Cedar Hill Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Coraopolis, Pennsylvania.
- Location
- 951 Brodhead Road, Coraopolis, Pennsylvania 15108
- CMS Provider Number
- 395620
- Inspections on file
- 42
- Latest survey
- April 28, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Cedar Hill Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to maintain adequate hot water temperatures on two of three units, resulting in residents experiencing only lukewarm or cold water for bathing and daily care. Staff, including RNs, LPNs, NAs, and housekeeping, reported that one boiler malfunctioned, causing prolonged periods when the North and South units lacked sufficient hot water, while the subacute unit retained normal temperatures and was used for showers and filling basins. Maintenance staff acknowledged that for several days two units did not have readily available hot water in resident rooms and that no temperature monitoring was conducted during that time. During the survey, measured hot water temperatures at multiple resident sinks and shower rooms on the affected units were in the mid‑90s to just under 100°F, and several residents reported low water temperatures, difficulty or inability to comfortably shower, and needing to let water run extensively to reach only lukewarm levels.
Surveyors found that the facility failed to notify the Department of Health when two of three nursing units experienced a disruption in hot water service. The NHA acknowledged that a boiler malfunction resulted in running water that was not warm enough and that the issue was not reported because the water was not completely shut off and did not affect the entire building. A maintenance employee reported that two units lacked readily available hot water in resident rooms for a period of time, that no water temperatures were taken, and that one boiler was replaced, requiring a 30-minute shutdown of water service. The facility did not report these hot water service disruptions to the State Agency.
A resident who was dependent for lower body dressing arrived at an outside appointment without pants, and the facility failed to report this incident as an allegation of neglect to the State Agency, as required by policy and regulation.
Surveyors found that two residents' MDS assessments did not accurately document the provision of dialysis and oxygen therapy, despite physician orders and care plans confirming these treatments. The discrepancies were confirmed by the RNAC after review of clinical records and staff interviews.
Two residents with diabetes who were prescribed insulin and using continuous glucose monitoring systems (Libre) did not have their care plans updated to include interventions or documentation for the Libre system, despite physician orders and ongoing use. This deficiency was confirmed by both the NHA and DON, who acknowledged the care plans did not reflect the residents' current needs.
A resident with dementia and moderately impaired cognition was not provided with the required assistance to have their food cut into small pieces at mealtime, as specified in their care plan and meal ticket. The resident was observed attempting to tear apart a whole chicken breast with their fingers, and staff confirmed that the necessary assistance was not given.
Two residents did not receive care as ordered by their physicians: one was not consistently provided with a prescribed sling for a fracture, and another used a continuous glucose monitoring device without an active physician order for its use or care, as confirmed by staff interviews and record review.
A resident with an indwelling urinary catheter was found with the drainage bag uncovered and lying on the floor, in violation of facility policy and infection control standards. An LPN confirmed the failure to provide appropriate catheter care and services as required.
A resident with end stage renal disease and a physician-ordered fluid restriction repeatedly received fluids in excess of the prescribed limit, with no evidence of physician review or staff and resident education on the restriction. The facility also lacked orders and documentation for monitoring and dressing changes of the resident's dialysis access site, as confirmed by the DON and Nursing Home Administrator.
A resident with PTSD, dysphagia, and anxiety did not receive trauma-informed care, as there was no completed Trauma Informed Care Evaluation and the care plan addressing PTSD was not completed in a timely manner. This was confirmed by the facility's social worker.
Two residents were served meals that did not match their documented dietary preferences and physician orders, as indicated on their tray assembly tickets. Staff confirmed that the meals provided, including incorrect main dishes and the presence of restricted items like salt packets, did not align with the residents' specified needs.
A resident with multiple diagnoses, including heart failure and cellulitis, was started on a new antibiotic without the required notification to their representative. Facility policy mandates such notifications and documentation, but review of records and staff interviews confirmed this did not occur.
A resident with multiple diagnoses, including heart failure and increased confusion, had a urinalysis with culture and sensitivity (UA/CS) ordered verbally by a Unit Manager to an RN supervisor, rather than by a physician as required by facility policy. The DON confirmed this did not meet professional standards of practice for obtaining physician orders.
The facility did not respond to call bells in a timely manner for several residents with significant medical needs, as shown by repeated complaints, direct observations of long wait times, and resident interviews describing delays in receiving assistance, especially during evening and weekend shifts or when agency staff were present.
The facility failed to use PPE appropriately in two droplet precaution rooms, risking cross-contamination. Observations revealed a housekeeper and a nurse assistant not wearing required PPE, despite signage and availability. Staff interviews confirmed the deficiency, acknowledging the need for full PPE in these rooms.
The facility failed to notify the Department of Health of all positive Covid-19 cases during a current outbreak involving four residents. The Nursing Home Administrator misunderstood the reporting requirements, believing only the initial report was necessary, leading to non-compliance with health department regulations.
The facility failed to maintain the confidentiality of resident health information by placing red signs on the doors of several residents, indicating their COVID-19 infection status. This action violated the residents' privacy rights as confirmed by two RNs, who noted that the facility's previous practice was to use green signs for enhanced droplet precautions.
The facility failed to ensure medications were not left unattended at the bedside for three residents. One resident had a pill left on their bedside table, another had two inhalers without orders for self-administration, and a third had eye drops without physician orders. LPNs confirmed the failure to properly store and secure medications, and the DON acknowledged the issue.
The facility failed to ensure call bells were within reach for two residents, leading to a deficiency. One resident with hypertension, hyperlipidemia, and depression could not access her call bell, which was confirmed by an LPN. Another resident with hemiplegia, aphasia, and dysphagia also had an inaccessible call bell, confirmed by another LPN. This failure violated resident care policies and nursing services requirements.
A facility failed to ensure that a POLST or physician order for code status was available for a resident with diabetes, hypertension, and hyperlipidemia. A review of the resident's clinical record did not reveal the necessary documents, and an LPN confirmed the absence of a code status, indicating a failure to assure the availability of physician orders for life-sustaining treatment preferences.
The facility failed to notify the Office of the Long-Term Care Ombudsman Division about the hospital transfers of two residents. One resident with hypertensive heart disease, dementia, and major depressive disorder was not provided with bed hold policy information, and the Ombudsman was not notified. Another resident with anxiety, depression, and high blood pressure was also transferred without Ombudsman notification. The Social Service Director was unaware of the notification requirement.
A facility failed to document a resident's schizoaffective disorder diagnosis according to professional standards. The resident was admitted with major depressive disorder, but the diagnosis of schizoaffective disorder was not recorded until much later, despite symptoms being present. Interviews with staff confirmed the absence of necessary documentation, leading to a deficiency finding.
A resident with chronic kidney disease and other conditions eloped from the facility due to inadequate supervision. The resident was last seen in his room expressing concerns about his son. An LPN assisted him back to his room, but later, the resident was missing, and a car was seen leaving the facility. The resident's son confirmed he was with him but refused to return him or sign an AMA form. Staff interviews revealed the resident had expressed a desire to leave earlier, but no exit-seeking behavior was noted.
A facility failed to specify the size of an indwelling catheter in a physician order for a resident with a foley catheter. The resident, diagnosed with high blood pressure, kidney insufficiency, and depression, had a care plan indicating the catheter's presence, but the order lacked necessary size details, contrary to facility policy.
The facility failed to obtain physician orders and informed consent for the use of enabler/side rail assist bars for two residents. There was no documentation of assessments or evaluations to justify the use of these devices, as confirmed by staff interviews and record reviews.
A facility failed to provide required annual in-service education for an RN, as mandated by their policy. The RN's personnel record lacked documentation for training on essential topics such as resident rights, abuse, infection control, and dementia management. This deficiency was confirmed by the HR Director.
A resident with diabetes did not receive her prescribed Jentadueto medication as ordered, due to a failure in medication administration and documentation. The medication was not administered on a specific day, and although it was reordered, there was no documentation of provider notification. The issue was confirmed by the CRNP and DON.
A facility failed to disinfect a respiratory spacer and prevent cross-contamination during a dressing change. An LPN placed a used spacer in a medication cart without cleaning it, and during a dressing change, did not use a barrier, skipped hand hygiene, and failed to clean the tray table, leading to potential cross-contamination.
The facility failed to notify two residents or their representatives of the bed-hold policy during hospital transfers, as required by their policy. Despite the facility's Transfer Notice of Bed Hold Policy and Readmission policy, which mandates providing written information about the bed-hold policy prior to or at the time of transfer, this was not done for residents with conditions such as hypertensive heart disease, dementia, anxiety, and depression. Staff interviews confirmed the lack of documentation and notification, violating resident rights.
A resident with chronic kidney disease, diabetes, and depression passed away, and the facility failed to convey the resident's funds within the required 30 days. Despite processing a refund request and printing a check, the responsible party had not received the funds eight months later. The Nursing Home Administrator was unaware of the delay, highlighting a lapse in managing resident funds.
The facility failed to address Resident Council concerns for three consecutive months, including issues with call light response times, nurse aides' availability and attitudes, meal setup, and missing clothing items. Despite repeated complaints, there was no evidence of how these concerns were assigned or resolved.
Failure to Maintain Adequate Hot Water Temperatures on Two Units
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment by not maintaining acceptable hot water temperatures on two of three units (North and South). Facility policies titled “Resident Environment” and “Water Temperature” required a safe, comfortable environment and potable hot and cold water at outlets at all times. The grievance log documented two concerns related to hot water: one from a resident reporting issues with hot water temperatures and another from a resident’s daughter reporting no hot water. Staff interviews confirmed that one boiler had been having issues and that two units experienced only lukewarm water, while the subacute unit retained hot water. Multiple staff members, including RNs, LPNs, NAs, and housekeeping, reported that there had been a period when hot water was not adequate on one side of the building, describing the water as lukewarm and stating that residents on the affected units had to use the subacute side for showers or to obtain hot water for basins. The Nursing Home Administrator acknowledged that the boiler had issues and that water was not warm enough, although it was not completely shut off. Maintenance staff stated that for several days, from a Friday afternoon until a Tuesday morning, the North and South units did not have readily available hot water in the rooms and that no water temperatures were taken during that time; the water was described as feeling cool. During the survey tour, direct measurements of hot water temperatures at resident room sinks and shower rooms on the North and South units showed readings in the mid‑90s to just under 100°F, below the facility’s stated goal of 107–108°F for hot water. Residents reported that for about a week the water temperatures had been low, that they had only recently resumed showers that felt warmer, and that the water had to run quite a bit and still only became lukewarm. One resident reported taking a cold shower that morning, stating it was not enjoyable and that they could not wash their hair, while another resident in the same room described the water as “barely” warm. These observations and interviews demonstrate that residents on two units did not have consistent access to adequately hot water for bathing and daily care.
Plan Of Correction
1. The hot-water boiler system was replaced on 4/14/26. 2. The water temperatures were checked throughout the facility and are within range. 3. The NHA or designee educated the maintenance director on maintaining comfortable water temperatures. 4. The NHA or designee with audit the water temperatures in the facility 5x a week for 4 weeks. The findings will be forwarded to QAPI.
Failure to Notify State Agency of Hot Water Service Disruption
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to notify the Department of Health of a disruption in hot water service affecting two of three nursing units (North Unit and South Unit). During an interview, the Nursing Home Administrator (NHA) reported that one hot water boiler had issues and was repaired, stating that there was always running water but it was not warm enough and that the problem was not building-wide. When asked, the NHA acknowledged that the issue was not reported to the State Agency because the water was not completely shut off and did not affect the entire building. In a separate interview, a maintenance employee stated that two of the three units did not have readily available hot water in resident rooms a few weeks prior, that no water temperatures were taken and the water felt cool, and that one boiler was replaced. The maintenance employee also confirmed that to connect the new boiler, the water was shut down for about 30 minutes, and that the facility did not notify the Department of Health of this disruption of hot water service for the two affected units. No specific residents, medical histories, or clinical conditions were described in the report in relation to this deficiency.
Plan Of Correction
1.The hot-water boiler system malfunctioning was reported to the DOH via ERS system. 2.The unit's affected still had access to water on their units and hot water on the subacute unit. 3.The regional NHA, educated the NHA on the topics that need to be reported to the DOH. 4.The NHA or designee will audit all events within the facility for 4 weeks to ensure that all events are reported appropriately. The findings will be reported to QAPI.
Failure to Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect involving one resident. According to the facility's Abuse Protection policy, all accidents or incidents, regardless of severity, must be reported to the department supervisor and to State agencies as required. A review of the clinical record showed that a resident, who was dependent for lower body dressing due to multiple diagnoses including high blood pressure, cancer, and a mood disorder, arrived at an outside appointment without any pants on. The outside provider notified the facility of this incident. Despite this notification, the facility did not include the incident in the information submitted to the State Agency. During an interview, the Nursing Home Administrator confirmed that the incident was not identified or reported as an allegation of neglect. This failure to report was found to be in violation of the facility's own policy and state regulations.
Inaccurate MDS Documentation for Dialysis and Oxygen Therapy
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the care and treatments provided to two residents. For one resident with end stage renal disease, high blood pressure, and diabetes, the MDS did not indicate that dialysis was performed, despite physician orders and the care plan confirming regularly scheduled dialysis sessions. This omission was confirmed by the Registered Nurse Assessment Coordinator (RNAC) during an interview. For another resident with diabetes, high blood pressure, and dependence on supplemental oxygen, the MDS did not indicate that oxygen therapy was being provided, even though physician orders and the care plan documented continuous oxygen use via nasal cannula. The RNAC also confirmed this discrepancy during an interview. These findings were based on a review of facility policy, the RAI User's Manual, clinical records, and staff interviews.
Failure to Update Care Plans for Residents Using Continuous Glucose Monitoring
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that accurately reflected the current status and needs of two residents. For one resident with diagnoses including hypertension, depression, and diabetes, physician orders indicated the use of both fast-acting and long-acting insulin, as well as a continuous glucose monitoring system (Libre). However, the resident's care plan did not include interventions or documentation related to the use of the Libre system, despite its active use as ordered by the physician. Similarly, another resident with atrial fibrillation, hypertension, and type 2 diabetes mellitus was prescribed insulin and also utilized a Libre continuous glucose monitoring system with self-checks. The care plan for this resident also failed to address the use of the Libre system. These omissions were confirmed by both the Nursing Home Administrator and the Director of Nursing during interviews, who acknowledged that the care plans were not updated to reflect the residents' current needs as required by facility policy and regulatory standards.
Failure to Provide Required Mealtime Assistance
Penalty
Summary
A deficiency was identified when staff failed to provide appropriate assistance with meals for a resident diagnosed with heart failure, atrial fibrillation, and dementia, who had moderately impaired cognition as indicated by a BIMS score of 12. The resident's care plan and meal ticket both specified that staff were to cut food into small pieces at mealtimes. However, during an observation, the resident was seen sitting in a wheelchair at bedside, attempting to tear apart a whole chicken breast with their fingers, indicating that staff had not followed the care plan instructions. A nurse aide confirmed that the resident was not provided the required assistance, and the DON also acknowledged the failure to comply with the care plan. The facility's policy on the flow of care, which requires continuous implementation to promote quality of life and mandates that the charge nurse evaluate compliance, was not followed in this instance. This resulted in the resident not receiving the necessary support to maintain their ability to perform activities of daily living, specifically during mealtime.
Failure to Follow Physician Orders for Treatment and Device Management
Penalty
Summary
The facility failed to provide care and treatment as ordered by the physician for two residents. For one resident with diagnoses including high blood pressure, cancer, and a fracture, the physician ordered the resident to wear a sling at all times except for hygiene. However, observations on two separate occasions found the resident without the sling, and staff interviews confirmed that the sling was not in place as ordered. For another resident with diagnoses of atrial fibrillation, hypertension, and type 2 diabetes mellitus, the clinical record showed an order for insulin administration and noted the use of a continuous glucose monitoring device (libre). However, there was no active physician order for the use, care, or changing of the glucose monitoring device. The DON confirmed that no such order was present in the resident's record.
Failure to Provide Proper Catheter Care and Maintain Infection Control Standards
Penalty
Summary
A deficiency was identified when a resident with a history of high blood pressure, obstructive and reflux uropathy, and urinary tract infection was observed with an indwelling urinary catheter. The resident's catheter drainage bag was found lying uncovered on the floor, contrary to facility policy and standard infection control practices. This observation was confirmed by an LPN, who acknowledged that the drainage bag was not covered as required. The facility failed to ensure that appropriate treatments and services were provided for the use of an indwelling urinary catheter for this resident, as documented in the clinical record and confirmed through staff interview.
Failure to Maintain Dialysis Fluid Restrictions and Access Site Monitoring
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for a resident with end stage renal disease who required hemodialysis and a strict fluid restriction. Despite physician orders specifying a daily fluid restriction of 1200cc, with detailed breakdowns for dietary and nursing staff, the resident repeatedly received fluids in excess of the prescribed limit on multiple days. Documentation showed that the resident's fluid intake exceeded the ordered amount on at least ten occasions, and there was no evidence that the physician reviewed these overages or that the resident or staff were educated on the importance of adhering to the fluid restriction as outlined in the care plan. Additionally, the facility did not ensure that orders were in place to monitor the resident's dialysis access site for bleeding, infection, or erosion, nor were there orders to change the dressing as required. The Medication Administration Record lacked documentation of the total fluid intake for certain days, and interviews with staff confirmed gaps in monitoring and documentation. The Director of Nursing and Nursing Home Administrator acknowledged these failures, confirming that the facility did not maintain the resident's fluid restriction as ordered and did not have appropriate orders or monitoring in place for the dialysis access site.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with post-traumatic stress disorder (PTSD), dysphagia, and anxiety. The resident's record showed that, despite having physician orders for anxiety medications, there was no Trauma Informed Care Evaluation completed to identify and address the resident's trauma-related needs. Additionally, the care plan for PTSD was not completed in a timely manner. This was confirmed during an interview with the facility's social worker, who acknowledged the absence of the required evaluation and the delay in care plan completion. These findings demonstrate that the facility did not take necessary steps to eliminate or mitigate triggers that could cause re-traumatization for the resident, as required by regulatory standards.
Failure to Follow Resident Dietary Preferences and Tray Assembly Tickets
Penalty
Summary
The facility failed to follow tray assembly tickets reflecting resident dietary preferences and physician orders for two residents. For one resident with diagnoses including anemia, hypertension, and diabetes, the tray assembly ticket specified a hamburger on a bun with ketchup, but the resident was served Salisbury steak with gravy instead. The nurse aide confirmed the discrepancy, stating the tray was given without checking the ticket, and acknowledged that the meal did not match the resident's listed preferences. Another resident with heart failure, hypertension, and depression had a physician order for a regular diet with no mayonnaise and no salt packet. Despite the tray assembly ticket specifying cornflake chicken breast and other items, the resident was served Salisbury steak with gravy and noodles. Additionally, the resident's tray included two salt packets, contrary to the dietary restriction. Both the nurse aide and the Dietary Director confirmed that the meals served did not align with the tray assembly tickets or the residents' dietary preferences and restrictions.
Failure to Notify Resident Representative of New Antibiotic Initiation
Penalty
Summary
The facility failed to notify the resident representative of the initiation of a new antibiotic for one of three residents reviewed. According to the facility's policy, the responsible party or guardian must be informed of changes in the resident's condition or occurrences, and the nurse is required to document the name of the person notified, along with the date and time, in the nurse's notes. For the resident in question, who had diagnoses including high blood pressure, depression, and heart failure, a new order for Keflex was started to treat cellulitis of the right hip. The physician's progress notes confirmed the clinical assessment and the start of the antibiotic treatment. However, a review of the resident's progress notes did not show any documentation that the resident's representative was notified about the new antibiotic. This was further confirmed during an interview with the Nursing Home Administrator, who acknowledged that the notification did not occur. The deficiency was cited under multiple Pennsylvania Codes related to the responsibility of the licensee, management, resident care policies, and nursing services.
Failure to Follow Professional Standards for Physician Orders
Penalty
Summary
The facility failed to follow professional standards of practice in obtaining physician orders for one resident. Specifically, a Unit Manager provided a verbal order for a urinalysis with culture and sensitivity (UA/CS) to a Registered Nurse supervisor, despite not being a physician. The facility's policy requires that telephone or verbal orders must be recorded in the clinical record by the nurse receiving the order and must be provided by a physician. The resident involved had diagnoses of high blood pressure, depression, and heart failure, and was experiencing increased confusion, prompting the order for the UA/CS. The Director of Nursing confirmed that the Unit Manager was not authorized to give such orders, resulting in a failure to adhere to professional standards of practice.
Failure to Timely Respond to Resident Call Bells
Penalty
Summary
The facility failed to accommodate the call bell needs of four out of nine residents, as evidenced by multiple sources including policy review, resident council meeting minutes, grievance logs, direct observations, and interviews with staff and residents. Facility policies require that call lights be answered as soon as possible and that care be provided continuously to promote quality of life, with call lights kept within reach and answered in a timely manner. Despite these policies, repeated concerns about delayed call bell responses were documented in resident council meeting minutes over several months, and a grievance was filed by a family member regarding call bell response times. Specific residents affected included individuals with significant medical needs such as deep vein thrombosis, multiple sclerosis, anemia, heart failure, cancer, diabetes, and reduced mobility. Interviews revealed that residents experienced prolonged wait times for assistance, with reports of waiting over an hour for help, particularly during evening and weekend shifts or when agency staff were present. One resident described having to use a cup to urinate due to lack of timely assistance, while another reported an incontinence episode and waiting over an hour for help, resulting in the need for a complete bed bath. Observations confirmed that call lights were not answered promptly, with one instance showing a 17-minute wait time. Staff interviews, including with the Director of Nursing and the Nursing Home Administrator, confirmed awareness of complaints regarding call bell response times, especially on weekends. The facility's failure to respond to call bells in a timely manner for these residents was acknowledged, constituting a deficiency in meeting the residents' needs and preferences as required by facility policy and state regulations.
Inappropriate Use of PPE in Droplet Precaution Rooms
Penalty
Summary
The facility failed to appropriately use Personal Protective Equipment (PPE) in two out of 18 droplet precaution rooms, which are designated for infection control measures to prevent the spread of diseases transmitted through respiratory droplets. During a tour of the COVID and exposed unit, it was observed that although droplet isolation signage and PPE were available at each room, staff members did not adhere to the required PPE protocols. Specifically, a housekeeper and a nurse assistant were observed not wearing the appropriate PPE, such as gowns, gloves, masks, and eyewear, while performing their duties in these rooms. Interviews with staff confirmed the deficiency, as both the nurse assistant and a registered nurse acknowledged the requirement to wear full PPE, including an N-95 mask, gown, gloves, and face covering, when entering droplet isolation rooms. The Director of Nursing also confirmed the facility's failure to use PPE appropriately, which posed a potential risk for cross-contamination and the spread of infections. The clinical records of residents in the affected rooms indicated current physician orders for droplet isolation and COVID testing, with care plans updated to reflect these isolation needs.
Plan Of Correction
1. All residents in rooms 227-236 have been assessed by the DON to ensure that no harm has occurred by not wearing appropriate PPE in their rooms. No findings noted. 2. All Covid isolation rooms have been assessed to ensure that they have the appropriate signage outside of their rooms and orders. 3. IP or Designee will educate Employees on the appropriate PPE to wear in isolation rooms. 4. DON or designee will audit 5 covid isolation rooms for 4 weeks to ensure that staff are wearing appropriate PPE. All findings will be reported to QAPI.
Failure to Report All Positive Covid-19 Cases
Penalty
Summary
The facility failed to notify the Department of Health of all health department reportable diseases, specifically during a current outbreak of Covid-19. Documentation reviewed on January 30, 2025, revealed that the facility did not report all positive Covid-19 cases, which included four residents. This oversight was identified during a review of the facility's documentation and confirmed through staff interviews. During an interview, the Nursing Home Administrator (NHA) admitted to not reporting all positive Covid-19 cases, believing that only the initial report was necessary. This misunderstanding led to the facility's failure to comply with the notification requirements for reportable diseases, as outlined in the regulations. The deficiency was confirmed by the NHA during the interview process, highlighting a gap in the facility's adherence to mandatory reporting protocols.
Plan Of Correction
1. All Covid-19 positives have been reported to the DOH through the ERS system. 2. The NHA or designee will complete a look back to ensure that all Covid-19 positives within the last 30 days have been reported. 3. The Regional NHA will educate the NHA and DON on reporting all cases of Covid-19. 4. The NHA or designee will audit that all new Covid-19 cases are reported to the DOH for the next month. All findings will be reported to QAPI.
Breach of Resident Health Information Confidentiality
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of resident healthcare information for twelve residents. This deficiency was identified through a review of facility policies, observations, and staff interviews. The facility's policy on the Health Insurance Portability and Accountability Act (HIPAA) and resident rights, both dated 4/17/24, emphasized the importance of keeping resident health information private and confidential. However, during observations on 09/17/24, it was noted that signs printed in red ink were placed on the outside of several residents' doors, indicating their infection with COVID-19. This action directly disclosed the residents' health status to anyone passing by, thereby violating their privacy rights. Interviews with Registered Nurses (RN) Employee E14 and Employee E3 confirmed the breach of confidentiality. RN Employee E14 acknowledged that the facility should not disclose specific health conditions, while RN Employee E3 noted that the signs were new and questioned their appropriateness, as the facility previously used green signs for enhanced droplet precautions. Both RNs confirmed that the facility failed to adhere to the required standards for maintaining the confidentiality of residents' health information, as stipulated by 28 Pa. Code 201.29(j) and 28 Pa. Code 211.5(b).
Failure to Secure Medications at Bedside
Penalty
Summary
The facility failed to ensure medications were not left unattended at the bedside for three residents. During an observation, a round white pill was found unattended on a resident's bedside table, and the resident indicated that the nurse left before they finished taking their medication. An LPN confirmed the failure to properly store and secure medications. Another resident had two inhalers on their overbed table without physician orders for self-administration or instructions to leave them at the bedside. An LPN stated the resident was alert and could keep them at the bedside, but later removed the medications and confirmed the failure to secure them. A third resident had a bottle of eye drops on their bedside table without physician orders for self-administration. An LPN assumed the resident's son brought them and removed the eye drops, confirming the failure to properly store and secure medications. The Director of Nursing confirmed the facility's failure to store drugs and biologicals in a safe, secure, and orderly manner for these residents.
Call Bell Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call bells were within reach for two residents, leading to a deficiency in accommodating the needs and preferences of these residents. Resident R30, who was diagnosed with hypertension, hyperlipidemia, and depression, was observed sitting in her wheelchair with her call light button wrapped on the enabler/side rail assist bar on the opposite side of the bed, making it inaccessible. When asked what she would do if she needed help, Resident R30 expressed uncertainty as she could not reach her call bell. This was confirmed by an LPN who acknowledged that the call bell was out of reach. Similarly, Resident R108, who had diagnoses of hemiplegia of the right dominant side, aphasia following cerebral infarction, and dysphagia, was observed with his call bell hanging off the right-side bed rail, also out of reach. Resident R108 confirmed his inability to reach the call light, and this was corroborated by another LPN. The facility's failure to ensure that call bells were accessible to these residents was a violation of their resident care policies and nursing services requirements, as well as resident rights.
Failure to Ensure POLST Availability for a Resident
Penalty
Summary
The facility failed to ensure that a Physician Orders for Life Sustaining Treatment (POLST) or a physician order for code status was available for a resident, identified as Resident R336. This deficiency was identified during a review of the facility's policy on Advanced Directives and the clinical records of Resident R336, who was admitted with diagnoses including diabetes, hypertension, and hyperlipidemia. On a specific date, a review of the resident's clinical record did not reveal a POLST or a physician order for code status. During an interview, an LPN confirmed the absence of a code status for the resident, indicating a failure to assure the availability of the necessary physician orders and POLST for the resident's life-sustaining treatment preferences.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide timely notification to the Office of the Long-Term Care Ombudsman Division regarding the transfer of two residents to the hospital. Resident R41, who had a history of hypertensive heart disease, dementia, and major depressive disorder, was transferred to the hospital on July 17, 2024, but there was no documented evidence that the resident or their representative received written information about the facility's bed hold policy at the time of transfer. Additionally, the facility did not provide written notification to the Ombudsman for this hospitalization. Similarly, Resident R107, who was diagnosed with anxiety, depression, and high blood pressure, was transferred to the hospital on October 21, 2023, and returned to the facility later. The facility also failed to document evidence of notifying the Ombudsman about this hospitalization. During interviews, the Social Service Director admitted to not notifying the Ombudsman of hospital transfers, indicating a lack of awareness of this requirement. This oversight was confirmed during a subsequent interview with the Nursing Home Administrator.
Failure to Document Schizoaffective Disorder Diagnosis
Penalty
Summary
The facility failed to provide care and services according to accepted standards of clinical practice by not properly identifying a resident's diagnosis of schizoaffective disorder. The resident, identified as R45, was admitted with a history of major depressive disorder and other medical conditions but did not have a documented diagnosis of schizoaffective disorder until March 10, 2021. Prior to this date, the resident's clinical records, including the History and Physical assessment and PASRR screening, did not reflect this diagnosis, despite psychiatric progress notes indicating symptoms consistent with schizoaffective disorder. Interviews with facility staff, including social services and the nursing home administrator, revealed that there was no additional documentation to support the diagnosis of schizoaffective disorder before March 10, 2021. A new PASRR screening provided by the administrator also failed to acknowledge the diagnosis of a serious mental illness. This lack of documentation and failure to diagnose according to professional standards resulted in a deficiency finding by the surveyors.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision, resulting in the elopement of a resident identified as Closed Resident Record CR132. The resident, who had been admitted with chronic kidney disease, hyperlipidemia, and generalized muscle weakness, was last seen in the facility at approximately 5:30 p.m. on 6/22/24. Despite expressing concerns about his son earlier in the day, there was no indication of elopement risk during a conversation with a staff member. However, later that evening, the resident was found to be missing from his room, and a search was initiated by the staff, including the Nursing Home Administrator and Director of Nursing, with the assistance of local police. The investigation revealed that an Agency LPN had seen the resident attempting to transfer from a travel wheelchair to his wheelchair and assisted him back to his room. The resident mentioned waiting for his son, and the LPN informed the nurse of this interaction. However, the resident was not located in his room later, and a car was seen leaving the facility around the time of his disappearance. The resident's son was later contacted and confirmed that the resident was with him, but he refused to return the resident or sign an AMA discharge form. Interviews with staff indicated that the resident had expressed a desire to leave the facility earlier in the day, but no exit-seeking behavior was observed. The facility's elopement policy was not effectively implemented, as the resident was able to leave the premises without proper authorization or supervision. The incident highlighted a lapse in the facility's supervision and monitoring processes, as the resident was able to leave the facility without staff knowledge, resulting in an elopement.
Lack of Catheter Size Specification in Physician Order
Penalty
Summary
The facility failed to include physician order specifications for the size of an indwelling catheter for a resident with a foley catheter. The resident, who was admitted with diagnoses of high blood pressure, kidney insufficiency, and depression, had a care plan indicating the presence of a foley catheter. However, the physician order dated 9/12/24 did not specify the size of the catheter and balloon, which is a requirement according to the facility's policy on medication and treatment orders. This omission was identified during a review of the resident's clinical records and was communicated to the Director of Nursing.
Failure to Obtain Orders and Consent for Bed Rails
Penalty
Summary
The facility failed to adhere to its policy regarding the use of enabler/side rail assist bars, resulting in deficiencies for two residents. For Resident R30, the facility did not have a current physician order for the use of enabler/side rail assist bars, as confirmed by a Licensed Practical Nurse. Additionally, there was no evidence of an assessment to determine the resident's symptoms or reasons for using the side rails, nor was there informed consent obtained from the resident or their legal representative. Similarly, for Resident R75, the facility did not have physician orders for the use of enabler/side rail assist bars, and there was no documentation of a Side Rail Assist Bar Evaluation or consent. The Director of Nursing confirmed that the facility did not conduct ongoing accurate assessments to ensure the enabler/side rail assist bars were used appropriately to meet the residents' needs and address the associated risks. These actions and inactions led to the facility's failure to comply with the regulations outlined in 28 Pa. Code 201.14(a), 211.10(c)(d), and 211.12(d)(1)(5).
Failure to Provide Annual In-Service Education for RN
Penalty
Summary
The facility failed to ensure that nursing staff received the required annual in-service education for one out of six nursing personnel, specifically Registered Nurse Employee E5. The facility's in-service training policy mandates that all personnel complete annual training on various topics, including resident rights, abuse, neglect, behavioral health, infection control, and dementia management, as a condition of continued employment. However, a review of RN Employee E5's personnel record revealed the absence of documentation for these mandatory in-services. This deficiency was confirmed during an interview with the Director of Human Resources, who acknowledged the lapse in ensuring that RN Employee E5 received the necessary annual training.
Failure to Administer Diabetic Medication as Ordered
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by the physician for a resident, identified as R385. The resident, who was admitted with diagnoses including diabetes, chronic kidney disease, and morbid obesity, had a physician's order for Jentadueto, a diabetes medication, to be administered twice daily. However, a review of the Medication Administration Record for September 2024 revealed that the medication was not administered on September 10, 2024. Although the medication was reordered by an LPN, there was no documented evidence that the provider was notified of the missed dose. During a Resident Council Meeting, a resident expressed concern about the unavailability of diabetic medication. In a subsequent interview, the resident confirmed that the facility did not have her diabetic medication available and was informed it was being reordered. Interviews with the CRNP and the Director of Nursing confirmed the missed dose and the lack of documentation regarding the notification of the provider. The Director of Nursing acknowledged the failure to provide the medication as per the physician's order.
Infection Control Deficiencies in Respiratory Equipment and Dressing Change
Penalty
Summary
The facility failed to properly disinfect a respiratory equipment spacer for one resident and prevent cross-contamination during a dressing change for another. In the first instance, a Licensed Practical Nurse (LPN) administered medication using an albuterol inhaler with a spacer to a resident. After the administration, the LPN placed the spacer into a plastic bag and stored it in the medication cart without cleaning it according to the manufacturer's instructions. The LPN admitted to not knowing the proper procedure and confirmed that the facility did not properly disinfect the respiratory equipment. In the second instance, during a dressing change for a resident with a left foot amputation, the LPN did not place a barrier under the wound before cleansing, failed to perform hand hygiene after cleansing the wound, and did not clean the tray table after removing supplies. The LPN also took a bottle of Vashe wound cleanser into the resident's room and returned it to the treatment cart without proper precautions. The LPN confirmed these actions, indicating a failure to prevent cross-contamination during the dressing change.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify residents or their representatives of the bed-hold policy during hospital transfers, as required by their own policy. This deficiency was identified through a review of facility policy, clinical records, and staff interviews. The facility's Transfer Notice of Bed Hold Policy and Readmission policy mandates that written information about the bed-hold policy be provided to residents or their legally responsible parties prior to or at the time of transfer to a hospital or other temporary leave. However, this procedure was not followed for two residents who were transferred to the hospital. Resident R41, who had diagnoses including hypertensive heart disease, dementia, and major depressive disorder, was transferred to the hospital and later returned to the facility. The clinical record for Resident R41 lacked documented evidence that the resident or their representative received written information about the bed-hold policy at the time of transfer. Similarly, Resident R107, with diagnoses of anxiety, depression, and high blood pressure, was also transferred to the hospital and returned without documented evidence of notification about the bed-hold policy. Interviews with facility staff confirmed these omissions, indicating a failure to comply with the facility's policy and resident rights as outlined in 28 Pa. Code: 201.29(b)(d)(j).
Delayed Conveyance of Resident Funds After Death
Penalty
Summary
The facility failed to convey resident funds and close the account upon discharge or death in a timely manner for one of the five resident records reviewed. Resident R1, who had chronic kidney disease, diabetes, and depression, was pronounced dead at the facility. Despite the requirement under the Code of Federal Regulations to convey the resident's funds within 30 days of death, the responsible party for Resident R1 had not received any refund checks from the facility eight months after the resident's death. The facility's business office had processed a refund request, and a check was printed on the same day the refund was approved. However, the check had not been cleared as of the date of the report. The Nursing Home Administrator was unaware of the delay in sending the refund, indicating a lapse in the facility's management of resident funds. This deficiency was identified during a review of facility policy, clinical records, resident fund account statements, and staff interviews.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to provide evidence that Resident Council concerns were assigned to the appropriate department, facility responses to Resident Council concerns, and how the facility resolved the repetitive Resident Council concerns for three consecutive months (January, February, and March 2024). The Resident Council meeting minutes indicated ongoing issues such as call lights not being answered, nurse aides being unavailable or on their phones, attitudes of nurse aides, meal trays not being set up, and missing clothing items. These concerns were consistently reported but not addressed adequately by the facility. The Grievance and Complaint Log for February and March 2024 also reflected similar issues, including unacceptable call light response times, attitudes from nurse aides, cold meals, and lack of assistance with meals. Despite these repeated complaints, the facility did not have a Resident Council policy and failed to document how these concerns were being resolved. The Nursing Home Administrator confirmed the lack of evidence regarding the assignment and resolution of these concerns during an interview on March 15, 2024.
Latest citations in Pennsylvania
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
