Edenbrook At Hampton
Inspection history, citations, penalties and survey trends for this long-term care facility in Wilkes Barre, Pennsylvania.
- Location
- 1548 Sans Souci Parkway, Wilkes Barre, Pennsylvania 18702
- CMS Provider Number
- 395249
- Inspections on file
- 35
- Latest survey
- April 10, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Edenbrook At Hampton during CMS and state inspections, most recent first.
A resident with intact cognition was moved to a new room after returning from a brief hospitalization, but staff did not give advance written notice or explain the reason for the change. The resident and her daughter reported that she was awakened to find staff packing her belongings, was not told where she was going or who she would room with, and was not given a chance to tour the room or meet the roommate. The record showed no documentation that her rooming preferences were considered or that written notice was provided before the transfer.
Failure to document and communicate refusal of ordered lab monitoring: A resident with epilepsy and moderate cognitive impairment refused blood work for ordered Keppra, Vimpat, and Vitamin D monitoring. The record lacked evidence that the IDT assessed the reason for refusal, discussed alternatives, evaluated the impact, or communicated the refusal to the practitioner, and the DON acknowledged the missing documentation.
A resident with severe protein-calorie malnutrition and a TPN central IV catheter had ordered central line flushes and TPN administration documented inconsistently. LPNs signed the MAR as performing the flushes and TPN infusion, while progress notes showed the RN completed the procedures. An LPN stated she did not perform the IV therapy because it was outside her scope, and the DON confirmed only RNs were permitted to administer TPN and central line flushes via the central venous catheter and that documentation had to match the actual nurse who performed the care.
Insulin Administered Outside Ordered Parameters: A resident with epilepsy and Type 2 DM was ordered Insulin Aspart 5 units SQ BID, with instructions to hold the dose if BG was below 110 mg/dL. Review of the MAR showed nursing staff administered the insulin multiple times when BG readings were below the ordered threshold, and the DON confirmed the order was not followed.
Pain medication was administered outside physician-ordered parameters for a resident with Type 2 DM who was cognitively intact. The MAR showed Oxycodone was given for pain ratings below the ordered severe-pain range, and Tramadol was given for pain above the ordered moderate-pain range. The DON reviewed the findings of five administrations that did not match the prescribed pain scales.
A resident with ESRD receiving hemodialysis had a care plan directing staff to monitor the fistula site for bleeding and keep an emergency dialysis supply kit at the bedside. During observation, no kit, clamps, pressure dressings, or other dialysis emergency supplies were present or readily accessible, and an LPN confirmed the supplies were missing despite the care plan requirement.
A resident with PTSD and intact cognition had a care plan that did not identify PTSD symptoms, triggers, or resident-specific interventions to reduce triggers or re-traumatization. The NHA confirmed the facility could not demonstrate culturally competent, trauma-informed care in line with professional standards and the resident’s experiences and preferences.
Failure to Ensure Timely Availability of Prescribed Medication: A resident with dementia and anxiety had an order for Levothyroxine Sodium 125 mcg for thyroid disease, but the MAR showed missed 6:00 AM doses when the medication was not administered because the supply had been depleted. The DON confirmed the facility did not ensure the medication was received from the pharmacy before it ran out, and there was no documented evidence that it was obtained and available as ordered.
Failure to Implement Contact Precautions for a Resident with VRE: A resident with infective endocarditis, VRE bacteremia, and bacterial peritonitis had a care plan for Contact/Isolation Precautions, but staff did not post precaution signage, did not place needed disposal equipment near the room exit, did not educate the resident and family, and were observed entering the room without gowns and gloves during care. The DON and Infection Preventionist confirmed the infection control policy was not followed.
Two residents were not protected from abuse by another resident with a known history of aggression and behavioral disturbances. Despite documented incidents of physical aggression, including choking and pushing, and visible injuries, the facility did not provide adequate supervision or substantiate abuse allegations, resulting in repeated harm and emotional distress.
A resident with major depressive disorder was involved in a physical altercation with a roommate, resulting in ongoing emotional distress. Although immediate physical interventions were taken, no social services support was provided to address the resident's psychosocial needs following the incident, as confirmed by staff and documentation review.
Surveyors found that multi-dose insulin pens, including Insulin Lispro and Insulin Glargine, were opened and in use without being dated as required, and one Insulin Glargine pen was used past its expiration date. These issues were confirmed by an LPN and the Nursing Home Administrator, indicating non-compliance with facility policy and state regulations.
Hampton House Rehabilitation and Nursing Center failed to provide a functional, resident-only telephone and ensure privacy for resident phone calls. A resident reported the non-operational phone in the B-Wing Resident Lounge, which had exposed wires and no dial tone, but no maintenance work order was placed to fix it. Additionally, residents had to use a phone behind the nursing station, lacking privacy. This was confirmed by an LPN and the Nursing Home Administrator.
The facility failed to provide adequate staffing and supervision for two residents with dementia, leading to frequent incidents of wandering, aggression, and safety concerns. Despite care plans and interventions, the residents' behaviors persisted, causing fear and discomfort among other residents. Management was unaware of the extent of these issues and could not demonstrate sufficient staffing on the B-Wing.
The facility failed to maintain proper food safety and sanitation practices, as observed during an inspection. The sanitizing solution in the 3-compartment sink was ineffective, and several unsanitary conditions were noted, including splattered ceiling tiles, an overflowing garbage receptacle, and dust and debris on walls and equipment. The Food Service Manager confirmed these deficiencies.
The deficiency involves attending physicians failing to respond to pharmacy recommendations for medication assessments and dose reductions for residents with various diagnoses. Instead, a CRNP signed off on these recommendations, contrary to regulations. The DON confirmed this practice, highlighting a deficiency in the facility's pharmacy and nursing services.
The facility failed to maintain an effective pest control program, with a persistent fly infestation in the A hall nursing unit. Despite ongoing issues for months, the pest control company only began treatment in July and did not provide adequate recommendations for ongoing control. The Nursing Home Administrator confirmed the facility's failure to address the issue effectively.
The facility failed to maintain a clean and safe environment, as observed in a resident's room with soiled tube feeding equipment and dried solution on the floor. Additionally, the medication room had dirt, debris, and a strong mildew smell, while the shower room was infested with sewer flies and had unsanitary conditions. These issues were confirmed by the DON and Nursing Home Administrator.
A facility failed to develop a comprehensive care plan for a resident receiving Eliquis for pulmonary embolism. The care plan did not include the anticoagulant therapy or interventions to monitor for bleeding. This deficiency was confirmed by the NHA and DON, violating 28 Pa. Code 211.12 (d)(5) Nursing services.
The facility failed to accurately monitor the weights of two residents, leading to deficiencies in identifying changes in nutritional parameters. One resident experienced a significant weight loss without timely intervention, while another had fluctuating weights due to inaccurate mechanical lift weighings. The facility did not follow its weight policy or explore alternative weighing methods, impacting nutritional assessments.
A facility failed to create and implement a person-centered care plan for a resident with dementia, who exhibited behaviors like wandering and agitation. The care plan lacked individualized interventions based on the resident's preferences and history, and the facility did not provide necessary non-pharmacological approaches or specialized services to manage the resident's dementia-related behaviors.
A resident with a urinary tract infection did not receive timely antibiotic treatment due to the facility's failure to obtain necessary medication from the pharmacy. The resident's physician was not notified of the missed dose, and the facility did not use its emergency pharmacy services to prevent the delay. The DON confirmed these lapses in protocol.
A facility failed to implement individualized incontinence care for a resident with dementia and muscle wasting. The resident was always incontinent and placed on an Incontinence Care and Comfort plan, but the current care plan did not address their urinary incontinence or include necessary interventions. The facility also failed to document the implementation of the care plan each shift, as confirmed by the DON.
The facility failed to provide detailed written notices for hospital transfers for several residents, lacking correct contact information for appeal assistance and advocacy services. This was confirmed by the Nursing Home Administrator, violating resident rights and licensee responsibilities.
The facility failed to maintain a safe and clean environment in C Hall, with issues such as missing floor molding, exposed wiring, and debris accumulation. Observations included dead bugs in light fixtures, peeling floor molding, and leaking pipes in resident rooms. The Nursing Home Administrator and DON confirmed the need for a safe, clean, and orderly environment.
The facility failed to provide scheduled showers to five residents who required assistance, as documented in June 2024. Despite being scheduled for showers, these residents either did not receive them or were given bed baths without documented preference. The DON confirmed the oversight but could not explain the missed showers, violating nursing services regulations.
A resident with bilateral below-knee amputations was subjected to verbal and mental abuse by a nurse aide during an argument. The aide used derogatory and threatening language, witnessed by other staff, leading to the aide's termination. The facility failed to protect the resident from such abuse, violating resident rights and nursing services regulations.
A resident experienced verbal and mental abuse by a Nurse Aide, which was witnessed by staff but not reported to the State Survey Agency until a week later. The resident, who is cognitively intact, was subjected to threatening and derogatory remarks. Despite the incident, the Nurse Aide continued to work with residents until the abuse was reported and addressed by the facility administration.
The facility failed to investigate an injury of unknown source for a resident with Alzheimer's and osteopenia, and did not promptly address a witnessed incident of verbal and mental abuse by a nurse aide towards a cognitively intact resident with bilateral leg amputations. The aide continued to work with residents for about a week after the incident, and the facility administration could not locate witness statements collected after the abuse.
A resident with cognitive intactness and a history of polyosteoarthritis and bilateral below-knee amputations was verbally and mentally abused by a nurse aide. Despite the incident being witnessed by staff and the aide's eventual termination, the facility failed to assess the resident for psychosocial harm or provide supportive services. The resident expressed fear and distress, and the Director of Social Services confirmed the lack of documentation for any supportive visits or assessments.
A sit-to-stand lift in the residents lounge area was found to be malfunctioning, with the left leg of the base not moving when activated by the electronic controller. This issue was observed in the presence of the DON, who confirmed the facility's failure to maintain the equipment in a safe operating condition.
A resident with severe cognitive impairment and multiple diagnoses developed pressure ulcers due to the facility's failure to implement a positioning schedule, use pressure-reducing devices, and apply barrier creams as per policy. The DON confirmed the lack of consistent preventive measures.
The facility failed to administer pain medication as prescribed and did not attempt non-pharmacological interventions for a resident with severe pain. Despite the resident's complaints and the ineffectiveness of the medications, the facility did not follow its policy to notify the physician or attempt alternative pain relief methods. The DON confirmed these deficiencies.
Failure to Provide Written Notice and Honor Room Preference Before Room Change
Penalty
Summary
The facility failed to honor a resident’s rooming preferences and failed to provide written notice, including the reason for the room change, before a facility-initiated transfer for one resident. The resident was admitted to the facility and initially lived on B Hall, then was moved to a room on A Hall after returning from a five-day hospitalization. The resident was cognitively intact with a BIMS score of 15 and stated that she awoke to staff packing her belongings, was not told where she was going or who she would room with, and was not given the opportunity to tour the new room or meet the new roommate. She reported that staff told her only that her current room was being renovated and that the move was temporary, and she was upset that she had no advance notice to prepare for the move. The resident’s daughter, who served as the resident representative, reported that she was not notified in advance or in writing about the room change. She stated that Social Services called her on the morning of the move and said the resident would be transferred that afternoon, and that the resident would be assigned to a window bed despite her preference for a bed closer to the door and bathroom. The clinical record contained no documentation that written notice, including the reason for the room change, was provided before the relocation, and there was no documented evidence that the resident’s preferences were considered or that she was offered a chance to view the new room or meet the roommate prior to the move. Social Services provided a Room Change Request Letter indicating verbal notification was given, but the facility could not produce evidence of prior written notification.
Failure to Document and Communicate Refusal of Ordered Lab Monitoring
Penalty
Summary
The facility failed to establish mechanisms for documenting and communicating a resident’s refusal of ordered laboratory monitoring to the interdisciplinary team and failed to follow its policy regarding refusal of treatment for Resident 12. Resident 12 was admitted with epilepsy and was moderately cognitively impaired, with a BIMS score of 7 on the quarterly MDS dated April 5, 2026. The facility policy on resident rights and refusal of care or treatment required the DON or designee to meet with the resident to determine the reason for refusal, attempt to resolve concerns, discuss alternatives and potential consequences, and document detailed information related to the refusal in the medical record. Resident 12 had a physician order for laboratory monitoring of Keppra, Vimpat, and Vitamin D every 90 days. The clinical record showed that on September 9, 2025, Resident 12 refused to allow laboratory staff to obtain blood work for these ordered tests. The record did not include documentation that the interdisciplinary team assessed the reason for the refusal, discussed alternative options such as rescheduling the blood draw, evaluated the clinical impact of the refusal, or communicated the refusal to the practitioner. There was no evidence in the medical record that a member of the interdisciplinary team met with Resident 12 to determine why the blood work was refused, and the DON acknowledged during interview that the record did not show the required documentation or policy follow-through.
Inaccurate documentation and unauthorized IV therapy administration
Penalty
Summary
The facility failed to ensure nursing services were provided in accordance with professional standards of quality by allowing documentation and performance of specialized IV therapy through a central venous catheter to be inconsistent and, in some instances, performed or recorded by staff who were not the qualified staff identified in the record. The deficiency involved Resident 86, who was admitted with severe protein-calorie malnutrition and surgical aftercare following surgery on the digestive system, and who had a TPN central IV catheter in place on admission. A physician ordered the central line to be flushed with 10 cc of normal saline before and after TPN administration twice daily, and later ordered TPN Electrolytes IV Concentrate at 100 milliliters per hour intravenously once daily for parenteral nutrition. Review of the April 2026 MAR showed that between April 5 and April 9, LPNs signed the MAR as administering the central line flushes, and between April 6 and April 9, LPNs documented that they administered the TPN infusion via the central venous catheter. However, corresponding nursing progress notes for those dates indicated that the RN completed the central line flushes and the TPN administration. During interview, an LPN stated she did not administer the TPN infusion or central line flushes because those procedures were outside her training and scope of practice, and that she notified the RN to perform them. She also stated that although she did not perform the procedures, she documented on the MAR that she had administered them while separately documenting in the clinical record that the RN completed them. The DON confirmed that, according to facility policy, only RNs were permitted to administer TPN and perform central line flushes via a TPN central venous catheter, and that the nurse who administers the medication or treatment must accurately document it on the MAR.
Insulin Administered Outside Ordered Blood Glucose Parameters
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of quality by not ensuring that licensed nurses administered prescribed insulin according to the physician-ordered blood glucose parameters for one resident. The resident had diagnoses including epilepsy and Type 2 diabetes mellitus, and the quarterly MDS dated March 27, 2026, indicated the resident was cognitively intact with a BIMS score of 14. A physician order dated September 1, 2025 directed staff to administer Insulin Aspart 5 units subcutaneously twice daily and to hold the dose if the resident's blood glucose was below 110 mg/dL. Review of the December 2025 and January 2026 MARs showed the insulin was administered on multiple occasions when blood glucose readings were below that ordered threshold, including readings of 97, 99, 106, 104, and 81 mg/dL. The DON confirmed on April 9, 2026, that nursing staff failed to follow the physician order and administered insulin outside the ordered parameters on the identified dates.
Pain Medication Administered Outside Ordered Parameters
Penalty
Summary
The facility failed to follow physician orders for pain medication administration for one cognitively intact resident with Type 2 Diabetes Mellitus. Resident 7 had a BIMS score of 15 on the quarterly MDS, indicating no impairment in memory or thinking. The resident had an order for Oxycodone HCL 5 mg every six hours as needed for severe pain rated 7 through 10, but the September 2025 MAR showed the medication was administered on four occasions for documented pain ratings of 0, 0, 5, and 6, which were outside the ordered parameters. Resident 7 also had an order for Tramadol HCL 25 mg every six hours as needed for pain rated 4 through 6. The October 2025 MAR showed Tramadol 25 mg was administered for a documented pain level of 8, which was outside the ordered range. During an interview, the DON reviewed the findings related to the administration of pain medications outside physician-ordered parameters on five occasions.
Missing Emergency Dialysis Supplies at Bedside
Penalty
Summary
The facility failed to ensure that emergency dialysis supplies were readily available for a resident receiving hemodialysis. Resident 11 was admitted with end stage renal disease and had a comprehensive care plan initiated that addressed ongoing hemodialysis treatments. The care plan directed staff to monitor the left upper extremity fistula site for bleeding, apply pressure, obtain assistance if complications occurred, and maintain an emergency dialysis supply kit at the bedside for immediate response to dialysis access complications. During an observation of Resident 11's room, no emergency dialysis supply kit, clamps, pressure dressings, or other dialysis access emergency supplies were present at the bedside, mounted on the wall, or otherwise readily accessible. An LPN confirmed that the supplies were absent and stated that an emergency kit with appropriate dialysis emergency supplies should have been present and readily accessible according to the care plan. The findings were reviewed with the NHA, and the cited deficiency referenced resident care policies and nursing services requirements.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered plan to provide trauma-informed care for a resident with a diagnosis of Post-Traumatic Stress Disorder (PTSD). A review of the resident’s clinical record showed the resident was admitted with PTSD, and the Quarterly MDS dated February 20, 2026, identified the resident as cognitively intact with a BIMS score of 14 and confirmed the PTSD diagnosis. The resident’s care plan, which was in effect at the time of review on April 9, 2026, did not identify the resident’s PTSD symptoms or triggers, and it did not include resident-specific interventions to minimize triggers or prevent re-traumatization. During interview on April 9 at 12:30 PM, the Nursing Home Administrator confirmed the facility was unable to demonstrate that it provided culturally competent, trauma-informed care in accordance with professional standards of practice and the resident’s experiences and preferences.
Failure to Ensure Timely Availability of Prescribed Medication
Penalty
Summary
The facility failed to ensure the timely acquisition and availability of prescribed medications for Resident 29, who was admitted with diagnoses including dementia and anxiety. A physician ordered Levothyroxine Sodium 125 mcg by mouth in the morning for thyroid disease on November 20, 2025, and the resident’s MAR for April 1, 2026 through April 10, 2026 showed the medication was not administered at the ordered 6:00 AM time on April 8, April 9, or April 10, 2026. The facility policy titled Ordering and Receiving Non-Controlled Medications stated that medications and related products are to be received from the provider pharmacy on a timely basis and that the nursing care center maintains accurate records of medication order and receipt. During an interview on April 10, 2026, at 12:15 PM, the DON confirmed the facility failed to ensure Levothyroxine Sodium 125 mcg was received from the pharmacy before the supply was depleted for Resident 29, and there was no documented evidence that the medication was obtained and available for administration as ordered.
Failure to Implement Contact Precautions for Resident with VRE
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program by not implementing Transmission-Based Precautions for a resident with VRE bacteremia and other serious infections. The resident was admitted with diagnoses including infective endocarditis, vancomycin-resistant enterococci (VRE) bacteremia, and bacterial peritonitis, and the care plan dated April 6, 2026 identified the need for Contact/Isolation Precautions because of VRE in the bloodstream. The facility policy required clear precaution signage, PPE availability outside the room, and proper disposal equipment near the exit, but these measures were not in place. On April 7, 2026, observation of the resident's room showed no precaution signage at the entrance to indicate Contact Precautions or required PPE. No appropriate waste receptacle or linen hamper was observed inside the room near the exit for disposal of PPE before leaving the room. The resident and the resident's husband stated they had not been informed of the need for Contact Precautions or the related infection prevention practices, and they reported that staff had not consistently worn gowns when entering the room since admission. On April 8, 2026, multiple staff were observed entering and exiting the resident's room without wearing required PPE, including gowns and gloves, during resident care activities. During an interview on April 10, 2026, the DON and Infection Preventionist confirmed the facility failed to implement its infection control policy for this resident, including the lack of precaution signage, missing equipment such as linen and waste receptacles, lack of education for the resident and family, and inconsistent staff adherence to PPE requirements.
Failure to Prevent Resident-on-Resident Abuse and Inadequate Supervision
Penalty
Summary
The facility failed to protect two residents from abuse by another resident with a known history of physical aggression. Resident 82, who had diagnoses including dementia with behavioral disturbance and anxiety, exhibited aggressive behaviors such as intrusive wandering and physical aggression. Despite these known risks, the facility did not maintain adequate supervision or implement sufficient interventions to prevent Resident 82 from physically assaulting other residents. The first incident involved Resident 82 placing his arms around the neck of another resident in the television lounge, which was witnessed by staff and resulted in staff intervention. Following this initial event, Resident 82 continued to display aggressive behaviors, including yelling, cursing, and unsuccessful redirection attempts by staff. A second incident occurred when Resident 82 grabbed another resident by the neck and pushed him, resulting in visible redness on the resident's neck. This incident was reported by the victim and corroborated by staff documentation, yet the facility did not substantiate the abuse allegation, citing a lack of direct staff witnesses despite physical evidence and consistent resident statements. The facility's failure to provide consistent and adequate supervision for Resident 82, despite his documented history of aggression and psychiatric recommendations, led to repeated incidents of physical aggression and emotional distress for other residents. The facility also failed to substantiate abuse allegations in the presence of physical signs of injury and credible witness statements, further contributing to the deficiency.
Failure to Provide Social Services After Resident Altercation
Penalty
Summary
A resident with a diagnosis of major depressive disorder and a BIMS score indicating cognitive intactness was involved in an altercation with a roommate, during which the roommate grabbed the resident's throat. Facility documentation confirmed physical evidence of the incident, including redness on the resident's neck, and immediate interventions were implemented to separate the residents and change rooms. Despite these actions, the resident continued to experience distress and requested support in managing his emotional response to the incident, including education from a psychiatric provider. However, interviews with facility staff and review of the clinical record revealed that no social services intervention or visit was provided to address the resident's psychosocial needs following the altercation. Both the social services staff member and the Nursing Home Administrator confirmed the absence of documented social services support for the resident after the incident, resulting in a failure to provide medically-related social services to help the resident achieve the highest possible quality of life.
Failure to Properly Label and Store Multi-Dose Insulin Pens
Penalty
Summary
The facility failed to comply with accepted standards for the labeling and storage of multi-dose medications, as observed during a review of a medication cart on the C Hall unit. Specifically, one multi-dose insulin pen of Insulin Lispro and two multi-dose pens of Insulin Glargine were found opened and in use without being labeled with the date they were initially opened, contrary to facility policy and manufacturer guidelines. Additionally, one Insulin Glargine pen was labeled with an opening date but was still in use past its recommended 28-day discard date. These deficiencies were confirmed through observation in the presence of an LPN and further verified during interviews with both the LPN and the Nursing Home Administrator. The facility's own policy requires opened multi-use vials or bottles to be dated to ensure proper tracking for expiration, and manufacturer instructions specify discard timelines for insulin pens. The failure to date and timely discard these medications resulted in non-compliance with state pharmacy and nursing service regulations.
Deficiency in Resident Communication Privacy and Access
Penalty
Summary
Hampton House Rehabilitation and Nursing Center was found to be non-compliant with federal and state regulations regarding residents' rights to communication privacy and access. The facility failed to provide a functional, resident-only telephone for a resident in the B-Wing Resident Lounge, as the phone was non-operational with exposed wires and no dial tone. This issue was reported by the resident during a Resident Council Meeting, but no action was taken to address the concern, as evidenced by the absence of a maintenance work order to repair the phone. Additionally, the facility did not ensure privacy for residents making telephone calls. Residents were required to use a landline telephone located behind the nursing station, which did not provide privacy as it was positioned on the counter, necessitating residents to sit in front of the nursing station during calls. This arrangement was confirmed by a licensed practical nurse and the Nursing Home Administrator, who acknowledged the lack of privacy and access to a functional, resident-only telephone, impacting residents' ability to communicate confidentially and independently.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. FTAG 576- Rights to forms of Communication with Privacy- B lounge not working. 1. B wing Resident Lounge Phone fixed immediately. 2. January 2025 Resident council minutes were reviewed to ensure any concerns documented were resolved. 3. 3 cordless phone devices were purchased for each of the nursing units providing access to additional functional, resident-only telephones. Cordless phones to be utilized by residents in their resident room allowing for privacy, confidentiality and independent communications. 4. NHA/Designee will provide education to current staff regarding Resident's Right to Forms of Communication with Privacy. 5. NHA/Designee will conduct weekly audits x4 and then monthly x3 to ensure all Resident-only telephones are appropriately working. Results of the audits will be reviewed at the facility QA meeting. 6. NHA/Designee will conduct monthly audit x3 to ensure all monthly resident council documented concerns have work orders and work orders are addressed and appropriately resolved. Results of the audits will be reviewed during facility QA meeting. 7. Date of Compliance March 7, 2025.
Inadequate Staffing and Supervision of Residents with Dementia
Penalty
Summary
The facility failed to provide sufficient staff with the necessary competencies and skills to manage and supervise the wandering and aggressive behaviors of two residents, identified as Residents 4 and 20. Resident 4, admitted with dementia and violent behavior, exhibited frequent incidents of wandering into other residents' rooms, exit-seeking behaviors, and aggression towards staff and other residents. Despite interventions outlined in the resident's care plan, such as 15-minute checks and redirection, these behaviors persisted, leading to a subacute fracture of the resident's left foot, raising concerns about the adequacy of supervision. Resident 20, also admitted with dementia, displayed similar behaviors, including wandering into other residents' rooms, verbal aggression, and physical aggression, such as attempting to strike staff members with a cane. The care plan for Resident 20 included interventions like the use of a wander guard system and calm redirection, but these measures were insufficient to manage the resident's behaviors effectively. Interviews with residents and staff revealed that the presence of Residents 4 and 20 caused fear and discomfort among other residents, with reports of intrusions into personal spaces and aggressive encounters. The facility's management, including the Nursing Home Administrator and Director of Nursing, were unaware of the extent of these behavioral incidents and could not provide evidence of sufficient staffing with appropriate skills on the B-Wing. Interviews with staff indicated that the facility did not assign enough personnel to manage the behaviors and conduct the required checks, leading to repeated incidents of resident-on-resident intrusions and safety concerns.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. FTAG 741- Sufficient/Competent Staff-Behavioral Health Needs- supervision and safety of residents. 1. Facility unable to retroactively correct sited deficient practice. 2. Identified behavioral residents, residents #4 and #20, to be assessed and evaluated with Behavioral Health Services. 3. Identified residents #4 and #20 current recreational activity plan of care to be reviewed and evaluated. Based on additional needs identified, recreational activity schedule to be adjusted to meet needs of residents. 4. 30 day-look back of current facility residents with diagnosis of Dementia reviewed for any repeated incidents of resident-on-resident, intrusions, aggressive behaviors, and safety concerns. 5. Residents identified with repeated behavior will be assessed and evaluated with Behavioral Health Services. 6. Current staff will be educated on meeting the needs of behavioral residents. 7. Recreational Activity will assess identified residents and implement resident centered activities program. 8. Clinical team will review previous day incident reports involving identified residents related to behavioral health to ensure interventions meet identified residents' behavioral health needs. 9. NHA/Designee will conduct weekly audits x4 then monthly audits x2 to ensure behavioral health needs are being met clinically and socially. 10. Results of audits will be reviewed during facility QA meeting. 11. Date of Compliance March 7, 2025.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain acceptable practices for the storage and service of food, which increased the risk of food-borne illness. During an inspection, it was observed that the sanitizing solution in the 3-compartment sink was ineffective, with a test strip indicating zero parts per million of sanitation solution, contrary to the required 200-400 PPM. The Food Service Manager confirmed the deficiency and was unsure why the solution was so weak. Additionally, several unsanitary conditions were noted, including splattered ceiling tiles, an overflowing garbage receptacle without a lid, and dust and debris on walls and equipment. Further observations revealed that the exhaust hood over the stove had discolored rags stuck in it, and a container labeled for hard-boiled eggs was cracked, exposing its contents to potential contamination. The hosing attached to the water filter and coffee maker was heavily corroded with dust and debris. These conditions were confirmed by the Food Service Manager, who acknowledged that the kitchen areas should be maintained in a sanitary manner to prevent contamination and foodborne illness.
Failure of Attending Physicians to Respond to Pharmacy Recommendations
Penalty
Summary
The deficiency involves the failure of attending physicians to act upon pharmacist-identified irregularities in the medication regimens of several residents. The report highlights that the attending physicians did not provide appropriate responses to pharmacy recommendations for medication assessments and potential dose reductions. Instead, the facility's consultant psychiatric CRNP responded to these recommendations, which is not in accordance with the regulations requiring the attending physician's involvement. The report details specific cases involving four residents with various diagnoses, including bipolar disorder, depressive disorder, mood disorder, and dementia. For each resident, the consultant pharmacist made recommendations regarding the evaluation of psychopharmacological medications and the need for gradual dose reductions or specific rationales if dose reductions were not indicated. However, the attending physicians failed to document individualized responses, and the CRNP signed off on the recommendations instead. The Director of Nursing confirmed that the CRNP was responding to the pharmacy recommendations rather than the attending physicians, as required by regulation. This failure to comply with the regulatory guidelines for medication regimen reviews and physician responses constitutes a deficiency in the facility's pharmacy and nursing services, as well as the oversight by the medical director.
Ineffective Pest Control Program in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by observations and staff interviews. A strong mildew and sewage smell was detected in the A hall nursing unit medication room, along with the presence of a flying bug. In the A hall nursing unit shower room, a significant infestation of sewer flies was observed, with flies covering the walls, tub, and shower stalls, and numerous dead flies on the floor. An LPN confirmed that the bug issue had persisted for at least four months and worsened over the summer, affecting both the shower and medication rooms. The pest control company contracted by the facility did not begin treating the fly infestation until July 9, 2024, despite the problem being ongoing for months. The pest control reports indicated treatments were applied, but no recommendations were provided to the facility for ongoing drain treatments to control the flies between visits. Subsequent reports showed the treatments were ineffective, and the pest control company failed to offer specific sanitation or treatment recommendations. The Nursing Home Administrator confirmed the facility's failure to implement necessary measures for effective pest control.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, as evidenced by multiple observations of unsanitary conditions. On August 20, 2024, it was observed that in Room B14, a resident's tube feeding pump and pole were soiled with dried tube feeding solution, and there were dried spots of the solution on the floor. This issue persisted, as a subsequent observation on August 23, 2024, revealed that the dried solution remained on the pump, pole, and floor. Additionally, on August 22, 2024, the A hall nursing unit medication room was found to have dirt and debris on the floor, accompanied by a strong mildew and sewage smell. A flying bug was also observed in the room. The A hall nursing unit shower room was noted to have a large number of sewer flies covering the walls, with multiple dead flies on the floor, in the tub, and splattered on the walls. Wet clumps of paper were found on the floor, and the shower curtain had brown stains. Cracked tiles were observed on the wall near the floor. These conditions were confirmed by the Director of Nursing and the Nursing Home Administrator, who acknowledged the facility's responsibility to maintain a clean and sanitary environment daily.
Failure to Develop Comprehensive Care Plan for Anticoagulant Therapy
Penalty
Summary
The facility failed to develop a person-centered care plan that included individual medication therapy for a resident. Resident 12, who was admitted with a diagnosis of hypertension, was receiving Eliquis, an anticoagulant medication, twice a day for a history of pulmonary embolism. However, the resident's care plan did not identify the anticoagulant therapy or include interventions to monitor for bleeding. This deficiency was confirmed during an interview with the Nursing Home Administrator and Director of Nursing, who acknowledged that comprehensive care plans were not developed for the resident. The failure to include the necessary medication therapy and monitoring interventions in the care plan was a violation of 28 Pa. Code 211.12 (d)(5) Nursing services.
Failure to Monitor Resident Weights Accurately
Penalty
Summary
The facility failed to consistently and accurately monitor resident weights, leading to deficiencies in identifying changes in nutritional parameters for two residents. Resident 40 experienced a significant weight loss of 19.9% over 30 days, dropping from 167 lbs to 133 lbs. Despite the Registered Dietitian (RD) questioning the accuracy of the weight, a reweigh confirmed the loss, yet no new interventions were implemented until weeks later. The resident's nutritional care plan had not been updated since April, despite the significant weight change. Resident 91, who was NPO and required a feeding tube, also experienced issues with weight monitoring. The resident's weight fluctuated significantly due to jerky movements during mechanical lift weighings, leading to inaccurate weight records. Despite a significant weight loss of 16.2 pounds in less than a week, the facility did not obtain a timely re-weight within the 72-hour policy window. The RD noted the weight changes but did not recommend new interventions, as the tube feeding was deemed adequate. Interviews with the Nursing Home Administrator and Director of Nursing confirmed the facility's failure to follow its weight policy. The facility did not explore alternative methods for obtaining accurate weights for dependent residents, impacting the ability to perform accurate assessments of nutritional requirements. This lack of timely and accurate weight monitoring led to deficiencies in the care provided to these residents.
Failure to Implement Individualized Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement an effective individualized person-centered care plan for a resident diagnosed with dementia, leading to a deficiency. The resident, who was admitted with a diagnosis of dementia and was severely cognitively impaired, exhibited behaviors such as intrusive wandering, striking out, screaming, and agitation over several months. Despite these behaviors, the resident's care plan did not address their dementia diagnosis or include individualized interventions tailored to their preferences, social history, customary routines, and interests. The facility did not provide evidence of necessary care and services, including interdisciplinary non-pharmacological approaches, purposeful activities, or environmental modifications to manage the resident's dementia-related behaviors. An interview with the Nursing Home Administrator confirmed the absence of an individualized person-centered plan to address these behaviors. The facility's failure to provide specialized services and supports, such as activities, nutrition, and environmental modifications, based on the resident's abilities and dementia-related behaviors, was noted as a deficiency.
Failure to Administer Timely Antibiotic Treatment
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of practice by not ensuring timely administration of physician-ordered medication for a resident with a urinary tract infection. Resident 93, who was admitted with diagnoses including Guillain-Barre Syndrome, neuromuscular dysfunction of the bladder, and urine retention, had a confirmed urinary tract infection based on urine culture results received on July 24, 2024. Despite new orders for the antibiotic Ceftriaxone to be administered intramuscularly for seven days, the medication was not given on July 27, 2024, due to the facility waiting for Lidocaine from the pharmacy. The clinical record did not show that the resident's physician was notified of the missed dose, and the facility did not utilize its contracted emergency pharmacy to prevent the delay in treatment. Interviews with the Director of Nursing confirmed these failures, highlighting that the nursing staff did not implement emergency provisions to contact the emergency pharmacy, resulting in a delay in the administration of the prescribed antibiotic therapy.
Failure to Implement Incontinence Care Plan
Penalty
Summary
The facility failed to implement individualized approaches for incontinence care for one resident, identified as Resident 25. The facility's policy on Urinary and Bowel Incontinence Evaluation and Management, last reviewed in April 2024, requires residents not suitable for a toileting schedule to be placed on an Incontinence Care and Comfort plan, which involves checking and changing every two to three hours. Resident 25, who was admitted with diagnoses including dementia and muscle wasting, was always incontinent of bowel and bladder and had poor potential for a toileting schedule. However, the resident's current plan of care did not identify their urinary incontinence or include interventions to provide necessary care and services. Additionally, the facility failed to document that the incontinence care and comfort plan was being implemented and completed each shift for Resident 25. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the failure to provide maintenance care to the resident.
Deficient Transfer Notices for Hospital Transfers
Penalty
Summary
The facility failed to provide sufficiently detailed written notices of facility-initiated transfers to the hospital for seven residents. The written notices lacked the correct address and phone number for assistance with the appeal process and the correct contact information for the advocacy of persons with disabilities and mental health. This deficiency was identified during a review of the clinical records of the affected residents, who were transferred to the hospital on various dates between April and August 2024. The Nursing Home Administrator confirmed during an interview that the information provided to the residents was incorrect. The facility's failure to provide accurate and complete transfer notices violated resident rights and the responsibility of the licensee as outlined in 28 Pa. Code 201.29(h) and 28 Pa. Code 201.14(a).
Facility Fails to Maintain Safe and Clean Environment in C Hall
Penalty
Summary
The facility failed to maintain a safe, clean, and orderly environment in one of its resident units, specifically C Hall. Observations revealed several deficiencies, including a missing floor strip molding at the nursing station, which left a hole filled with rocks, dirt, metal, and other debris. Additionally, an ethernet outlet cover was detached, exposing interior wiring, and there were issues with phone wires. In the resident shower room, dead bugs and debris were found inside a ceiling light fixture, and a thick layer of dust covered the ceiling vent and fan blades. Further observations in various resident rooms highlighted additional issues. In room C-16, floor molding was peeling, revealing dark discoloration, and trash such as a banana peel and food wrappers were found on the floor. Room C-3 had peeling floor molding with surrounding stains and dirt on the bathroom floor. Room C-13 had trash and debris on the floor, while room C-9 had a missing name identification plate and a continuously running toilet. Room C-17 had a leaking pipe under the bathroom sink. In the resident lounge, a lift-to-stand device was found with frayed and peeling medical tape. These observations were confirmed by the Nursing Home Administrator and Director of Nursing, acknowledging the need for a safe, clean, and orderly environment.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to ensure that residents who were dependent on staff for assistance with activities of daily living were consistently provided showers as planned. This deficiency was identified for five out of ten residents sampled. Resident B1, who was cognitively intact and required substantial assistance for showering, reported not receiving scheduled showers on two occasions in June 2024. The facility's documentation confirmed the absence of showers on these dates without any record of refusal by the resident. Similarly, Resident B2, who required supervision for showering, did not receive scheduled showers on two occasions in June 2024. The facility's records did not indicate any refusal by the resident. Resident B3, who was newly admitted, reported not being offered a shower since admission, and the facility's documentation showed missed showers with no applicable reason provided. Resident B4, requiring maximal assistance, received bed baths instead of showers on two occasions, with no documentation of preference for bed baths. Resident B5, who required total assistance, also received bed baths instead of showers on two occasions, with no documented preference for bed baths. The Director of Nursing confirmed that the residents should have been showered as scheduled and was unable to explain why the showers were not provided. The facility's failure to provide showers as planned violated the nursing services regulation, specifically 28 Pa. Code 211.12 (d)(5).
Resident Subjected to Verbal and Mental Abuse by Staff
Penalty
Summary
The facility failed to protect a resident, identified as Resident A1, from verbal and mental abuse by a staff member, Employee 3, a nurse aide. The incident occurred on June 8, 2024, when Resident A1, who is cognitively intact and has bilateral below-knee leg amputations, confronted Employee 3 outside the nursing station. The confrontation escalated into an argument where Employee 3 used derogatory and threatening language towards Resident A1, including statements about his amputations and threats of harm. Multiple staff members witnessed the altercation, including Employee 5, another nurse aide, and Employee 4, a registered nurse, who intervened to separate the parties. Employee 5 reported hearing Employee 3 use profanities and make threats towards Resident A1, while Employee 4 confirmed that he had to physically prevent Employee 3 from approaching Resident A1 further. The altercation was characterized by yelling and the use of abusive language by Employee 3, which was corroborated by witness statements and interviews conducted during the investigation. The facility's investigation concluded that Employee 3's actions constituted mental abuse, as defined by the facility's policy on abuse. The Director of Nursing and the Nursing Home Administrator acknowledged the failure to protect Resident A1 from such abuse, confirming that Employee 3 was suspended and subsequently terminated following the incident. The deficiency was identified as a violation of resident rights and nursing services regulations.
Failure to Timely Report Resident Abuse
Penalty
Summary
The facility failed to timely report the witnessed abuse of a resident, identified as Resident A1, to the State Survey Agency. The incident involved Employee 3, a Nurse Aide, who made threatening and derogatory statements to Resident A1, which met the definition of mental and verbal abuse. The abuse occurred on June 8, 2024, but was not reported to the State Survey Agency until June 15, 2024, seven days after the incident. This delay in reporting violated the facility's abuse prohibition policy, which mandates immediate reporting of abuse allegations. Resident A1, who is cognitively intact with a BIMS score of 15, was involved in an altercation with Employee 3 outside the nursing station. During the argument, Employee 3 made threatening remarks, including telling Resident A1 that he would end up dead and using derogatory language. Witnesses, including Employee 4, a Registered Nurse, and Employee 5, a Nurse Aide, confirmed the altercation and the abusive language used by Employee 3. Despite the severity of the incident, Employee 3 continued to work with residents for the remainder of the shift and was not suspended until a week later. The facility's administration, including the Director of Nursing and the Nursing Home Administrator, acknowledged the failure to report the abuse within the required timeframe. They were unable to provide the surveyor with the statements that Employee 4 claimed to have submitted on the day of the incident. The delay in addressing the abuse and the continued employment of Employee 3 with resident contact until June 15, 2024, highlights the facility's failure to adhere to its own policies and federal and state regulations regarding the timely reporting of abuse.
Failure to Investigate and Protect Residents from Abuse
Penalty
Summary
The facility failed to timely and thoroughly investigate an injury of unknown source for Resident CR1, who was admitted with Alzheimer's disease and osteopenia. The resident was found with a tibia-fibula fracture, and the facility did not conduct a thorough investigation to rule out potential abuse, neglect, or mistreatment. Employee 3, a nurse aide, documented providing care to the resident without assistance, contrary to the resident's care plan, but the facility did not identify this discrepancy in their investigation. Additionally, the facility failed to promptly investigate a witnessed incident of verbal and mental abuse by Employee 3 towards Resident A1, who was cognitively intact and had bilateral below-knee leg amputations. Employee 3 made threatening and derogatory statements to Resident A1, and despite the incident being witnessed by other staff, the facility did not immediately remove Employee 3 from resident care. Employee 3 continued to work at the facility and interact with residents, including Resident A1, for about a week following the incident. The facility's administration was unable to locate witness statements collected by Employee 4, RN, following the abuse incident involving Resident A1. The Director of Nursing and Nursing Home Administrator confirmed that the facility failed to protect residents from potential further abuse by allowing Employee 3 to continue working with residents after the incident. Employee 3 was not suspended until several days later, after another employee reported concerns to the facility administration.
Failure to Provide Social Services After Resident Abuse
Penalty
Summary
The facility failed to provide necessary therapeutic social services to a resident following an incident of verbal and mental abuse by a staff member. The resident, who was cognitively intact and had a history of polyosteoarthritis and bilateral below-knee amputations, was subjected to threatening and derogatory statements by a nurse aide. This incident was witnessed by other staff members, and the nurse aide was eventually terminated. However, the facility did not assess the resident for psychosocial harm or provide any documented supportive visits after the incident. The altercation occurred when the resident confronted the nurse aide, leading to an argument where the aide made threatening remarks. Despite the intervention of a registered nurse who witnessed the incident, the nurse aide continued to work at the facility for a week following the altercation, even entering the resident's room. The resident expressed fear and distress, staying up late during the aide's shifts due to concerns for his safety. Interviews with staff confirmed the details of the incident and the lack of immediate action by the facility administration. The Director of Social Services acknowledged that there was no documentation of any assessment or supportive services provided to the resident after the abuse. This lack of action and documentation highlights the facility's failure to meet regulatory requirements for providing adequate social services to address the resident's mental and psychosocial well-being after the incident.
Sit-to-Stand Lift Malfunction
Penalty
Summary
The facility failed to ensure that essential resident care equipment, specifically a sit-to-stand lift, was in safe operating condition. During an observation in the second floor B wing residents lounge area, it was noted that one out of three sit-to-stand lifts was not functioning properly. The adjustable leg base of the lift, which is designed to extend open to accommodate various positions and provide a wider base of support during resident transfers, had a malfunctioning left leg that would not move when activated by the electronic controller. This issue was confirmed during an interview with the Director of Nursing (DON), who acknowledged the facility's failure to maintain the equipment in a safe operating condition.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to promptly act upon known risk factors for pressure sore development and did not timely implement individualized measures to prevent pressure sores and promote healing for a resident. The resident, who had severe cognitive impairment and required extensive assistance with bed mobility and transfers, was identified as being at risk for skin breakdown. Despite this, there was no evidence of the implementation of a positioning schedule, utilization of pressure-reducing wedges or pillows, or application of barrier creams according to the facility's policy during January and February 2024. The resident was admitted with multiple diagnoses, including a fracture of the right femur, reduced mobility, and moderate protein-calorie malnutrition. The care plan included interventions such as encouraging good nutrition and hydration, using prevalon boots, and providing a bariatric specialty mattress and chair pad. However, the facility did not consistently implement these measures. The resident developed a purple area on the right heel and later an unstageable pressure ulcer on the buttocks, indicating a failure to follow the planned interventions. The Director of Nursing confirmed that the facility could not demonstrate the consistent implementation of measures to prevent pressure ulcers and promote healing. The resident's condition worsened, resulting in a deep tissue injury and an unstageable pressure ulcer. The facility's failure to adhere to its policies and procedures for skin integrity and pressure ulcer prevention led to the resident's deteriorating condition.
Failure to Provide Effective Pain Management
Penalty
Summary
The facility failed to administer pain medication as prescribed by the physician and did not attempt non-pharmacological interventions to alleviate pain for Resident D2. The resident, who was readmitted to the facility with multiple diagnoses including a hip fracture, rheumatoid arthritis, and a dislocated kneecap, frequently experienced severe pain that was not effectively managed by the prescribed medication regimen. Despite the resident's complaints of severe pain and the ineffectiveness of the administered medications, there was no evidence that the facility attempted non-pharmacological interventions or notified the physician about the inadequacy of the pain management plan. The resident's Medication Administration Record (MAR) indicated that while the scheduled Morphine Sulfate was administered as ordered, the as-needed Oxycodone and Tramadol were often ineffective in managing the resident's pain. The facility's policy required non-pharmacological interventions and physician notification if the pain regimen was ineffective, but these steps were not documented or followed. The Director of Nursing confirmed that the facility did not provide effective pain management, did not consistently attempt non-pharmacological interventions, and failed to notify the practitioner as required by the facility's 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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