Elan Skilled Nursing And Rehab, A Jewish Senior Li
Inspection history, citations, penalties and survey trends for this long-term care facility in Scranton, Pennsylvania.
- Location
- 1101 Vine Street, Scranton, Pennsylvania 18510
- CMS Provider Number
- 395103
- Inspections on file
- 18
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 14 (1 serious)
Citation history
Health deficiencies cited at Elan Skilled Nursing And Rehab, A Jewish Senior Li during CMS and state inspections, most recent first.
Surveyors found unsanitary conditions in the kitchen, including debris and rodent droppings on floors and under the dishwasher, along with used gloves, garbage, and utensils in food service areas. Multiple sticky traps in food prep and tray line areas contained live and dead cockroaches, indicating active infestation where food and utensils were handled. Although the facility had a pest control contract and was receiving rodent treatments, the Dietary Director and pest control provider confirmed that no targeted cockroach treatment was being performed, despite documented cockroach activity near the kitchen. There was no documentation that staff monitored for cockroaches or implemented increased sanitation or environmental controls to ensure food was stored, prepared, and served under sanitary, pest-free conditions for all residents.
The facility failed to maintain an effective pest control program on two nursing units and in the kitchen. Although a pest control contractor was providing regular services focused on mice on upper floors and general treatments elsewhere, surveyors observed a dead cockroach behind a resident’s bed and rodent droppings with food debris in a third-floor kitchenette. Pest control records noted prior roach activity and rodent droppings, but no additional targeted treatment was provided for roaches after the initial finding, and the Director of Maintenance acknowledged that no specific preventative measures for cockroach control were being implemented in the kitchen.
Surveyors found that the facility did not maintain an effective pest control program, as evidenced by ongoing fruit fly and mouse activity on two nursing units. Despite internal work orders and staff efforts to address pests, the pest management contractor was not informed of the issues, and pest activity was observed in resident areas. A resident with paraplegia reported repeated mouse sightings and evidence of food being eaten by rodents, with further observations confirming the presence of droppings and gnaw marks.
The facility did not accurately complete MDS assessments for three residents, omitting documentation of a surgical wound, a fall, and multiple falls with injury, despite these events being present in clinical records. These discrepancies were confirmed through record review and staff interviews.
A resident with cognitive impairment developed a persistent rash, and although a CRNP ordered a dermatology consult and diagnostic tests for suspected scabies, these were not completed. The resident was treated for other skin conditions until a wound physician later identified scabies, by which time multiple residents required treatment for exposure. Facility staff confirmed that the lack of timely diagnostic follow-through may have delayed identification and mitigation of the outbreak.
The facility failed to provide written notification of its bed-hold policy to residents or their representatives upon hospital transfer. This deficiency was identified through a review of clinical records and staff interviews, revealing that three residents were transferred to the hospital without receiving the necessary written information. The Clinical Operations Executive confirmed the absence of documented evidence of this provision.
The facility failed to follow physician orders for medication administration for three residents, resulting in a deficiency. Residents with hypertension and other conditions were given medications without documented evidence of required blood pressure and heart rate checks. This lack of adherence to physician-prescribed parameters was confirmed by the Clinical Operations Executive.
The consultant pharmacist failed to identify drug irregularities for two residents, including dual antidepressant therapy and lack of justification for antipsychotic use. Despite identifying a dosing discrepancy for Aricept, the pharmacist did not ensure timely physician action. The DON confirmed these failures, which violated Pennsylvania Code regulations.
The facility failed to maintain a clean and safe environment on the 5th floor. A Broda chair was heavily soiled with various substances, and a fall mat in a resident's room had large tears exposing the internal foam. These issues were confirmed by an LPN and acknowledged by the DON and Nursing Home Administrator, who stated that resident care equipment should be kept clean and sanitary.
A resident with a history of inappropriate behavior was not adequately monitored, leading to an incident of sexual abuse involving another resident who was unable to consent. Additionally, a resident requiring specific transfer assistance was neglected, resulting in a fall. The facility's delay in reporting and implementing safety measures contributed to these deficiencies.
A facility failed to follow its abuse prohibition procedures after an incident where a resident was observed holding another resident's hand on his genital region. The incident was not reported to the administration or authorities until two days later, despite policy requiring immediate reporting. The involved resident was severely cognitively impaired and unable to consent, and there was no documentation or protective measures implemented following the incident.
A resident with diabetes and CHF experienced significant weight loss, and the facility failed to implement and document planned nutritional interventions. Despite adjustments to dietary preferences and plans for supplements like Ensure pudding and ProStat, there was no evidence of their administration in the MAR. The RD confirmed the lack of implementation and documentation of these interventions.
The facility failed to ensure the availability of emergency supplies for two residents receiving hemodialysis, as required by physician orders and facility policy. Both residents were found to have only one fanny pack with emergency supplies on their wheelchairs, with the second required pack missing from their rooms. This deficiency was confirmed by staff and placed the residents at risk for delayed emergency intervention.
A facility failed to offer routine annual dental services to a Medicaid resident. The resident had been admitted to the facility, but there was no documented evidence of dental services being offered in the past year. This was confirmed by the Clinical Operations Executive during an interview.
The facility failed to maintain the automatic sprinkler system in three locations across three floors. Observations revealed missing components and obstructions, including a lack of a suspended ceiling assembly in the basement, a plastic bag affixed to a sprinkler head on the fifth floor, and a missing escutcheon plate on the first floor. These issues were confirmed by the Facility Administrator and Facilities Manager.
The facility failed to maintain the smoke barrier separation doors on the fifth floor, as the Clay Street smoke barrier doors required adjustment to fully latch. This issue was confirmed during an exit interview with the Facility Administrator and the Facilities Manager.
The facility was found to have exceeded the maximum allowable story height for its construction type, classified as an unprotected, noncombustible building. The building was three stories higher than permitted, affecting all six floors. This was confirmed during an exit interview with the Facility Administrator and Facilities Manager.
The facility failed to maintain the required fire resistance rating for vertical enclosures, affecting all six floors. Observations revealed that HVAC shafts adjacent to exit stair towers lacked the necessary two-hour fire resistance. Additionally, the Clay Street exit stair tower on the fourth and fifth floors had inadequate construction, with insufficient drywall and unprotected steel beams. This deficiency was confirmed during an exit interview with the Facility Administrator and Facilities Manager.
A resident with severe cognitive impairment was left unassisted for 25 minutes during a meal, despite needing supervision and assistance. Staff were occupied with other residents, and the unit was understaffed, leading to delays in providing necessary help. The DON acknowledged the facility's responsibility to ensure residents are treated with respect and dignity.
A facility failed to maintain accurate clinical records for a resident with cerebral infarction, who was receiving hospice services. Despite physician's orders, the resident's nutritional intake was not documented for 18 meals in August, and progress notes lacked this information. The DON confirmed the oversight but could not explain the lack of documentation.
Unsanitary Kitchen Conditions and Unaddressed Cockroach Infestation
Penalty
Summary
The deficiency involves the facility’s failure to maintain the kitchen in a sanitary condition and free of pest infestation while preparing, storing, and serving food for all residents. During a kitchen tour, surveyors observed debris and rodent droppings on the dishwashing area floor and along the perimeter floors throughout the kitchen. Under the dishwasher, the floor was soiled and contained used latex gloves, garbage, bottle caps, a fork, and rodent droppings. These conditions were present in active food service and dishwashing areas where food, utensils, and food-contact surfaces are handled. In the food preparation and tray line service area, surveyors observed seven sticky traps placed on the floor. One trap under the left side of the food preparation area contained five cockroaches, three of which were alive and moving. Another trap on the right side of the kitchen contained five cockroaches, with two alive and moving, and a third trap contained four cockroaches, two of which were alive and moving. These observations showed live and dead cockroaches present in food preparation and storage areas. The report notes that cockroaches are known vectors for disease-causing organisms such as Salmonella, E. coli, and Staphylococcus, and that their presence in these areas created a high risk of contamination of food, utensils, and food-contact surfaces with disease-causing organisms, placing all 135 residents in a situation of Immediate Jeopardy to their health and safety. Interviews and record reviews showed that the facility had an ongoing pest control contract but did not ensure that cockroach activity in or near the kitchen was specifically addressed. The Director of Dietary Services stated that the outside pest control company had been treating the kitchen for rodents since December 2025, but the area was not being treated to prevent cockroaches. A dietary worker reported not seeing many cockroaches recently but acknowledged having seen them in the past. The Nursing Home Administrator confirmed that pest control services were requested in December 2025 in response to a rodent infestation and that remediation services twice weekly were recommended. Pest control inspection reports documented that on January 5, 2026, the pest management provider identified cockroaches at a coffee station located about 50 feet from the kitchen entrance and identified a potential rodent entry point in the dishwasher room, but there was no documentation that cockroach-specific treatment was initiated. The pest control provider confirmed observing German cockroach activity at the coffee station and stated that routine services consisted of perimeter spraying, with no targeted cockroach treatment areas identified. The facility did not provide documented evidence that staff were monitoring for cockroaches in the kitchen or that increased sanitation measures or environmental controls were implemented to ensure food was stored, prepared, distributed, and served under sanitary conditions and free of pest infestation.
Removal Plan
- Dispose of exposed food items
- Cease food preparation
- Transition dietary services to an outside vendor until pest mitigation was completed
- Activate pest control services for immediate treatment of source areas, including clean-out treatment, aerosol application, and gel treatments
- Place the kitchen under continuous monitoring by the Director of Dietary Services and the Nursing Home Administrator
- Schedule audits for each meal
- Conduct a comprehensive inspection of the kitchen by a licensed pest control inspector
- Implement aerosol treatment for immediate control and gel application for prevention
- Educate dietary staff on the facility's Pest Control and Kitchen Sanitation Policies and Protocols
- Review all residents for signs and symptoms of foodborne illness
- Initiate audits of pest control logs and environmental monitoring
- Implement inspection and monitoring by the pest control provider
Failure to Maintain Effective Pest and Rodent Control on Nursing Units and Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program to keep the building free of insects and rodents on Nursing Units 3 and 4 and in the kitchen. The facility’s own Preventative Maintenance Program policy required an ongoing pest control program to ensure the building was kept free of insects and rodents. Documentation showed that the facility contracted with a licensed pest control company to perform remediation services twice weekly, including mass trapping and baiting on upper floors and monitoring lower floors, and recommended that food in resident rooms be stored in plastic containers. Pest control service records documented several visits with interior perimeter inspections and treatments, including common areas, bathrooms, and hallways, and noted roach treatment at a first-floor coffee station and rodent droppings on the fourth floor. Despite these measures, surveyor observations and interviews showed ongoing pest activity that was not effectively addressed. On one observation date, a dead cockroach was found behind a resident’s bed in a resident room, and rodent droppings and significant food debris and crumbs were observed in drawers and throughout the third-floor kitchenette. The outside pest control provider reported being aware of roaches since an earlier visit and confirmed that no additional targeted treatment for roaches had been provided since that time, with efforts focused instead on mice activity on the fourth and fifth floors and only general treatment on other floors. The Director of Maintenance stated that construction on the first floor may have contributed to cockroaches moving toward the kitchen and acknowledged that the facility was not implementing preventative measures specific to cockroach control in the kitchen.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program to ensure the environment was free of insects, pests, and rodents on two out of four resident nursing units. Despite having a policy requiring ongoing pest control, documentation showed that while work orders were entered and completed for fruit fly issues on one unit, there was no evidence that these issues were communicated to the pest management contractor. Observations revealed the continued presence of small black flying insects in the resident dining area, and the pest management contractor confirmed he had not been informed of fruit fly problems nor treated for them in recent months. The Director of Maintenance reported that staff used cleaning agents and pesticides, but these actions were not coordinated with the pest management contractor. Additionally, a resident with paraplegia, who was cognitively intact, reported seeing mice in her room for over a month and discovered a partially eaten candy bar, which was a gift from a family member. Observations in her room and other resident rooms revealed multiple mouse-like droppings and evidence of gnawing. Pest management records did not document any mouse activity until surveyors made inquiries, indicating a lack of effective monitoring and communication regarding rodent issues. These findings were reviewed with facility leadership, confirming the deficiency in maintaining a pest-free environment.
Inaccurate MDS Documentation for Multiple Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for three residents, as required by the Resident Assessment Instrument (RAI) Manual. For one resident with a history of Borderline Personality Disorder and Post Traumatic Stress Disorder, the quarterly MDS did not document the presence of a surgical wound on the left neck area, despite clinical records showing a wound evaluation by a specialty physician. For another resident admitted with a fractured clavicle and cellulitis, the quarterly MDS failed to record a fall that occurred during the assessment period, even though the clinical record documented the incident. Additionally, a third resident with a right artificial shoulder joint had three falls within the MDS assessment reference period, including one resulting in a forehead hematoma, but none of these falls were documented in the annual MDS. These inaccuracies were confirmed through clinical record reviews and staff interviews, where the Registered Nurse Assessment Coordinator acknowledged the omissions in the MDS documentation for all three residents.
Failure to Complete Ordered Diagnostic Evaluation for Suspected Scabies
Penalty
Summary
The facility failed to follow physician-ordered diagnostic evaluation for suspected scabies in one resident, which contributed to a delay in identifying and mitigating the spread of scabies among residents. Specifically, a resident with dementia and major depressive disorder developed a raised papular rash, and the CRNP ordered a dermatology consultation, skin scraping, or biopsy to determine the cause. Although these diagnostic procedures were ordered, there was no documentation that they were completed, and the resident was instead treated for an allergic-type rash and later with various topical and oral medications for skin symptoms. Over the following weeks, the resident's symptoms persisted and worsened, with continued itching, scratching, and the development of additional lesions. Despite ongoing symptoms and further physician orders for different treatments, the facility did not obtain the required dermatology evaluation, skin scraping, or biopsy as initially ordered. Eventually, a wound physician identified the rash as consistent with a mite reaction on microscopic examination, and the resident was treated for scabies with permethrin cream and placed on contact precautions. The failure to promptly complete the ordered diagnostic evaluation potentially contributed to the spread of scabies within the facility. Another resident was confirmed positive for scabies on microscopic exam, and a total of thirty-six residents received treatment for exposure. Interviews with the Infection Preventionist and DON confirmed that the lack of timely diagnostic follow-through may have delayed identification and mitigation of the outbreak.
Failure to Provide Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of its bed-hold policy to residents or their representatives upon transfer to a hospital, as required by regulations. This deficiency was identified through a review of clinical records and staff interviews, which revealed that three residents, identified as Residents 27, 124, and 102, were transferred to the hospital without receiving the necessary written information about the facility's bed-hold policy. Resident 27 was transferred on November 27, 2024, Resident 124 on November 26, 2024, and Resident 102 on December 10, 2024. The Clinical Operations Executive confirmed the absence of documented evidence of the provision of this information during an interview conducted on January 23, 2025.
Plan Of Correction
1. Residents 27, 102, and 124 are MA or MAP residents and did not lose their assigned beds while out at the hospital. We are unable to correct those past occurrences. 2. All residents who transfer out to the hospital or on therapeutic leave have the potential to be affected by deficient practice. 3. All nursing staff will be educated regarding the bed hold policy and procedure. The business office and social services have been educated regarding the electronic completion of the bed hold notice. 4. Business Office Manager or designee will audit all transfers out of the building and therapeutic leaves daily during the business week for four (4) weeks then weekly until substantial compliance is achieved. All results will be submitted and reviewed in QAPI.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to adhere to physician orders for medication administration for three residents, resulting in a deficiency. Resident 121, who was diagnosed with hypertension and end-stage renal disease, had a physician order for Carvedilol with specific instructions to hold the medication if the systolic blood pressure was less than 100 mm Hg or the heart rate was less than 60 beats per minute. However, the Medication Administration Records for December 2024 and January 2025 showed that the medication was administered without documented evidence of blood pressure or heart rate checks prior to administration. Similarly, Resident 124, with diagnoses of hypertension and chronic atrial fibrillation, had a physician order for Atenolol with instructions to hold the medication under the same conditions. The records from November 2024 to January 2025 indicated a lack of consistent documentation of vital signs before administration. Resident 46, diagnosed with hypertension, depression, and dementia, had orders for Metoprolol and Norvasc with specific parameters for holding the medication. The records for December 2024 and January 2025 also lacked evidence of vital sign monitoring before administering these medications. An interview with the Clinical Operations Executive confirmed the failure to consistently obtain and document the necessary vital signs before medication administration for these residents.
Plan Of Correction
1. There is no way for the facility to retroactively address resident #121's supplemental documentation. Drug was discontinued on 01/16/2025. Resident #124's heartrate and blood pressure parameters, per physician order, were added to the physicians order effective 01/23/2025. Nursing staff is collecting this clinical information and administering based on parameters. Resident #46's heartrate and blood pressure parameters, per physician order, were added to the physicians' orders effective 01/23/2025. Nursing staff is collecting this clinical information and administering based on parameters. 2. A review was completed by the Director of Nursing on 02/05/2025 of vasoactive, antiarrhythmics, and antihypertensive orders for in-house residents to assure clinical parameters, as ordered by the physician, are in place and being utilized in the administration of the medications. 3. The Clinical Coordinator or designee will educate licensed nursing staff regarding the requirement to assure clinical parameters for medication, as ordered by the physician, are in place and being utilized in the administration of the medications. 4. The DON or designee will complete a weekly review of vasoactive, antiarrhythmics, and antihypertensives for newly admitted and current in-house residents to assure clinical parameters for medication, as ordered by the physician, are in place and being utilized in the administration of the medications. This review will continue weekly for the next three months. Audit results will be reported to the Quality Assurance Performance Improvement committee monthly for three months to ensure continued compliance.
Consultant Pharmacist Fails to Identify Drug Irregularities
Penalty
Summary
The consultant pharmacist at the facility failed to identify drug irregularities during monthly medication reviews for two residents. Resident 114, who was diagnosed with dementia with behavioral disturbances and major depressive disorder, was prescribed dual antidepressant therapy with Venlafaxine and Mirtazapine. Despite the presence of duplicate antidepressant therapy, the consultant pharmacist did not identify this irregularity or provide recommendations to assess the appropriateness of the therapy. Additionally, there was no documented clinical rationale justifying the prescribing of two antidepressants. Resident 130, diagnosed with dementia with severe agitation and depression, was prescribed Olanzapine, an antipsychotic, without documented justification for its use. The consultant pharmacist's new admission medication review failed to identify the lack of documented justification for the continued use of Olanzapine. Furthermore, the pharmacist identified a discrepancy in the dosing of Aricept, but the resident continued to receive the medication as prescribed without timely clarification or modification. The Director of Nursing confirmed that the consultant pharmacist failed to identify and address medication regimen irregularities for both residents. Additionally, Resident 130's attending physician did not timely act upon the pharmacist's recommendations and failed to provide a documented clinical rationale for the continued use of antipsychotic medication. These deficiencies were found to be in violation of specific Pennsylvania Code regulations related to pharmacy and nursing services.
Plan Of Correction
1. The facility cannot correct the untimely action to justify the prescribing of two antidepressants. However, Resident #114 has an active Gradual Dose Reduction (GDR) in place since 02/03/25 to discontinue his Venlafaxine, removing the antidepressant duplicate therapy. The facility cannot correct the delay in the physician response to pharmacist recommendation. Medication was discontinued on 01/08/2025. Resident #130 has documented clinical rationale for the continuation of Zyprexa as ordered. 2. The DON completed an audit of in-house residents presently on duplicate antidepressant medications on 02/07/2025. Listing reviewed with consulting pharmacist. Consulting pharmacist to issue medication regimen reviews to the appropriate physician to document the clinical rationale justifying the continued prescribing of duplicate antidepressant medication. 3. The DON or designee will re-educate the consulting pharmacist, attending physicians, and medical directors to Tag F 0756 and CMS 483.45(c)(1)(2)(4)(5) requirements, along with the facility's Monthly Medication Regimen Review Policy. 4. The DON or designee will review the monthly medication reviews sent to Elan Skilled by the consulting pharmacist and compare them to the listing of new residents receiving duplicate antidepressant therapy to ensure compliance with CMS 483.45(c)(1)(2)(4)(5) and facility policy. This review will take place for the next three months. Audit results will be reported to the Quality Assurance Performance Improvement committee to determine compliance.
Facility Fails to Maintain Clean and Safe Environment on 5th Floor
Penalty
Summary
The facility failed to maintain a clean and safe environment for residents on the 5th floor, as observed on January 23, 2024. A Broda chair located in the hallway outside a resident's room was found to be heavily soiled with a crusty orange substance on the seat, a dried white and brown substance on the footrest, and dirt and debris, including a significant amount of hair, entangled in the rear wheels. Additionally, a fall mat in the resident's room was observed to have large tears, exposing the internal foam. These observations were confirmed by a licensed practical nurse and later acknowledged by the Director of Nursing and the Nursing Home Administrator, who stated that resident care equipment should be maintained in a clean and sanitary manner.
Plan Of Correction
1. The immediate corrective action for the identified Broda chair: the seat, footrest, and wheels were cleaned. Also, the fall mat in room 504 was replaced. 2. EVS Director or designee will conduct an initial audit of all Broda chairs and floor mats to identify other residents who may have the potential to be affected by deficient practice. 3. All EVS staff will be educated regarding the scheduled cleaning of Broda chairs. All nursing staff will be educated to identify and rectify fall mats that are in poor condition. 4. EVS Director or designee will audit all Broda chairs and floor mats weekly for four (4) weeks, then monthly until substantial compliance is achieved. All results will be submitted and reviewed in QAPI.
Failure to Prevent Abuse and Neglect in LTC Facility
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident. Resident 102, who was moderately cognitively impaired, had a documented history of sexually inappropriate behavior. Despite this, the facility did not implement sufficient interventions to prevent an incident where Resident 102 was observed holding Resident 289's hand on his genital region. Resident 289, who was severely cognitively impaired and unable to consent to sexual contact, expressed discomfort and confusion about the incident. The facility delayed reporting and implementing safety measures for two days after the incident. Additionally, the facility failed to prevent neglect of another resident, Resident 25, who required assistance from two staff members and a sit-to-stand lift for transfers. Employee 6, a nurse aide, assisted Resident 25 to the bathroom without following the care plan, resulting in the resident falling. The aide attempted to support the resident with her arm, but the resident became unsteady and fell, landing on his bottom. The Director of Nursing confirmed that the aide did not adhere to the care plan, which led to the fall. The facility's policies on abuse and neglect were not effectively implemented, as evidenced by the incidents involving Residents 289 and 25. The failure to address Resident 102's inappropriate behavior and the neglect of Resident 25's care plan requirements resulted in deficiencies in resident safety and care. These incidents highlight the need for the facility to ensure that staff are adequately trained and that care plans are strictly followed to prevent abuse and neglect.
Plan Of Correction
1. Resident 289 was discharged from the facility on 10/26/2024. A referral to psych services made for Resident 102 and an IDT approach continues. Resident 25 sustained no injury related to fall. Resident 25 was monitored for 72hrs and no change in condition was noted. Employee 6 was educated regarding reading residents' Kardex prior to providing care as well as abuse and neglect. 2. Residents of the facility have the potential to be affected by deficient practice. Staff records will be audited for Abuse/Neglect training over the past 12 months. Clinical Coordinator or designee will review new-hire CNA records for training in reading and adherence to the resident plan of care. 3. CNAs will be educated regarding adherence to the resident's plan of care. Facility staff will be educated regarding Abuse and Neglect upon hire and annually. 4. Director of Nursing or designee will audit all changes to the resident Kardex and Tasks five (5) times per week during the business week for two (2) weeks then weekly for four (4) weeks until substantial compliance is achieved. All results will be submitted and reviewed in QAPI.
Failure to Implement Abuse Prohibition Procedures
Penalty
Summary
The facility failed to implement its abuse prohibition procedures in response to an alleged sexual abuse incident involving two residents. On October 7, 2024, Resident 102 was observed holding Resident 289's hand on his genital region in the lunchroom. Despite the facility's policy requiring immediate reporting of such incidents, the administration and relevant authorities were not notified until October 9, 2024, two days after the incident. The facility's policy mandates that all allegations of abuse be reported immediately to the Charge Nurse, Director of Nursing (DON), Administrator, and the resident's physician, and that the incident be reported to the Department of Health and local police within two hours. However, these procedures were not followed, resulting in a delay in reporting and investigation. Resident 289, who was severely cognitively impaired and unable to consent to sexual activity, was not protected according to the facility's policies. There was no documentation of the incident in the clinical records of either resident, and no evidence that the facility's administrator, DON, attending physician, or the resident's responsible party were notified at the time of the incident. Additionally, the facility did not develop or implement a plan to prevent future occurrences and protect Resident 289 and other female residents from Resident 102's inappropriate behavior. The facility's failure to follow its abuse reporting and investigation policies was confirmed by a Clinical Operations Executive.
Plan Of Correction
1. Resident 289 was discharged from the facility on 10/26/2024. A referral for psychological services made for Resident 102 and an interdisciplinary approach continues. 2. Facility residents have the potential to be affected by deficient practice. The facility will identify other residents on the affected unit to assess their ability to consent. Any resident without the ability to consent will be monitored for safety. The facility will continue to conduct sex offender checks for new admissions prior to facility acceptance with completion of the Trauma Informed Care evaluation upon admission, to determine resident history of and risk for abuse. 3. Facility staff will be educated regarding Abuse and Neglect policies and procedures, specifically, the reporting guidelines upon hire and annually, focusing on immediate identification, reporting of abuse, and initiating interventions for monitoring and preventing recurrence by the facility. 4. Documentation and concern forms will be reviewed daily during the business week for four (4) weeks to identify any potential areas of concern then weekly until substantial compliance is achieved. Audit results will be submitted and reviewed by the Quality Assurance Performance Improvement committee.
Failure to Implement and Document Nutritional Interventions for Weight Loss
Penalty
Summary
The facility failed to consistently implement and document interventions for significant weight loss for a resident, identified as Resident 67, who was at nutritional risk. The resident, diagnosed with diabetes and congestive heart failure, experienced a significant weight loss of 5.5% within one month, which was attributed to fluid loss from IV Lasix therapy. Despite the Registered Dietitian (RD) adjusting the resident's dietary preferences and planning for additional nutritional supplements, there was no documented evidence that these interventions were consistently implemented or communicated to the physician or responsible party in a timely manner. Further weight loss was noted, reaching an 8% loss within one month, prompting the RD to discuss and plan for the administration of Ensure pudding and ProStat as nutritional supplements. However, the Medication Administration Record (MAR) lacked documentation of the administration or consumption of these supplements. The RD confirmed that the facility failed to implement the planned nutritional interventions and did not document the physician-ordered nutritional interventions, which were crucial to maintaining the resident's nutritional parameters and preventing further weight loss.
Plan Of Correction
1. Resident # 67 has Ensure Pudding once daily and ProStat twice daily added to his EMAR to now collect supplement administration and consumption to deter weight loss. 2. The Registered Dietitian completed an audit of current in-house resident supplements ordered to ensure that both supplement administration and consumption are being captured in the medical record. 3. The Clinical Coordinator or designee will re-educate licensed nursing staff and the Registered Dietitian regarding the facility's current Weighing of Residents Policy and the order entry process for supplements to ensure consistent implementation and documentation of physician-ordered nutritional interventions to maintain nutritional parameters and deter weight loss of a resident. 4. The Registered Dietitian or designee will review current in-house and new resident orders for supplementation weekly for three months to ensure consistent implementation and documentation of physician-ordered nutritional interventions to maintain nutritional parameters and deter weight loss of a resident. Audit results will be reported to the Quality Assurance Performance Improvement committee to determine compliance.
Failure to Provide Emergency Dialysis Supplies
Penalty
Summary
The facility failed to ensure the availability of necessary emergency supplies for two residents receiving hemodialysis, as required by physician orders and facility policy. Resident 121, who has end-stage renal disease and relies on hemodialysis, was observed to have only one fanny pack containing emergency supplies on her wheelchair, with the second required pack missing from her room. This was confirmed by both the resident and a licensed practical nurse. Similarly, Resident 187, who also depends on renal dialysis, was found to have only one fanny pack on the wheelchair, with the second pack missing from the room, as confirmed by another LPN. The facility's policy mandates that residents with temporary catheters for dialysis must have an emergency protocol kit available at all times, with staff required to check the presence of these kits every shift. The absence of the second fanny pack in the rooms of both residents was confirmed by the Clinical Operations Executive, indicating a failure to comply with physician orders and facility policy. This deficiency placed the residents at risk for delayed emergency intervention in the event of complications related to their dialysis access sites.
Plan Of Correction
1. For Residents #121 and #187, fanny packs with emergency supplies were placed in the resident room and on their wheelchair per National Kidney Foundation and the facility's Care of the Dialysis Resident Policy/Procedure. 2. The DON assessed current in-house hemodialysis residents on 02/05/2025. Current in-house hemodialysis residents had a fanny pack with emergency supplies located both in the resident room and on the resident wheelchair. 3. The Clinical Coordinator or designee will re-educate licensed facility staff regarding the facility's Care of the Dialysis Resident Policy/Procedure requirement for a fanny pack with emergency supplies to always be available in the resident room and on the resident wheelchair. 4. The DON or designee will continue to review current in-house hemodialysis residents weekly to assure compliance regarding the facility's Care of the Dialysis Resident Policy/Procedure requirement for a fanny pack with emergency supplies to be always located both in the resident room and on the resident wheelchair. This weekly review will continue for the next three months. Audit results will be reported to the Quality Assurance Performance Improvement committee monthly for three months to assure continued compliance.
Failure to Provide Routine Dental Services to a Medicaid Resident
Penalty
Summary
The facility failed to provide routine annual dental services to a resident whose payor source was Medicaid. The resident, identified as Resident 88, was admitted to the facility on an unspecified date, and there was no documented evidence that dental services had been offered to them in the past year. This deficiency was confirmed during an interview with the Clinical Operations Executive on January 23, 2025, who acknowledged that the facility had not offered the required dental services to Resident 88. The survey concluded on January 24, 2025, without any record of dental services being provided to the resident.
Plan Of Correction
1. Resident 88 was referred to in-house dental services. 2. All residents have the potential to be affected by deficient practice. Director of Nursing will audit all residents to identify any resident who may not have had dental services. 3. Social Services will be educated regarding the Dental Services Policy and Procedures. 4. All residents are offered dental services upon admission. All residents without dental services in the previous 12 months will be offered dental services. All residents will be scheduled for dental services per policy and procedure. Social Services or designee will audit Dental services monthly until substantial compliance is achieved. All results will be submitted and reviewed in QAPI.
Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain the automatic sprinkler system in three specific locations, affecting three out of six floors. During an observation on January 7, 2025, several deficiencies were noted: the make-up air room in the basement lacked a suspended ceiling assembly with surface-mounted sprinkler heads; a plastic bag material was found affixed to an automatic sprinkler head in the fifth-floor Personal Laundry; and a sprinkler head assembly in the first-floor Dietary Office was missing an escutcheon plate. These deficiencies were confirmed during an exit interview with the Facility Administrator and the Facilities Manager.
Plan Of Correction
Observation 1: The make-up air room, located at the basement level, lacked a suspended ceiling assembly (surface-mounted sprinkler heads). 1) What systematic changes will be put into place to ensure that the deficiency does not recur, and how the corrective action(s) will be monitored? The current 2 sprinkler heads in the air make-up room are scheduled to be inverted to upright heads. The remainder of the drop ceiling will be removed. Sprinkler head and in-house fire inspections will be completed quarterly. The Director of Facilities Management will report the inspection findings to the QAPI committee. Observation 2: Plastic bag material was affixed to an automatic sprinkler head, located within the fifth floor Personal Laundry. 1) What systematic changes will be put into place to ensure that the deficiency does not recur, and how the corrective action(s) will be monitored? Plastic bag material was removed from the automatic sprinkler head in the fifth floor personal laundry area. Sprinkler head and in-house fire inspections will be completed quarterly. The Director of Facilities Management will report the findings to the QAPI committee. Observation 3: A sprinkler head assembly, located within the first floor Dietary Office, lacked an escutcheon plate. 1) What systematic changes will be put into place to ensure that the deficiency does not recur, and how the corrective action(s) will be monitored? The escutcheon plate on the sprinkler assembly in the Dietary Office was replaced. Sprinkler head and in-house fire inspections will be completed quarterly. The Director of Facilities Management will report the findings to the QAPI committee.
Smoke Barrier Door Deficiency on Fifth Floor
Penalty
Summary
The facility failed to maintain the smoke barrier separation doors on the fifth floor, specifically the Clay Street smoke barrier doors. During an observation on January 7, 2025, at 11:07 a.m., it was noted that these doors required adjustment to fully latch. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager later that day, between 12:15 p.m. and 12:20 p.m.
Plan Of Correction
Observation 1: Observation revealed the fifth floor, Clay Street smoke barrier separation doors required adjustment to fully latch. 1) What systematic changes will be put into place to ensure that the deficiency does not recur, and how the corrective action(s) will be monitored: The Smoke Barrier Separation Door was adjusted to fully closed by the Assistant Director of Maintenance. All Barrier separation doors will be inspected to ensure proper closing during all fire drills by the members of our Maintenance team on their assigned floors during the fire drills. Barrier Separation door inspections will be submitted to QAPI Committee Quarterly by the Director of Maintenance and presented for review/discussion.
Excessive Building Height Deficiency
Penalty
Summary
The facility was found to have exceeded the maximum allowable story height for its type of construction, which is classified as an unprotected, noncombustible building. This deficiency was observed during a survey conducted on January 7, 2025, between 10:30 a.m. and 11:00 a.m. The building was noted to be three stories higher than permitted for its construction type, affecting all six floors of the facility. This finding was confirmed during an exit interview with the Facility Administrator and the Facilities Manager later that day.
Inadequate Fire Resistance in Vertical Enclosures
Penalty
Summary
The facility failed to maintain the required fire resistance rating for multiple vertical enclosures, affecting all six floors. During an observation on January 7, 2025, it was noted that the vertical enclosures protecting the HVAC shafts adjacent to the exit stair towers did not meet the necessary two-hour fire resistance rating. Additionally, the construction of the Clay Street exit stair tower on the fourth and fifth floors was found to be inadequate, consisting of two sheets of drywall on the inside and one sheet on the corridor and resident room side of metal studs, with unprotected steel beams included as part of the enclosure. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager.
Failure to Respect Resident Dignity During Meal Service
Penalty
Summary
The facility failed to conduct meal service in a manner respectful of each resident's personal dignity, specifically for one resident with severe cognitive impairment and dementia. This resident, who requires supervision and assistance when eating, was observed sitting with her meal in front of her for 25 minutes without any staff assistance or encouragement to eat. During this time, staff were assisting other residents, and the resident was left unassisted despite her care plan indicating the need for limited staff assistance and participation in the feeding assistance program. Interviews with staff revealed that the unit is often understaffed, leading to delays in providing necessary assistance to residents during meals. Staff acknowledged that the resident's meal should not have been placed in front of her until assistance was available. The Director of Nursing confirmed the high acuity of residents requiring meal assistance on the unit and acknowledged the facility's responsibility to ensure residents are treated with respect and dignity, which was not upheld in this instance.
Failure to Document Nutritional Intake for Resident Receiving Hospice Services
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for a resident, identified as Resident CR1, who was admitted with a diagnosis of cerebral infarction. Physician's orders indicated that hospice services were initiated for the resident on March 26, 2023, and monthly weight monitoring was discontinued on March 28, 2023. However, a documentation survey report for August 2024 revealed that there was no documented information regarding the resident's nutritional intake for 18 meals during that month. Additionally, the progress notes from August 1, 2024, through August 29, 2024, lacked documentation of the resident's nutritional intake. The resident was discharged to home with external hospice provider services on August 29, 2024. During an interview, the Director of Nursing confirmed the facility's responsibility to ensure accurate and complete clinical records and acknowledged the failure to document the resident's nutritional intake, without providing an explanation for the oversight.
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Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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