Casselman Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Meyersdale, Pennsylvania.
- Location
- 201 Hospital Drive, Meyersdale, Pennsylvania 15552
- CMS Provider Number
- 395661
- Inspections on file
- 43
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Casselman Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with cognitive impairment, delirium, and diagnoses including dementia, anxiety, depression, and a psychotic disorder was ordered 0.25 mg of Ativan twice daily by splitting 0.5 mg tablets, with the unused half tablets to be disposed of per facility policy requiring two staff witnesses and signatures. Review of the MAR and controlled drug count record showed that while the ordered dose was administered, there was no documentation of dual-witness disposal for multiple administrations where half-tablet waste should have been recorded. The DON confirmed that required two-staff signatures for controlled medication waste were missing from the controlled drug records.
A deficiency was identified when food served to residents was not at the required safe and appetizing temperatures. During a meal service, a test tray delivered to residents' rooms was found to have baked fish and mixed vegetables below the required 135°F, with the vegetables described as cold and unpalatable. The Dietary Director confirmed that food should be served at correct temperatures and be palatable.
A resident with severe cognitive impairment and a history of physical aggression was involved in an altercation, striking another resident multiple times. Following this incident, the care plan was not revised to include new interventions to prevent future occurrences, as required by facility policy and regulations.
An LPN continued to work with an expired license for several months due to the facility's failure to verify licensure status, which was only discovered during an internal audit. No care concerns were identified during this period.
Surveyors identified that MDS assessments for three residents were inaccurately coded, failing to reflect the administration of anticonvulsant and antibiotic medications as documented in physician orders and MAR/TARs. The DON confirmed these assessment errors following review of clinical records and staff interviews.
The facility did not update care plans for two residents after their medication regimens changed. One resident's care plan continued to list diuretic therapy despite the medication being discontinued, and another's care plan listed anticoagulant therapy that was no longer being administered. These discrepancies were confirmed through MAR reviews and staff interviews.
A resident with cognitive impairment and bowel incontinence did not receive bowel care in accordance with physician orders and facility policy. Despite multiple episodes of no bowel movement for more than three days, there was no documentation that the prescribed laxative was offered or administered as required, and further interventions were not provided when the initial laxative was ineffective. The DON confirmed that staff did not follow the bowel protocol or physician's orders.
A nurse aide worked for several months with an expired certification before the lapse was discovered by facility staff. The aide's certification had expired, but she continued to provide care until the issue was identified and she was removed from the schedule.
A resident's Gabapentin blister pack was not properly labeled to reflect updated physician orders, resulting in a mismatch between the medication label and the current dosing instructions. An LPN confirmed the discrepancy and noted that a 'change in direction sticker' was missing, which was also acknowledged by the DON as a failure to follow labeling procedures.
A resident with hypothyroidism, who was prescribed levothyroxine, had a physician's order for a TSH lab to be drawn at the next lab collection. The TSH test was not included in the labs that were drawn, and there was no documentation that it was obtained as ordered. This was confirmed by the DON, indicating a failure to follow physician orders and facility policy.
A deficiency was identified when a sprinkler head near the dishwashing room on the third floor was found to have an excessive gap around the escutcheon, affecting one of seven smoke compartments. This issue was confirmed by facility leadership during the survey.
Surveyors found that two corridor doors, one on the third floor and one on the second floor, did not latch when tested, affecting two smoke compartments. The Facility Administrator and Maintenance Director confirmed these deficiencies, which were not in compliance with fire and smoke protection requirements.
Surveyors observed that smoke barrier doors near a third-floor room failed to self-close and latch when tested, affecting two smoke compartments. Facility leadership confirmed the deficiency.
A resident who was cognitively intact and required staff assistance for daily care was prescribed Morphine for pain management. An LPN misappropriated three doses of the resident's Morphine, replacing them with other pills, as confirmed by the DON and facility records.
A resident with severe pain and a prescription for Dilaudid had several doses of the controlled medication signed out, but there was no documentation in the MAR to confirm administration on those occasions. The DON confirmed the absence of required documentation, indicating a failure to maintain accurate records for controlled substances.
Two residents with moderate cognitive impairment and care needs were found to have their call bells out of reach, contrary to facility policy and their care plans. One resident's call bell was positioned on the wall above the bed, while another's was found on the floor near the bed. Staff and the DON confirmed that the call bells should have been accessible to the residents.
A resident with cognitive impairment and limited mobility developed worsening pressure ulcers. Despite repeated wound consultant recommendations to use an alternating pressure pad (APP) for offloading, there was no evidence that this intervention was discussed with the physician or implemented. Facility leadership was unclear about the APP, and the resident's condition progressed to osteomyelitis, requiring hospital transfer.
The facility failed to maintain a clean and homelike environment, as evidenced by an ice machine on a chipped and stained platform in the ice room and unrepaired holes in a resident's room drywall. The Maintenance Director confirmed the issues, and the resident expressed dissatisfaction with the condition of their room.
The facility failed to replace mechanical lift batteries as per manufacturer's instructions, leading to batteries losing charge quickly and hindering staff's ability to provide timely care. Observations revealed several batteries were over seven years old, exceeding the recommended lifespan. Despite staff concerns, the facility believed there were enough backup batteries. The Maintenance Director confirmed the need for replacement, and the Nursing Home Administrator noted ongoing efforts to update the facility.
A resident with multiple health conditions experienced a decline in condition, prompting an LPN to notify the RN Supervisor. Although the RN Supervisor reportedly assessed the resident, this assessment was not documented, resulting in incomplete clinical records.
A medication cart was left unattended and unlocked by an LPN while entering a resident's room, contrary to the facility's policy requiring locked compartments for medications. This was confirmed by both the LPN and the Nursing Home Administrator.
A facility failed to obtain required documentation from a hospice provider for a resident with multiple sclerosis receiving hospice services. Despite the facility's policy requiring coordination and documentation, there was no updated charting from hospice nurse aides, LPNs, or RNs in the resident's records. The DON confirmed the absence of this documentation.
A resident experienced a significant health decline, leading to a hospital transfer. The facility failed to provide written notification of the transfer and its reasons to the resident and her representative, as confirmed by the Nursing Home Administrator.
A resident with cognitive impairment and a history of falls did not receive ordered orthostatic blood pressure monitoring due to an incorrect order entry, leading to a deficiency in care. The resident experienced dizziness and falls, prompting a CRNP to order the monitoring, but the facility failed to document the completion of this task.
The facility did not adhere to its policy of maintaining water temperatures at or below 110 degrees Fahrenheit, as observed by the Maintenance Director who recorded temperatures between 114 and 125 degrees Fahrenheit in resident areas. Both the Maintenance Director and the Nursing Home Administrator acknowledged the discrepancy and the need for adjustment.
The facility failed to document the administration of controlled medications for three residents, despite signing out doses for them. The residents, who were receiving opioid medications for pain management, had no documented evidence of receiving the signed-out doses. The Director of Nursing confirmed the lack of documentation, highlighting a deficiency in the medication administration process.
The facility failed to update and revise care plans for four residents after multiple incidents involving aggressive behavior and altercations. Despite the facility's policy requiring ongoing assessments and care plan revisions, the care plans for these residents did not reflect their current needs and conditions.
The facility failed to protect a resident from abuse when one resident hit another, resulting in an eye injury. The incident occurred after one resident repeatedly bumped into the other's chair, leading to a physical altercation. The facility's policy on abuse was not upheld, as confirmed by the Nursing Home Administrator.
Failure to Document Witnessed Disposal of Controlled Medication Waste
Penalty
Summary
Surveyors identified a failure to maintain accountability for controlled medications for one resident receiving Ativan. Facility policy dated April 7, 2025, required that waste or disposal of controlled medications be completed in the presence of the nurse and a witness, with both signing the disposition sheet. For this resident, physician orders dated January 14, 2026, directed administration of 0.25 mg of Ativan twice daily by cutting a 0.5 mg tablet in half, with the remaining 0.25 mg half tablet to be disposed of as waste. The January 2026 MAR reflected the ordered 0.25 mg twice-daily dosing, and the controlled drug count record showed that 0.5 mg tablets were being split to obtain the prescribed dose. However, review of the controlled drug count record revealed no documented evidence that two staff members witnessed and signed for the disposal of the unused 0.25 mg half tablets on multiple specific dates and times in January 2026. These missing dual signatures occurred on January 17 at 7:55 p.m., January 21 at 8:12 a.m., January 23 at 8:16 p.m., January 28 at 7:26 p.m., and January 31 at 9:07 p.m. The resident involved had a quarterly MDS dated January 15, 2026, indicating cognitive impairment, dependence for care needs, signs of delirium, and diagnoses including dementia, anxiety, depression, and psychotic disorder, and was receiving controlled antianxiety medications. In an interview on February 18, 2026, at 3:11 p.m., the Director of Nursing confirmed there was no documentation that two staff members witnessed and signed for the disposal of the half tablets on the identified dates and times.
Failure to Serve Food at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to serve food that was both palatable and at safe, appetizing temperatures, as required by its own policy and the Federal Food Code. During a lunch meal service, a test tray was observed leaving the kitchen and being delivered to residents' rooms, with the last resident receiving their meal approximately 35 minutes after the tray left the kitchen. Temperature checks revealed that the baked fish and mixed vegetables were below the required holding temperature of 135 degrees Fahrenheit, with the fish at 122.8 degrees and the vegetables at 119.0 degrees. The mixed vegetables were noted to be cold and unpalatable. The Dietary Director confirmed that food should be served at correct temperatures and be palatable.
Failure to Update Care Plan After Resident Altercation
Penalty
Summary
The facility failed to revise or update the care plan for a resident after an incident involving physical aggression. According to the facility's policy, care plans must be reviewed and revised to reflect changes in a resident's status. A resident with severe cognitive impairment, paranoid schizophrenia, and a history of physical aggression was involved in an altercation with another resident, during which he struck the other resident multiple times. Despite this incident, there was no documented evidence that the care plan was updated to include new interventions to prevent similar future incidents. Review of clinical records and staff interviews confirmed that the care plan for the resident with a history of aggression had not been revised following the altercation. The Nursing Home Administrator indicated uncertainty about what additional interventions could be implemented, but acknowledged that the care plan had not been changed after the event. This failure to update the care plan was identified during the survey as a deficiency in compliance with regulatory requirements.
LPN Worked with Expired License Due to Lapse in Verification
Penalty
Summary
A deficiency occurred when a licensed practical nurse (LPN) continued to work at the facility after her nursing license had expired. According to the Pennsylvania Code and the facility's own records, the LPN's license expired on June 30, 2024, but she continued to provide care from July 1, 2024, until a whole-house audit conducted on January 1, 2025, revealed the lapse. During this period, the LPN was not authorized to practice, as her license was not current, which is a violation of professional standards and state regulations. The facility failed to ensure that the LPN's license status was monitored and verified prior to allowing her to work. The lapse was only discovered through an internal audit, not through routine verification processes. No care concerns or adverse outcomes related to resident care were identified during the time the LPN worked with an expired license. The deficiency was cited as past non-compliance with professional standards of quality as required by federal and state regulations.
Inaccurate MDS Medication Coding for Multiple Residents
Penalty
Summary
Casselman Healthcare and Rehabilitation Center was found to be noncompliant with federal and state regulations regarding the accuracy of Minimum Data Set (MDS) assessments for three residents. Surveyors determined that the facility failed to accurately complete MDS assessments as required by the Resident Assessment Instrument (RAI) User's Manual. Specifically, for one resident receiving Gabapentin for diabetic neuropathy and another receiving Pregabalin for neuropathy, the assessments did not indicate that these residents had received anticonvulsant medications during the seven-day assessment period, despite documentation in the Medication Administration Records confirming administration of these drugs. Additionally, a third resident who was prescribed and received Silvadene (an antibiotic cream) for wound care was not coded as having received an antibiotic in the corresponding MDS assessment. These inaccuracies were confirmed through review of physician orders, medication and treatment administration records, and staff interviews, including confirmation by the Director of Nursing. The failure to accurately code the administration of anticonvulsant and antibiotic medications in the MDS assessments resulted in the facility not meeting the requirements for accurate resident assessments as outlined in 42 CFR Part 483 and the Pennsylvania Long Term Care Licensure Regulations.
Plan Of Correction
The MDS assessments (Minimum Data Set, a standardized assessment tool) for R3, R38, and R53 were modified per Resident Assessment Instrument (RAI) manual requirements. The Nursing Home Administrator re-educated the Director of Nursing and MDS Coordinator on the need to ensure coding for Gabapentin, Pregabalin, and Silvadene are accurate on the MDS. Whole house audit was completed by the MDS Coordinator to identify any other residents who may have orders for Gabapentin, Pregabalin, or Silvadene that were miscoded. Any identified MDS coding errors were fixed and the MDS resubmitted per RAI manual requirements. The Interdisciplinary team will review new orders daily (Monday through Friday) to identify any Gabapentin, Pregabalin, and Silvadene to note the need to correctly code the MDS when scheduled to be completed. The audit outcomes will be presented to the Quality Assurance Committee for review and recommendations.
Failure to Revise Care Plans After Changes in Medication Therapy
Penalty
Summary
The facility failed to ensure that the care plans for two residents were updated and revised to accurately reflect their current care needs. For one resident with a history of Multiple Sclerosis, the care plan indicated ongoing diuretic therapy, but a review of the Medication Administration Record (MAR) showed that the resident was not receiving any diuretic medication. This discrepancy was confirmed by the LPN Assessment Coordinator, who acknowledged that the care plan should have been revised to reflect the discontinuation of the diuretic therapy, but it was not. For another resident with a diagnosis of necrotizing fasciitis, the care plan documented that the resident was receiving anticoagulant therapy. However, the MAR revealed that the resident had not received any anticoagulant medications since a specific date. The Nursing Home Administration confirmed that the resident was no longer on anticoagulant therapy and that the care plan should have been updated accordingly, but this revision did not occur. These findings were based on clinical record reviews and staff interviews, and they demonstrate a failure to revise care plans following changes in residents' medication regimens.
Plan Of Correction
Care plan for R4 and R9 was discontinued immediately and a modified care plan was shown to the surveyor. The Nursing Home Administrator educated the MDS Coordinator, Director of Nursing, and other members of the interdisciplinary team on the need to ensure care plans are being discontinued when medication orders are discontinued. A whole house medication audit for the last 30 days will be completed, and any modifications needed to care plans will be completed as appropriate. Members of the interdisciplinary team will audit discontinued orders daily (Monday through Friday) for three weeks to ensure all appropriate care plans have been discontinued. The audit outcomes will be presented to the Quality Assurance Committee for review and recommendations.
Failure to Follow Bowel Protocol and Physician Orders for Cognitively Impaired Resident
Penalty
Summary
The facility failed to follow physician's orders and its own bowel protocol policy for a resident who was cognitively impaired, required assistance with daily care, was always incontinent of bowel, and had a diagnosis of paranoid schizophrenia. According to the facility's policy, if a resident has not had a bowel movement for three full days, the licensed nurse is to follow the bowel protocol as ordered by the physician, which includes administering a laxative and monitoring for effectiveness, with further interventions if needed. For this resident, there were multiple documented periods where no bowel movement occurred for more than three days, but there was no evidence that the prescribed 30 ml of Milk of Magnesia Suspension was offered or administered as required after the third day/ninth shift of no bowel movement. On one occasion, the laxative was administered five days after the last bowel movement, but it was ineffective and no further interventions were documented. Additional periods of five or more days without a bowel movement were also noted, with no documentation that the bowel protocol was followed or that the resident was offered or declined the medication. The DON confirmed that staff did not follow the facility's bowel policy and physician's orders for the resident on the identified dates.
Plan Of Correction
R42 is care planned as non-complaint with taking medications including medications ordered as part of the bowel protocol. R42 is care planned as combative and easily agitated and at times will not allow staff to touch him, which includes bowel protocol measures ordered. Resident 42 was ordered MiraLAX for constipation. Staff will encourage resident to take bowel protocol medications as ordered. Re-education will be complete by the Director of Nursing for all licensed nursing staff on following bowel protocols and documentation of refusals. An audit was conducted of all residents during the annual survey to ensure all residents that had not had a bowel movement after day 3 were given bowel protocols completed as ordered. The Director of Nursing or designee will audit whether the bowel protocol is being followed per order daily for 6 weeks. The audit outcomes will be presented to the Quality Assurance Committee for review and recommendations.
Nurse Aide Worked with Expired Certification
Penalty
Summary
The facility failed to ensure that a nurse aide maintained an active certification on the nurse aide registry as required by federal regulations. Specifically, the personnel file for an agency nurse aide showed that her certification expired on May 31, 2024. Despite this, the nurse aide continued to work in the facility from June 1, 2024, through January 1, 2025, without the facility being aware of the expired certification. The lapse was only discovered when the nurse aide herself notified the facility on January 1, 2025, at which point she was immediately removed from the schedule. A review of the facility's job description confirmed that an active nurse aide certification was necessary to perform the functions of the position. The Director of Human Resources confirmed in an interview that the nurse aide's certification had expired and should have been renewed prior to expiration, but the facility did not identify the lapse until several months later. This resulted in the nurse aide working for an extended period without the required active certification.
Failure to Properly Label Resident Medication Following Order Change
Penalty
Summary
The facility failed to ensure that medications were properly labeled for one resident. According to the facility's policy, all medications and biologicals must be labeled in accordance with state and federal regulations, including appropriate instructions and precautions. For one resident, physician's orders indicated a specific dosing schedule for Gabapentin, requiring two 300 mg capsules daily and one 300 mg capsule at bedtime. However, during a medication administration observation, it was found that the label on the resident's blister pack for Gabapentin did not match the current physician's orders. The blister pack label instead indicated a different dosing schedule, with one 300 mg capsule daily and two 300 mg capsules at bedtime. An interview with the LPN administering the medication confirmed the discrepancy between the medication label and the resident's current orders. The LPN also acknowledged that a "change in direction sticker" should have been present on the blister pack to alert staff to the updated orders. The DON further confirmed that the absence of this sticker was a failure to follow proper labeling procedures, as required by facility policy and regulations.
Plan Of Correction
R37 medication label was corrected immediately at the time of survey. R37 no longer resides at facility. Re-education will be conducted by the Director of Nursing for all licensed staff on the need to ensure that any labels needed for medication direction change are put onto the medication card. Medication direction change orders were reviewed to ensure all previous direction changes are correct on the medication labels. Medication change orders will be reviewed daily during Morning Meeting (M-F) and labels verified for accuracy by the Director of Nursing or designee. A pharmacy representative will be included in the ongoing audits and will assist with audits of the medication change orders and medication labels during monthly reviews. The audit outcomes will be presented to the Quality Assurance Committee for review and recommendations.
Failure to Obtain Ordered TSH Lab for Resident with Hypothyroidism
Penalty
Summary
A review of facility policies, clinical records, and staff interviews revealed that the facility failed to obtain laboratory studies as ordered by a physician for one resident. The facility's policy required that laboratory services be provided or obtained when ordered by a physician or other qualified practitioner, and that such services meet the needs of residents. For a resident with hypothyroidism, a pharmacy review recommended monitoring of TSH/thyroid panel due to the resident's use of levothyroxine. A physician's order was in place for staff to obtain a TSH level at the next lab draw, and the resident's care plan also indicated that labs should be obtained as ordered. However, when laboratory tests were drawn, the TSH level was not included, and there was no documented evidence that the TSH level was obtained as ordered. This was confirmed by the Director of Nursing during an interview. The failure to obtain the ordered TSH lab for the resident with hypothyroidism constituted noncompliance with both facility policy and regulatory requirements.
Plan Of Correction
The TSH lab (thyroid stimulating hormone) for R3 was completed and results received prior to end of survey. Lab result was reviewed with MD and no adverse impact to the resident as a result of delayed lab test. Re-education will be conducted by the Director of Nursing for all registered Nurses on the need to ensure all ordered TSH labs are written on the lab requisition form. An audit was conducted of all the TSH to ensure all labs were completed as ordered. New process was put in place with a Lab Form being completed on every lab day (Mon, Wed), that includes residents' name, lab testing to be completed, signature of phlebotomist and documentation of Y= Completed, N=Not completed, UTO=Unable to obtain, or refusal and Nurse Signature. The Director of Nursing or designee will audit every Monday and Wednesday for 6 weeks. The audit outcomes will be presented to the Quality Assurance Committee for review and recommendations.
Sprinkler System Maintenance Deficiency Identified
Penalty
Summary
During an inspection, it was observed that the sprinkler head located near the dishwashing room on the third floor had an excessive gap around the escutcheon. This issue was identified on July 30, 2025, at 11:00 a.m. The deficiency was confirmed in an interview with the Facility Administrator and Maintenance Director later that day. The report specifies that this failure to maintain the automatic sprinkler system affected one of seven smoke compartments in the facility. No information regarding residents or their medical conditions was included in the report, and the deficiency is limited to the maintenance and physical condition of the fire protection system.
Plan Of Correction
On July 30, 2025, the Maintenance Director repaired the excessive gap around the escutcheon. The Nursing Home Administrator re-educated the Maintenance Director and maintenance assistant on the need to ensure no excessive gaps are present around the sprinkler heads. The Maintenance Director conducted a whole house audit to ensure no other sprinkler heads had an excessive gap. The Maintenance Director or designee will conduct a sprinkler head monthly audit. The audit findings will be submitted to the Safety Committee for review.
Failure to Maintain Properly Latching Corridor Doors
Penalty
Summary
Surveyors observed that the facility failed to maintain corridor doors in accordance with NFPA 101 and CMS regulations. Specifically, during an inspection on July 30, 2025, it was found that the door to Room 300 on the third floor and the door to Room 222 on the second floor did not latch when tested. These deficiencies were identified in two of the seven smoke compartments within the facility. The observations were confirmed through interviews with the Facility Administrator and Maintenance Director, who acknowledged the issues with the corridor doors. The report does not mention any specific residents affected or provide details about their medical history or condition at the time of the deficiency. The deficiency is limited to the failure of the doors to latch properly, as required for fire and smoke protection.
Plan Of Correction
On July 30, 2025, the Maintenance Director adjusted the Room 300 door and the Room 222 door and ensured the doors latched. The Nursing Home Administrator re-educated the Maintenance Director and maintenance assistant on the need to ensure all corridor doors latch properly. The maintenance staff will conduct a whole house audit to ensure all corridor doors in all smoke compartments latch properly. All corridor doors will be checked weekly during Interdisciplinary Team room rounds, and work orders will be submitted for any doors not latching properly. Room rounds reports are reviewed during morning meetings and submitted to the Safety Committee as appropriate for review.
Smoke Barrier Doors Failed to Self-Close and Latch
Penalty
Summary
During an observation on July 30, 2025, at 10:00 a.m., surveyors found that the smoke barrier doors near Room 300 on the third floor did not self-close and latch when tested. This deficiency affected two of seven smoke compartments in the facility. The issue was confirmed in an interview with the Facility Administrator and Maintenance Director later that day. No information regarding residents' medical history or condition at the time of the deficiency was provided in the report.
Plan Of Correction
On July 30, 2025, the Maintenance Director adjusted the smoke barrier doors near room 300 on the third floor to ensure the doors self-close and latch when tested. The Nursing Home Administrator re-educated the Maintenance Director and maintenance assistant on the need to ensure all smoke barrier doors self-close and latch when tested. The Maintenance Director re-tested all smoke barrier doors on all floors to ensure the smoke barrier doors self-close and latch when tested. The smoke barrier doors are already on a weekly testing schedule, but maintenance will increase frequency as needed during seasonal weather changes that may increase/decrease swelling of doors. Results will be submitted to the Safety Committee for review.
Misappropriation of Resident's Controlled Medication by LPN
Penalty
Summary
A facility failed to protect a resident from the misappropriation of their medication. According to facility policy, all controlled substances must be handled, stored, and documented in compliance with laws and regulations. However, a review of records revealed that a resident, who was cognitively intact and required staff assistance for daily care due to peripheral vascular disease, was prescribed Morphine for pain management. The controlled drug record indicated that three doses of Morphine were signed out for the resident on a specific date. An investigation found that the resident's medication packet was missing three doses of Morphine, and that an LPN had misappropriated the Morphine tablets, replacing them with other pills. This was confirmed by the DON, who stated that the LPN took the resident's Morphine. The incident was documented in facility investigative records and confirmed through staff interviews.
Failure to Accurately Document Administration of Controlled Substances
Penalty
Summary
The facility failed to maintain a complete and accurate accounting of controlled medications for one resident. According to facility policy, staff are required to initial the Medication Administration Record (MAR) after administering each medication and before giving the next, and to maintain an individual controlled substance record for each resident receiving such medications. For one resident with a diagnosis including lumbosacral disc displacement and an order for Dilaudid 2 mg every six hours as needed for severe pain, the controlled drug record showed that doses of Dilaudid were signed out on three separate occasions. However, there was no documented evidence in the resident's MAR that these doses were actually administered on the dates in question. This discrepancy was confirmed by the Director of Nursing, who acknowledged the lack of documentation to indicate that the resident received the signed-out doses. The findings indicate a failure to follow facility policy and regulatory requirements for the administration and documentation of controlled substances.
Call Bells Not Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure that call bells were within reach for two residents, as required by its own policy and care plans. For one resident with moderate cognitive impairment, a history of seizures, and a risk for falls, the call bell was observed to be positioned on the wall above her bed and out of her reach. When asked, the resident was unaware of the call bell's location, and a nurse aide confirmed it was not accessible to her. The resident's care plan specifically indicated that the call bell should be within reach due to her fall risk. For another resident, also with moderate cognitive impairment and requiring assistance with toileting, the call bell was found on the floor near the bed, not within the resident's reach while he was asleep in bed. The care plan for this resident required staff to encourage the use of the call bell for assistance. An LPN confirmed that the call bell was out of reach and that the resident did use it. The Director of Nursing also confirmed that both residents' call bells should have been accessible.
Failure to Implement Wound Consultant Recommendations for Pressure Ulcer Care
Penalty
Summary
The facility failed to provide pressure ulcer care in accordance with professional standards by not ensuring that wound consultant recommendations were reviewed with the attending physician for a resident with pressure ulcers. The resident, who had moderate cognitive impairment, was dependent on staff, had limited range of motion, and a history of stroke, developed a Stage II pressure ulcer on the sacrum that later became unstageable and a new Stage II ulcer on the left heel. Wound clinic notes documented recommendations to change wound treatments and to consider the use of an alternating pressure pad (APP) for offloading, but there was no evidence that these recommendations, specifically the use of an APP, were discussed with the physician or implemented in a timely manner. Further review showed that the resident's sacral ulcer required surgical debridement and that the wound consultant repeatedly recommended the use of an APP. Facility leadership, including the Nursing Home Administrator and Director of Nursing, were unclear about what an APP was, and there was no documentation that the recommended intervention was put in place. The resident's condition progressed to osteomyelitis of the sacrum, resulting in transfer to the hospital for further treatment.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment in specific areas, as observed during a survey. In the second floor ice room, an ice machine was placed on a wooden platform that had chipped paint and a blackish-brown removable substance on its surface, measuring approximately 10.0 x 15.0 inches. The Maintenance Director confirmed that the ice machine had previously leaked, causing water to drip onto the platform and resulting in the accumulation of the substance. In a resident's room, there were four holes in the drywall to the left of the television, each measuring approximately 5.0 x 4.0 inches. The resident expressed dissatisfaction with the condition of the wall, and both the Maintenance Director and the Nursing Home Administrator acknowledged that the drywall was not homelike and required repair. These observations indicate a failure to provide a safe, clean, and comfortable environment as required by regulations.
Plan Of Correction
Ice machine platform was cleaned with proper chemical and painted. Weekly audits will be conducted 1x per week for 2 weeks to ensure the platform is clean. Ice machine rooms will be added to the monthly housekeeping deep clean schedule thereafter. The audit outcomes will be presented to the Quality Assurance Committee for review and recommendations. The four holes in the Resident 1 room were repaired during the survey and witnessed by surveyor that the holes were patched. The patches were painted and repairs are complete. A whole house audit was conducted for all resident rooms for holes in drywall. All rooms noted to have holes in drywall were patched and painted. Room rounding form was modified to include any dry wall repairs identified in rooms. Members of the interdisciplinary team round in assigned rooms and will identify any rooms with holes in drywall. Rounding sheets will be reviewed at morning meeting (M-F) and work orders entered for repairs.
Failure to Replace Mechanical Lift Batteries
Penalty
Summary
The facility failed to maintain mechanical lifts in safe operating condition by not replacing battery packs as per the manufacturer's instructions. The ArjoHuntleigh Lifter Battery Pack SPL3021, used in the facility's mechanical lifts, has a variable battery life of 2-5 years, depending on proper charging practices. Observations and staff interviews revealed that the batteries were losing charge quickly, making it difficult for staff to provide timely and safe care to residents. The batteries were not being recharged regularly, and some were not removed from the lifts when not in use for extended periods. During observations, several battery chargers and batteries were found with dates indicating they were over seven years old, exceeding the manufacturer's recommended lifespan. The Maintenance Director confirmed that nine batteries were over seven years old, and two were over three years old, acknowledging that they should be replaced according to the manufacturer's instructions. Despite staff concerns about the batteries' age and performance, the facility believed there were enough backup batteries to complete their work. The Nursing Home Administrator acknowledged the facility's ongoing efforts to update and improve the building, including replacing batteries as feasible.
Plan Of Correction
The facility evaluated the number of lifts required on each floor to meet resident needs based on the current census. One Arjo sit to stand lift and one Arjo hoyer lift were made available on each floor. All other lifts were stored for future use. The facility purchased eight (8) new lift batteries, one for each lift and one back-up for each lift. All new batteries will be labeled with the date. The maintenance director will keep purchase records. When the census increases and if additional lifts are needed, additional batteries will be purchased at that time. The Maintenance Director will round daily M-F x2 weeks to check battery chargers to ensure the green light was lit and batteries are charging. The Maintenance Director will inspect new batteries on a quarterly basis to ensure batteries are holding a charge. Results of quarterly inspections will be brought to the safety committee for review.
Incomplete Documentation of Resident Assessment
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented for a resident, identified as Resident 5. A quarterly Minimum Data Set (MDS) assessment indicated that Resident 5 had several medical conditions, including anemia, heart failure, hypertension, diabetes, cerebral vascular accident, and chronic obstructive pulmonary disease, and was receiving oxygen therapy. On November 2, 2024, a nursing note by an LPN documented that the resident exhibited increased lethargy, altered mental status, rapid respirations, and was diaphoretic. The LPN replaced the resident's oxygen tubing and informed the Registered Nurse Supervisor on duty. However, there was no documented evidence in the clinical record that an assessment by the Registered Nurse Supervisor was conducted at that time. An interview with the LPN revealed that she was assigned to the third floor but went to the second floor to change the oxygen tubing for residents after discovering that the second floor LPN had left. Upon noticing a decline in Resident 5's condition, she notified the Assistant Director of Nursing, who was the Registered Nurse Supervisor on duty, and he reportedly assessed the resident. However, the Nursing Home Administrator confirmed that the assessment by the Registered Nurse Supervisor was not documented, which constituted a failure to maintain complete and accurate clinical records as required by professional standards.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that medications were properly secured in the medication cart, as required by their policy. The policy, dated May 31, 2024, mandates that compartments containing medications must be locked when not in use, and that medication carts should not be left unattended if open. On August 13, 2024, at 8:58 a.m., a Licensed Practical Nurse left a medication cart unattended and unlocked in the hallway while entering a resident's room. This was confirmed during an interview with the nurse at the time of the observation. Additionally, the Nursing Home Administrator confirmed that the medication cart should have been locked when unattended.
Failure to Obtain Required Hospice Documentation
Penalty
Summary
The facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for a resident receiving hospice services. The facility's Hospice Program policy required coordination with the hospice representative to meet the resident's personal care and nursing needs, including documenting communication to ensure the resident's needs were addressed 24 hours per day. However, there was no documented evidence in the resident's clinical record or the hospice provider's clinical record that the facility obtained updated charting from hospice nurse aides, LPNs, or RNs for the resident. The resident in question was cognitively intact, receiving hospice services, and had a diagnosis of multiple sclerosis. Physician's orders indicated hospice treatment due to a terminal illness related to multiple sclerosis. Despite this, the last hospice nurse aide charting was dated nearly a year prior, and the last LPN and RN charting were several months old. An interview with the Director of Nursing confirmed the absence of the required charting in the resident's clinical record and the hospice provider's clinical record.
Failure to Provide Written Notification of Hospital Transfer
Penalty
Summary
The facility failed to provide written notification to a resident and the resident's representative regarding the transfer to a hospital and the reason for hospitalization. This deficiency was identified during a review of clinical records and staff interviews. Specifically, the incident involved a resident who was admitted to the facility and later experienced a significant decline in health, including increased weakness and orthostatic blood pressures. The resident expressed feelings of dizziness and fatigue, prompting a decision to transfer her to the hospital for further evaluation. Despite notifying the resident's son verbally about the transfer, the facility did not provide a written notice to either the resident or her representative, as required. The Nursing Home Administrator confirmed that no written notice was given because the resident was considered her own responsible party. This oversight was a violation of the regulations that mandate timely written notification of transfers, including the reasons for such actions, to the resident and their representative.
Failure to Follow Physician's Orders for Orthostatic Blood Pressure Monitoring
Penalty
Summary
The facility failed to follow physician's orders for a resident who experienced multiple falls. The resident, who was cognitively impaired and required substantial assistance for daily care, had a history of heart failure and hypertension. After experiencing two falls, one of which resulted in a skin tear and hip pain, a CRNP ordered orthostatic blood pressures to be taken for three days as a precaution due to the resident's intermittent dizziness when standing. Despite the physician's orders, there was no documented evidence that the facility obtained the required orthostatic blood pressures for the resident. An interview with the Director of Nursing confirmed that the staff did not complete the task because the order was entered incorrectly, and staff were not prompted to perform the necessary checks. This oversight led to a deficiency in providing appropriate treatment and care according to the resident's needs and physician's orders.
Failure to Maintain Safe Water Temperatures
Penalty
Summary
The facility failed to maintain an environment free of potential safety hazards related to hot water temperatures. A policy dated January 31, 2024, specified that water heaters servicing resident areas should not exceed 110 degrees Fahrenheit. However, during observations on June 21, 2024, the Maintenance Director recorded water temperatures ranging from 114 to 125 degrees Fahrenheit in sinks on the second and third floors. An interview with the Maintenance Director confirmed that the water temperatures should not exceed 110 degrees Fahrenheit, and he acknowledged the ability to adjust the temperatures as needed. The Nursing Home Administrator also confirmed that the water temperatures were higher than they should have been.
Failure to Document Administration of Controlled Medications
Penalty
Summary
The facility failed to ensure the accountability of controlled medications for three residents, as revealed through a review of facility policy, clinical records, and staff interviews. The policy required nurses to initial the Medication Administration Record (MAR) after administering medication, but there was no documented evidence that doses of controlled drugs signed out for administration were actually given to the residents. For Resident 2, doses of morphine sulfate and tramadol were signed out on April 28, 2024, but not documented as administered. Similarly, for Resident 3, doses of oxycodone were signed out on March 7 and 8, 2024, without documentation of administration. Resident 4 had doses of oxycodone signed out on March 21 and April 6, 2024, with no evidence of administration. The residents involved had various medical conditions and were receiving opioid medications for pain management. Resident 2 was cognitively intact, required assistance with care needs, and was receiving hospice services. Resident 3 was understood, dependent for most care needs, and also receiving hospice services. Resident 4 was cognitively intact, independent with care needs, and had end-stage renal disease. The Director of Nursing confirmed the lack of documentation for the administration of the controlled drugs, indicating a failure in the facility's medication administration process.
Failure to Update Resident Care Plans
Penalty
Summary
The facility failed to ensure that residents' care plans were updated and revised to reflect their specific care needs. This deficiency was identified for four of seven residents reviewed. The facility's policy mandates that care plans be revised as information about the resident and their condition changes, but this was not adhered to in several instances. For example, Resident 1's care plan, dated October 16, 2023, did not reflect the resident's behaviors and necessary interventions after multiple incidents involving other residents. Similarly, Resident 4's care plan, dated November 8, 2023, did not include updated interventions despite the resident's repeated verbal and physical altercations with other residents. Resident 6's care plan also lacked updates after incidents involving Resident 4's aggressive behavior towards him. The report highlights specific incidents where the care plans were not updated. For instance, Resident 4 was involved in multiple altercations with other residents, including an incident where Resident 1 hit Resident 4, causing a small scleral abrasion. Despite these incidents, there was no documented evidence that the care plans for Residents 1, 4, or 6 were updated to include individualized, specific care and services interventions. Additionally, Resident 2 reported ongoing issues with Resident 1, including attempts to hit her, but their care plans were also not updated to reflect these incidents. Interviews with the MDS Assessment Coordinator confirmed that the care plans for Residents 1, 2, 4, and 6 were not updated or revised after the incidents. This failure to update care plans is a violation of the facility's policies and Pennsylvania Code 28 Pa. Code 211.12(d)(5) Nursing Services, which requires that care plans be developed, reviewed, and revised by a team of health professionals to ensure they reflect the residents' current needs and conditions.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to ensure that residents were free from abuse, as evidenced by an incident involving Resident 1 and Resident 4. Resident 1, who was cognitively intact and had a diagnosis of anxiety, was involved in an altercation with Resident 4, who had multiple sclerosis and a history of stroke. The incident occurred when Resident 4 accidentally bumped into Resident 1's chair multiple times, leading Resident 1 to hit Resident 4 in the face. This resulted in Resident 4 sustaining a small scleral abrasion and subconjunctival hemorrhage in the right eye, for which an antibiotic ointment was prescribed. Statements from both residents and a witness confirmed the altercation, with Resident 1 admitting to hitting Resident 4 and Resident 4 describing the incident as an unprovoked attack. The facility's policy on abuse, which mandates that residents have the right to be free from abuse and neglect, was not upheld in this case. The Nursing Home Administrator confirmed the incident, indicating a failure in protecting Resident 4 from abuse by another resident.
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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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