Dunmore Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Dunmore, Pennsylvania.
- Location
- 1000 Mill Street, Dunmore, Pennsylvania 18512
- CMS Provider Number
- 395567
- Inspections on file
- 25
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Dunmore Health Care Center during CMS and state inspections, most recent first.
Nursing staff did not follow a physician-ordered bowel management protocol for a resident who went five days without a documented bowel movement. Required interventions, including administration of Milk of Magnesia, a suppository, and an enema, were not provided, and the physician was not notified as ordered. The DON confirmed these omissions.
The facility did not follow its abuse prohibition policy by failing to verify previous employment for two new hires, an LPN and a nurse aide, as required by regulations. Personnel files lacked documentation of contact with their most recent former employers, and the NHA could not provide evidence that these checks were completed.
A resident with chronic medical conditions received Oxycodone, a narcotic pain medication, on several occasions without documented attempts at non-pharmacological pain interventions or pain assessment, despite facility policy requiring such steps before administering PRN analgesics.
The facility did not ensure that both oncoming and off-going nurses consistently signed narcotic count sheets for controlled (Schedule II) medications during shift changes on two medication carts. Multiple omissions of required signatures were found in narcotic logbooks, as confirmed by LPNs and the administrator, in violation of facility policy and state regulations.
A resident with dementia, encephalopathy, respiratory failure, and a history of falls was receiving multiple CNS-active medications. After a recent fall, the consultant pharmacist recommended a gradual dose reduction of duloxetine, but the attending physician declined without documenting a clinical rationale in the medical record, resulting in a deficiency.
Surveyors found that multiple opened multi-dose insulin pens, including Insulin Aspart and Insulin Glargine, were in use on a medication cart without required documentation of the date opened or expiration date. Manufacturer labels and facility policy both required this information, but it was left blank, and staff confirmed the pens were in use without proper dating.
A resident at Dunmore Health Care Center experienced a change in condition, with symptoms of clamminess and lethargy, and an oxygen saturation level of 87%. Despite concerns raised by the resident's daughter and the presence of an RN supervisor, no thorough assessment was documented. The following day, an RN noted the resident's condition had not improved, and labs indicated an infection, but the resident was not transferred to the hospital until hours later, where she was diagnosed with sepsis.
The facility did not meet the required nurse aide to resident ratios on two night shifts, providing fewer nurse aides than mandated for a census of 85 residents. On both occasions, no additional higher-level staff were available to compensate for the deficiency.
The facility did not meet the required LPN to resident ratios on a night shift, having 2.00 LPNs instead of the required 2.13 for 101 residents. This was confirmed through staffing records and an interview with the Nursing Home Administrator, with no additional staff available to compensate.
The facility did not meet the required minimum of 3.2 hours of direct resident care per day. On several occasions, the nursing care hours fell short, with the facility providing only 3.09, 3.05, and 3.10 hours per resident on different days. This was confirmed by the Nursing Home Administrator.
The facility failed to maintain fire safety for a vertical opening between two floors. The self-closing devices were removed from the Private Dining Room's double doors, which are part of a one-hour, two-story vertical opening. This deficiency was confirmed during an interview with the Facility Administrator and Facilities Manager.
The facility failed to maintain a smoke-tight enclosure for the Trash Room door on the first floor, as observed during a survey. This deficiency affects one of the two floors and was confirmed by the Facility Administrator and Facilities Manager.
A deficiency was identified in the facility where the door to a resident's room on the first floor was not smoke-tight, failing to meet fire safety standards. This was confirmed during an exit interview with the Facility Administrator and Facilities Manager.
The facility did not maintain the smoke barrier separation doors on the first floor near the Nurse's Station, as they required adjustment to fully latch. This issue was observed and confirmed during an interview with the Facility Administrator and Facilities Manager.
A facility failed to ensure a resident received appropriate services to maintain or improve mobility. The resident, with diagnoses including diabetes and muscle weakness, was recommended for a restorative nursing program (RNP) after physical therapy discharge. Despite a care plan for range of motion exercises, there was no nursing evaluation of the RNP from May to December. The Assistant DON admitted to not reviewing programs, and the Administrator confirmed the facility's responsibility to provide necessary services.
The facility failed to develop individualized toileting programs for two residents, one with a history of UTIs and another with esophageal cancer. Both residents' continence statuses were not properly assessed, and required 72-hour tracking was not completed, leading to inadequate care plans.
The facility failed to create individualized care plans for two residents with dementia, neglecting to address their specific behavioral symptoms and preferences. Both residents were severely cognitively impaired, yet their care plans lacked interventions based on their personal histories and interests, compromising their dignity and autonomy.
A facility failed to document clinical justification for a resident's continued use of multiple antidepressants. Despite recommendations for gradual dose reduction, the requests were declined without resident-specific rationale. The Director of Nursing confirmed the lack of physician documentation for the antidepressant use.
A facility failed to maintain accurate clinical records for a resident with dementia due to an incomplete transfer of care plans during a change in electronic medical record systems. The DON confirmed the care plan was incomplete and was unsure how many residents had complete records.
A facility failed to implement an effective quality assurance plan to address incomplete medical records following a change in electronic systems. A resident's care plan for Dementia with Lewy Bodies was not fully transferred, and the DON confirmed the issue was not part of the facility's quality assurance program.
The facility failed to implement a comprehensive infection control program, resulting in the spread of scabies among residents. A resident with heart failure and anxiety developed a rash, which was inadequately assessed and documented, leading to a delayed scabies diagnosis. Another resident sharing the room was not informed or treated for scabies, further indicating lapses in infection control practices.
The facility failed to determine if two residents had advance directives upon admission and did not offer them the opportunity to formulate one. Despite having a policy in place, there was no documented evidence that the facility ascertained the presence of advance directives or informed the residents of their rights. Both residents had POLST forms but lacked advance directive documentation.
A facility failed to ensure accurate MDS Assessments for a resident, incorrectly indicating the use of restraints. The resident, with cardiovascular disease, depression, and diabetes, had no physician's orders for restraints. The DON confirmed the error in the MDS coding.
A facility failed to follow a physician-ordered bowel protocol for a resident, who went five consecutive days without a bowel movement. The prescribed treatments, including Milk of Magnesia, a bisacodyl suppository, and a mineral oil enema, were not administered, and there was no evidence of physician notification. The DON could not provide evidence of protocol adherence or timely physician notification.
A facility failed to create a person-centered care plan for a resident with PTSD, neglecting to identify symptoms or triggers and lacking specific interventions to prevent re-traumatization. Staff interviews revealed unawareness of the diagnosis, and the facility could not demonstrate culturally competent, trauma-informed care according to professional standards.
A facility failed to provide a written notice of a hospital transfer to a resident and their representative. The resident, diagnosed with COPD, was transferred to the hospital, but there was no documented evidence of a notice being given. This was confirmed by the Nursing Home Administrator.
A facility failed to provide a resident and their representative with written notice of the bed-hold policy upon the resident's transfer to the hospital. The deficiency was identified through a review of clinical records and a staff interview, revealing no documented evidence of notification. The NHA could not provide proof of informing the resident or their representative about the bed-hold and reserve bed payment policy.
The facility's infection control policy did not meet Act 52 requirements, lacking a multidisciplinary committee and effective infection control measures. The infection preventionist confirmed the policy's deficiencies, and no infections were reported to the state since May 2024.
A facility failed to maintain a complete and accurate record of a resident's personal possessions upon admission and discharge. The resident's clinical record lacked an inventory of personal belongings, which should have been completed and signed by the resident or their representative. The ADON confirmed the absence of documented evidence for the inventory, resulting in a failure to ensure accurate accountability for the resident's belongings.
A facility failed to document the disposition of medications for a resident upon discharge, as required by their policy. The resident was admitted and later discharged without any record of medication accounting or disposition. This deficiency was confirmed by the DON, highlighting a lapse in the facility's medication management process.
The facility failed to prevent accidental ingestion and medication mismanagement, leading to a resident ingesting Betadine left unattended after a treatment without a physician's order. Observations revealed unattended personal care items and medications in resident rooms, posing risks of accidental consumption. Another resident was left unsupervised with a medication cup, despite not self-administering medications.
A resident with severe cognitive impairment ingested Betadine left at the bedside by a nurse, mistaking it for a protein solution. Despite notifying poison control and receiving guidance, the facility failed to consistently monitor and assess the resident's condition until the following day, deviating from professional nursing standards and facility policy.
Failure to Implement Physician-Ordered Bowel Protocol and Notify Physician
Penalty
Summary
Nursing staff failed to implement a physician-ordered bowel management protocol for a resident who did not have a documented bowel movement over a five-day period. The resident's clinical record included active orders for a stepwise bowel regimen, including administration of Milk of Magnesia if no bowel movement occurred after three days, a bisacodyl suppository if there was no result on the fourth day, and a Fleet enema if there was still no result on the fifth day, with instructions to notify the physician if the interventions were ineffective. Review of the resident's bowel tracking records and Medication Administration Record revealed no evidence that any of the ordered interventions were administered during the five-day period without a bowel movement. Additionally, there was no documentation that the physician was notified as required by the protocol. The DON confirmed that the bowel protocol was not implemented and the physician was not notified during this time.
Failure to Complete Required Employee Screening for Abuse Prevention
Penalty
Summary
The facility failed to implement its own procedures for screening prospective employees as required by both federal and state regulations. Specifically, a review of the facility's abuse prohibition policy indicated that references from two previous employers must be obtained for all new hires. However, personnel files for two employees, a Licensed Practical Nurse and a Nurse Aide, showed that there was no documentation that the facility had contacted their most recent former employers to verify employment history or eligibility for work in a long-term care setting. During an interview, the Nursing Home Administrator was unable to provide evidence that these required employment verifications had been completed. This lack of documentation and follow-through resulted in the facility not adhering to its written abuse prevention policy and regulatory requirements for employee screening. No information was provided regarding any residents directly affected or their medical conditions at the time of the deficiency.
Failure to Attempt Non-Pharmacological Pain Interventions Before Administering Narcotics
Penalty
Summary
The facility failed to follow its own pain management policy by not attempting non-pharmacological interventions before administering a narcotic pain medication to a resident. According to the facility's policy, non-pharmacological methods such as repositioning, relaxation techniques, or heat/cold therapy should be tried prior to giving a PRN (as needed) pain medication, and pain intensity should be documented. However, review of the clinical record for a resident with diagnoses including COPD and a bladder neoplasm showed that Oxycodone, a narcotic, was administered on multiple occasions without any documentation of attempted non-pharmacological interventions or assessment of pain level before or after administration. The resident was cognitively intact, as indicated by a BIMS score of 13, and had physician orders for both Acetaminophen and Oxycodone for pain management. The orders did not specify pain intensity levels for Acetaminophen, and for Oxycodone, it was to be used for severe pain. Despite this, the electronic Medication Administration Record (eMAR) showed that Oxycodone was given several times in September without any record of pain assessment or use of non-pharmacological interventions, contrary to facility policy. This was confirmed during an interview with the Nursing Home Administrator.
Failure to Accurately Document Controlled Medication Counts at Shift Change
Penalty
Summary
The facility failed to ensure accurate documentation of controlled (Schedule II) medications by both oncoming and off-going nurses during shift changes for two medication carts. According to facility policy, Schedule II controlled medications must be jointly counted and documented by both nurses at each shift change. However, a review of the narcotic logbooks for the First Floor [NAME] Hall and First Floor East Hall medication carts revealed multiple instances where required signatures were missing from the narcotic count sheets. Specific omissions included missing signatures from either or both nurses on several dates and shifts, as confirmed by staff interviews. Interviews with LPNs and the Nursing Home Administrator confirmed that the narcotic sheets were not consistently signed as required. The facility's expectation is for staff to follow procedures that promote accurate controlled drug records, but the documentation reviewed showed repeated failures to comply with these procedures. The cited deficiencies are in violation of state regulations regarding nursing service, pharmacy services, and clinical records.
Physician Failed to Document Rationale for Declining Pharmacist's Medication Recommendation
Penalty
Summary
A deficiency was identified when the attending physician failed to document a clinical rationale for declining a consultant pharmacist's recommendation regarding a resident's medication regimen. The resident in question was admitted with diagnoses including unspecified dementia without behavioral disturbance, encephalopathy, respiratory failure, and a history of multiple falls. The pharmacist's monthly drug regimen review noted that the resident was receiving three or more central nervous system (CNS) active medications—specifically lorazepam, duloxetine, quetiapine, and tramadol—and had recently experienced a fall. The pharmacist recommended a gradual dose reduction (GDR) of duloxetine due to the risks associated with polypharmacy and recent fall history. The attending physician reviewed the pharmacist's recommendation but declined to implement the suggested GDR of duloxetine. However, the physician did not provide an acceptable clinical rationale in the resident's medical record to justify this decision. This omission was identified during a review of the clinical record and confirmed through staff interviews. The deficiency was discussed with the Nursing Home Administrator and Director of Nursing.
Failure to Properly Label and Date Multi-Dose Insulin Pens
Penalty
Summary
Surveyors observed that the facility failed to comply with accepted standards for labeling and storing multi-dose insulin pens on one of two medication carts inspected. Specifically, on the 1 East Hall medication cart, one multi-dose insulin pen of Insulin Aspart and three multi-dose insulin pens of Insulin Glargine were found to be opened and in use without documentation of the date opened or the expiration date. Manufacturer-provided labels on the pens, which included designated spaces for this information, were left blank. Additionally, one Insulin Glargine pen had a blank sticker affixed, indicating it was in use but not properly dated. A review of the facility's policy and the manufacturer's instructions confirmed that opened multi-dose insulin pens must be dated and discarded within 28 days unless otherwise specified. Interviews with an LPN and the Nursing Home Administrator confirmed that the pens were in use and not dated as required by both facility policy and manufacturer guidelines. The failure to document the date opened and expiration date for these medications constituted noncompliance with pharmacy service regulations and resident care policies.
Failure to Timely Assess and Escalate Care for Resident
Penalty
Summary
Dunmore Health Care Center was found to be non-compliant with professional standards of nursing care as outlined in 42 CFR Part 483 Subpart B. The deficiency was identified during an Abbreviated Complaint Survey, which revealed that the facility failed to conduct and document a thorough nursing assessment following a change in condition for a resident. The resident, who was admitted to the facility with aphasia and cognitive impairment, experienced a significant change in condition when her daughter reported concerns about her being clammy and lethargic, with an oxygen saturation level of 87%. Despite the presence of an RN supervisor, there was no documented evidence of a completed assessment at that time. Further review showed that there was a delay in addressing the resident's condition, as no additional documentation was made until the following morning when another RN noted the resident's condition had not improved and contacted the physician. Although STAT labs were ordered and returned with results indicating an elevated white blood cell count consistent with an active infection, the resident was not transferred to the hospital until several hours later. The resident was subsequently diagnosed and treated for sepsis. Interviews with the Nursing Home Administrator and Director of Nursing confirmed the failure to timely assess and escalate care, resulting in a lack of nursing services consistent with professional standards.
Plan Of Correction
Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Resident #1 no longer resides at the community. Employee #2 provided 1:1 education on resident assessment post change in condition by the DON/Designee. To identify like residents that have the potential to be affected, the DON/Designee conducted a 2 week look back of nursing progress notes and 24 hour reports to validate that a thorough and timely nursing assessment was conducted post change in condition. To prevent this from happening again, the DON/Designee will educate the licensed nurses on recognizing and intervening in the event of change in resident condition. The registered nurse will be educated on conducting and documenting a timely assessment and follow-up when a change in condition is identified. The education will be completed by 2-6-25. To prevent this from happening again, the Regional Nurse will educate the Interdisciplinary team on reviewing changes in condition at morning meetings to ensure compliance. The education will be completed by 2-6-25. To monitor and maintain ongoing compliance, the DON/Designee will conduct an audit of 5 residents with changes in condition per week for 4 weeks, then monthly for 2 months to ensure professional standard of practice and timely follow-up. Results of audits will be submitted to the QAPI committee for further review and recommendation.
Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios on two occasions, as evidenced by a review of staffing records. On January 19, 2025, during the night shift, the facility provided 5.07 nurse aides instead of the required 5.67 for a census of 85 residents. Similarly, on January 21, 2025, the night shift had 7.07 nurse aides instead of the required 7.73 for the same census. No additional higher-level staff were available to compensate for this deficiency, leading to a failure in maintaining the mandated staffing levels.
Plan Of Correction
The facility cannot retroactively correct the past C.N.A Ratios. Moving forward, the facility will continue to make good faith effort to schedule staff to meet or exceed the mandated ratios of one NA to 10 residents on day shift; one NA to 11 residents on evening shift and one NA to 15 residents on night shift. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios. The facility contracts with agencies to supply aides to meet requirements, but call offs and no-shows result in unmet ratios. The facility is working to hire and train staff to achieve the minimum staffing ratios for nurse aides. The facility offers bonuses to staff to encourage staff to pick up additional shifts. To prevent this from reoccurring, the RDCS re-educated the NHA, DON, and Scheduler on the updated staffing regulations in relation to the minimum ratio of one NA to 10 residents on days, one NA to 11 residents on evenings, and one NA to 15 residents on nights. The staffing is reviewed each day for the subsequent day(s) by the NHA and/or DON to ensure adequate staff to meet or exceed the minimum ratios. Needs are posted each week for internal staff to pick up extra shifts as well as posted with outside agencies. To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum NA ratios. Audits will be completed 5x weekly x4 weeks; 3x weekly x1 month and weekly x1 month. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
LPN Staffing Deficiency on Night Shift
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios on one of the 21 shifts reviewed. Specifically, on January 21, 2025, during the night shift, the facility had 2.00 LPNs instead of the required 2.13 for a census of 101 residents. This deficiency was confirmed through a review of the facility's weekly staffing records and an interview with the Nursing Home Administrator. No additional higher-level staff were available to compensate for this deficiency, leading to non-compliance with the staffing regulations effective July 1, 2023.
Plan Of Correction
The facility cannot retroactively correct the past LPN Ratios. Moving forward, the facility will continue to make good faith effort to schedule staff to meet or exceed the mandated ratios of one LPN to 25 residents on day shift; one LPN to 30 residents on evening shift and one LPN to 40 residents on night shift. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios. The facility contracts with agencies to supply LPN's to meet requirements but call offs and no-shows result in unmet ratios. The facility is working to hire and train staff to achieve the minimum staffing ratios for LPN's. The facility offers bonuses to staff to encourage staff to pick up additional shifts. To prevent this from reoccurring, the RDCS re-educated the NHA, DON and Scheduler on the updated staffing regulations in relation to the minimum ratio of one LPN to 25 residents on days, one LPN to 25 residents on evenings and one LPN to 40 residents on nights. The staffing is reviewed each day for the subsequent day(s) by the NHA and/or DON to ensure adequate staff to meet or exceed the minimum ratios. Needs are posted each week for internal staff to pick up extra shifts as well as posted with outside agencies. To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum NA ratios. Audits will be completed 5x weekly x4 weeks; 3x weekly x1 month and weekly x1 month. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to consistently meet the state regulation requiring a minimum of 3.2 hours of direct resident care per resident each day. On January 19, 2025, the facility provided only 3.09 hours, on January 21, 2025, 3.05 hours, and on January 22, 2025, 3.10 hours of direct care nursing per resident. These staffing levels were below the mandated minimum requirement. This deficiency was confirmed during an interview with the Nursing Home Administrator on January 24, 2025.
Plan Of Correction
The facility cannot retroactively correct the staffing PPD issues. The facility utilizes staffing agencies, bonuses for staff, and actively recruiting for new staff. Management staff is utilized to achieve mandated staffing requirements. To prevent this from reoccurring, the RDCS re-educated the NHA, DON, and Scheduler on the updated staffing regulations in relation to the daily PPD of 3.2 hours. The staffing is reviewed each day for the subsequent day(s) by the NHA and/or DON to ensure adequate staff to meet or exceed the minimum PPD. Needs are posted each week for internal staff to pick up extra shifts as well as posted with outside agencies. The deployment sheets are developed in advance so staffing challenges can be addressed. A good faith effort is made to achieve the mandated staffing requirements. Supervisors are educated on the importance of filling call offs to meet requirements. To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum PPD. Audits will be completed 5x weekly x4 weeks; 3x weekly x1 month and weekly x1 month. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
Vertical Opening Fire Safety Deficiency
Penalty
Summary
The facility failed to maintain proper fire safety measures for a vertical opening between two floors. During an observation on December 23, 2024, it was noted that the self-closing devices had been removed from the double doors of the Private Dining Room. These doors are part of a one-hour, two-story vertical opening, which is required to have a fire resistance rating of at least one hour. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager.
Plan Of Correction
Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. The plan of correction is prepared and executed as a means to continually improve quality of care and to comply with all applicable state and federal regulatory requirements. Door closer has been installed on the Private Dining Room door. Door closers throughout the facility have been audited and are working properly. NHA/Designee educated the Maintenance Director on NFPA 101 Hazardous Areas-Enclosures. Maintenance Director will randomly audit door closures 1x week for 4 weeks then monthly x2.
Hazardous Area Enclosure Deficiency
Penalty
Summary
The facility failed to maintain a hazardous area enclosure, specifically the Trash Room door on the first floor, which was not smoke-tight. This deficiency was identified during an observation conducted on December 23, 2024, at 10:53 a.m. The issue was confirmed during an exit interview with the Facility Administrator and the Facilities Manager later that day. The deficiency affects one of the two floors in the facility, indicating a failure to comply with the requirements for hazardous area enclosures as outlined in NFPA 101 standards.
Plan Of Correction
The first floor Trash Room door was corrected and made smoke tight. Hazardous area doors were audited and are all smoke tight. NHA/Designee educated the Maintenance Director on NFPA 101 Hazardous Area-Enclosures. Maintenance Director will randomly audit Hazardous area doors 1x week for 4 weeks then monthly x2.
Deficiency in Corridor Door Smoke-Tightness
Penalty
Summary
The facility failed to maintain a smoke-tight corridor opening, specifically affecting the door to resident Room 122 on the first floor. This deficiency was identified during an observation conducted on December 23, 2024, at 11:23 a.m. The door did not meet the requirement to resist the passage of smoke, which is essential for ensuring the safety and protection of residents in the event of a fire or smoke emergency. During an exit interview with the Facility Administrator and the Facilities Manager later that day, the deficiency regarding the corridor opening was confirmed. The report does not provide additional details about the specific condition of the door or any immediate impact on the residents, but it highlights a failure to comply with the necessary fire safety standards as outlined in the NFPA 101 and CMS regulations.
Plan Of Correction
Resident # 122 Room Door was corrected and made smoke tight. Corridor doors were audited and are all smoke tight. NHA/Designee educated the Maintenance Director on NFPA 101-Corridor Doors. Maintenance Director will randomly audit Corridor doors 1x week for 4 weeks then monthly x2.
Smoke Barrier Door Deficiency on First Floor
Penalty
Summary
The facility failed to maintain the smoke barrier separation doors on the first floor, specifically those located closest to the Nurse's Station. During an observation conducted on December 23, 2024, at 10:50 a.m., it was noted that these doors required adjustment to fully latch. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager later that day, between 1:25 p.m. and 1:30 p.m.
Plan Of Correction
First floor, smoke barrier separation doors, were adjusted and fully latch. Smoke barrier separation doors throughout the facility were audited and fully latch. NHA/Designee educated the Maintenance Director on NFPA 101 Subdivision of Building Spaces-Smoke Barrier. Maintenance Director will randomly audit Smoke barrier separation doors 1x week for 4 weeks then monthly x2.
Failure to Evaluate Restorative Nursing Program for Resident
Penalty
Summary
The facility failed to ensure that a resident received appropriate services and assistance to maintain or improve mobility with maximum practicable independence. Resident 6, who was admitted with diagnoses including diabetes and muscle weakness, was recommended for a restorative nursing program (RNP) after being discharged from physical therapy. The care plan included specific interventions for active and passive range of motion exercises. However, there was no nursing evaluation of the RNP program to assess the resident's progress or the need to revise the program from its inception in May 2024 through the end of the survey in December 2024. The Assistant Director of Nursing confirmed that RNP programs should be evaluated monthly and documented in the medical record, but admitted to not reviewing any programs since taking over in May 2024. The Nursing Home Administrator acknowledged the facility's responsibility to ensure residents receive appropriate services to maintain or improve mobility. This lack of evaluation and documentation led to the deficiency, as the facility did not adhere to its policy of providing necessary services to maintain or improve the resident's mobility.
Plan Of Correction
Documentation on resident 6 cannot be corrected. Resident 6 will have current restorative program evaluated for effectiveness and appropriateness. To identify residents with the potential to be affected, DON/designee will audit residents currently on restorative nursing to ensure nursing evaluation is present. To prevent from re-occurring, DON/designee will educate ADON on process for restorative initiation and regular documentation and evaluation. To monitor and maintain compliance, DON/designee will audit 5 resident charts weekly x 4 then monthly x 2 to ensure regular evaluation is completed on RNP. All results will be brought to QAPI committee.
Failure to Implement Individualized Toileting Programs
Penalty
Summary
The facility failed to develop and implement individualized measures for the toileting needs of two residents, leading to deficiencies in bowel and bladder management. Resident 27, who was readmitted with diagnoses including sepsis, COPD, and morbid obesity, was noted to be always incontinent of urine and bowel. Despite having a history of UTIs and being unable to walk to the bathroom, the facility did not complete a 72-hour bladder and bowel tracking form as required by their policy. This omission resulted in the absence of a scheduled toileting program or an individualized incontinence management schedule in the resident's care plan. Resident 74, admitted with esophageal cancer, metabolic encephalopathy, and protein calorie malnutrition, was also affected by the facility's failure to assess continence status. Although the resident was alert, oriented, and able to stand and pivot with assistance, the bowel continence section of their admission observation was incomplete. The admission MDS indicated occasional urinary incontinence and frequent bowel incontinence, yet no trial toileting program was attempted, and no individualized toileting or incontinence management program was developed. Interviews with the Assistant Director of Nursing confirmed that the facility did not assess the continence status of Residents 27 and 74 upon admission, nor did they complete the required 72-hour bladder and bowel tracker. Consequently, the facility failed to develop comprehensive care plans that reflected the residents' toileting needs, compromising their highest practicable level of independence and dignity.
Plan Of Correction
1. Resident 27 and 74 will have a new 72 hour bowel and bladder diary initiated, and based on the results of the assessment, an individualized plan will be implemented if indicated. 2. To identify residents with the potential to be affected, DON/designee will audit current residents to ensure a 72 hour bowel and bladder diary was completed as per policy. 3. To prevent from re-occurring, DON/designee will educate nursing staff on the continence management program. 4. To monitor and maintain, DON/designee will audit new admissions weekly x 4 weeks for evaluation of bladder function and appropriate program, then monthly for 2 months. All findings will be taken to the QAPI committee.
Failure to Implement Individualized Dementia Care Plans
Penalty
Summary
The facility failed to develop and implement individualized person-centered care plans for two residents diagnosed with dementia. Resident 18 was admitted with a diagnosis of dementia and was assessed as severely cognitively impaired. However, the facility did not create a care plan that addressed the resident's dementia-related behavioral symptoms, nor did it include interventions based on the resident's preferences, social history, or interests. This lack of a tailored care plan meant that the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety were not maximized through individualized, non-pharmacological approaches. Similarly, Resident 19, who was diagnosed with Dementia with Lewy Bodies and also assessed as severely cognitively impaired, did not have an individualized care plan addressing their specific needs. The care plan in place failed to incorporate the resident's preferences, past life history, and customary routines to manage or decrease dementia-related behavioral symptoms. An interview with the Nursing Home Administrator confirmed the absence of evidence for the development and implementation of such individualized care plans for both residents.
Plan Of Correction
Resident 18 is deceased and resident 19 dementia care plan has been added. To identify other residents with the potential to be affected, the DON/designee completed an audit of all residents with dementia diagnosis to ensure care plan was developed and met residents individualized needs and care. To prevent this from re-occurring, the DON/designee educated the licensed nursing staff on dementia, specific individualized needs and plan of care. To monitor and maintain ongoing compliance, the DON/designee will audit new admissions with a diagnosis of dementia to confirm all care plans meet resident's individualized needs and care weekly then monthly x 2. All results will be brought to QAPI committee.
Lack of Clinical Justification for Antidepressant Use
Penalty
Summary
The facility failed to ensure proper documentation and clinical justification for the continued use of multiple antidepressant medications for a resident diagnosed with acute dementia. The resident, who was severely cognitively impaired, was prescribed Mirtazapine, Trazadone, and Sertraline for depression. Despite recommendations from the consultant pharmacist for a gradual dose reduction (GDR) of Mirtazapine and Trazadone, these requests were declined by the RN nurse practitioner and physician assistant, respectively. The reasons provided were that a GDR was contraindicated due to recent hospitalization for behavior against staff and that the resident's psych medications were managed by a consultant psychiatrist. The pharmacy consultant report did not include a resident-specific rationale to justify the continued use of multiple antidepressants, and there was no documented evidence to support the concurrent use of these medications. An interview with the Director of Nursing confirmed the lack of clinical justification from the attending physician for the continued administration of the antidepressants. This deficiency was identified during a survey, highlighting the facility's failure to comply with regulations regarding unnecessary medication use.
Plan Of Correction
Resident 19 documentation from facility MD for declination of GDR and use of multiple antidepressants has been added to clinical record. To identify other residents that have the potential to be affected, the DON/designee will complete an audit of concurrent antidepressant medications to ensure justification of use. To prevent this from reoccurring, the DON/designee will educate ADON and MD on proper documentation required for continued use of multiple antidepressant medications. MD will be responsible to comply with the regulation. To monitor and maintain ongoing compliance, the DON/designee will audit pharmacy recommendations for residents with concurrent antidepressant medications monthly x 4 to ensure all MD documentation of declination of GDR and justification of continued use. Any missing documentation will be brought to the Medical Director for review. All results will be brought to QAPI committee.
Incomplete Transfer of Resident Care Plans During EMR System Change
Penalty
Summary
The facility failed to maintain accurate clinical records for one of the 18 residents sampled, specifically Resident 19. Resident 19 was admitted with a diagnosis of acute dementia, including Dementia with Lewy Bodies, which affects mental abilities and can cause visual hallucinations. The facility transitioned to a new electronic medical record system on April 8, 2024, but did not completely transfer all care plans, including the dementia care plan for Resident 19. During an interview, the Director of Nursing confirmed that Resident 19's care plan was incomplete and acknowledged that not all resident medical information was transferred to the new system. The Director of Nursing was unaware of how many current residents had complete medical records at the time of the survey.
Plan Of Correction
Resident 18 is deceased and resident 19 dementia care plan has been added. To identify other residents with the potential to be affected, the DON/designee completed an audit of all residents with dementia diagnosis to ensure care plan was developed and met residents individualized needs and care. To prevent this from re-occurring, the DON/designee educated the licensed nursing staff on dementia, specific individualized needs and plan of care. To monitor and maintain ongoing compliance, the DON/designee will audit new admissions with a diagnosis of dementia to confirm all care plans meet resident's individualized needs and care weekly then monthly x 2. All results will be brought to QAPI committee.
Incomplete Medical Records Due to System Change
Penalty
Summary
The facility failed to develop and implement an effective quality assurance plan capable of identifying and correcting ongoing quality deficiencies related to maintaining complete and accurate medical records. A review of the facility's Quality Assurance and Performance Improvement (QAPI) program policy revealed that its purpose is to proactively improve care delivery and engage stakeholders in maximizing quality of life and care. However, the facility's QAPI activities did not address the issue of incomplete medical records following a change in electronic medical record systems. The deficiency was highlighted by the incomplete transfer of a care plan for a resident diagnosed with Dementia with Lewy Bodies. The resident's care plan, initiated in July 2022, was not fully transferred to the new electronic system implemented in April 2024. During interviews, the Director of Nursing (DON) confirmed the incomplete status of the resident's care plan and acknowledged that the facility did not know how many residents had complete medical records. The ongoing issue with medical record transfers was not included in the facility's quality assurance program, indicating a failure to identify and address this deficiency.
Plan Of Correction
Resident 19's clinical record is complete. To identify other residents that have the potential to be affected, the facility will complete an audit to ensure all medical records are complete. To prevent re-occurrence, the contracted medical records consultant will educate medical records personnel on complete chart requirements. To monitor and maintain compliance, the medical records/designee will audit new admissions weekly for 4 weeks and monthly for 2 months to ensure records are complete. All results will be brought to the QAPI committee.
Inadequate Infection Control Program Leads to Scabies Spread
Penalty
Summary
The facility failed to develop and implement a comprehensive infection control program to prevent the spread of infectious diseases, specifically scabies, among its residents. This deficiency was identified through observations, review of the facility's infection control tracking logs, and staff interviews. The facility's policy for Infection Prevention and Control, last reviewed on December 4, 2024, was intended to systematically prevent, identify, control, and reduce the risk of infections. However, the facility did not adhere to its own policy, as evidenced by the inadequate management of scabies cases among residents. Resident 56, who was admitted with diagnoses including heart failure, hypertension, and anxiety, was found to have a rash related to scabies. Despite multiple nursing notes and physician visits addressing the resident's itchy rash, there was a lack of comprehensive and accurate skin assessments. The resident's condition was not properly documented, and the facility failed to implement appropriate contact precautions and treatment in a timely manner. The resident's condition worsened over time, leading to a dermatology consultation that confirmed a scabies diagnosis. Additionally, Resident CR1, who shared a room with Resident 56, was not notified of the scabies diagnosis nor offered treatment as recommended by the dermatology office. This oversight further highlights the facility's failure to implement proper infection control practices. The Assistant Director of Nursing (ADON) confirmed that the facility did not follow its established policy and procedures for skin assessments, contributing to the spread of scabies among residents.
Plan Of Correction
Resident 56 skin check is current. Resident CR1 deceased. To identify residents with potential to be affected, DON/designee will audit residents to ensure skin observations are current and issues identified will be addressed. To prevent from re-occurring, DON/designee will educate licensed nursing staff on skin assessment policy. To monitor and maintain compliance, DON/designee will audit 5 residents weekly x 4 then monthly x 2 for current skin assessments. All results will be brought to QAPI committee.
Failure to Ascertain and Offer Advance Directives
Penalty
Summary
The facility failed to ascertain whether two residents had advance directives upon admission and did not offer them the opportunity to formulate one. The facility's policy, last reviewed on December 2, 2024, requires that upon admission, a team member should meet with the resident to discuss and offer to formulate an advance directive. However, for Resident 74, who was admitted with diagnoses including esophageal cancer and metabolic encephalopathy, there was no documented evidence that the facility determined if the resident had an advance directive or offered information to formulate one. The resident's clinical record only contained a Pennsylvania Physician Orders for Life-Sustaining Treatment (POLST) but lacked any advance directive documentation. Similarly, Resident 18, admitted with unspecified dementia and severe cognitive impairment, also had a POLST indicating a DNR status but no documented evidence of an advance directive or that the facility discussed or offered the opportunity to formulate one with the resident's representative. An interview with the social services director confirmed the absence of documentation indicating that the facility had determined the presence of advance directives for these residents or informed them of their rights to formulate one.
Plan Of Correction
Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. The plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements. Resident 18 is deceased. Advanced directives have been offered to resident 74 and documented in clinical chart. To identify residents with the potential to be affected, SS/designee will audit current residents to determine if advanced directives have been offered. Any resident not offered will be offered and documented in clinical record. To prevent re-occurrence, the Social Service Director will be educated by NHA/designee on the proper process for advanced directives. To monitor and maintain compliance, the Social Service Director/designee will audit new admissions for advanced directives weekly for 4 weeks, then monthly for 2 months. All findings will be brought to the QAPI committee.
Inaccurate MDS Assessment for Restraints
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) Assessments accurately reflected the status of a resident. Specifically, the quarterly review MDS for a resident, dated November 2, 2024, incorrectly indicated that the resident had a form of restraints in place. However, a review of the resident's clinical record did not reveal any evidence of restraints being used. The resident was admitted with diagnoses including cardiovascular disease, depression, and diabetes. An interview with the Director of Nursing confirmed that there were no physician's orders for restraints, nor did the resident require them, indicating that the MDS was coded in error.
Plan Of Correction
Resident MDS was corrected on 12/9/2024. To identify residents with the potential to be affected, MDS assessments in the last 14 days will be reviewed for accuracy by the MDS coordinator. To prevent this from recurring, education will be provided to the MDS coordinator by the regional MDS coordinator regarding MDS accuracy. To monitor and maintain compliance, 5 random charts will be reviewed weekly x 4 and then monthly x 2 for accuracy by the MDS coordinator/designee. All results will be brought to the QAPI committee.
Failure to Follow Bowel Protocol for Resident
Penalty
Summary
The facility failed to provide services consistent with professional standards of practice by not following physician orders for a bowel protocol for Resident 59. The resident had physician orders for a specific bowel regimen, which included administering Milk of Magnesia, a bisacodyl suppository, and a mineral oil enema in a sequential manner if no bowel movement occurred over consecutive days. Despite these orders, the facility did not administer the prescribed treatments during a period in November 2024 when the resident did not have a bowel movement for five consecutive days. Additionally, there was no documented evidence that the staff notified the physician about the resident's lack of bowel movement during this period. The Director of Nursing was unable to provide evidence that the bowel protocol was followed or that the physician was notified in a timely manner. This deficiency was identified through observation, clinical record review, and interviews with the resident and staff.
Plan Of Correction
Resident documentation cannot be corrected. To identify residents with the potential to be affected, the DON/designee will complete an audit of bowel records for the previous 14 days to ensure all protocols have been followed. To keep from re-occurring, the DON/designee will educate all licensed staff to follow bowel protocol and notify MD of deviation. To monitor and maintain compliance, the DON/designee will audit 5 residents' bowel protocol and documentation weekly for 4 weeks, then monthly for 2 months. Any negative findings will be corrected immediately. All results will be brought to the QAPI committee.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to develop and implement an individualized person-centered care plan for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). Upon review of the clinical records, it was found that the resident's care plan did not identify PTSD symptoms or triggers, nor did it include specific interventions to minimize these triggers and prevent re-traumatization. This oversight was noted during a review conducted on December 11, 2024. Interviews with facility staff revealed a lack of awareness and action regarding the resident's PTSD diagnosis. The Director of Social Services confirmed that she was unaware of the diagnosis and that no care plan had been established to address it. Additionally, the Nursing Home Administrator acknowledged the facility's inability to provide culturally competent, trauma-informed care in line with professional standards, which would account for the resident's experiences and preferences to mitigate potential triggers.
Plan Of Correction
PTSD care plan has been added to resident 78 plan of care. To identify residents with the potential to be affected, the Social Service Director/designee will audit residents with current PTSD diagnosis to ensure care plan is in place. To prevent re-occurrence, the NHA/designee will educate the Social Service Director to ensure the plan of care for residents with PTSD has care plan updated with specific needs. To monitor and maintain compliance, the Social Service Director/designee will audit new admissions with a diagnosis of PTSD weekly for 4 weeks, then monthly for 2 months to ensure the care plan is present and specific needs are identified. All results will be brought to the QAPI committee.
Failure to Provide Written Notice of Transfer
Penalty
Summary
The facility failed to provide written notices of a facility-initiated hospital transfer to a resident and their representative. This deficiency was identified for one resident out of the 18 sampled. The resident, who had been admitted to the facility with chronic obstructive pulmonary disease, was transferred to the hospital on November 20, 2024. However, there was no documented evidence that the resident or their responsible party received a written notice of the transfer and the reason for it. This was confirmed during an interview with the Nursing Home Administrator, who acknowledged the lack of documentation for the transfer notice.
Plan Of Correction
Community cannot correct past practices. Community cannot correct past practices. 3. To prevent from re-occurring, DON/designee will educate licensed staff on transfer/discharge paperwork requirement. DON/designee will educate BOM to ensure paperwork has been received timely. 4. To monitor and maintain compliance, DON/designee will audit 3 transfers per week x 4 then monthly x 2 to ensure discharge/transfer paperwork has been received. All findings will be brought to QAPI committee.
Failure to Provide Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notice of its bed-hold policy to a resident and the resident's representative upon the resident's transfer to the hospital. This deficiency was identified during a review of clinical records and a staff interview. Specifically, Resident 2 was transferred to the hospital on November 20, 2024, and later readmitted to the facility. However, 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. During an interview, the Nursing Home Administrator was unable to provide evidence that the facility informed Resident 2 and their representative of the bed-hold and reserve bed payment policy upon the hospital transfer.
Plan Of Correction
Community cannot correct past practices. To identify residents with the potential to be affected, DON/Designee will audit the last 7 days of discharges to ensure bed hold policy requirement is met. To prevent from re-occurring, DON/designee will educate licensed staff on bed hold policy requirement. DON/designee will educate BOM to ensure paperwork has been received timely. To monitor and maintain compliance, DON/designee will audit 3 transfers per week x 4 then monthly x 2 to ensure bed hold policy has been received. All findings will be brought to QAPI committee.
Non-compliance with Act 52 Infection Control Plan
Penalty
Summary
The facility failed to comply with the requirements of Act 52 regarding its infection control plan. The current infection prevention and control policy, last reviewed in December 2024, was found to be lacking in several areas. The policy is intended to prevent, identify, control, and reduce the risk of infections among employees, volunteers, visitors, and contract healthcare workers. However, it did not include all the necessary components as mandated by Act 52, such as a multidisciplinary committee involving various staff members and community representatives, effective measures for detecting and controlling healthcare-associated infections, and protocols for handling MRSA and MDRO exposures. During the survey, it was confirmed by the infection preventionist that the facility's infection control policy did not meet all the requirements of Act 52. Additionally, there was no evidence of infections being reported to the state reporting agency since May 2024, which is a requirement under Act 52. This lack of compliance indicates a significant gap in the facility's infection control measures, potentially affecting the health and safety of residents and healthcare workers.
Plan Of Correction
PA-PSRS is now current. To identify residents with the potential to be affected, DON/designee will complete an audit of the last 30 days of the requirements of ACT52 to ensure requirements are met. To prevent re-occurrence, DON/designee will educate ADON/IP on requirements of ACT52. To monitor and maintain compliance, DON/designee will audit submission of data to PA-PSRS monthly x 4 to ensure requirements are met. All results will be brought to the QAPI committee.
Failure to Document Resident's Personal Property Inventory
Penalty
Summary
The facility failed to maintain a complete and accurate record of a resident's personal possessions upon admission and discharge. This deficiency was identified through a review of clinical records and staff interviews, specifically concerning one resident, referred to as Resident 84. The resident was admitted to the facility on September 5, 2024, and discharged on September 24, 2024. However, the clinical record for Resident 84 did not include an inventory of personal belongings that should have been completed and signed by the resident or their representative upon both admission and discharge. An interview with the Assistant Director of Nursing (ADON) confirmed that the facility was unable to provide documented evidence of an inventory record for Resident 84's personal property, thus failing to ensure accurate accountability for the resident's belongings.
Plan Of Correction
Resident 84 discharged. To identify residents with the potential to be affected, medical records personnel will audit all current residents to ensure that a current inventory sheet is in the medical record. To prevent re-occurrence, the DON/designee will educate nursing staff on inventory sheet policy. To monitor and maintain compliance, medical records will audit new admissions weekly for 4 weeks and monthly for 2 months to ensure inventory sheets are complete. All results will be brought to the QAPI committee.
Failure to Document Medication Disposition Upon Resident Discharge
Penalty
Summary
The facility failed to adhere to its own policy regarding the disposition of medications upon a resident's discharge. Specifically, the facility's policy mandates that upon a resident's discharge or leave of absence, their medications should be immediately removed from the medication cart, and any unused medications should be disposed of. The method of disposition and the quantity of the drugs are required to be documented on the resident's chart using the Medication Disposition/Destruction Form. However, in the case of Resident 84, who was admitted on September 5, 2024, and discharged on September 24, 2024, there was no documented evidence of the accounting or disposition of any remaining medications. The deficiency was confirmed during an interview with the Director of Nursing (DON) on December 12, 2024, who acknowledged the lack of documentation regarding the disposition of Resident 84's medications. This oversight indicates a failure in the facility's process to ensure proper control and accountability of medications awaiting final disposition, as required by their policy and regulatory standards.
Plan Of Correction
Resident 84 has been discharged. To identify residents with the potential to be affected, the DON/designee will audit discharges within the last 5 days to ensure medication dispositions are complete. To prevent re-occurrence, the DON/designee will educate licensed nursing staff on the medication destruction/return process. To monitor and maintain compliance, the DON/designee will audit 5 discontinued/returned medications weekly for 4 weeks, then monthly for 2 months. All results will be brought to the QAPI committee.
Failure to Prevent Accidental Ingestion and Medication Mismanagement
Penalty
Summary
The facility failed to maintain an environment free of potential accident hazards, leading to the accidental ingestion of Betadine by a resident. Resident A1, who was severely cognitively impaired and diagnosed with encephalopathy and type 2 diabetes mellitus, ingested Betadine left unattended at the bedside after a heel dressing change. The nurse performed the treatment without a physician's order and left the Betadine in a medication cup, which the resident mistook for a liquid protein solution. The incident was reported after the resident's family observed the ingestion, and poison control was contacted. Further observations revealed additional safety lapses, including unattended personal care items and medications in resident rooms. During a tour, a barrier cream, Acetic Acid irrigation solution, shaving cream, normal saline solution, sterile water, and an irrigation kit were found unattended and without expiration dates in various resident rooms. These items were accessible to residents, posing a risk of accidental consumption or misuse. Another incident involved Resident A2, who was moderately cognitively impaired with dementia and depression. A medication cup filled with multiple medications was left unsupervised on the resident's bedside table. The resident was scheduled to receive several medications, but there was no documentation of self-administration, and the resident was not supervised while taking the medications. The Director of Nursing confirmed that the resident should have been supervised and did not self-administer medications.
Failure to Monitor Resident After Ingestion of Harmful Substance
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of quality by not thoroughly assessing and consistently monitoring a resident after the resident ingested a potentially harmful substance. The incident involved a resident who was severely cognitively impaired and had a history of encephalopathy and type 2 diabetes mellitus. The resident ingested approximately 10 milliliters of Betadine 10% solution, mistaking it for a liquid protein solution, after it was left at the bedside by a nurse following a heel dressing change. The on-call physician and poison control were notified, and poison control recommended feeding the resident a carbohydrate and monitoring for vomiting. However, there was no documented evidence that the nursing staff consistently monitored and assessed the resident for any changes in condition from the time of ingestion until the following day. The Director of Nursing was not aware of the incident until the next day, indicating a lack of timely communication and documentation. The facility's policy required that any change in a resident's condition be addressed with emergency care as needed, and information should be gathered before contacting a physician. Despite this, there was no evidence of consistent monitoring or timely assessment of the resident's condition following the ingestion of Betadine, which was a deviation from the expected nursing standards and facility policy.
Latest citations in Pennsylvania
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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