Cedarbrook Senior Care And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Allentown, Pennsylvania.
- Location
- 350 S. Cedarbrook Road, Allentown, Pennsylvania 18104
- CMS Provider Number
- 395465
- Inspections on file
- 24
- Latest survey
- April 17, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Cedarbrook Senior Care And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that the facility did not maintain a safe, clean, and comfortable environment on four nursing units. A men’s bathroom had a stained privacy curtain, and multiple mechanical lifts, sit-to-stand lifts, mobile vital signs baskets, and a Broda chair had thick hair and debris wrapped around their wheels. A mobile bedside commode in a men’s bathroom contained a collection bucket with yellow liquid and brown spatter that remained unemptied and uncleaned over several days, with a urine odor present. Additional equipment on another unit also had hair, debris, and a dried white substance on its surfaces, demonstrating a pattern of unclean resident care equipment and bathroom fixtures.
A resident with vascular dementia, heart disease, and a history of stroke had physician orders for a wander alert bracelet and aspirin as an antiplatelet, but the MDS assessment inaccurately documented these treatments. The MDS indicated that no wander alarm was used during the look-back period and incorrectly coded the resident as receiving an anticoagulant rather than an antiplatelet. The RN Assessment Coordinator later confirmed that the MDS should have reflected daily use of a wander alert bracelet and antiplatelet therapy.
Surveyors found that staff failed to provide necessary fingernail and grooming care to two residents who were care planned as needing assistance with ADLs. One resident with a history of stroke and hemiparesis was repeatedly observed in bed with long, chipped, and dirty fingernails, and reported that she preferred short nails, needed them cut, had not been offered nail care, and had not refused it. Another resident with primary HTN and chronic CHF was observed on multiple occasions in a wheelchair with similarly long, chipped, and dirty fingernails. For both residents, there was no documentation that nail care was offered or that care was refused, and the DON confirmed they should have received fingernail care.
Surveyors found that staff failed to follow physician orders for medications and diagnostic testing for three residents. One resident with recurrent UTIs continued to receive methenamine even while receiving ordered antibiotics, despite instructions to hold the methenamine when antibiotics were prescribed. Another resident with diabetes, CKD, and Alzheimer’s received fast-acting insulin with meals on multiple occasions when blood glucose levels were documented as below 100 mg/dL, contrary to ordered hold parameters. A third resident with a vesicointestinal fistula had an ordered cystogram that was not scheduled within the physician-specified two-week timeframe because the appointment request was not sent to the scheduler promptly.
A resident with vascular dementia, muscle weakness, and tremors, who was care planned and had MD orders for foam-handled utensils, a suction lip plate, and a two-handled cup with lid at all meals, was repeatedly observed in the dining room without this adaptive equipment on lunch trays. On multiple occasions, the suction lip plate and foam utensil handles were missing, and at another meal the foam handles, suction lip plate, and two-handled cup with lid were all absent. The DON acknowledged that the resident should have received all ordered adaptive eating equipment at every meal.
Staff failed to follow the facility’s Enhanced Barrier Precautions policy for a resident with diabetes, chronic kidney disease, obstructive uropathy, and an indwelling urinary catheter. The resident’s care plan required staff to use gowns and gloves during close contact care, including brief changes. During observation, a NA changed the resident’s brief wearing gloves but no gown, while an RN present acknowledged that a gown should have been used. The DON later confirmed that staff were required to wear a gown during this type of care, demonstrating noncompliance with the facility’s infection control policies.
A resident with dementia and severe cognitive impairment was found by family to have a patch of hair missing or extremely short on the front of the scalp, and the resident’s daughter reported concern that the hair had been shaved and that there was a bruise along the scalp line. Facility policy required immediate reporting of all alleged abuse and injuries of unknown source to nursing leadership, the Abuse Coordinator, and state and local officials, but the facility did not report this allegation or the associated injury to the State Survey Agency or local agencies. The ADON acknowledged that the alleged violation was not reported as required, resulting in a failure to follow mandated abuse reporting regulations.
A resident with dementia, Alzheimer's disease, and severe cognitive impairment, who required staff supervision for personal hygiene and had known wandering and exit-seeking behaviors, was not adequately protected from accident hazards. Despite a care plan calling for setup assistance and safety cues for grooming, the resident obtained and used a disposable razor, later found in a purse in her closet, and was noted to have a patch of hair missing or extremely short on the front of her scalp, which she reported she had cut herself. The ADON acknowledged the resident should not have had a razor in her possession.
The facility failed to serve meals promptly, resulting in two residents being left without meals while others at their table were eating. One resident waited 10 minutes, and another waited 30 minutes before being served.
The facility failed to ensure that the MDS assessments were completed to accurately reflect the status of two residents. Clinical record reviews revealed that Sections C and D of their MDS assessments were incomplete. The MDS Coordinator confirmed that these sections were not completed during the assessment period.
The facility failed to implement physicians' orders for three residents. One resident was not weighed daily as ordered, another was not provided with compression stockings, and a third was given blood pressure medication despite elevated readings without notifying the physician.
Failure to Maintain Clean and Safe Resident Care Equipment and Bathrooms
Penalty
Summary
Surveyors determined that the facility failed to provide a safe, clean, and comfortable environment on four of 13 nursing units (C3, D2, D3, and D4). On Unit C3, the men’s bathroom contained a blue privacy curtain that was dirty with stains on both sides. On Unit D2, two mechanical lifts were observed with thick hair and debris wrapped around their wheels. On Unit D3, one mechanical lift and a sit-to-stand lift had thick hair and debris wrapped around the wheels, a mobile vital signs basket had thick hair and debris on its wheels, and a Broda chair between resident rooms had thick hair and debris wrapped around its wheels. In the men’s bathroom on Unit D3, a mobile bedside commode had a collection bucket containing yellow liquid and a brown substance spattered inside, and this bucket remained unemptied and uncleaned over multiple observations on three separate days, with an odor of urine coming from the commode. On Unit D4, two mechanical lifts and a mobile vital signs basket were also observed with thick hair and debris wrapped around the wheels, and there was a dried white substance on the legs of the vital signs basket. These conditions were cited under 42 CFR 483.10(i) Safe Environment and related Pennsylvania Code provisions, and the deficiency had been previously cited on 5/9/2025.
Inaccurate MDS Coding for Wander Alarm and Antiplatelet Therapy
Penalty
Summary
The facility failed to ensure an accurate MDS assessment for one sampled resident when clinical record review, observation, and staff interview showed discrepancies between physician orders and the MDS coding. The resident had vascular dementia, heart disease, and a history of stroke, with a physician’s order dated July 25, 2019 directing staff to apply a wander alert bracelet. However, the MDS assessment dated January 23, 2026 indicated in Section P (restraints and alarms) that the resident was not wearing a wander alarm during the last seven days of the look-back period, despite the order for daily use of a wander alert bracelet. Additionally, a physician’s order dated July 15, 2024 directed staff to administer aspirin as an antiplatelet medication, but the same MDS assessment documented that the resident was receiving an anticoagulant medication during the last seven days of the review period. The MDS therefore inaccurately reflected the type of medication being administered, coding aspirin as an anticoagulant instead of an antiplatelet. In an interview, the RN Assessment Coordinator confirmed that the MDS completed on January 23, 2026 was inaccurate and should have captured both the use of an antiplatelet medication and the daily use of a wander alert bracelet.
Failure to Provide Assisted Nail and Grooming Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate grooming and nail care for two residents who required assistance with activities of daily living (ADLs). Clinical record review showed that one resident had a history of stroke with hemiparesis and was care planned as needing staff assistance with ADLs. On multiple observations over three consecutive days, this resident was seen in bed with long, chipped fingernails that were dirty with a substance underneath. The resident stated she preferred her nails short, that her nails needed to be cut, that staff had not offered to cut her nails, and that she had not refused such care. There was no documentation in the clinical record indicating that nail care had been offered or that the resident had refused. Another resident, with diagnoses including primary hypertension and chronic congestive heart failure and who was also care planned as requiring staff assistance with ADLs, was observed on three separate days out of bed in a wheelchair with similarly long, chipped, and dirty fingernails with a substance underneath. For this resident as well, there was no evidence in the record that staff had offered nail care or that the resident had refused it. During an interview, the Director of Nursing confirmed that both residents should have been provided with fingernail care, indicating that the expected nursing services for grooming were not carried out as required.
Failure to Follow Physician Orders for Medications and Diagnostic Testing
Penalty
Summary
The deficiency involves failures to follow physician orders and ordered parameters for medications and diagnostic testing for three residents. For one resident with frequent urinary tract infections and cerebral infarction with hemiparesis, a physician ordered methenamine daily for UTI prevention with instructions not to administer it when an antibiotic was ordered. Later, the physician ordered cephalexin for seven days, followed by doxycycline for seven days. Review of the MAR showed that staff administered both antibiotics while continuing to give methenamine, contrary to the physician’s order. The DON confirmed that the physician’s orders were not followed and medications were administered outside the ordered parameters. Another resident with diabetes, chronic kidney disease, and Alzheimer’s disease had an order for insulin lispro with meals, which was later increased, with instructions to hold the insulin if the resident was not eating or if blood sugar was less than 100 mg/dL. The MAR showed that staff administered the insulin with breakfast on four occasions when the documented blood sugar was below 100 mg/dL, contrary to the order. A third resident with a vesicointestinal fistula was discharged from the hospital with an order for a cystogram to be completed in two weeks. The attending physician approved and ordered the test and directed staff to schedule the appointment, but there was no evidence that staff requested the appointment until several days later, and the cystogram was ultimately scheduled beyond the two-week timeframe. The DON confirmed that the request for the appointment was not sent to the scheduler in a timely manner.
Failure to Provide Ordered Adaptive Eating Equipment at Meals
Penalty
Summary
The facility failed to provide ordered adaptive eating equipment and utensils for a resident with vascular dementia, muscle weakness, and tremors. The resident’s care plan identified a risk for nutrition problems and specified the need for foam handles on utensils, a suction lip plate, and a two-handled cup with a lid for all meals. Physician orders directed staff to provide a two-handled cup with lid beginning in early September 2025 and to provide foam utensil handles and a suction lip plate beginning in early October 2025 with all meal trays. Despite these orders and care plan directives, multiple dining observations showed that the resident did not receive the required adaptive equipment. On two consecutive lunch observations, the resident’s tray did not include the suction lip plate or foam utensil handles, and on a subsequent lunch observation, the tray lacked the foam handles, suction lip plate, and the two-handled cup with lid. In an interview, the DON confirmed that the resident should have been provided with all of this adaptive equipment at every meal.
Failure to Follow Enhanced Barrier Precautions During Brief Change
Penalty
Summary
Facility staff failed to follow the facility’s Enhanced Barrier Precautions policy for a resident requiring infection prevention measures. The policy, last reviewed on February 7, 2026, required staff to wear a gown and gloves during high-contact resident care activities, such as changing briefs. Clinical record review showed that Resident 2 was admitted with diabetes, chronic kidney disease, and obstructive uropathy, and had an indwelling urinary catheter. The resident’s care plan specified that Enhanced Barrier Precautions were required and directed staff to wear gloves and gowns during close contact interactions. On April 16, 2026, at 10:29 a.m., a nurse aide was observed changing the resident’s brief while not wearing a gown, despite a registered nurse present at the time acknowledging that a gown should have been worn. In a subsequent interview, the Director of Nursing confirmed that staff should have worn a gown while changing this resident’s brief, indicating noncompliance with the facility’s infection prevention and control policies and Pennsylvania nursing services regulations.
Failure to Report Alleged Abuse and Injury of Unknown Origin to Required Authorities
Penalty
Summary
The facility failed to report an alleged violation involving suspected abuse and an injury of unknown origin to the State Survey Agency and local agencies as required by its own policy and state regulations. Facility policy on Resident Abuse, Neglect, Misappropriation of Property and Other Related Offenses, last reviewed February 7, 2026, required that all incidents and allegations of abuse, including injuries of unknown source, be reported immediately to the Nursing Supervisor, Nursing Administration, Abuse Coordinator, and to local and other officials as mandated by state law. Clinical record review showed that Resident 83 had dementia, cognitive communication deficiency, and Alzheimer's disease, with a Minimum Data Set indicating severe cognitive impairment. On April 6, 2026, nursing documentation reflected that the resident’s family alerted staff that a patch of hair was missing or extremely short on the front of the resident’s scalp, and a staff statement recorded that the resident’s daughter was concerned the resident’s hair had been shaved and that there was a bruise along the scalp line. Despite these allegations and the injury of unknown origin, there was no evidence that the facility reported the incident to the State Survey Agency or local agencies, and the Assistant Director of Nursing acknowledged that the facility failed to report the alleged violation to the appropriate authorities. This deficiency was cited under 28 Pa. Code 201.14(c) Responsibility of licensee, 28 Pa. Code 201.18(b)(1)(e)(1) Management, and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Failure to Prevent Cognitively Impaired Resident’s Access to Razor
Penalty
Summary
The facility failed to implement adequate safety interventions to prevent accidents for one resident with severe cognitive impairment. The resident had diagnoses including dementia, cognitive communication deficiency, and Alzheimer's disease, and the MDS indicated she required staff supervision for bathing and personal hygiene tasks such as shaving, combing hair, and washing hands and face. Her care plan identified that she was at risk for severely impaired decision-making capacity related to these diagnoses and directed staff to provide setup assistance for hygiene and grooming and to provide cues for safety depending on her fluctuating cognitive status. The care plan also documented a behavior of wrapping jewelry and other personal belongings in tissues and placing items in various locations in her room, such as drawers, purses, and pillowcases. Facility documentation showed that the resident had been moved to a secure unit after multiple observations of wandering and exit-seeking behaviors. On a later date, a nurse's note documented that a patch of hair was missing or extremely short on the front of the resident's scalp, and the resident stated she had cut it herself with a razor. A search of her room revealed a disposable razor with a few small hair follicles inside a purse in her closet. In an interview, the Assistant DON stated that the resident should not have had a razor in her possession, indicating that staff had not prevented the resident from accessing the razor despite her cognitive impairment and need for supervision with personal hygiene.
Failure to Serve Meals Promptly
Penalty
Summary
The facility failed to ensure that meals were served in a manner that promoted and maintained each resident's dignity for two of 36 sampled residents. During the lunch meal on the Station 5 unit, Resident 82 was observed without a meal while other residents at the same table were eating. Resident 82 was looking around the room and reaching for other residents' trays and was not served her lunch tray until 10 minutes later. Similarly, on another day, Resident 175 was observed without a meal while other residents at the same table were eating. Resident 175 was seen throwing her hands in the air, making the sign of praying hands, and reaching towards other residents' trays. She was not served her lunch tray until 30 minutes later when staff members escorted her to her room. The Assistant Director of Nursing confirmed that meals in the dining room should be served one table at a time.
Incomplete MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments were completed to accurately reflect the residents' status for two of 36 sampled residents. Clinical record reviews revealed that Sections C (Brief Interview for Mental Status) and D (Mood Interview) of Resident 310's MDS assessment were incomplete. Similarly, Sections C and D of Resident 437's MDS assessment were also incomplete. In an interview, the MDS Coordinator confirmed that these sections were not completed during the assessment period to reflect the residents' current status.
Failure to Implement Physicians' Orders
Penalty
Summary
The facility failed to ensure that physicians' orders were implemented for three residents. Resident 402, diagnosed with congestive heart failure, diabetes mellitus, and dementia, had a physician's order to be weighed daily and notify the physician if the weight was outside the range of 150-160 lbs. The resident's weight exceeded this range on two occasions, but there was no documented evidence that the physician was notified. The Assistant Director of Nursing (ADON) confirmed this oversight during an interview. Resident 437, with chronic kidney disease and edema, had a physician's order to wear compression stockings while out of bed to prevent edema. The resident was observed multiple times without the compression stockings while out of bed. The Director of Nursing confirmed that the physician's order was not followed. Resident 450, with a history of stroke, high blood pressure, and dementia, had a physician's order to administer a blood pressure medication and notify the physician if the systolic blood pressure (SBP) was greater than 150 mm Hg. The medication was administered despite elevated SBP readings on several occasions, and there was no evidence that the physician was notified. The ADON confirmed this failure during an interview.
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.
