure to Complete Background Checks Before Hire: Review of the facility policy, personnel files, and staff interview showed that two NA employees began work before criminal background checks were completed. The files showed the background check requests were made after the hire dates, and the NHA confirmed the screening was not done prior to employment for two of five personnel files reviewed.
Admission agreement signed without confirmed capacity. A resident with dementia, moderate cognitive impairment on BIMS, and pre-admission concerns for worsening cognition, poor self-care, and frequent falls signed his own admission paperwork. The record did not show attempts to contact his HC POA before the signature, and staff later acknowledged the resident was confused and that a psych note described cognitive deficits and memory gaps requiring POA support.
Lack of Nursing Participation in Care Conferences: The facility failed to promote a multidisciplinary approach during care conferences for two residents. Care conference sign-in sheets showed attendance by social work, dietary, and therapy, but nursing was not present. One resident had epilepsy, spinal stenosis, and COPD, and the other had CHF, anemia, and coronary atherosclerosis. The DOSS stated nursing was unavailable for the meetings.
Failure to Properly Assess and Document a Heel Pressure Wound: A resident with anemia, HTN, and ESRD developed an open area on the left heel that was treated with Medi honey and border gauze, but wound documentation was incomplete. The wound care team could not evaluate the resident at times because the resident was at dialysis, and nursing notes failed to include ordered weekly measurements and wound type/characteristics. An RN confirmed the facility failed to timely categorize the wound, care plan the actual wound, and document measurements as ordered.
The facility failed to provide appropriate catheter care for two residents with urinary catheters. One resident with MS, neurogenic bladder, and a Foley catheter, and another resident with prostate cancer, diabetes, obstructive uropathy, and a suprapubic catheter, were observed in bed with catheter drainage bags on the floor; one bag also lacked a dignity bag. An RN confirmed the observations.
Failure to Care Plan for Colostomy Management: The facility failed to develop care plans for the care and management of a colostomy for two residents. Both residents had an ostomy noted on the MDS and physician orders for weekly and PRN colostomy appliance changes, but their current care plans did not include colostomy care. The RNAC confirmed the omission during interview.
A resident with ESRD, anemia, and HTN had dialysis orders that were not reflected in the care plan, which listed different treatment days and pickup time. Dialysis Record of Visit forms also showed incomplete communication with the dialysis center on multiple occasions, and an RN confirmed the discrepancies and incomplete documentation.
Improper Labeling and Storage of Insulin Pens: Surveyors found multiple insulin pens in a medication cart with missing open dates and expiration dates, and one Lantus pen had its original resident name crossed out and replaced with another resident’s name using a marker. An LPN confirmed the altered label and incorrect dose, and the DON acknowledged the issue. A later observation found another Lantus insulin in the cart without an open date or expiration date, which an RN confirmed.
A resident with dementia, moderate cognitive impairment on BIMS, and a documented POA signed admission paperwork that included a binding arbitration agreement. The record described the resident as confused, a poor historian, and unable to care for himself, while staff noted family concerns about the POA and did not document attempts to contact the POA. The NHA later confirmed the facility failed to ensure the resident had the capacity to understand the arbitration agreement.
Failure to Offer Influenza Immunization: A resident with HTN, anxiety, and depression did not have documentation that the flu vaccine was offered, administered, or declined. The MDS showed the resident did not receive the influenza vaccine in the facility for the current season, and the DON confirmed the omission.
Failure to Offer and Document COVID-19 Vaccination: The facility failed to ensure COVID-19 vaccination was offered to two residents and failed to document whether the vaccine was administered or declined. One resident had HTN, anxiety, and depression, and the other had anxiety, depression, and constipation; both were coded as not up to date on their MDS, and their records showed prior COVID-19 vaccinations without documentation of any later offer or refusal. The DON confirmed the omission.
Expired supplies were found on the Fourth Floor crash cart and AED, including oxygen masks, a tracheostomy kit, Ambu bags, and AED pads. Facility documentation showed no monitoring of the AED, and an RN stated the crash cart and AED should be checked daily but confirmed that no one was monitoring the AED function or the expired items.
Incomplete Investigation of Injury of Unknown Origin: The facility failed to complete a thorough investigation for a resident who fell, later went to the ER for altered mental status, and was found to have a left toe fracture. The DON stated the investigation only reviewed progress notes and did not include interviews, witness statements, or a summary of findings, despite policy requiring a full review of documentation, records, and interviews.
Incomplete contact information for the State LTC Ombudsman program and Adult Protective Services was posted in three locations, including the First Floor and the 2nd and 4th floor nursing units. Surveyors observed that the Ombudsman posting lacked the name and email address, and the APS posting lacked the name, mailing address, phone number, and email address. The NHA confirmed the missing information.
Survey Results Not Readily Accessible: The facility failed to ensure postings identifying the location of the DOH’s most recent survey results were readily accessible to residents and visitors at the First Floor, Nursing Unit Second Floor, and Nursing Unit Fourth Floor. During observation, no such postings were seen, and the NHA stated the survey results binder had broken and was in the office.
A facility failed to display required written information for residents and/or their responsible person on how to apply for Medicare and Medicaid benefits and how to receive refunds for previous payments covered by Medicare and Medicaid. Surveyors observed the missing information on the First Floor, Second Floor nursing unit, and Fourth Floor nursing unit, and the NHA confirmed the omission.
The facility did not maintain comfortable air temperatures on one nursing unit, despite a policy requiring temperatures in common resident areas to be kept between 71°F and 81°F. During a tour with the NHA, multiple rooms on the 2nd floor were measured between 64°F and 68°F. Several residents reported that it had been cold for about a week, described the environment as cold or "kind of cold," and complained of being cold in their rooms. The NHA acknowledged that the facility failed to ensure comfortable temperature levels on the 2nd floor.
Two residents with orders for regular hemodialysis did not have complete dialysis communication forms for multiple visits, as required by facility policy. The DON confirmed that documentation was incomplete, resulting in inconsistent communication with the dialysis provider.
The facility did not ensure timely and accurate behavioral services from outside vendors for two residents, as psychological service notes were documented for individuals who were either not present or had already passed away, according to staff confirmations and clinical records.
The facility did not inform the State agency when a new Medical Director replaced the previous one, as confirmed by the Nursing Home Administrator during an interview.
Multiple rooms on one unit were found to be missing bed frames, mattresses, and functional furniture, with some rooms also being used for storage instead of resident accommodation. The NHA confirmed these rooms were not available for resident use and lacked required furnishings as mandated by regulations.
A resident with multiple medical conditions developed a new abscess on the back. Despite existing physician orders for skin assessments and antibiotics, an LPN, without a physician's order, attempted to squeeze and manipulate the abscess using lidocaine cream, gauze, and tweezers. The procedure caused significant pain and bleeding, and the resident was subsequently transferred to the hospital for further care. Facility staff confirmed that the LPN acted outside the scope of practice and against facility policy.
Two residents with tracheostomies did not receive care consistent with professional standards, as the facility failed to maintain current physician orders, implement individualized care plans, and ensure staff competency in tracheostomy care. Emergency supplies were missing or improperly stored, staff lacked training in emergency and routine trach procedures, and care plans were incomplete or outdated. These failures resulted in one resident experiencing a complete tracheostomy obstruction and both residents suffering respiratory and emotional distress.
A resident with multiple medical conditions who required assistance with bed mobility fell from bed and sustained a head injury after side rails ordered by a physician were not installed or included in the care plan. Staff interviews and documentation revealed delays and confusion regarding the installation of side rails, and the resident had previously requested them and reported prior falls. The DON confirmed the facility failed to provide necessary goods and services to prevent the fall, resulting in actual harm.
The facility did not have its four week cycle menu and nutritional substitutes reviewed and approved by a Registered Dietitian before implementation for a period of ten months, as required by policy. This lapse was confirmed by the NHA and was not in compliance with dietary service regulations.
Staff failed to prevent cross contamination during a dressing change and medication passes, including improper use of PPE and hand hygiene. Surfaces used during care were not cleaned, and medications were handled with bare hands. The facility also did not implement or document an infection control surveillance plan, and staff and residents were not tested for infectious diseases according to national standards.
The facility did not implement an antibiotic stewardship program for ten months, as required by its own policies. Infection control surveillance records lacked documentation of antibiotic monitoring, and the infection preventionist and leadership confirmed that no such monitoring or stewardship activities were conducted during this time.
The facility did not have a qualified individual onsite to oversee the infection prevention and control program for a period of several months. The assigned IP was not certified until late in the period and was still learning the role, which was confirmed by the Administrator and DON.
The facility did not provide required Quality Assurance and Performance Improvement (QAPI) training to five nurse aides, as confirmed by a review of education records and staff interview. This failure was cited under regulations for licensee responsibility, management, and staff development.
The facility did not monitor or log dish machine temperatures per shift in the main kitchen for a ten-month period, as required by policy. This was confirmed during kitchen tours and interviews with the NHA, Dietary Manager, and Corporate Director of Dining Services.
The facility did not provide an activities program that met the needs of its residents, as several residents reported insufficient variety and limited access to activities, especially for those wishing to go outdoors or participate in creative and challenging options. Activity calendars showed early end times, overlapping schedules, and lacked details on locations, while clinical records had inadequate documentation of resident participation. The NHA confirmed these deficiencies during an interview.
Unqualified Dietary Manager
Penalty
Summary
The facility failed to employ a qualified Director Manager to manage the daily operations of the Dietary Department for six months. During interviews, the Dietary Manager stated that the Registered Dietitian normally came to the facility once per week, usually on Thursdays, and later stated that he had been employed as the Dietary Manager since November 2025 but was not a Certified Dietary Manager. The Nursing Home Administrator confirmed that the facility did not provide documented evidence that the Dietary Manager met the qualifications for the position.
Failure to Monitor Food and Refrigerator Temperatures
Penalty
Summary
The facility failed to properly monitor food temperatures in the main kitchen and failed to monitor refrigerator temperatures in one of three unit refrigerators on the Ground Floor. A review of the facility policy, Preventing Foodborne Illness- Food Handling dated 2/11/26, indicated that refrigeration functioning and food temperatures were to be monitored at designated intervals throughout the day and documented according to state-specific requirements, and that refrigerated food was to be stored below 41 degrees Fahrenheit. During an observation in the main kitchen on 4/8/26 at 11:45 a.m., the Tray line Temperature Log for March and April 2025 was found to have missing data. Of 114 meals served during the month of March and the beginning of April, 18 meals had no recorded food temperatures, including 10 breakfast meals, 10 lunch meals, and 18 dinner meals. During an interview the same day, the Dietary Manager confirmed that the facility failed to monitor food temperatures to prevent food borne illness. During a later observation on 4/10/26 at 9:26 a.m., a Receptionist entered the Conference Room, opened the refrigerator, and removed a prepared, bagged lunch for a dialysis resident. At that time, the refrigerator did not have a thermometer or Temperature Log to show that residents' lunches were being kept at an appropriate temperature, and the Nursing Home Administrator later confirmed that the facility failed to properly monitor refrigerator temperatures in one of three unit refrigerators.
Unaddressed MRRs for Psychotropic and Antidepressant Medications
Penalty
Summary
The facility failed to ensure that medication regimens were free from potentially unnecessary psychotropic medications for three residents. Review of facility policies showed that antipsychotic medications were to be used only when necessary for specific indicated conditions, and that the consultant pharmacist was to complete monthly medication regimen reviews (MRRs), document findings in the medical record, and communicate medication-related problems and recommendations to the responsible prescriber and facility leadership. For one resident with diagnoses of coronary artery disease, diabetes, and psychotic disorders, the record did not contain documentation that the June 2025 MRR was completed by the physician. The resident’s February 2026 MRR included a pharmacist recommendation to assess the resident for a gradual dose reduction of Zyprexa 10 mg, but the clinical record did not include a response from the attending physician. A CRNP later documented that no GDR would be done because the medication had been effective at alleviating behavioral and physical symptoms that could pose a risk of harm to the resident or others. For another resident with dementia with agitation, stroke, and anxiety, the January 2026 MRR noted that Remeron and Seroquel did not have an FDA-labeled indication, but the clinical record did not include a response from the attending physician, and the recommendation was signed by an NP. A later January 2026 MRR was also not found in the record and had no documented physician response. For a third resident with hypertension, repeated falls, and depression, MRRs in May 2025 and November 2025 recommended reassessment of Effexor dosing, but the clinical record did not include physician responses to either recommendation; in both instances, a CRNP documented that a GDR was contraindicated because symptoms such as depression or anxiety would return or worsen. The DON confirmed that the attending physician did not address the MRRs for this resident.
Failure to Communicate Transfer Information and Notify on Bed-Hold and Ombudsman Requirements
Penalty
Summary
The facility failed to make certain that necessary resident information was communicated to the receiving health care provider for four of five sampled residents who were transferred to the hospital and expected to return. For Residents R2, R7, R40, and R76, the clinical record did not show documented evidence that the facility sent information including care plan goals, advance directive information, specific instructions for ongoing care, resident representative information, and other information needed to meet the resident’s specific needs at the receiving facility. Resident R2 was admitted with diagnoses including high blood pressure, coronary artery disease, and cerebral infarction, and was transferred to the hospital and later returned to the facility. Resident R7 was admitted with diagnoses including high blood pressure, diabetes, and seizures, and was transferred to the hospital and returned the same day. Resident R40 was admitted with diagnoses including epilepsy, spinal stenosis, and chronic obstructive pulmonary disease, and was transferred to the hospital and later returned. Resident R76 was admitted with diagnoses including diabetes, nicotine dependence, and chronic pain, and was transferred to the hospital. For each of these residents, the record lacked documented evidence that the required transfer information was communicated. The facility also failed to notify the resident or resident’s representative of the bed-hold policy for Resident R2 at the time of transfer to the hospital. In addition, the Office of the State Long-Term Care Ombudsman was not notified upon hospital transfer for Residents R2, R7, R36, and R76. Resident R36 was admitted with diagnoses including congestive heart failure, anemia, and coronary atherosclerosis, and was transferred to the hospital and later returned to the facility. The DON and Social Worker confirmed the missing communication, bed-hold notification, and Ombudsman notification issues during interviews.
Failure to Follow Ordered Treatments and Neurological Monitoring
Penalty
Summary
The facility failed to provide appropriate treatment and care in accordance with orders and professional standards for two residents. One resident was admitted with diagnoses including high blood pressure, a right below-the-knee amputation, and frostbite. Hospital discharge orders dated 2/17/26 directed the facility to apply a 4 x 4, ABD pad, kerlix, and ACE wrap to the right lower extremity surgical site and change it every day, but the facility’s physician orders did not include that treatment order until 10 days later on 2/27/26. An RN confirmed that the treatment was not ordered to the resident’s right lower extremity surgical site until that later date. Another resident with diagnoses including high blood pressure, Alzheimer’s disease, and repeated falls was found on the floor after tripping, and the nursing progress note directed neurological assessments every 15 minutes for one hour, every 30 minutes for one hour, hourly for four hours, then every four hours for 24 hours. The record showed one neurological assessment completed at 10:59 a.m., but no subsequent neurological assessments were documented after that initial assessment. The DON confirmed that the facility failed to complete the additional neurological assessments as ordered.
Failure to Provide Proper Nebulizer Care
Penalty
Summary
Safe and appropriate respiratory care was not provided for three residents who had physician orders for nebulizer treatments. Facility policy stated nebulizer equipment tubing should be changed every seven days and stored in a plastic bag with the resident’s name and date when not in use. Resident R25, who had diagnoses including high blood pressure, diabetes, and schizophrenia, had an order for Ipratropium-Albuterol Solution via nebulizer as needed for shortness of breath, wheezing, or coughing. During observation, R25 was lying in bed with the nebulizer machine on an over-bed table; the tubing was not dated, was not stored in a bag when not in use, and the nebulizer machine had dried debris on the front of it. Resident R26, who had diagnoses including dementia, high blood pressure, and depression, had an order for Albuterol Sulfate Nebulization Solution every six hours for cough. During observation, R26 was lying in bed with the nebulizer machine on a bedside table; the tubing was dated 3/19/26 and was not stored in a bag when not in use. Resident R70, who had diagnoses including schizophrenia, Parkinson’s disease, and anxiety, had an order for Ipratropium-Albuterol Solution every eight hours for shortness of breath and wheezing. During observation, R70 was sitting in a wheelchair with the nebulizer machine on the windowsill; the tubing was dated 3/19/26 and was not stored in a bag when not in use. An LPN stated the tubing should be changed weekly and confirmed the tubing, storage, and debris concerns for R25, R26, and R70.
Failure to Complete Annual Nurse Aide Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations at least once every 12 months for three nurse aide personnel records: NA Employee E8, NA Employee E9, and NA Employee E10. Facility policy titled In-Service Training, Nurse Aide, dated 2/11/26, stated that the facility completes a performance review of nurse aides at least every 12 months. Review of the personnel files for NA Employee E8, hired 12/8/20, NA Employee E9, hired 6/5/05, and NA Employee E10, hired 2/21/24, showed that their records did not include annual performance evaluations as required. During interview, the NHA stated that performance evaluations were not being completed because the previous HR person was not completing staff education correctly, and that evaluations were done for everyone in March. The NHA confirmed that the facility failed to complete annual performance evaluations at least once every 12 months for these three nurse aide personnel records.
Missing Physician Review of Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to provide documentation that monthly medication regimen reviews (MRRs) were completed and reviewed by the residents’ attending physician for five residents: R4, R9, R10, R46, and R50. The cited facility policy stated that the consultant pharmacist performs MRRs at least monthly, documents the review and findings in the medical record, and communicates medication-related problems and recommendations to the responsible prescriber and facility leadership. Survey review found missing June 2025 MRR documentation for R4, R9, and R10, and missing physician review documentation for multiple MRRs for R46 and R50. Resident R4 had diagnoses including coronary artery disease, diabetes, and psychotic disorders. The record showed a pharmacist recommendation on 2/10/26 to assess Zyprexa for gradual dose reduction, but the chart did not include a response from the attending physician; instead, a CRNP documented, “No GDR,” and stated the medication would continue because it had been effective. The DON stated she could not find a completed pharmacy review for June 2025 and confirmed the facility failed to provide documentation that MRRs were completed and reviewed by the attending physician monthly for R4. Resident R10 had diagnoses including high blood pressure, bipolar disorder, and schizophrenia. The record showed a pharmacist recommendation on 5/31/25 to consider ordering a hemoglobin A1c for Detemir insulin, but there was no response from the attending physician; a CRNP later documented that the test should not be ordered because it was not medically necessary. Resident R46 had MRRs dated 1/10/26 and 1/23/26 with pharmacist recommendations regarding Remeron and Seroquel lacking FDA-labeled indications, but the chart did not include attending physician responses and one review could not be located. Resident R50 had diagnoses including high blood pressure, repeated falls, and depression; pharmacist recommendations on 5/30/25 and 11/24/25 regarding Effexor dose reassessment were not responded to by the attending physician, and the CRNP documented that GDR was contraindicated. The DON confirmed that monthly medication regimen reviews were being addressed by the facility and nurse practitioners rather than the residents’ attending physician for R10, R46, and R50.
Menu Items Not Followed for Multiple Residents
Penalty
Summary
The facility failed to follow the menu for five residents during meal observations, with trays not matching the tray tickets or planned menu items. Resident R39 and Resident R13 were observed at lunch on 4/7/26; R39 received a mechanical soft hamburger, onion rings, peas and carrots, and ice cream, while R13's tray was missing the hamburger bun. Later that same meal observation, R13's tray ticket listed milk, a hot beverage, a turkey sandwich with Swiss cheese, onion rings, peas and carrots, and ice cream, but the tray did not include the turkey sandwich. Instead, the sandwich was bologna with American cheese because the kitchen was out of Swiss and turkey. Resident R34 was observed at breakfast on 4/8/26 with a tray ticket listing bacon, cold cereal, two waffles, diet syrup, margarine, orange juice, and milk, but the tray contained two sausage patties instead of bacon, hot cereal instead of cold cereal, and no milk. Resident R53 and Resident R72 were observed at lunch on 4/6/26 with tray tickets listing apple/cranberry drink, baked chicken, gravy, potatoes, Brussel sprouts, fruit cocktail, and milk, but both trays were missing milk. Staff interviews confirmed that R53 and R72 did not receive milk, and another staff member confirmed that R34 received the wrong breakfast items and no milk.
Infection Control Surveillance, Refrigerator Monitoring, and Medication Pass Cross-Contamination
Penalty
Summary
The facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for seven of 11 months, including May 2025, June 2025, July 2025, August 2025, September 2026, October 2025, and November 2025. Review of the facility’s infection control documentation for the previous 11 months failed to reveal surveillance for tracking infections for residents during those months. During interview, the DON stated that the previous IP had handed over a stack of papers in December to be placed in the infection control binder, and the DON confirmed the facility failed to implement an infection control program with surveillance for those months. The facility also failed to properly monitor the temperature of one resident’s personal refrigerator. Resident R19 was admitted with diagnoses of anemia, high blood pressure, and diabetes, and was observed using the refrigerator daily. The refrigerator had a temperature log dated January 2026, and RN E11 confirmed the facility failed to properly monitor the refrigerator temperature. In addition, during a medication pass, LPN E12 placed medication in an ungloved hand before putting it into a medicine cup and administering it to Resident R67. LPN E12 confirmed the medication was touched without a glove and then given to the resident, demonstrating failure to prevent cross contamination during the medication pass.
Failure to Implement Antibiotic Stewardship Monitoring
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for seven of 11 months, including May 2025, June 2025, July 2025, August 2025, September 2025, October 2025, and November 2025. Review of the facility's infection control policies and procedures showed that the purpose of the antibiotic stewardship program was to monitor the use of antibiotics in residents, and that the IP, or designee, was to review antibiotic utilization as part of the program and identify situations not consistent with appropriate antibiotic use. Review of facility documentation for each of the affected months showed Order Listing Reports printed on 12/9/25, but the reports did not include evidence that antibiotic monitoring had been completed for those months. During an interview on 4/7/26, the DON stated that the previous IP had handed her a bunch of papers in December to put in the infection control binder, and she did not like the way the IP did things. The DON confirmed that the facility failed to implement the antibiotic stewardship program for the seven months identified in the report.
Missing Required Effective Communication Training
Penalty
Summary
The facility failed to provide training on Effective Communication for five of five staff members, including one LPN, one RN, and three NAs. Facility policy titled In-Service Training, All Staff required regular in-service education for direct care staff on effective communication with residents and family, along with other required topics, and stated that training must be completed prior to providing care, annually, and as necessary based on the facility assessment. Completed training was to be documented by the staff development coordinator or designee with the date and time, topic, competency summary, and hours completed. During interviews, the NHA stated that the facility had recently made staff complete education and later stated that there was no employee education for 2025. The NHA explained that the previous HR employee did not do the job correctly and that the outgoing corporate company was not monitoring the work. Review of the personnel files for the five staff members showed no annual in-service training on Effective Communication for 1/1/25 through 12/31/25. The facility did provide education test packets for four staff members, and for one NA the packets were signed but undated.
Failure to Provide Resident Rights Training
Penalty
Summary
Staff members were not provided training on Resident Rights and facility responsibilities as required by facility policy. Review of the facility's In-Service Training policy showed that all staff are required to participate in regular in-service education on topics including resident rights and responsibilities, abuse prevention, QAPI, infection prevention and control, behavioral health, and compliance and ethics, with training completed before providing care, annually, and as needed based on the facility assessment. The policy also required documentation of the date and time of training, topic, competency assessment summary, and hours completed. Review of personnel files showed no annual in-service training on Resident Rights for five staff members: an LPN, an RN, and three NAs. The facility provided education test packets for some of the staff, but the records did not show annual Resident Rights training for 1/1/25 through 12/31/25, and one NA's packets had no date present. During interviews, the NHA stated the facility had recently made staff complete education, could not locate employee education records for 2025, and later confirmed there was no employee education for 2025 because the previous HR employee had not done the job correctly and the outgoing corporate company had not monitored the work.
Failure to Provide Required Abuse, Neglect, and Exploitation Training
Penalty
Summary
The facility failed to provide annual training on Abuse, Neglect, and Exploitation for five of five staff members reviewed: one LPN, one RN, and three NAs. The facility policy for In-Service Training, All Staff dated 2/11/26 required regular in-service education for all staff, including training on preventing abuse, neglect, exploitation, and misappropriation of resident property, as well as dementia management and resident abuse prevention. The policy also stated training must be completed before staff provide care, annually, and as needed based on the facility assessment, with documentation maintained by the staff development coordinator or designee. During interviews, the NHA stated the facility had recently made staff complete education and later acknowledged there was no employee education for 2025. Review of the personnel files showed no annual in-service training on Abuse, Neglect, and Exploitation for the LPN, RN, and three NAs for the 1/1/25 through 12/31/25 period. The facility did provide education test packets for four staff members, and two packets for one NA were signed but undated, but the files still did not include the required annual training documentation. The NHA confirmed the facility failed to provide the required training for all five staff members.
Failure to Provide Required QAPI Training
Penalty
Summary
The facility failed to provide required annual in-service training on the Quality Assurance and Performance Improvement (QAPI) program for five of five staff members reviewed: one LPN, one RN, and three NAs. Facility policy titled In-Service Training, All Staff, dated 2/11/26, stated that all staff are required to participate in regular in-service education and that required topics include the elements and goals of the facility QAPI program, with training to be completed before staff provide care, annually, and as needed based on the facility assessment. During interviews, the NHA stated that the facility had recently made everyone complete education and later stated there was no employee education for 2025 because the previous HR employee did not do the job correctly and the outgoing corporate company was not monitoring the work. Review of the personnel files for the five staff members showed education test packets dated in March 2026, but no annual in-service training on the QAPI program from 1/1/25 through 12/31/25. For one NA, the education packets were signed but undated. The NHA confirmed that the facility failed to provide QAPI training for these five staff members.
Failure to Provide Required Infection Control Training
Penalty
Summary
The facility failed to provide required Infection Control training for five staff members, including one LPN, one RN, and three NAs. Review of the facility’s In-Service Training policy showed that all staff were required to participate in regular in-service education on topics including the infection prevention and control program standards, policies, and procedures, with training to be completed before providing care, annually, and as needed based on the facility assessment. The policy also required documentation of the date and time of training, the topic, a summary of the competency assessment, and the hours completed. During interviews, the NHA stated that the facility had recently made staff complete education and later stated that there was no employee education for 2025 because the previous HR employee did not do the job correctly and the outgoing corporate company was not monitoring the work. Review of the personnel files for LPN Employee E6, RN Employee E7, NA Employee E8, NA Employee E9, and NA Employee E10 showed education test packets dated in March 2026, but no annual in-service training on Infection Control from 1/1/25 through 12/31/25. The NHA confirmed that the facility failed to provide Infection Control training for these five staff members.
Failure to Provide Required Compliance and Ethics Training
Penalty
Summary
The facility failed to provide annual training on Compliance and Ethics for five of five staff members: one LPN, one RN, and three NAs. Facility policy required all staff to participate in regular in-service education, including compliance and ethics training, with training completed prior to providing care, annually, and as needed based on the facility assessment. The policy also required completed training to be documented by the staff development coordinator or designee, including the date and time of training, topic, competency assessment summary, and hours completed. Review of personnel files showed that the LPN, RN, and three NAs did not have annual in-service training on Compliance and Ethics documented for the period from 1/1/25 through 12/31/25. The facility provided education test packets for four of the five staff members, and for one NA the packets were signed but undated. During interviews, the NHA stated that there was no employee education for 2025, that the previous HR employee did not do the job correctly, and that after the prior employee left on March 1, the facility reviewed education records and realized there was none. The NHA confirmed that the facility failed to provide training on Compliance and Ethics for the five staff members.
Failure to Provide Required Staff In-Service Training
Penalty
Summary
The facility failed to provide required training on Dementia Management and Resident Abuse Prevention for five staff members: one LPN, one RN, and three NAs. Review of the facility’s In-Service Training policy showed that staff are required to complete regular in-service education on topics including preventing abuse, neglect, exploitation, and misappropriation of resident property, including dementia management and resident abuse prevention, with training completed prior to providing care, annually, and as needed based on the facility assessment. During interviews, the NHA stated that the facility had recently made staff complete education and later stated that there was no employee education for 2025 because the previous HR employee did not do the job correctly and the outgoing corporate company was not monitoring the work. The NHA also stated that once the prior HR employee left, the facility reviewed the education records and realized there was none, then began educating staff. The DON stated that only the nurse aides received both test packets, and confirmed that only NAs received a packet containing topics such as HIPAA, Falls Prevention, Restorative Nursing Services, Emergency Procedures, Workplace Safety, Understanding and Responding to Behavioral Symptoms of Dementia, Customer Service, Trauma Informed Care, and Dementia Training. Personnel file review showed that the LPN and RN had education test packets, but the packets did not include Dementia Management training, and their files did not include annual in-service training on Dementia Management and Resident Abuse Prevention for the year reviewed. The three sampled NAs also lacked annual in-service training on those topics in their files, and facility nurse aide training records showed that each of the three NAs did not receive the required minimum of 12 hours of in-service education during the year reviewed. The NHA confirmed the facility failed to provide the required training on Dementia Management and Resident Abuse Prevention for the five staff members and failed to ensure the three sampled NAs received 12 hours of annual in-service education.
Failure to Provide Required Behavioral Health Staff Training
Penalty
Summary
The facility failed to provide Behavioral Health training for five of five staff members, including an LPN, an RN, and three NAs. Facility policy titled In-Service Training, All Staff, dated 2/11/26, required regular in-service education for all staff and listed Behavioral health among the required training topics, with training to be completed prior to providing care, annually, and as necessary based on the facility assessment. The policy also required documentation of the date and time of training, topic, competency assessment summary, and hours completed. Review of personnel files showed no annual Behavioral Health in-service training for the five employees for the 1/1/25 through 12/31/25 period. The facility provided education test packets for some staff dated in March 2026, and one NA had signed packets without dates, but the files still did not contain annual Behavioral Health training for the required period. During interviews, the NHA stated that the facility had recently made staff complete education, could not locate employee education records for 2025, and later confirmed that there was no employee education for 2025 and that the facility failed to provide Behavioral Health training for the five staff members.
Failure to Complete Background Checks Before Hire
Penalty
Summary
Develop and implement policies and procedures to prevent abuse, neglect, and theft was cited after review of the facility policy, personnel files, and staff interview showed that the facility failed to properly screen two employees by not completing criminal background checks before they started work. The policy titled "Abuse, Neglect, Exploitation and Misappropriation Prevention Program" dated 2/11/26 stated that employee background checks are to be conducted and that the facility will not knowingly employ individuals with findings of abuse, neglect, exploitation, misappropriation of property, or mistreatment, or with certain disciplinary actions on a professional license. Review of NA Employee E4's personnel file showed a hire date of 2/9/26, but the criminal background check was requested on 2/26/26, after the hire date. Review of NA Employee E5's personnel file showed a hire date of 2/27/26, but the criminal background check was requested on 4/7/26, also after the hire date. During interview, the Nursing Home Administrator confirmed that the facility failed to properly screen these two employees by failing to conduct a criminal background check prior to the start of employment for two of five personnel files reviewed.
Admission Agreement Signed Without Confirmed Capacity
Penalty
Summary
The facility failed to ensure that one resident had the capacity to understand the terms of the admission agreement before signing it. Resident R64 was admitted with diagnoses including hypertension, hyperlipidemia, and dementia, and the admission MDS showed a BIMS score of 11, indicating moderate cognitive impairment. Pre-admission hospital documentation described the resident as a poor historian with cognitive impairment/dementia that was likely worsening, along with concerns about inability to care for self, frequent falls, balance problems, and not taking medications for months. The record showed that Resident R64's admission agreement was completed and signed by the resident, even though the clinical record did not include documentation that attempts were made to contact the resident's health care POA. The resident's POA was listed in the pre-admission paperwork and on the Durable Health Care POA document, but the facility did not document efforts to involve that representative before the resident signed the paperwork. A nursing note also described the resident as very confused and slightly agitated, and the social worker documented family concerns about the current POA's intentions and finances. During interview, the NHA stated the resident signed his own paperwork because no one was answering the phone and the family thought the POA was stealing his money. The NHA also stated that it took until December to get someone to evaluate the resident for capacity, and referenced a psychology note that said the resident had cognitive deficits and memory gaps and needed a POA to help with medical, financial, and other needs. Despite this, the facility allowed the resident to sign the admission agreement, and the NHA confirmed the facility failed to ensure the resident had the capacity to understand the terms of the admission agreement.
Lack of Nursing Participation in Care Conferences
Penalty
Summary
The facility failed to promote a multidisciplinary approach with care conferences for two residents. Resident R40 was admitted to the facility and had an MDS dated 2/2/26 that listed epilepsy, spinal stenosis, and COPD. Review of the multidisciplinary care conference sign-in sheets dated 1/8/26 and 4/2/26 showed attendance by social work, dietary, and therapy, but not nursing. Resident R36 was admitted to the facility and had an MDS dated 3/27/26 that listed CHF, anemia, and coronary atherosclerosis. The multidisciplinary care conference sign-in sheet dated 3/23/26 also showed attendance by social work, dietary, and therapy, but not nursing. During an interview on 4/9/26 at 1:00 p.m., the Director of Social Services stated that nursing was unavailable during the care conference meetings dated 1/8/26, 3/23/26, and 4/2/26.
Failure to Properly Assess and Document a Heel Pressure Wound
Penalty
Summary
The facility failed to make certain that Resident R6 received proper treatment for a pressure ulcer and failed to document the wound as ordered. Resident R6 was admitted with diagnoses including anemia, hypertension, and ESRD. On 1/30/26, staff were notified by an aide of an open area on the resident’s left outer heel; the area measured 2 x 2 cm, was cleaned with saline, and an order was obtained for Medi honey with a 4 x 4 border gauze once daily. A wound care consult was completed, but on 2/3/26 the skin and wound team could not evaluate the resident because the resident was at dialysis. Subsequent documentation described the left heel as having a plantar and lateral area with two small open areas and no active drainage, but the note did not include wound measurements or the type of wound. A physician order dated 2/24/26 directed staff to measure and document the wound appearance in a nurses note at bedtime every seven days for wound tracking. The 2/24/26 progress note described the left heel pressure wound as having granulation and no drainage, but did not include measurements. Additional progress notes on 3/3/26 and 3/10/26 also failed to include wound measurements, and the wound care team again documented that the resident could not be evaluated because the resident was at dialysis. During interview, RN E11 confirmed the facility failed to categorize the wound timely, failed to care plan the actual wound, and failed to document weekly measurements as ordered for Resident R6.
Improper Catheter Bag Placement for Two Residents
Penalty
Summary
The facility failed to ensure appropriate catheter care for two residents with urinary catheters. The facility policy for catheter care stated the purpose of the procedure was to prevent infection of the resident's urinary tract and directed that catheter tubing and drainage bags be kept off the floor. Resident R1 had diagnoses including multiple sclerosis, neurogenic bladder, and malnutrition, and had a physician order for a Foley catheter with monthly changes. Resident R73 had diagnoses including prostate neoplasm, diabetes, and obstructive uropathy, and had a physician order to empty a suprapubic catheter every shift and document the amount. Both residents had care plans stating they would be free from catheter-related trauma through the review date. During observation, R1 was finishing breakfast in bed and the urinary catheter bag was on the floor and did not have a dignity bag. RN E11 confirmed the bag was on the floor and lacked a dignity bag. During another observation, R73 was resting in bed and the catheter bag was also on the floor. RN E11 confirmed the catheter bag was on the floor. The report cited failures related to catheter care and nursing services for these two residents.
Failure to Care Plan for Colostomy Management
Penalty
Summary
The facility failed to create a care plan for the care and management of a colostomy for two residents. Facility policy titled Colostomy/Ileostomy Care, dated 2/11/26, stated that its purpose was to provide guidelines to help prevent exposure of the resident's skin to fecal matter and to review the resident's care plan for special needs. Review of the clinical record showed that Resident R59 was admitted to the facility, had diagnoses including malnutrition, anal cancer, and difficulty walking, and the MDS dated 2/9/26 indicated an ostomy was present. A physician order dated 2/17/26 directed that the colostomy appliance wafer and bag be changed every week and as needed. Review of Resident R59's current care plan showed no care plan for colostomy care and management. Resident R72 was also admitted to the facility, had diagnoses including COPD, BPH, and cirrhosis of the liver, and the MDS indicated an ostomy was present. A physician order dated 2/17/26 directed that the colostomy appliance wafer and bag be changed every week and as needed. Review of Resident R72's current care plan also showed no care plan for colostomy care and management. During an interview on 4/10/26 at 9:40 a.m., the RNAC confirmed the facility failed to create a care plan for the care and management of a colostomy for both residents.
Incomplete Dialysis Communication and Outdated Care Plan
Penalty
Summary
The facility failed to provide consistent and complete communication with the dialysis center for one resident who required hemodialysis services. The resident was admitted with anemia, high blood pressure, and ESRD, and had a physician order for dialysis on Tuesday and Saturday with a chair time of 10:15 a.m. The facility policy stated that residents receiving hemodialysis would have ongoing assessment and monitoring before and after dialysis and ongoing communication and collaboration with the dialysis facility. The resident’s current care plan did not match the physician order, as it listed dialysis on Tuesday, Thursday, and Saturday with a 6:00 a.m. pickup. Review of the Dialysis Record of Visit forms showed incomplete communications from the dialysis center on multiple dates. During interview, the RN confirmed the incomplete dialysis communications and acknowledged that the current care plan was not reflective of the resident’s current orders.
Improper Labeling and Storage of Insulin Pens
Penalty
Summary
The facility failed to properly store and label medications in one of two medication carts, identified as the Fourth Floor South Cart. Review of the facility’s policies showed that medications are to be stored in a safe, secure, and orderly manner, and that any medication packaging with missing, incomplete, improper, or incorrect labels is to be returned to the pharmacy for proper labeling. The facility’s labeling policy also stated that all medications must be properly labeled in accordance with state and federal guidelines, and that only the dispensing pharmacy can label or alter a medication package. During a medication cart review, surveyors observed a Lantus insulin pen with an incorrect open date of 4/7/26, another Lantus insulin pen with no open date and no expiration date, and three Novolog insulin pens with no open date and no expiration date. A Lantus insulin pen also had the resident’s original name crossed out with a blue marker and another resident’s name written on the pharmacy label with blue marker, and the dose was incorrect because the pen had not been sent from the pharmacy for that resident. An LPN confirmed these findings and stated the altered insulin pen should be destroyed because the original resident was no longer there and the medication was not labeled for the current resident. The DON was shown the altered insulin pen and confirmed the facility failed to properly store medical supplies in the Fourth Floor South Cart. On a later medication pass observation, a Lantus insulin was again found in the cart with no open date and no expiration date, and an RN confirmed the finding.
Failure to Verify Capacity Before Signing Arbitration Agreement
Penalty
Summary
The facility failed to ensure that a resident had the capacity to understand the terms of a binding arbitration agreement before signing admission paperwork. Resident R64 was admitted with diagnoses including high blood pressure, hyperlipidemia, and dementia, and the admission MDS dated 8/17/25 showed a BIMS score of 11, indicating moderate cognitive impairment. Pre-admission hospital records described the resident as a poor historian with cognitive impairment/dementia that was likely worsening, inability to care for self, poor medication adherence, frequent falls, balance problems, and decreased energy. The record also showed that Resident R64 had a Durable Health Care POA naming Resident Representative RR1 effective 12/13/23, and the pre-admission paperwork listed RR1 as the emergency contact. A nursing progress note documented that the resident was very confused and slightly agitated. A social work note stated that two cousins visited and discussed family concerns about the current POA, while the facility record did not include documentation that attempts were made to contact the POA. The admission agreement was signed by Resident R64 on 8/22/25. During interviews, the NHA stated the facility’s binding arbitration agreement was included in the admission paperwork and reviewed at admission, and later stated the resident signed his own paperwork because no one was answering the phone and the family thought the POA was stealing his money. The NHA and social worker also referenced a psychology note from 12/29/25 stating the resident had cognitive deficits and memory gaps and needed a POA to help with medical, financial, and other decisions, while also noting he was only mildly cognitively impaired and could choose who to assign as POA. The NHA ultimately confirmed the facility failed to ensure residents had the capacity to understand the terms of a binding arbitration agreement for Resident R64.
Failure to Offer Influenza Immunization
Penalty
Summary
The facility failed to make certain that an influenza immunization was offered to one resident, R26. Facility policy stated that all residents and staff are offered the vaccine prior to the onset of influenza season, and the vaccination policy stated that all residents will be offered vaccines that help prevent infectious diseases unless medically contraindicated or already vaccinated. Review of the clinical record showed that R26 was admitted to the facility and had diagnoses of high blood pressure, anxiety, and depression. The resident’s MDS dated 2/7/26 indicated that the influenza vaccine was not received in the facility for this year’s influenza vaccination season. The clinical record did not include documentation that the influenza vaccination was offered and administered or declined. During interview, the DON confirmed that the facility failed to make certain that an influenza immunization was offered to R26.
Failure to Offer and Document COVID-19 Vaccination
Penalty
Summary
The facility failed to make certain that a COVID-19 vaccination was offered to two residents, R26 and R48, and failed to document that the vaccine had been offered, administered, or declined. Facility policy titled Coronavirus Disease (COVID-19) - Vaccination of Residents, dated 2/11/26, stated that each resident is to be offered the COVID-19 vaccine unless it is medically contraindicated or the resident has already been immunized. Resident R26 was admitted to the facility and had diagnoses of high blood pressure, anxiety, and depression. The resident's MDS dated 2/7/26 coded the COVID-19 vaccination status as not up to date, and the clinical record showed the last COVID-19 vaccination was on 11/5/21, with no documentation that the vaccine was offered and administered or declined since that time. Resident R48 was also admitted to the facility and had diagnoses of anxiety, depression, and constipation. The resident's MDS coded the COVID-19 vaccination status as not up to date, and the clinical record showed the last COVID-19 vaccination was on 11/20/23, with no documentation that the vaccine was offered and administered or declined since then. During interview, the DON confirmed the facility failed to make certain the COVID-19 vaccination was offered to these two residents.
Expired crash cart and AED supplies were found on the Fourth Floor
Penalty
Summary
The facility failed to make certain that equipment was in safe operating condition for one of two crash carts on the Fourth Floor and one of two AEDs on the Fourth Floor. Review of the facility Crash Cart policy indicated that all contents must be within expiration dates, and review of the AED policy indicated that personnel should keep a spare battery and adhesive pads, record expiration dates on maintenance tasks, and document checks. However, review of the facility document labeled Emergency Crash Cart revealed no monitoring of the facility's AED. During observation of the Fourth Floor crash cart, expired supplies were found, including oxygen masks, a tracheostomy kit, and two Ambu bags. During observation of the Fourth Floor AED, an expired AED pad was found. During interview, an RN stated that the crash cart and AED should be checked daily and confirmed that no one monitors the function of the AED or the expired supplies on the crash cart and AED.
Incomplete Investigation of Injury of Unknown Origin
Penalty
Summary
The facility failed to initiate a thorough investigation for an injury of unknown origin involving Resident R10. Facility policy stated that reports of resident abuse, including injuries of unknown origin, are to be reported and thoroughly investigated, with review of documentation, medical records, observations, and interviews with relevant staff, residents, family, and witnesses. However, the investigation for Resident R10 did not include a summary of findings, witness statements, or interviews with employees, residents, or family members regarding how the injury may have occurred. Resident R10 was admitted with diagnoses including high blood pressure, chronic pain, and iron deficiency. The resident fell on 3/2/26 with no injury noted, then was sent to the ER on 3/8/26 for altered mental status and was diagnosed at the hospital with a left toe fracture and placed in a boot before returning to the center on 3/12/26. Review of the facility's records showed attempts to obtain hospital records, which confirmed that a fracture occurred at some point, but the facility investigation only reviewed progress notes from the fall through the hospital transfer. During interview, the DON stated that no interviews were conducted and confirmed that the facility failed to complete a thorough investigation for the injury of unknown origin.
Incomplete Posting of Ombudsman and APS Contact Information
Penalty
Summary
The facility failed to post complete contact information for the State Long-Term Care Ombudsman program and Adult Protective Services at three locations: the First Floor, Nursing Unit Second Floor, and Nursing Unit Fourth Floor. During observations on 4/7/26 from 12:51 p.m. through 1:10 p.m., surveyors found that the posted Ombudsman information did not include the Ombudsman’s name or email address. The same observations showed that the Adult Protective Services posting did not include APS’s name, mailing address, phone number, or email address. During an interview on 4/7/26 at 2:13 p.m., the Nursing Home Administrator confirmed that the facility failed to post complete contact information for both programs as required.
Survey Results Not Readily Accessible
Penalty
Summary
The facility failed to ensure that postings identifying the location of the Department of Health’s most recent survey results were readily accessible to residents and visitors at three of three locations: the First Floor, Nursing Unit Second Floor, and Nursing Unit Fourth Floor. During observations on 4/7/26 from 12:51 p.m. through 1:10 p.m., no postings were seen in the facility identifying where the most recent survey results could be found. During an interview on 4/7/26 at 2:13 p.m., the Nursing Home Administrator stated that the survey results binder had broken and was in the administrator’s office. The administrator confirmed that the facility had failed to ensure the survey results postings were readily accessible at the three identified locations.
Missing Medicare and Medicaid Posting Information
Penalty
Summary
The facility failed to display written information for residents and/or their responsible person on how to apply for Medicare and Medicaid benefits and how to receive refunds for previous payments covered by Medicare and Medicaid in areas where postings were available, including the First Floor, Second Floor Nursing Unit, and Fourth Floor Nursing Unit. During observations on 4/7/26 from 12:51 p.m. through 1:10 p.m., surveyors found that the required information was not included on the postings in those locations. During an interview on 4/7/26 at 2:13 p.m., the Nursing Home Administrator confirmed that the facility had failed to display the required written information in the building.
Failure to Maintain Comfortable Temperature Levels on One Nursing Unit
Penalty
Summary
The facility failed to maintain comfortable and safe air temperature levels on one of two nursing units, specifically the 2nd floor. The facility’s “Safe and Homelike Environment” policy, dated 7/24/25, states that the facility will provide a safe, clean, comfortable, and homelike environment and will maintain comfortable and safe temperature levels, striving to keep temperatures in common resident areas between 71°F and 81°F. During a tour and interview with the Nursing Home Administrator on 1/29/26 at 10:45 a.m., multiple rooms on the 2nd floor were found to have temperatures below this range, with readings of 64°F, 66°F, 67°F, and several rooms at 68°F. Resident interviews conducted later that day further confirmed concerns about low temperatures. One resident reported that the facility had been cold for about a week, though not at the time of the interview. Another resident stated it was “kind of cold” in the facility that day, while additional residents reported that it had been cold, that it was cold in their room, or directly complained of being cold. At 3:30 p.m. on the same day, the Nursing Home Administrator confirmed that the facility failed to ensure comfortable air temperature levels on the 2nd floor nursing unit, in violation of 28 Pa. Code 201.18(b)(3) regarding management responsibilities.
Failure to Maintain Consistent Dialysis Communication and Documentation
Penalty
Summary
The facility failed to maintain consistent and complete communication regarding dialysis care for two residents who required regular hemodialysis treatments. According to facility policy, ongoing communication and collaboration with the dialysis provider is required, including the use of telephone or written communication such as dialysis communication forms. For both residents, who had diagnoses including end stage renal disease, diabetes, seizures, high blood pressure, and anemia, physician orders and care plans specified dialysis three times weekly. However, a review of dialysis record of visit forms over a specified period revealed that all forms for both residents were incomplete. Interviews with the Director of Nursing confirmed that the required documentation was not fully completed for these residents, resulting in a lack of consistent communication with the dialysis facility. This deficiency was identified through review of clinical records, facility policy, and staff interviews, and was cited under relevant state codes for clinical records and nursing services.
Failure to Provide Timely and Accurate Behavioral Services from Outside Vendors
Penalty
Summary
The facility failed to provide behavioral services from outside vendors in a timely and accurate manner for two residents. According to facility policy, the facility is responsible for obtaining and ensuring the timeliness and professional standards of outside services. For one resident, clinical records showed a psychological services progress note was documented on a date when the resident was not present in the facility, as confirmed by the Nursing Home Administrator. For another resident, a psychological services progress note was also documented after the resident had already passed away, as confirmed by the Director of Nursing. These findings were based on a review of clinical records, facility documents, and staff interviews. The records indicated discrepancies in the provision and documentation of behavioral services, with services being recorded for residents who were either not present or deceased at the time. The facility acknowledged these failures during staff interviews.
Failure to Notify State Agency of Medical Director Change
Penalty
Summary
The facility failed to notify the State agency of a change in its Medical Director at the time the change occurred. Review of facility data showed that Doctor Employee E1 was the Medical Director as of 1/1/20, but during an interview, the Nursing Home Administrator stated that Doctor Employee E1 was no longer employed and that Doctor Employee E2 became the new Medical Director effective 7/24/25. The Nursing Home Administrator confirmed during the interview that the State agency had not been informed of this change in Medical Director as required by regulations.
Missing Beds, Mattresses, and Furniture in Resident Rooms
Penalty
Summary
Surveyors observed that multiple resident rooms on the third floor were missing essential furnishings, including bed frames, mattresses, and functional furniture. Both single and dual occupancy rooms were affected, with some rooms lacking one or two bed frames and mattresses, as well as necessary furniture. Additionally, one double occupancy room was found to have a key lock on the doorknob and was being used for storage rather than for resident accommodation. These findings were based on direct observation during the survey. During an interview, the Nursing Home Administrator confirmed that the rooms in question were not readily available for resident use as required. The absence of proper beds, mattresses, and furniture was acknowledged, and it was stated that these items were on order. The deficiency was cited under federal and state regulations requiring that each resident be provided with a separate bed of proper size and height, a clean and comfortable mattress, appropriate bedding, and functional furniture suitable to the resident's needs.
LPN Performed Unauthorized Procedure on Resident Abscess
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) performed a procedure outside of accepted standards of practice on a resident who had a history of spinal stenosis, anxiety disorder, hypertension, and hypothyroidism. The resident was identified as having a potential for skin impairment and had a new abscess on her back, which was documented by nursing staff. Physician orders were in place for skin assessments and antibiotics, but there were no orders for any invasive procedures such as excision, debridement, or lancing of the abscess. Despite these orders and facility policy, the LPN proceeded to manipulate the abscess after the resident requested assistance. The LPN used lidocaine cream, gauze, and tweezers, and attempted to squeeze the abscess, resulting in pain and bleeding. The LPN did not have a physician's order to perform this procedure and did not use sanitized instruments, as reported by the resident. The Assistant Director of Nursing (ADON) and other nursing staff confirmed that LPNs are not permitted to lance or excise abscesses and that the LPN had been instructed not to intervene in this manner. Following the unauthorized intervention, the resident experienced significant pain and required transfer to the hospital, where further medical intervention was necessary. Interviews with staff and review of facility documentation confirmed that the LPN's actions were not in accordance with professional standards, facility policy, or the scope of practice for LPNs. This failure resulted in actual harm to the resident and was reported to facility leadership.
Failure to Provide Safe and Appropriate Tracheostomy Care
Penalty
Summary
The facility failed to provide tracheostomy care consistent with professional standards of practice for two residents, resulting in an Immediate Jeopardy situation. Both residents had tracheostomies and required specialized respiratory care, including suctioning, oxygen therapy, and regular monitoring. The facility did not maintain current physician orders for tracheostomy care, failed to implement individualized care plans, and did not ensure that staff were competent or properly trained in tracheostomy care. For one resident, the care plan was not updated within 48 hours of admission, and there were no orders for suctioning, tracheostomy care, or enhanced barrier precautions. The other resident's care plan and orders were discontinued and not reinstated upon readmission, leaving the resident without necessary tracheostomy care instructions. Observations revealed that essential emergency supplies, such as an Ambu bag, obturator, and appropriately sized inner cannulas, were not available at the bedside. Suction equipment was improperly stored, and expired supplies were found in residents' rooms. Staff interviews confirmed a lack of training and competency in tracheostomy care, including emergency procedures, suctioning, and obtaining tracheostomy cultures. One LPN admitted to not receiving any training on tracheostomy care and was unaware of emergency protocols or how to obtain a tracheostomy culture. Additionally, staff failed to follow physician orders for oxygen therapy and did not notify the physician when changes in oxygen demand occurred. Residents reported that staff did not know how to care for tracheostomies, and one resident experienced a complete tracheostomy obstruction, requiring hospital transfer and intervention. Documentation and monitoring were inconsistent, with care plans lacking details on the frequency of tracheostomy care and the size of inner cannulas. The facility assessment did not include tracheostomy care, and staff files lacked evidence of education or competency in this area. These failures led to significant respiratory and emotional distress for the residents involved.
Failure to Provide Ordered Side Rails Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate goods and services to prevent falls, resulting in neglect of a resident who required partial to moderate assistance with bed mobility. The resident had significant medical diagnoses, including respiratory failure, heart failure, and diabetes, and was assessed as needing help to roll in bed. Despite a physician's order for bilateral side rails, the resident's care plan did not include the use of side rails, and they were not present on the bed at the time of the incident. During care, a nurse aide was repositioning the resident in bed without the use of side rails, and the bed was in a high position. The resident rolled out of bed and sustained a head injury, including a minimally depressed right orbital floor fracture, requiring transfer to the hospital. Interviews and documentation confirmed that the resident had previously requested side rails and reported prior falls from bed, but no new interventions were implemented. Staff interviews revealed confusion about the process and timeliness for installing side rails after an order was placed, with delays attributed to maintenance procedures. Observations after the incident showed the resident with visible injuries and without side rails on the bed. Multiple staff members, including nurse aides, LPNs, and the occupational therapist, acknowledged that side rails should have been installed promptly following the physician's order. The Director of Nursing confirmed that the facility failed to provide necessary goods and services to prevent the fall, resulting in actual harm to the resident.
Menus Not Reviewed by Registered Dietitian Prior to Implementation
Penalty
Summary
The facility failed to ensure that its four week cycle menu and nutritional substitutes were reviewed and approved by a Registered Dietitian prior to implementation for a period spanning ten months, from June 2024 to March 2025. Review of facility policies indicated that each resident should be provided with a nourishing, well-balanced diet that meets daily nutritional and special dietary needs. However, documentation showed that the menus and nutritional substitutes did not include a signed review by the Registered Dietitian for the specified period. This was confirmed by the Nursing Home Administrator during an interview, acknowledging that the required review and approval process by the Registered Dietitian was not completed as mandated by facility policy and regulatory requirements.
Failure to Prevent Cross Contamination and Implement Infection Control Surveillance
Penalty
Summary
The facility failed to prevent cross contamination during clinical care and medication administration, as well as to implement an effective infection control surveillance plan. During a dressing change for one resident, an LPN placed a garbage bag on the overbed tray table and a disposable gown on the dresser, using the gown as a clean field for dressing supplies. The LPN did not clean the surfaces before or after the procedure, used PPE inconsistently, and failed to maintain proper hand hygiene throughout the dressing change. The LPN confirmed these lapses during an interview. During medication passes, two LPNs were observed using improper hand hygiene techniques, such as wiping hands with a washcloth soaked in hand sanitizer and returning it to the medication cart, and handling medications with bare hands. One LPN picked up a medication bottle lid from the floor and replaced it without performing hand hygiene, then continued preparing medications. These actions were confirmed by the staff involved during interviews. The facility also failed to implement and document an infection control surveillance plan in accordance with national standards. There was no line listing for COVID-19 or Influenza cases, and staff and residents were not tested according to established protocols. The infection preventionist was unfamiliar with outbreak management procedures, and symptomatic staff were not promptly tested for COVID-19. The Director of Clinical Operations and the Director of Nursing confirmed these failures in monitoring, tracking, and testing for infectious diseases.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for a period of ten months, from June 2024 through February 2025. Review of the facility's infection control policies indicated that the purpose of the antimicrobial stewardship program was to monitor antibiotic use among residents, including documentation of indications for use. However, infection control surveillance records for October 2024 through February 2025 did not include evidence that antibiotic monitoring was completed, and the infection preventionist was unable to provide documentation for June 2024 through September 2024. During interviews, the infection preventionist, who began the role in January 2025, and facility leadership confirmed that antibiotic monitoring and stewardship activities were not carried out during this period.
Failure to Designate Qualified Onsite Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified individual onsite to be responsible for implementing the infection prevention and control program from January 2025 to March 2025. According to staff interviews, the person assigned as the infection preventionist (IP) began the role in January 2025 but did not become certified until March 27, 2025, and was still learning the responsibilities associated with the position. The Nursing Home Administrator and DON confirmed that during this period, the facility did not have a qualified individual onsite fulfilling the required duties for infection prevention and control, as mandated by federal and state regulations.
Failure to Provide QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training on its Quality Assurance and Performance Improvement (QAPI) program to five staff members. A review of facility education documents for 2024 showed that none of the five nurse aides had received QAPI training. This was confirmed during an interview with a Human Resources employee, who acknowledged that the required QAPI training had not been provided to these staff members. The deficiency was cited under state regulations related to the responsibility of the licensee, management, and staff development. No information was provided regarding any residents' medical history or condition in relation to this deficiency.
Failure to Monitor and Log Dish Machine Temperatures
Penalty
Summary
The facility failed to properly monitor and log dish machine temperatures per shift in the main kitchen over a ten-month period. According to the facility's dish machine temperature policy, a test run should be completed before use, and temperatures should be recorded on a monitoring log if the required temperature is reached. During two separate tours of the kitchen, surveyors did not find any per shift temperature logs for the dish machine. Interviews with the Nursing Home Administrator, Dietary Manager, and Corporate Director of Dining Services confirmed that the facility did not monitor or log dish machine temperatures as required from June 2024 to March 2025.
Failure to Provide Comprehensive Activities Program
Penalty
Summary
The facility failed to implement an activities program that met the needs of its residents, as evidenced by interviews, documentation review, and direct observation. Four out of six interviewed residents expressed dissatisfaction with the variety and scheduling of activities, stating they desired more diverse, creative, and challenging options, as well as increased access to outdoor activities for both smokers and non-smokers. The activity calendars for January through March showed that most activities ended by 2pm or 3pm, with limited variety and overlap between popular activities such as bingo and scheduled smoking times, preventing some residents from participating. Additionally, the calendars did not specify the locations or nursing units where activities were held, further limiting accessibility. Review of clinical records revealed inadequate documentation of resident participation in activities, with some records lacking any notes of involvement and others containing only sporadic entries over several months. During an interview, the Nursing Home Administrator confirmed the absence of sufficient documentation and acknowledged that the current activities program did not meet resident needs. These findings demonstrate a failure to provide a comprehensive activities program as required by state regulations.
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Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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