Edenbrook On Second Ave
Inspection history, citations, penalties and survey trends for this long-term care facility in Kingston, Pennsylvania.
- Location
- 200 Second Avenue, Kingston, Pennsylvania 18704
- CMS Provider Number
- 395397
- Inspections on file
- 52
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Edenbrook On Second Ave during CMS and state inspections, most recent first.
A cognitively impaired resident with dementia was the subject of an allegation of possible sexual assault reported by a cognitively intact roommate with a history of depression, hallucinations, and prior trauma. The roommate reported hearing a male CNA speak to the resident in a manner she interpreted as sexual while providing care in the early morning, and later reported a possible rape to facility staff. Although the facility’s abuse policy required immediate law enforcement notification, preservation of evidence, and prompt transfer for ED evaluation with a rape kit, the facility did not secure the scene, allowed the resident to be bathed, delayed notifying police for several hours, and did not ensure timely transfer for a sexual assault exam. Separately, the facility failed to follow its own employment screening policy for the CNA involved, as no documented reference checks or employment verifications were obtained from the two prior employers listed on his application.
Surveyors found unsanitary conditions in the food and nutrition services department and multiple resident pantries, including dirty floors, undated and improperly stored food items, stained appliances, and soiled surfaces. These findings were confirmed by facility administration, who acknowledged the expectation for sanitary maintenance and proper food dating.
Surveyors identified widespread failures in housekeeping and cleanliness across multiple units, with observations of dirty floors, debris, stains, and substance buildups in resident rooms, common areas, and bathrooms. Two residents reported that cleaning was infrequent and pointed out visible dirt and dust in their rooms, while the administrator confirmed the facility's responsibility for maintaining a clean environment.
Several residents with intact cognition and chronic medical conditions reported frequent, prolonged delays in staff response to call bell activations, with some waiting over an hour for assistance and others experiencing staff turning off call bells without providing care. These delays occurred during both day and night shifts, and included instances where a resident with vision impairment could not access the call bell, which was found out of reach during observation.
The facility failed to thoroughly assess and document a spinal cord stimulator for a resident with chronic pain, omitting it from both the admission assessment and care plan. Additionally, another resident with epilepsy did not receive prescribed anti-seizure medication prior to an off-site appointment as ordered, with inaccurate documentation in the MAR and no supporting late entry or progress note. These actions did not comply with professional standards of nursing practice or facility policy.
Staff failed to store personal care equipment and a urinary catheter drainage bag according to infection control protocols. Bedpans and wash basins were left unbagged and in direct contact with the floor, and urinals were unlabeled. A resident with a suprapubic catheter had their drainage bag resting on the floor, contrary to facility policy. The DON and Infection Preventionist confirmed these practices did not meet required standards.
A resident with a below the knee amputation and end stage renal disease, who was cognitively intact, was not invited to participate in the development or review of his person-centered care plan. There was no documentation of a care plan conference or invitation to participate, as confirmed by both the resident and facility staff.
A resident's MDS assessment inaccurately documented the discharge status as 'return anticipated' despite the resident not electing to pay privately to hold their bed during a hospital stay, indicating a return was not anticipated. The RN Assessment Coordinator confirmed the error after review of the clinical record and discharge planning information.
A facility failed to implement a planned intervention of placing a stop sign at a resident's doorway to deter wandering by a cognitively impaired resident. This omission resulted in a physical altercation when a resident with dementia entered the room of another resident known for verbal aggression. Staff interviews and documentation confirmed the intervention was not in place at the time of the incident, and the DON acknowledged the lapse in safety measures.
A resident with COPD was found to have a nebulizer mouthpiece and tubing that had not been changed for several months, contrary to facility policy requiring weekly changes. Staff and the DON confirmed the equipment was not replaced as required, resulting in a failure to provide safe and appropriate respiratory care.
A resident with severe cognitive impairment was admitted with both upper and lower dentures, but facility records inaccurately documented her oral status. The lower denture went missing shortly after admission and was not identified by staff, despite the resident's dependence on staff for oral care. The issue was only discovered after surveyor inquiry, resulting in a failure to provide timely and necessary dental services.
A nurse aide used a personal mobile device to take a photograph of a resident with severe cognitive impairment, without obtaining consent from the resident or her legal representative. Facility policy prohibits such actions, and no documentation of authorization was found. The incident was confirmed by the DON and raised concerns from the resident's Power of Attorney.
A resident with hypertension and type 2 diabetes was moved to a new room without consent while hospitalized after a fall. The facility attempted to notify the resident via phone, but he was unable to respond. Upon return, the resident found his room changed and belongings moved, negatively affecting his sleep. The administrator denied the resident's request to return to his original room, confirming the move was for staff convenience.
A resident with hypertension and type 2 diabetes fell in the shower room when a chair collapsed, sustaining scratches and later experiencing head pain and nausea. The facility failed to document the fall, assessments, injuries, or hospital transfer in the clinical records, and did not notify the resident's physician. The Nursing Home Administrator and DON confirmed the documentation failures, resulting in inaccurate and incomplete records.
A resident with morbid obesity and lymphedema required frequent bed linen changes due to excessive leakage. However, the facility failed to provide enough sheets for his bariatric bed, resulting in the resident lying on soiled sheets. Interviews revealed that sheets were often unavailable due to tearing or being cut to fit the bed, and the administration could not provide evidence of adequate linen changes.
The facility failed to provide written notice to residents or their representatives before making room changes, as required by federal regulations. Two residents did not receive written explanations for their room changes, which occurred due to room availability and short-term admission status. The facility's policy allowed for oral or written notice, contradicting federal requirements for written explanations.
Several residents in the facility reported significant delays in receiving care, such as incontinence care and assistance with toileting, impacting their quality of life and dignity. Cognitively intact residents experienced wait times ranging from 30 minutes to several hours, leading to frustration and, in some cases, unsafe self-transfers. The Nursing Home Administrator acknowledged the issue but could not provide an explanation for the delays.
The facility failed to maintain a clean and safe environment, as evidenced by soiled bed linens in two residents' rooms and unsanitary conditions in the A Hall shower room. Both residents, who were cognitively intact, reported that their bed linens had not been changed despite scheduled shower days. Observations confirmed the presence of stains on bed linens and the shower chair, and the Infection Preventionist acknowledged the facility's policy was not followed.
The facility failed to maintain oxygen equipment in a sanitary manner for three residents. A resident's nebulizer mask was left uncovered on an overbed table with opened beverages. Another resident's nebulizer mask was uncovered on a nightstand with personal items, and the bag was mislabeled. A third resident's BiPAP mask was left uncovered on a nightstand and later found on the floor next to a used glove. The Infection Preventionist confirmed that equipment should be bagged to prevent contamination.
The facility failed to properly store and dispose of medications in Medication Storage Room B. Observations revealed 89 medication cards awaiting destruction or return, contrary to facility policy. Medications for a discharged resident remained without a completed disposition form. Staff interviews confirmed the lapse in timely medication management.
A resident reported the misappropriation of property, including snacks and a phone charger, but the facility failed to report the incident to the appropriate authorities within the required timeframe. The resident, who was cognitively intact, expressed distress over the incident. The facility's investigation did not identify a perpetrator, and the administrator could not provide evidence of timely reporting as per the facility's abuse policy.
The facility failed to implement person-centered care plans for two residents, leading to deficiencies in care. One resident, at high risk for falls, lacked prescribed safety interventions like floor mats and a scoop mattress. Another resident with edema had no care plan addressing therapeutic measures like ace wraps. Staff confirmed these omissions, indicating a failure to meet residents' specific needs.
Two residents in an LTC facility did not receive necessary hygiene care. One resident, dependent on staff for bathing, missed scheduled bed baths, while another resident, requiring extensive assistance, was observed with poor personal hygiene. The facility did not implement planned interventions to address these deficiencies.
The facility failed to follow physician orders for two residents. A resident scheduled for an abdominal ultrasound was mistakenly given breakfast due to a lack of communication about their NPO status, leading to the test's cancellation. Another resident, prescribed ace wraps for their legs, was observed multiple times without them, and no wraps were available in their room or on the treatment cart.
A resident with a PICC line and diagnosed with osteomyelitis did not receive prescribed doses of IV antibiotics, Daptomycin and Cefepime, on three occasions. The facility's failure to administer these medications as ordered and to notify the attending physician of the missed doses was confirmed by a regional nurse consultant, indicating a deficiency in adherence to medication administration policies.
A resident with Parkinson's disease and a hip fracture had a physician's order for ace wraps on his legs, but observations over three days showed he was not wearing them, despite records indicating otherwise. Interviews with RNs confirmed the absence of ace wraps, and the Nursing Home Administrator could not explain the documentation discrepancy.
The facility failed to implement proper infection control practices, including the absence of designated PPE disposal containers for COVID-19 positive residents and improper handling of medical supplies for a resident with a stage 4 pressure ulcer. The infection preventionist confirmed these deficiencies, highlighting a lack of adherence to CDC guidelines.
A resident in a triple-occupancy room was found without ceiling privacy curtains, unlike their roommates, compromising their visual privacy. The resident, who is cognitively intact, confirmed the absence of curtains since moving in. The NHA acknowledged the requirement for privacy in resident rooms.
A resident with severe cognitive impairment was verbally abused by a nurse aide who used derogatory language while on a personal phone call. Despite reports to multiple staff members, the aide was not immediately removed, and the facility's investigation concluded the abuse was unsubstantiated, despite evidence of the resident's increased agitation.
A resident with severe cognitive impairment was verbally abused by a nurse aide who was on a personal phone call while providing care. Despite reports made to nursing staff, the facility failed to promptly investigate the allegations or protect the resident from further abuse, allowing the aide to continue providing care. The Director of Nursing could not provide evidence of a timely investigation or protective measures.
A resident with a history of substance abuse and identified as an elopement risk left the facility unsupervised multiple times without the required LOA forms or physician's orders. The facility's staff was unaware of the resident's unauthorized departure, and the incident was not documented in the clinical record. The facility failed to implement its LOA policy effectively, leading to the resident's elopement.
The facility did not follow its policy for dating multi-dose medication vials when opened, as observed on two medication carts. Vials of Lantus, Novolog, and Levemir injectables were found opened and in use without being dated, contrary to the facility's procedures. This was confirmed by the Nursing Home Administrator.
The attending physician failed to act on pharmacist-identified drug irregularities for three residents. Medications for depression and anxiety were due for assessment, but the physician either did not respond or deferred to telehealth services without documenting any actions taken. The DON and Nursing Home Administrator confirmed the lack of documentation and action, constituting a deficiency in pharmacy services and medical director responsibilities.
The facility failed to ensure fresh water was consistently readily accessible to residents, leading to complaints from multiple residents. The facility policy required fresh water to be provided daily and refilled on each shift, but residents reported that they had to ask for fresh water, and it was only provided during the night shift. The Nursing Home Administrator confirmed the expectation of water being passed once per shift, but the facility did not meet this standard, violating state regulations.
A facility failed to develop and implement a comprehensive care plan to address a resident's hydration needs, despite the resident being dependent on staff for assistance with drinking. The resident expressed frustration with long wait times for help, and the Director of Nursing could not provide evidence of a proper care plan.
The facility failed to follow physician orders for bowel protocol and diabetes management for two residents. One resident did not receive prescribed treatments for constipation, and another resident's insulin was administered over four hours late. The Director of Nursing confirmed these lapses in care.
A facility failed to timely assess and treat a pressure sore for a resident readmitted with heart failure. The pressure sore on the sacrum was not properly documented or treated until days after readmission, leading to a deep tissue injury. The DON confirmed the lack of timely assessment and intervention.
A resident fell during a transfer due to insufficient staff assistance and the use of an incorrect sling. The resident, who required a stand-up lift with two staff and a yellow sling, was transferred by a single nurse aide using a red sling, resulting in the resident sliding down and being lowered to the floor without injury.
The facility failed to ensure that a resident's care plan accurately reflected their dialysis needs, including the presence of a right chest Tesio site and necessary interventions for its care. This deficiency was confirmed by the DON.
The facility failed to date three multi-dose bottles of Tuberculin in one of the medication storage rooms, as required by their policy. This was confirmed by the DON during an interview.
A resident with Multiple Sclerosis and breast cancer, who was cognitively intact, had documented her dislike for fresh tomatoes upon admission. Despite this, she was repeatedly served salads containing fresh tomatoes, even after informing the registered dietitian and dietary manager. An observation confirmed the presence of fresh tomatoes in her salad, indicating a failure by the facility to honor her documented food preferences.
Failure to Implement Abuse Policy and Complete Required Employee Screening
Penalty
Summary
The deficiency involves the facility’s failure to follow its Abuse and Neglect Prevention Policy after an allegation of possible sexual assault involving one resident. The policy defined serious bodily injury to include sexual acts with a resident who is unable to consent or understand the nature of the act and required that, when maltreatment is suspected, the resident must be assessed for injuries and trauma, evidence must be preserved, and law enforcement and the State agency must be notified within specified time frames. The policy also directed staff not to bathe or clean the resident, not to wash or discard clothing or linens, not to destroy documentation, and to transfer the resident to the emergency department for medical examination, including a rape kit, when sexual abuse is suspected. In this case, the facility did not secure the scene, did not preserve potential evidence, did not ensure timely transfer for a sexual assault examination, and did not immediately notify law enforcement. Resident 1, who had dementia and a BIMS score of 03 indicating severe cognitive impairment, was the alleged victim. Resident 2, the cognitively intact roommate with a BIMS score of 14 and a history of depression, hallucinations, and prior traumatic domestic violence, reported to staff that a male nurse aide (Employee 1) had possibly sexually assaulted Resident 1. Resident 2 stated that at approximately 5:00 AM she heard Employee 1 in the room and bathroom with Resident 1, heard him say phrases such as "we are going to get it right this time," "I am not going to hurt you," and that he would be gentle, and heard Resident 1 call him names. Resident 2 did not see sexual contact and did not hear Resident 1 express distress such as saying "stop," but believed a rape occurred based on Employee 1’s manner of speaking and Resident 1’s reactions when Employee 1 was present. Resident 2 reported the allegation of possible rape to the Activity Director around late morning, who then brought her to the Nursing Home Administrator (NHA). A progress note documented that a body audit of Resident 1 was completed and no visible injuries were observed, and a social services interview documented that Resident 1 denied inappropriate touching, pain, or genital symptoms. Despite the facility’s policy requiring immediate police notification and prompt transfer for forensic medical evaluation when sexual abuse is suspected, the facility delayed both evidence preservation and external reporting. The NHA acknowledged that an allegation of possible rape was reported to her at approximately 11:00 AM, but law enforcement was not notified until 3:21 PM, several hours after the allegation was reported. Additionally, the resident was not transferred promptly for a sexual assault examination; instead, Resident 1 was bathed by a nurse aide on a later date to remove fecal matter from the private area, and the NHA’s account of when the responsible party was offered emergency room evaluation conflicted with the responsible party’s statement that no such option was offered during the initial visit and that staff repeatedly stated the incident did not occur. These actions and inactions resulted in failure to secure the scene, preserve potential forensic evidence, and ensure timely medical and forensic evaluation in accordance with the facility’s own abuse policy. A separate but related deficiency involved the facility’s failure to follow its own employee screening procedures for one staff member. The facility’s Vulnerable Adult Abuse and Neglect Prevention Policy and Employment Screenings Policy required reasonable efforts to obtain information from previous employers, including verification of dates of employment, position held, and other reference information, or alternative references when prior employment was not available. Employee 1, the nurse aide implicated in the allegation, listed two previous employers on the employment application. However, review of the personnel file showed no documented evidence that reference checks or employment verifications were obtained from either prior employer before the employee’s start date. The Director of Human Resources confirmed that the facility could not provide documentation showing reasonable efforts to contact Employee 1’s previous employers, indicating that the facility did not implement its own screening procedures intended to identify any history of abuse, neglect, exploitation, or mistreatment.
Deficient Sanitary Practices in Food Storage and Service Areas
Penalty
Summary
Surveyors observed that the facility failed to maintain sanitary conditions in the food and nutrition services department and in three of five resident pantry areas. Specific findings included a kitchen floor with visible dirt, discolorations, dust, and food debris along the perimeter. In the A Hall pantry, there was an opened, undated chocolate instant pudding mix, cabinets with dust and discolorations, a refrigerator with substance stains and discolorations, and a microwave containing used brown napkins and substance stains both inside and around the exterior. The B Hall pantry contained an opened plastic bag with white crackers, a microwave with food substance stains and food pieces, and a refrigerator with a soiled brown paper towel. Further observations in the Medbridge Hall pantry revealed an undated plastic bowl containing tan food in the refrigerator, brown-red substance stains along the bottom shelf of the refrigerator, and an undated frozen liquid drink in the freezer. The microwave in this area also had food pieces and a substance stain inside. These conditions were confirmed by the nursing home administrator, who acknowledged that food and nutrition service areas, as well as resident pantries, were expected to be maintained in a sanitary manner and that food items should be dated to ensure quality and safety.
Plan Of Correction
1. A Hall pantry has been cleaned, including the cabinets, refrigerator, and microwave. Undated/opened foods have been removed. B Hall pantry has been cleaned, including the cabinets, refrigerator, and microwave. Undated/opened foods have been removed. Med Bridge pantry has been cleaned, including the cabinets, refrigerator, and microwave. Undated/opened foods have been removed. The facility kitchen floor has been deep cleaned to ensure dirt, dust, and food pieces have been removed. 2. The facility is storing, preparing, distributing, and serving foods in accordance with professional standards for food service safety to prevent contamination and microbial growth in food. 3. Facility staff have been inserviced on the need to store, prepare, distribute, and serve food in a 4. NHA and/or Designee will audit the dietary and pantry areas to ensure environment is clean and foods labeled and dated. Audits will be completed 5x week for two weeks then weekly. Audits will be reviewed with the QAPI committee to determine if compliance is maintained and for any further action that may be needed. I Certify This Document to be a True and Correct Statement of Deficiencies and Approved Facility Plan of Correction for the Above-Identified Facility Survey
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
Edenbrook on Second Ave was found to be noncompliant with federal and state regulations regarding the maintenance of a safe, clean, comfortable, and homelike environment for residents. Surveyors observed multiple instances of uncleanliness and lack of proper housekeeping across four out of five nursing units, including Medbridge Hall, A Hall, B Hall, and D Hall. Specific findings included dirty floors, debris, stains, and substance buildups in common areas such as hallways, dining areas, and shower rooms. Resident council meeting minutes also documented complaints about inadequate housekeeping, such as only garbage being emptied, infrequent mopping, use of dirty water, dusty surfaces, spider webs, and uncleaned over-bed tables and bathrooms. Direct observations on the day of the survey revealed numerous cleanliness issues. These included a black mat with debris and discoloration in a dining area, clumps of hair and dirt in hallways, missing and stained tiles, saturated paper, and hair in shower room drains, as well as stained bathtubs and shower chairs. Floors around nursing stations and along baseboards were found with dirt, debris, and substance buildups. Lounge areas had stained trays and furniture, and floors with visible stains. Resident rooms were also observed with splattered substances, paper, dirt, dust, cobwebs, and leaves, as well as stained and dirty bathrooms. Interviews with residents confirmed the ongoing nature of these issues. One resident, with moderate cognitive impairment, stated that his room was never cleaned except when surveyors were present, and surveyors observed his room to be dirty. Another resident, who was cognitively intact, reported that staff did not clean every day and pointed out visible buildups of dirt and dust in her room. The Nursing Home Administrator acknowledged the facility's responsibility to maintain a clean and homelike environment for all residents.
Plan Of Correction
Black mat with white debris, wet paper towel, and black-gray discoloration on floor in front of the ice machine in the Medbridge dining area has been cleaned. Medbridge hallway outside room 108 has been cleaned. Medbridge shower room has been deep cleaned. Medbridge hallway adjacent to nursing station has had the wall cleaned and the floor cleaned. Dirt and debris in the A Hall nursing area has been cleaned including the running board. B Hall Shower room has been deep cleaned - drain, bathtub shower room floor has been cleaned. Plastic glove and pieces of debris including hair and paper have been removed. B Hallway edges and baseboard have been stripped/waxed and cleaned. B Hallway lounge has been cleaned and the floor stripped/waxed. D hall shower room floor, bathtub, shower chair, and drain have been cleaned. Resident #1's room A01-A has been deep cleaned. Resident #2's C07-A room has been deep cleaned. Room 101 has been deep cleaned including bathroom. Resident rooms, lounges, and dining rooms have been audited and areas that need to be cleaned identified and are being cleaned. Facility staff have been educated on the need to provide a safe, clean, comfortable, and homelike environment and on the need to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and homelike environment. B Hallway lounge has been cleaned and the floor stripped/waxed. D hall shower room floor, bathtub, shower chair, and drain have been cleaned. Resident #1's room A01-A has been deep cleaned. Resident #2's C07-A room has been deep cleaned. Room 101 has been deep cleaned including bathroom. Resident rooms, lounges, and dining rooms have been audited and areas that need to be cleaned identified and are being cleaned. Facility staff have been educated on the need to provide a safe, clean, comfortable, and homelike environment and on the need to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and homelike environment.
Failure to Respond Timely to Resident Call Bells
Penalty
Summary
The facility failed to provide care in a manner that promotes each resident's quality of life by not responding timely to residents' requests for assistance. Multiple residents reported excessive wait times after activating their call bell lights, with some waiting over an hour for staff to respond. During a resident council meeting, several residents described frequent delays, particularly during the evening shift, and instances where staff entered rooms, turned off call bell lights, and left without providing care. One resident recounted waiting two hours for incontinence care after the call bell was silenced, while another stated she typically waited at least 30 minutes for assistance. These delays were corroborated by interviews and observations, including a resident with vision impairment who was unable to access his call bell, which was found on the floor and out of reach during the surveyor's visit. Clinical record reviews revealed that the affected residents were cognitively intact and had various medical conditions, including chronic obstructive pulmonary disease, type 2 diabetes, and a below-the-knee amputation. Despite their ability to communicate their needs, these residents consistently experienced long wait times for care, both during the day and night shifts. The Nursing Home Administrator acknowledged that residents should receive timely care but was unable to explain the consistent delays reported by multiple residents.
Failure to Assess, Document, and Implement Physician Orders for Resident Care
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of practice for two residents. For one resident with a history of chronic pain syndrome, right below the knee amputation, and Type 2 diabetes, the facility did not thoroughly assess or document the presence of a spinal cord stimulator implant, which had been previously placed. The resident's admission assessment did not mention the device, and there were no physician orders or care plan interventions addressing the spinal cord stimulator, despite its relevance to the resident's medical condition and pain management needs. The Director of Nursing confirmed that the assessment, physician orders, and care plan failed to address the device as required. For another resident with epilepsy and depression, the facility did not provide nursing care in accordance with physician orders regarding anti-seizure medication administration. The resident was scheduled to receive Levetiracetam at a specific time before leaving for an off-site appointment, as per physician order. However, the medication administration record indicated the medication was given at a time when the resident was not present in the facility, and there was no late entry or progress note to justify this documentation. The resident reported not receiving the medication before leaving, despite requesting it, and subsequently experienced a seizure during the appointment, requiring emergency treatment. Facility policies required accurate transcription and implementation of physician orders, as well as timely and accurate documentation of medication administration. The facility's internal investigation acknowledged a failure to document the medication administration and did not include statements from the resident, her representative, or the accompanying CNA. The Director of Nursing confirmed that staff did not comply with physician orders or documentation standards, resulting in deficiencies in nursing services and medical record-keeping.
Improper Storage of Personal Care Equipment and Catheter Drainage Bag
Penalty
Summary
The facility failed to properly store resident personal care equipment and a urinary catheter drainage bag in accordance with its infection prevention and control program. Observations on two separate days revealed that bedpans and wash basins were left unbagged and in direct contact with the floor, wall, and garbage can in resident bathrooms on one nursing unit. Additionally, urinals containing liquid were found hanging on grab bars without resident identification, and multiple wash basins were stacked on toilet tanks without labeling. These practices were not in line with facility policy, which requires such items to be cleaned, bagged, and stored on the bottom shelf of each resident's nightstand. The Director of Nursing confirmed that the observed storage methods did not comply with established procedures. For one resident with spastic quadriplegic cerebral palsy and a suprapubic catheter, the catheter drainage bag was observed resting directly on the floor, despite being covered for privacy. Staff interviews confirmed that catheter drainage bags are required to be positioned to avoid floor contact, as per infection control protocols. The facility's failure to ensure proper storage and maintenance of personal care equipment and urinary drainage systems was confirmed through staff interviews and direct observation, resulting in noncompliance with infection prevention best practices.
Failure to Involve Resident in Care Planning Process
Penalty
Summary
The facility failed to conduct a care plan conference and did not ensure that a resident was invited to participate in the development and implementation of his person-centered care plan. Clinical record review showed that the resident, who was admitted with a below the knee amputation and end stage renal disease, was cognitively intact as evidenced by a BIMS score of 13. Despite this, there was no documentation of a care plan conference or any invitation extended to the resident to participate in the care planning process. During an interview, the resident confirmed that he had not been invited to participate in the care planning process or attend any care plan meetings. Further interviews with the DON and Admission's Director confirmed the absence of documentation showing that a care plan conference had been held or that the resident had been invited to participate. This deficiency was identified for one of 29 residents reviewed.
Inaccurate MDS Discharge Status Documentation
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident, specifically regarding the resident's discharge status. A review of the clinical record showed that the resident was admitted and later discharged to the hospital. The resident was private pay and chose not to continue private payment to hold their room during the hospitalization, which is a key indicator that the return to the facility was not anticipated. Despite this, the MDS assessment documented the discharge as 'return anticipated' in Section A0310F, which was inconsistent with the resident's payor status and discharge planning information. During an interview, the Registered Nurse Assessment Coordinator acknowledged the inaccuracy in the MDS assessment and confirmed that the discharge should have been recorded as 'return not anticipated.' This discrepancy was identified through a review of the clinical record, the RAI, and staff interviews, indicating that the facility did not accurately reflect the resident's discharge status as required.
Failure to Implement Planned Intervention Leads to Resident Altercation
Penalty
Summary
The facility failed to provide adequate supervision and implement a planned intervention to prevent intrusive wandering by a cognitively impaired resident, resulting in a resident-to-resident altercation. Resident 91, who is cognitively intact and has a history of verbal aggression, had a care plan intervention directing the placement of a stop sign at his doorway to deter wandering residents from entering. However, this intervention was not implemented at the time of the incident. Resident 103, who is severely cognitively impaired and identified as a wanderer and elopement risk, entered Resident 91's room, leading to a physical altercation in which Resident 91 struck Resident 103. Clinical records, staff interviews, and facility investigative documentation confirmed that the stop sign intervention was not in place at the time of the incident, and observations after the event continued to show the absence of the stop sign at Resident 91's doorway. The Director of Nursing acknowledged the facility's failure to implement the planned safety measure, which may have contributed to the altercation between the two residents.
Failure to Maintain Sanitary Respiratory Equipment
Penalty
Summary
Staff failed to maintain respiratory equipment in a sanitary and functional condition for one resident diagnosed with Chronic Obstructive Pulmonary Disease (COPD). Facility policy required that nebulizer mouthpieces and tubing be labeled with the date and changed weekly. However, observation revealed that the nebulizer tubing and mouthpiece in the resident's room were labeled with a date nearly three months prior and had not been changed since then. Interviews with a nurse aide and the Director of Nursing confirmed that the equipment had not been replaced according to policy. The Director of Nursing acknowledged that the facility did not follow its own procedures for maintaining respiratory equipment, resulting in the failure to provide safe and appropriate respiratory care for the resident.
Failure to Ensure Timely Dental Services Due to Inaccurate Documentation
Penalty
Summary
A resident with unspecified dementia and severe cognitive impairment was admitted to the facility with both upper and lower dentures, as documented on the Inventory Sheet of Personal Effects. However, the resident's clinical record and nursing assessments failed to accurately document the presence of dentures, instead indicating she had her own natural teeth and no dental concerns. The resident required maximum assistance or was totally dependent on staff for oral care. Several weeks after admission, the resident's lower denture went missing, but this was not identified or addressed by facility staff. The resident reported the loss to her husband but was unsure if it was communicated to the facility. The missing denture was only discovered after surveyor inquiries, and until that point, the resident had adapted by eating a soft, bite-sized diet. The Director of Nursing confirmed that the facility failed to recognize the missing denture due to inaccurate documentation at admission and did not ensure timely and necessary dental services for the resident.
Unauthorized Photograph of Resident Without Consent
Penalty
Summary
A facility staff member, specifically a nurse aide employed through an agency, took a photograph of a resident using a personal mobile device without obtaining consent from the resident or the resident's legal representative. The resident in question had diagnoses including Down syndrome and dementia, with clinical assessments indicating severe cognitive impairment and inability to communicate or make decisions regarding daily life. The facility's policy explicitly prohibits associates from photographing residents for personal use, and documentation review confirmed that no authorization for the photograph was provided by the resident or her Power of Attorney. The incident was discovered through a witness statement and confirmed by the Director of Nursing, who stated that the nurse aide admitted to taking the photograph and showing it to the resident's family member. The family member, who holds Power of Attorney, expressed concern and confirmed that no consent had been given for the photograph. The facility was unable to provide any documentation of consent for the image, and the staff member involved could not be reached for further investigation. The deficiency centers on the facility's failure to ensure the resident's right to personal privacy and confidentiality of personal and medical records.
Resident's Right to Refuse Room Change Violated
Penalty
Summary
The facility failed to ensure that a resident's room change was not completed for the purpose of staff convenience, violating the resident's right to refuse such a change. The resident, who had been admitted with diagnoses including hypertension and type 2 diabetes, was moved from Room A6 to Room B11 while he was at the hospital following a fall. The facility attempted to notify the resident of the room change by calling his phone three times and leaving messages, but the resident was unable to respond as he was in the hospital. Upon returning to the facility, the resident found that his room had been changed without his consent, and his belongings had been moved. The resident expressed dissatisfaction with the room change, stating that it negatively affected his sleep, and his request to return to his original room was denied. During an interview, the resident reported that the administrator dismissed his concerns, asserting authority over the decision. The Nursing Home Administrator confirmed that the facility did not afford the resident the right to refuse the room change, and the move was made for staff convenience, not considering the resident's rights.
Plan Of Correction
1. Resident #1 was offered a room change and declined. 2. A 14 day look back was completed of room changes. Any room change completed with the resident not present or RR not made aware will be re-offered a room change. Policy reviewed and revised. 3. Nurse educator will educate current social services and current LN's on revised room change policy. 4. DON/designee will audit all room changed during clinical stand up 5 x a week x 4 weeks to ensure policy is followed. Results to QAPI.
Failure to Document Resident Fall and Hospital Transfer
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for a resident, as required by professional standards of practice. The resident, who had a medical history of hypertension and type 2 diabetes, experienced a fall in the shower room when a shower chair collapsed. Although the resident sustained scratches and later reported head pain and nausea, prompting a transfer to the hospital, the facility did not document the fall, the assessments conducted, the injuries sustained, or the time of hospital transfer in the clinical records. Additionally, there was no documentation indicating that the resident's physician was notified of the incident. The deficiency was confirmed through a review of facility investigative reports, clinical records, and staff interviews. The Nursing Home Administrator and Director of Nursing acknowledged that the nursing staff failed to document consistently and accurately in the resident's clinical records, resulting in inaccuracies and incompleteness. This failure to document critical information contravenes the American Nurses Association Principles for Nursing Documentation and the Title 49 Professional and Vocational Standards, which mandate timely and accurate record-keeping to ensure high-quality care and informed decision-making by the healthcare team.
Plan Of Correction
1. Staff involved with resident #1 fall were educated on accurate documentation; a late entry note was placed into the chart. 2. A 14-day look back of falls will be completed to ensure the timely documentation/assessments were completed. Policy reviewed and revised. 3. The nurse educator will educate current LN's on the revised fall policy for post-fall documentation and assessment. 4. The DON/designee will review all falls in clinical stand up 5 times a week for 4 weeks, with results to QAPI.
Failure to Accommodate Resident's Linen Needs
Penalty
Summary
The facility failed to accommodate the needs of a resident requiring more frequent bed linen changes due to his medical condition. Resident 2, who was admitted with diagnoses including morbid obesity and lymphedema, reported that his sheets needed to be changed every shift because of excessive leakage from his legs. Despite this need, the resident stated that there were times when staff could not change the bed linens due to a lack of available sheets. Observations confirmed that Resident 2 was lying on visibly soiled sheets, and an interview with a laundry aide revealed that the facility often did not have enough sheets for the bariatric bed. The sheets were either tearing or being cut by staff to fit the bed. The nursing home administrator and director of nursing could not provide documented evidence that the resident's bed linens were being changed frequently enough to meet his needs, indicating a failure to reasonably accommodate the resident's individual requirements.
Failure to Provide Written Notice for Room Changes
Penalty
Summary
The facility failed to provide written notice to residents or their representatives before making room changes, as required by federal regulatory guidance under S483.10(e)(6). This deficiency was identified in two out of 15 room changes conducted between October 30, 2024, and November 4, 2024. Specifically, Resident 1 and Resident 2 did not receive written explanations for their room changes. Resident 1's clinical record contained a Room/Roommate Change Advance Notification Form dated November 4, 2024, indicating a room change on the same day due to room availability, but there was no evidence that the form was provided to the resident or their representative. Similarly, Resident 2, a cognitively intact resident, confirmed during an interview that they were moved on October 30, 2024, because they were considered a short-term admission. However, Resident 2 stated they did not receive any written notification of the room change. The facility's policy allowed for oral or written notice, which contradicts the federal requirement for written explanations. The nursing home administrator was unable to provide documented evidence of written explanations for the room changes during an interview on November 26, 2024.
Delayed Response to Resident Care Requests
Penalty
Summary
The facility failed to provide timely responses to residents' requests for assistance, impacting their quality of life and dignity. Seven residents, all cognitively intact, reported significant delays in receiving care, such as incontinence care and assistance with toileting. For instance, Resident 85 expressed frustration over waiting an hour or longer for incontinence care, sometimes resulting in soiled linens not being changed. Resident 66 reported waiting two and a half hours for care, leading to a disrupted sleep schedule. Similarly, Resident 3 experienced delays of up to two hours for assistance after soiling her brief. Other residents also shared their dissatisfaction with the care provided. Resident 57 mentioned waiting three hours for a cup of water and expressed a desire to transfer to another facility due to the long wait times. Resident 34, needing assistance to the bathroom, sometimes waited over an hour and resorted to transferring herself, despite safety concerns. Resident 6 reported waiting over 30 minutes for assistance and missing scheduled showers when regular staff were not available. Resident 38 noted frequent delays during specific shifts. The Nursing Home Administrator acknowledged the issue but could not explain the cause of the untimely responses.
Failure to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to provide adequate housekeeping services to maintain a clean and safe environment for residents in two specific rooms and the A unit. Observations revealed soiled bed linens in the rooms of two residents, identified as Resident 68 and Resident 39. Resident 68's bed had multiple reddish-brown stains on the pillowcase, a large yellow stain on the fitted sheet, and several light brown stains at the foot of the bed. Resident 39's bed also had multiple light brown stains on the fitted sheet. Both residents, who were cognitively intact with a BIMS score of 15, reported that their bed linens had not been changed in a while, despite their scheduled shower days. Resident 68 stated that his sheets were not changed after his shower the previous day, and Resident 39 mentioned that the shower room was often dirty, with a specific incident of fecal matter on the shower chair. Further observations confirmed the unsanitary conditions in the A Hall shower room, where brown stains and a pebble-shaped substance were found on the shower chair. A follow-up observation the next day showed that the conditions in Room A06 remained unchanged. An interview with the Infection Preventionist confirmed that the facility's policy required bed linens to be changed upon soilage and on residents' shower days, which was not adhered to in these cases. The facility's failure to maintain a clean and sanitary environment was in violation of their policy and regulatory requirements.
Failure to Maintain Sanitary Respiratory Equipment
Penalty
Summary
The facility failed to maintain oxygen equipment in a functional and sanitary manner for three residents. Resident 9, who was diagnosed with chronic obstructive pulmonary disease and atherosclerotic heart disease, had a nebulizer machine with tubing and a mask placed on an overbed table alongside opened beverages. The nebulizer mask was uncovered and not stored in a labeled plastic bag as per facility policy. Resident 22, diagnosed with heart failure and cerebral infarction, had a nebulizer machine with tubing and a mask on a bedside nightstand, along with an opened canister of hair spray, a bottle of lotion, and opened snack bags. The nebulizer mask was also uncovered and not bagged, and the plastic bag tied to the tubing was mislabeled with another resident's name and room number. Resident 135, who had asthma, chronic pulmonary edema, and obstructive sleep apnea, had a BiPAP machine with tubing and a fabric mask placed on a bedside nightstand with open beverage containers, opened snack packages, and toiletries. The BiPAP mask was left uncovered and not bagged. An additional observation revealed the BiPAP tubing and mask on the floor next to a used latex glove, indicating further non-compliance with sanitary storage practices. An interview with the Infection Preventionist confirmed that respiratory equipment should be bagged when not in use to prevent contamination.
Medication Storage and Disposition Deficiency
Penalty
Summary
The facility failed to implement proper procedures for the storage and disposition of medications on one of its nursing units, specifically in Medication Storage Room B. During an observation, it was found that medications were not being stored or disposed of according to the facility's policies. The facility's policy requires that discontinued medications be removed from the medication cart, inventoried, and either destroyed or returned to the pharmacy. However, it was observed that two mauve wash basins and a cardboard box contained a total of 89 medication cards that needed to be destroyed or returned, indicating a lapse in following the procedure. Further investigation revealed that medications prescribed for a resident who had been discharged remained in the medication room without a completed medication disposition form. Interviews with staff, including a licensed practical nurse and the Infection Preventionist, confirmed that the process for the timely disposition of medications was not being followed. This deficiency was noted under the regulations for pharmacy and nursing services, highlighting a failure in the facility's medication management system.
Failure to Timely Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to timely report an alleged violation of misappropriation of resident property for one resident. The facility's abuse policy requires that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including misappropriation of resident property, be reported immediately, but not later than 2 hours after the allegation if it involves abuse or results in serious bodily injury, or not later than 24 hours if it does not. However, the incident involving the misappropriation of a resident's property, which occurred on August 9, 2024, was not reported to the State Agency, Area Agency on Aging, and the police until August 13, 2024. The resident involved was admitted with diagnoses of end-stage renal disease with hemodialysis and a right femur fracture. The resident was cognitively intact, as indicated by a BIMS score of 15. On August 10, 2024, the resident reported that seventy dollars worth of snacks and a phone charger were taken from her bedside, which led to her being distraught and tearful. Despite the registered nurse supervisor being informed and addressing the situation, the facility's investigation, which concluded on August 13, 2024, did not identify a perpetrator. The administrator could not provide documented evidence that the facility's abuse policy was implemented timely in response to the resident's allegation.
Failure to Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans for two residents, leading to deficiencies in their care. Resident 63, who was admitted with hemiplegia and cerebral infarction, was identified as being at high risk for falls. Despite a care plan that included interventions such as bilateral floor mats and a scoop mattress, these measures were not observed during multiple inspections. Staff interviews confirmed the absence of these safety interventions, indicating a failure to implement the care plan designed to mitigate the resident's fall risk. Resident 87, admitted with Parkinson's disease and a hip fracture, had a physician's order for ace wraps to manage lower extremity edema. However, the comprehensive care plan did not address the resident's edema or include the therapeutic measures prescribed. The Nursing Home Administrator confirmed that the care plan failed to incorporate necessary interventions for the resident's condition, highlighting a lack of attention to the resident's specific medical needs.
Failure to Provide Scheduled Hygiene Care
Penalty
Summary
The facility failed to provide necessary services to maintain good personal hygiene for two residents. Resident 42, who was cognitively intact and dependent on staff for bathing, did not receive the scheduled two bed baths per week. The Task Documentation Report showed that the resident received a bed bath on only three occasions over a three-week period, missing scheduled baths on three other occasions. Despite the resident's preference for bed baths, the facility did not adhere to the schedule, resulting in a deficiency in care. Resident 138, who required extensive assistance with activities of daily living due to multiple health conditions, was observed with long, dirty fingernails and dry, peeling lips. The resident expressed a need for help with oral and nail care but was not always accepting of staff assistance. The care plan for Resident 138 included specific interventions to address non-compliance and promote personal hygiene, but there was no evidence that these interventions were implemented. The facility's failure to assist the resident with personal grooming and hygiene needs was confirmed by the regional nurse consultant.
Failure to Follow Physician Orders for NPO and Therapeutic Measures
Penalty
Summary
The facility failed to provide person-centered quality care by not adhering to physician orders for two residents. Resident 133, who was admitted with conditions including hepatic encephalopathy, dementia, and gastro-esophageal reflux disease, was scheduled for an abdominal ultrasound. A physician's order required the resident to be NPO after midnight prior to the test. However, due to a lack of communication among staff, the resident was given breakfast, resulting in the cancellation of the ultrasound. Interviews with staff revealed that the nurse aide was not informed of the NPO status, leading to the oversight. Additionally, the facility did not follow physician orders for Resident 87, who had diagnoses including Parkinson's disease and a hip fracture. The resident was prescribed ace wraps for his legs to be applied in the morning and removed at bedtime. Observations on multiple occasions revealed that the resident was not wearing the ace wraps as ordered, and there were no ace wraps available in the resident's room or on the nurse's treatment cart. Staff interviews confirmed the failure to apply the ace wraps as prescribed.
Failure to Administer IV Antibiotics as Prescribed
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of physician-ordered intravenous (IV) medications for a resident. The resident, who was readmitted to the facility with a PICC line and diagnosed with osteomyelitis, had specific orders for the administration of Daptomycin and Cefepime, both antibiotics used to treat bacterial infections. The facility's Medication Administration Policy mandates that medications be administered safely, timely, and as prescribed. However, the review of the resident's Medication Administration Record revealed that Daptomycin was not administered as ordered on one occasion, and Cefepime was missed on two separate occasions. The regional nurse consultant confirmed that the facility failed to administer three doses of the prescribed IV antibiotic therapy and did not notify the attending physician of these missed doses. This oversight is a violation of the facility's policies and state regulations concerning pharmacy and nursing services, as well as resident care policies. The failure to administer the medications as prescribed and to communicate the missed doses to the physician constitutes a deficiency in the care provided to the resident.
Inaccurate Treatment Documentation for Resident
Penalty
Summary
The facility failed to maintain complete and accurate records of treatment administration for a resident diagnosed with Parkinson's disease and a hip fracture. The resident had a physician's order for ace wraps to be applied to his bilateral legs in the morning and removed at bedtime, with skin integrity checks during application and removal. However, observations on three consecutive days revealed that the resident was not wearing the ace wraps as ordered, despite the Treatment Administration Record (TAR) indicating that the treatment had been administered at 6:00 AM each day. Interviews with registered nurses on each of the observed days confirmed that the resident was not wearing the ace wraps and that there were no ace wraps available in the resident's room or on the nurse's treatment cart. The Nursing Home Administrator was unable to explain why the nursing staff documented that the treatment was administered when it was not. This discrepancy between the documented records and the actual care provided constitutes a failure to maintain accurate medical records in accordance with professional standards.
Inadequate Infection Control and PPE Disposal Practices
Penalty
Summary
The facility failed to implement proper transmission-based precaution control practices to mitigate the risk of COVID-19 infections for several residents. Specifically, four residents who were COVID-19 positive did not have designated containers for the disposal of personal protective equipment (PPE) at the point of exit from their rooms. Instead, staff used residents' personal waste bins for disposing of used PPE, which is against the CDC guidelines for infection control. Additionally, one resident's meal tray was found with used PPE on it, indicating improper disposal practices. Furthermore, the facility did not have documented evidence of isolation precautions for one resident who was COVID-19 positive, despite signage indicating droplet transmission-based precautions were in effect. This lack of documentation suggests a failure in following proper procedures for isolation precautions. The infection preventionist confirmed these deficiencies during an interview, acknowledging the absence of designated PPE disposal containers and improper handling of meal trays. In another instance, the facility failed to maintain a safe and sanitary environment for a resident with a stage 4 pressure ulcer and a suprapubic catheter. Observations revealed undated and unlabeled medical supplies, including a piston syringe and a bottle of acetic acid, on the resident's bedside nightstand, along with various personal items. An LPN confirmed the lack of labeling and dating of these items, which were not stored in a manner to prevent the potential spread of infection. The infection preventionist also confirmed the facility's failure to maintain resident care equipment properly.
Lack of Privacy Curtains in Shared Room
Penalty
Summary
The facility failed to ensure full visual privacy for residents in shared rooms, specifically affecting one resident. Resident 107, who was admitted with acute kidney failure and intellectual disabilities, was found to be cognitively intact with a BIMS score of 15. During an observation, it was noted that Resident 107's bed in a triple-occupancy room lacked ceiling privacy curtains, unlike the other two beds in the room. Resident 107 confirmed the absence of privacy curtains since moving into the room a week prior. The Nursing Home Administrator acknowledged that each resident room should be designed and equipped to assure privacy.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse, as evidenced by an incident involving a nurse aide and a resident with severe cognitive impairment. The resident, who was hard of hearing and blind, was subjected to derogatory language by the aide while being cared for. The aide was on a personal phone call using profanity and made inappropriate comments about the resident's condition, which was reported by the resident's personal companion. Despite the incident being reported to multiple staff members, including an LPN supervisor and an RN supervisor, the aide was not immediately removed from duty and continued to care for the resident. The facility's investigation concluded that the abuse was unsubstantiated, citing that the resident was not affected by the incident, despite reports from the resident's companion and son indicating increased agitation in the resident following the event. The facility's failure to act promptly and appropriately in response to the reported verbal abuse violated the resident's rights and did not align with the regulatory guidance that considers the reasonable person concept. The incident highlights a breakdown in communication and response among the facility's staff, leading to a deficiency in ensuring the resident's safety and dignity.
Failure to Investigate and Prevent Resident Abuse
Penalty
Summary
The facility failed to timely and thoroughly investigate an allegation of resident abuse and prevent the potential for further abuse during the course of the investigation for one resident. The incident involved a resident with severe cognitive impairment and dementia, who required assistance from two staff members for bed mobility and toileting. The resident was subjected to verbal abuse by a nurse aide who was on a personal phone call while providing care, using profanity and making derogatory comments about the resident's condition. The abuse was initially reported by the resident's personal companion to nursing staff on two separate occasions, but no immediate action was taken to investigate the allegations or protect the resident from further abuse. The nurse aide accused of the abuse continued to provide care to residents, including the affected resident, which allowed the potential for further abuse to occur. The facility did not obtain any written or telephone statements from staff or residents regarding the allegation until several days after the initial report was made. During an interview, the Director of Nursing was unable to provide evidence that a timely and thorough investigation was conducted or that residents were protected from potential further abuse during the investigation. The facility's failure to act promptly and effectively in response to the abuse allegations resulted in a deficiency related to the protection of resident rights and the management of nursing services.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide necessary supervision and effective safety measures to prevent an elopement by a resident. The resident, who was cognitively intact and independently ambulatory, had a history of substance abuse and was identified as an elopement risk upon admission. However, the initial care plan did not include any planned interventions to mitigate this risk. The facility's Leave of Absence (LOA) policy required a physician's order and completion of specific forms before a resident could leave, but these procedures were not followed for the resident's LOAs. The resident signed out of the facility multiple times without the required LOA forms being completed, and there was no evidence of a physician's order approving these absences. On one occasion, the resident left the facility unsupervised, boarded a bus, and traveled to a nearby town without the facility's knowledge. The facility's staff, including the Director of Nursing and the social services director, were unaware of the resident's departure until after the fact, and there was no documentation of the incident in the resident's clinical record. Interviews with facility staff revealed that the facility did not implement its LOA policy effectively, and the staff was unaware of the resident's unauthorized departure. The Director of Nursing confirmed that the facility failed to follow its procedures, resulting in the resident leaving the facility without authorization and without the necessary supervision to ensure her safety.
Failure to Date Multi-Dose Medication Vials
Penalty
Summary
The facility failed to implement procedures to ensure proper labeling and storage of multi-dose medications on two of four medication carts observed. During an observation of the B Hall medication cart, it was found that vials of Lantus, Novolog, and Levemir injectables, all used to treat diabetes, were opened and in use but not dated when initially opened. Similarly, the C Hall medication cart contained an opened vial of Lantus injectable that was also not dated when initially opened. The facility's policy, last reviewed in November 2023, requires staff to check expiration dates and date multi-dose containers when opened. This policy was not followed, as confirmed by the Nursing Home Administrator during an interview. The deficiency was identified under 28 Pa. Code 211.9 (a)(1)(k) Pharmacy Services and 28 Pa. Code 211.12 (d)(3)(5) Nursing services.
Failure to Act on Pharmacist-Identified Drug Irregularities
Penalty
Summary
The attending physician failed to act on pharmacist-identified drug irregularities in the drug regimen of three residents. Resident 21 had an order for Trazodone 50 mg for depression, which was due for assessment. The physician's response was illegible and deferred to telehealth services. Resident 102 had multiple medications, including Lexapro 20 mg, Clonazepam 0.5 mg, and Lamictal 150 mg, all of which were due for assessment. The physician either did not respond or deferred to telehealth services without documenting any actions taken. Resident 112 had an order for Paroxetine 10 mg, a high-risk medication for the elderly, and the physician's response was to refer to psych without documenting any further action or rationale. The Director of Nursing confirmed that there was no documentation of the attending physicians acting upon these reports of drug irregularities. The attending physician and Certified Registered Nurse Practitioner (CRNP) solely deferred or referred the recommendations without documenting the action taken or not taken to address these irregularities. This was further confirmed during an interview with the Nursing Home Administrator. The lack of documentation and action on the identified drug irregularities constitutes a deficiency in pharmacy services and medical director responsibilities as per 28 Pa. Code 211.9 (k) and 28 Pa. Code 211.2 (d)(3)(8).
Failure to Provide Consistent Fresh Water to Residents
Penalty
Summary
The facility failed to ensure that fresh water was consistently readily accessible to residents, which is necessary to promote adequate hydration, meet residents' preferences, and maintain their comfort. The facility policy indicated that fresh water should be provided daily during the 11 PM - 7 AM shift and refilled on each shift as needed. However, interviews with residents and a review of Resident Council meeting minutes revealed that staff did not routinely provide fresh water daily, and residents had to consistently ask for it. Specifically, Resident 79 expressed frustration about having to ask for fresh water, and 17 out of 18 residents at a Resident Council meeting complained about the lack of regular water provision by the night shift staff. Additionally, during a group interview, three residents (67, 29, and 325) confirmed that fresh water was only provided during the third shift and not during other shifts unless requested by the residents. The Nursing Home Administrator confirmed that it was his understanding and expectation that water should be passed once per shift and as needed. However, the facility failed to demonstrate that fresh ice water was readily accessible as preferred by residents. This deficiency was observed in four out of 25 residents reviewed, indicating a systemic issue in the facility's hydration practices. The failure to provide fresh water consistently was a violation of the facility's policy and state regulations, specifically 28 Pa. Code 211.12 (d)(3)(5) Nursing services and 28 Pa. Code 211.10 (a)(d) Resident care policies.
Failure to Address Resident's Hydration Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan to address the hydration needs of a resident with multiple complex medical conditions, including Multiple Sclerosis, diabetes, and breast cancer. The resident, who was cognitively intact and dependent on staff for assistance with eating and drinking, had a care plan that did not include specific interventions to ensure adequate fluid intake. Despite the resident's care area assessment indicating dehydration as a concern, the care plan only included general monitoring for signs of dehydration without addressing the resident's dependency on staff for hydration needs. During an interview, the resident expressed frustration with long wait times for assistance with drinking, often resorting to asking non-nursing staff for help. The Director of Nursing was unable to provide documented evidence that the facility had developed and implemented a care plan to meet the resident's hydration needs. This deficiency was identified during a review of the resident's clinical records and interviews with the resident and staff.
Failure to Follow Physician Orders for Bowel Protocol and Diabetes Management
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of practice by not following physician orders for bowel protocol and diabetes management for two residents. Resident 11, who was admitted with diagnoses including congestive heart failure and constipation, had a prescribed bowel regimen that was not followed. The clinical records for January and February 2024 showed multiple instances where Milk of Magnesia, Dulcolax suppository, and Fleet enema were ordered but not administered, resulting in the resident going several days without a bowel movement. The Director of Nursing confirmed that the nursing staff did not carry out the physician-ordered bowel protocol for Resident 11. Resident 8, admitted with a diagnosis of diabetes mellitus, also experienced a failure in care. The resident had a physician order for Humalog insulin to be administered based on a sliding scale before meals and at bedtime. On March 8, 2024, the resident complained that an LPN took her blood sugar but did not administer the prescribed 14 units of insulin on time. The clinical records confirmed that the insulin, scheduled for 4:30 PM, was not administered until 8:42 PM, over four hours late. The Director of Nursing confirmed that the insulin was not administered timely as per the physician's order. These deficiencies highlight the facility's failure to adhere to physician orders for both bowel management and diabetes care, resulting in potential harm to the residents. The lack of proper administration of medications and treatments as prescribed by physicians indicates a significant lapse in the facility's nursing services and adherence to professional standards of practice.
Failure to Timely Assess and Treat Pressure Sore
Penalty
Summary
The facility failed to conduct timely and thorough assessments of a pressure sore and initiate timely treatment for a resident readmitted with heart failure. Upon readmission, the resident had a pressure sore on her sacrum, but there was no documented assessment to identify the stage, size, appearance, characteristics, drainage, or odor of the wound. Additionally, there were no physician orders for treatment of the pressure sore until two days after readmission. The wound was not assessed until three days after readmission, at which point it was identified as a deep tissue injury. The Director of Nursing confirmed that the facility did not timely assess or implement adequate measures to prevent the worsening of the pressure sore.
Failure to Provide Adequate Staff Assistance and Correct Devices During Transfer
Penalty
Summary
The facility failed to provide sufficient staff assistance and the correct assistive devices during a transfer, leading to a fall for Resident 8. Resident 8, who was admitted with diagnoses including displacement of an internal fixation device and congestive heart failure, was cognitively intact and required a stand-up lift with the assistance of two staff and a yellow sling for transfers. However, during a transfer from the bathroom, only one nurse aide was present, and the incorrect sling was used, resulting in the resident sliding down and being lowered to the floor without injury. The incident occurred when the nurse aide, Employee 2, attempted to transfer Resident 8 without the required second staff member and used a red sling instead of the prescribed yellow sling. Despite the resident's insistence on needing to use the bathroom, the aide was unable to find another staff member to assist and proceeded with the transfer alone. The resident began to slide out of the sling during the transfer, prompting the aide to lower the resident to the floor and seek help. Interviews and observations confirmed that the yellow sling was in the resident's room, and the facility's policy required two staff members for all transfers using a lift. The Director of Nursing confirmed the failure to provide documented evidence of the correct sling being used and acknowledged that the proper procedure for transferring the resident was not followed, leading to the incident.
Failure to Develop Accurate Dialysis Care Plan
Penalty
Summary
The facility failed to ensure that person-centered care plans were accurately developed to meet the individualized needs of a resident receiving dialysis. Resident 111, who was admitted with end-stage renal disease, had physician orders indicating dialysis three times a week and a right chest Tesio site that required monitoring for infection and emergency care instructions. However, the resident's care plan did not identify the Tesio site or include interventions for its care and emergency procedures. This deficiency was confirmed by the Director of Nursing during an interview.
Failure to Date Multi-Dose Medications
Penalty
Summary
The facility failed to implement procedures to ensure acceptable storage and use by dates for multi-dose medications in one of the two medication storage rooms observed (Station A). During an observation of Station A's medication room, three multi-dose bottles of Tuberculin were found opened and used without being dated when initially opened. This was confirmed by an interview with the Director of Nursing, who acknowledged that medications were supposed to be dated upon opening. The facility's policy on administering medications, last reviewed in November 2023, requires staff to check expiration dates and date multi-dose containers when opened.
Failure to Accommodate Resident's Food Preferences
Penalty
Summary
The facility failed to accommodate a resident's food preferences, specifically for Resident 94, who was admitted with diagnoses of Multiple Sclerosis and breast cancer. The resident, who was cognitively intact, had documented her dislike for fresh tomatoes upon admission. Despite this, she was repeatedly served salads containing fresh tomatoes, which she had requested to be excluded. This issue persisted even after the resident informed both the registered dietitian and the dietary manager about the problem. On March 12, 2024, during an interview, Resident 94 expressed her frustration about the salads containing fresh tomatoes. An observation of her lunch meal on the same day confirmed the presence of fresh tomatoes in her salad, despite her meal ticket clearly noting her preference for no fresh tomatoes. The registered dietitian later confirmed that the resident's preferences were documented and should have been honored, indicating a failure on the part of the facility to accommodate the resident's food preferences.
Latest citations in Pennsylvania
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
