Elm Terrace Gardens
Inspection history, citations, penalties and survey trends for this long-term care facility in Lansdale, Pennsylvania.
- Location
- 660 North Broad Street, Lansdale, Pennsylvania 19446
- CMS Provider Number
- 395507
- Inspections on file
- 15
- Latest survey
- April 7, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Elm Terrace Gardens during CMS and state inspections, most recent first.
Surveyors found that required sprinkler system inspection documentation was incomplete, with only three quarterly reports available and the 2nd quarter annual sprinkler report missing. During observation of the exterior car port, one of six sprinkler heads was obstructed by underside aluminum paneling. The Administrator and Maintenance Director confirmed both the missing documentation and the obstruction.
Surveyors found that oxygen cylinders stored within first- and second-floor nurses' stations were placed less than five feet from electrical receptacles and combustible materials, in violation of NFPA 99/101 requirements for separation of oxidizing gases from combustibles and ignition sources. The Administrator and Maintenance Director confirmed during interview that the cylinders were improperly stored in proximity to these combustible and ignition sources.
The facility failed to maintain and test its generator system as required, affecting the entire facility. Missing documentation included a natural gas reliability letter and records of monthly battery testing. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility did not maintain the fire-resistance rating of stair towers used as exits, affecting one of three levels. This was determined through observation and interview, showing non-compliance with NFPA 101 standards.
The facility was cited for fire safety and sprinkler system maintenance deficiencies. An unsealed penetration around fire alarm wiring was observed above a door in the second-floor stair tower. Additionally, a review of documents showed that required sprinkler gauge replacements, noted in an August 2024 report, had not been addressed by the time of the survey. These issues were confirmed during an exit interview with the facility's administration.
The facility did not maintain the fire resistance rating of its rubbish chutes, as observed when the rubbish chute door on the second floor Skilled Nursing Trash Room failed to self-close and latch. This issue was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility did not conduct a required fire drill for the second shift in the second quarter of 2024, as identified during a document review. This deficiency was confirmed in an interview with the Administrator and Maintenance Director, indicating non-compliance with NFPA 101 standards for quarterly fire drills on each shift.
The facility failed to maintain dignity during meal assistance for three residents with cognitive impairments and feeding difficulties. Observations showed that NAs stood while assisting these residents, contrary to facility protocols. The Administrator confirmed that staff should not stand over residents during feeding.
A facility failed to accurately complete the MDS assessment for a resident, incorrectly documenting a stage two pressure ulcer upon admission. Clinical records and staff interviews revealed no evidence of such a condition, and the DON confirmed the inaccuracy.
The facility failed to maintain sanitary food service practices in one dining area. A dietary aide was observed using the same pair of gloves for multiple tasks, including assisting a resident with utensils, clearing soiled plates, and preparing food for other residents, without changing gloves between tasks. This was contrary to the facility's hand hygiene policy, which requires changing gloves between tasks.
A facility failed to implement care planned interventions for a resident with a history of stroke and cognitive impairment, who was at risk for falls. The care plan required a fall mat to be placed on the left side of the bed, but observations on two days showed the mat was missing. This was confirmed by the Community RN Educator.
Incomplete Sprinkler Inspection Records and Obstructed Exterior Sprinkler Head
Penalty
Summary
Surveyors identified a deficiency in the facility’s compliance with NFPA 25 requirements for inspection, testing, and maintenance of the automatic sprinkler system. During document review, only three quarterly sprinkler inspection reports were available for the following time frames: 4th quarter dated 3/10/26, 3rd quarter dated 11/5/25, and 1st quarter dated 5/15/25, and the 2nd quarter annual sprinkler report was not available for review. In addition, during observation of the exterior car port area, one of six sprinkler heads was found to be obstructed by underside aluminum paneling. At the exit interview, the Administrator and Maintenance Director confirmed both the missing sprinkler system documentation and the obstructed exterior sprinkler head. No residents or specific patient conditions were mentioned in the report, and the deficiency focused solely on the facility’s failure to maintain complete sprinkler system inspection records and to ensure unobstructed sprinkler head coverage in the exterior car port.
Plan Of Correction
The Maintenance Director has hired a qualified vendor to facilitate quarterly sprinkler tests and will be conducted during the following months: August 2026, November 2026, and February 2027 to ensure compliance. The Maintenance Director has hired a qualified vendor to repair the sprinkler head within the exterior car port which was obstructed by aluminum paneling. Quarterly sprinkler head maintenance and the exterior sprinkler head repair will be monitored by the Maintenance Director and/or designee and presented to the Quality Council monthly to ensure compliance.
Improper Oxygen Cylinder Storage Near Combustibles and Electrical Receptacles
Penalty
Summary
Surveyors identified a deficiency related to improper storage of oxygen cylinders in the facility. During an observation conducted on the first and second floors between 10:30 a.m. and 12:15 p.m., oxygen cylinders were found stored within the nurses' stations. These cylinders were located less than five feet from electrical receptacles and combustible materials, contrary to NFPA 99 and NFPA 101 requirements for separation of oxidizing gases from combustibles and ignition sources. The deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director, who acknowledged that the oxygen cylinders were stored less than five feet from combustible and ignition sources. The report does not describe any specific residents, clinical conditions, or adverse events, but focuses on the environmental and storage practices for gas equipment within the nurses' stations on two of the three levels surveyed.
Plan Of Correction
Maintenance staff removed the oxygen cylinders from the first and second floor nurses stations. Nursing posted signage no oxygen cylinders are to be stored at the first and second floor nurses station to ensure cylinders are distanced from combustible materials/ignition sources. Maintenance will complete random monthly audits on first and second floor nurses stations to ensure oxygen is not being stored in those areas and present finding to the Quality Council monthly for review to maintain compliance.
Failure to Maintain and Test Generator System
Penalty
Summary
The facility failed to maintain and test its generator system in accordance with the required standards, affecting the entire facility. During a document review, it was found that the facility could not provide documentation for specific tests over the past twelve months. These missing documents included a natural gas reliability letter and records of monthly testing of battery specific gravity or battery conductance. The deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director. The lack of documentation indicates that the facility did not adhere to the necessary maintenance and testing protocols for its essential electrical systems, as outlined by NFPA standards. This oversight could potentially impact the facility's ability to ensure a reliable power supply in emergency situations.
Plan Of Correction
Maintenance Director has contacted the facility's natural gas company to obtain a copy of the Natural Gas Reliability Letter. Maintenance Director and/or designee initiated monthly testing of battery specific gravity or battery conductance to ensure the generator is properly maintained. Maintenance Director will present the Natural Gas Reliability Letter and monthly testing of the generator battery to Quality Council for review to ensure compliance.
Failure to Maintain Fire-Resistance Rating in Stair Towers
Penalty
Summary
The facility failed to maintain the fire-resistance rating of stair towers, which are used as exits, affecting one of the three levels. This deficiency was identified through observation and interview, indicating non-compliance with the NFPA 101 standards for stairways and smokeproof enclosures.
Plan Of Correction
Maintenance staff sealed the penetration surrounding the red fire alarm wiring, directly above the door, at the second floor stair tower #3, using through penetration fire stop system number C-BJ-3016 with the corresponding 3M through penetration fire stop system rating 3M Fire Barrier Sealant CP 25WB+. Maintenance staff will conduct monthly audits in the stair towers to assess for unsealed penetrations and repair as needed. Audits will be presented to the Quality Council for review to ensure compliance.
Fire Safety and Sprinkler System Deficiencies
Penalty
Summary
The facility was found to have deficiencies related to fire safety and sprinkler system maintenance. During an observation on April 7, 2025, at 1:00 p.m., surveyors identified an unsealed penetration surrounding red fire alarm wiring above the door in the second-floor stair tower #3. This issue was confirmed during an exit interview with the Administrator and the Maintenance Director later that day. Additionally, a document review revealed that the facility failed to maintain its sprinkler system as required. The Quarterly Sprinkler report from August 2, 2024, indicated that sprinkler gauges needed replacement by the end of 2024. However, there was no evidence of corrective action taken by the time of the survey on April 7, 2025. This lack of documentation was also confirmed during the exit interview with the facility's administration.
Plan Of Correction
Sprinkler gauges will be replaced by a qualified vendor to ensure the sprinkler system is properly maintained. Maintenance and a qualified vendor will assess sprinkler gauges throughout the facility and report findings to the Quality Council to ensure compliance.
Failure to Maintain Fire Resistance of Rubbish Chute
Penalty
Summary
The facility failed to maintain the fire resistance rating of its rubbish chutes and discharge rooms, specifically affecting one of the three levels. During an observation on April 7, 2025, at 1:10 p.m., it was noted that the rubbish chute door on the second floor Skilled Nursing Trash Room did not self-close and latch when tested. This deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director on the same day at 2:00 p.m.
Plan Of Correction
Maintenance staff repaired the rubbish shoot door in the second floor Skilled Nursing trash room to ensure it self-closes and latches when tested. Maintenance staff will audit the rubbish shoot door monthly to ensure proper functioning and report findings to the Quality Council to ensure compliance.
Failure to Conduct Required Fire Drill
Penalty
Summary
The facility failed to conduct a required fire drill for the second shift during the second quarter of 2024. This deficiency was identified during a document review on April 7, 2025, at 9:00 a.m. The absence of this fire drill was confirmed during an exit interview with the Administrator and the Maintenance Director later that day at 2:00 p.m. The report indicates that the facility did not meet the requirement of holding fire drills at least quarterly on each shift, as mandated by NFPA 101 standards.
Plan Of Correction
Maintenance staff will ensure fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. Maintenance staff will review fire drill logs with the Quality Council to ensure compliance.
Failure to Maintain Dignity During Meal Assistance
Penalty
Summary
The facility failed to provide assistance with dining in a manner that promoted and maintained dignity for three residents in one of the dining areas. Resident 18, diagnosed with Alzheimer's disease and dysphagia, required total assistance with feeding due to cognitive impairment. Similarly, Resident 27, also diagnosed with Alzheimer's disease and dysphagia, and Resident 54, with frontotemporal neurocognitive disorder, both required total assistance with feeding as per their care plans. However, observations revealed that nurse aides were standing while assisting these residents with their meals, which was against the facility's protocol for feeding residents. The observations took place on March 25, 2025, where NA 1 was seen standing while assisting Residents 18, 27, and 54, and NA 2 was observed standing while assisting Resident 27. In an interview, the Administrator confirmed that staff were instructed not to stand over residents while feeding them, indicating a failure to adhere to the facility's guidelines for maintaining resident dignity during meals.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident. Upon review of the clinical records and staff interviews, it was found that the MDS assessment inaccurately documented the presence of a stage two pressure ulcer upon the resident's admission. The admission nursing assessment did not provide evidence of a pressure ulcer, and a registered nurse confirmed that the resident did not have any pressure ulcers during admission. However, the MDS assessment incorrectly indicated the presence of a stage two pressure ulcer. The Director of Nursing confirmed the inaccuracy of the MDS assessment.
Failure to Maintain Sanitary Food Service Practices
Penalty
Summary
The facility failed to serve food in a sanitary manner in one of its dining areas, specifically on the Second Floor. The deficiency was identified through a review of the facility's Hand Washing/Hand Hygiene policy, dated January 7, 2025, which requires staff to wash their hands and change disposable gloves between tasks that may soil them. On March 25, 2025, Dietary Aide 1 was observed wearing the same pair of gloves while assisting a resident with utensils, clearing soiled plates, and preparing plates of food for other residents, without changing gloves between these tasks. This observation was confirmed in an interview with the Administrator on March 27, 2025, who stated that staff are expected to change gloves between tasks.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement care planned interventions for a resident who was admitted with a history of stroke, resulting in weakness on one side of the body, and altered mental status. The resident was identified as having a risk for falls due to confusion and lack of safety awareness. The care plan specified that a fall mat should be placed on the left side of the bed and checked every shift. However, observations on two consecutive days revealed that the fall mat was not in place while the resident was in bed. This deficiency was confirmed during an interview with the Community Registered Nurse Educator, who acknowledged that the fall mat should have been in place.
Latest citations in Pennsylvania
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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