Fox Subacute At Mechanicsburg
Inspection history, citations, penalties and survey trends for this long-term care facility in Mechanicsburg, Pennsylvania.
- Location
- 120 South Filbert St, Mechanicsburg, Pennsylvania 17055
- CMS Provider Number
- 396122
- Inspections on file
- 22
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Fox Subacute At Mechanicsburg during CMS and state inspections, most recent first.
Surveyors found that the facility did not properly obtain and document informed consent for psychotropic medications for two residents with serious mental health diagnoses. Both residents were receiving antipsychotic and antianxiety, and in one case antidepressant, medications, but their psychotropic consent forms were incomplete, with treatment conditions and/or specific medications left blank. Clinical records lacked documentation that the residents or their representatives were educated on the risks, benefits, side effects, or adverse reactions of these medications. The NHA reported that the facility’s practice was to have a psychotropic consent signed at admission only and not to obtain new consents when medications changed, and no progress notes were found to show that medication changes and related information had been discussed with the representatives.
The facility did not ensure that a physician or prescriber reviewed and responded to consultant pharmacist Medication Regimen Review (MRR) recommendations for three residents with serious conditions including heart failure, respiratory failure, and vertebral fracture. In each case, the pharmacist recommended additional monitoring or clarification of PRN antianxiety or antipsychotic/anticonvulsant orders, and nurses documented actions such as adding monitoring or a 14-day limit. However, there was no physician signature or documentation showing that a prescriber reviewed or addressed these medication irregularities, despite facility policy requiring prescriber involvement.
Surveyors found that care plans were not updated to reflect current interventions for two residents. For a resident with chronic respiratory failure on a ventilator, the care plan continued to list an outdated trach type and size despite a physician order for a different trach. For another resident with chronic respiratory failure and HTN who had a prior unwitnessed fall, the care plan still listed bilateral fall mats as an active intervention with placement every shift, even though the DON reported the mats had been discontinued and staff observations confirmed no mats were present in the room.
A resident with acute and chronic respiratory failure, hypoxia, ventilator dependence, and a gastrostomy tube had medications administered via the G-tube by an RN without prior verification of tube placement, despite facility policy and a physician order requiring confirmation of feeding tube placement before each instillation of tube feeding, medications, or water. The RN reported believing the prior verification policy was no longer in effect, while the DON confirmed that tube placement should have been checked before administering the medications.
A resident with a stage 3 pressure ulcer and other comorbidities did not receive ordered vitamin C 500 mg BID for wound healing after returning from a hospital stay. Although wound care documentation and dietitian notes repeatedly referenced vitamin C as part of the wound treatment plan, the original physician order had been discontinued when the resident was hospitalized and was never re-entered on readmission. The DON confirmed that the order should have been reinstated in accordance with the wound physician’s recommendations and facility policy requiring adherence to specific wound care and medication instructions.
Surveyors found that the facility did not follow its own Pharmacy Services policy requiring all opened multi-dose vials to be dated and discarded per product guidelines. In the first floor medication room, two opened vials of tuberculin skin testing solution were observed: one had no open date, and the other was dated more than 30 days prior, beyond the product’s 30‑day post-puncture expiration period. During interview, the DON and Assistant DON confirmed that multi-dose vials must be dated when opened and acknowledged that the dated tuberculin vial was expired and should have been discarded.
A nurse failed to follow infection control practices while administering medications via a G-tube to a resident. The nurse placed prepared medications on a heating unit, then handled a fall mat from the floor with gloved hands and set the medication cups on the mat. Without changing gloves or performing hand hygiene, the nurse proceeded to administer the medications while holding the end of the tube feeding administration tubing, which connects directly to the G-tube. The NHA and DON later confirmed that proper glove removal and hand hygiene should have occurred before medication administration.
A resident with quadriplegia and hypotension received oxycodone for pain, but staff failed to consistently document administration of the controlled substance on the MAR as required by facility policy. Discrepancies were found between the controlled drug record and the MAR, with several doses not properly signed off or documented at incorrect times. Nursing leadership confirmed the expectation for accurate documentation but could not explain the inconsistencies.
A resident with CHF and hypertension had physician orders for several lab tests, but while the CBC and urinalysis results were documented, the BMP result was missing from the clinical record. An LPN and the provider were aware that the BMP was not viable and decided not to redraw it, but this was not documented as required by facility policy.
The facility failed to perform the mandatory 3-year, 4-hour load bank test on its emergency generator, as required by NFPA standards. This deficiency was confirmed by the Director of Maintenance during an interview, indicating a lapse in the facility's adherence to the maintenance schedule necessary for ensuring reliable emergency power.
The facility failed to maintain common wall doors on the second floor, with gaps exceeding 1/8 inch and lacking positive latching. The doors were only secured by a magnetic release, allowing them to open freely during a fire alarm, as confirmed by the Director of Maintenance.
The facility failed to maintain clear exit access on the second floor, as required by NFPA 101 standards. Observations revealed obstructions in the corridor, including soiled-linen, trash containers, and a clean-linen cart, at various locations. The Director of Maintenance confirmed these obstructions, indicating non-compliance with safety codes.
The facility did not maintain the stairtower doors within the allowed gap margins. An observation revealed that the 2nd floor stairtower door had gaps greater than 1/8 inch, which was confirmed by the Director of Maintenance.
The facility did not conduct or document the required annual 90-minute test of the battery-powered emergency lighting in the Generator Room, as confirmed by the Director of Maintenance.
The facility failed to update and revise care plans for several residents, leading to deficiencies in care. A resident's care plan did not reflect necessary fall interventions, while another's care plan was not updated after medication changes. Additionally, care plans lacked detailed interventions and monitoring guidelines. The DON and staff acknowledged these oversights.
The facility failed to provide care according to professional standards for three residents. A resident with a tracheostomy had no documentation of skin assessments despite an order for antibiotic ointment. Another resident with COPD and hypertension had incomplete documentation of wound care treatments. A third resident with diabetes and renal disease had missing blood sugar checks and incorrect medication administration. The DON confirmed these issues and expected proper documentation and adherence to orders.
A facility failed to provide appropriate catheter care for a resident with an indwelling catheter, leading to multiple undocumented instances of foley output, catheter care, and flush kit changes. This resulted in the resident receiving antibiotic treatment for urinary tract infections twice. The DON confirmed that the facility's process and physician orders were not followed.
A resident with cerebral palsy and a tracheostomy was prescribed triple antibiotic ointment for skin damage at the stoma site without documented evidence of such damage. The facility's consultant pharmacist failed to identify the lack of clinical documentation during multiple reviews. The DON confirmed the oversight, and the resident's physician later discontinued the ointment after finding no skin damage.
A resident with hypertension and bipolar disorder was prescribed clonazepam and lorazepam without documented rationale for their duplicative use. The facility failed to adhere to the prescribed administration schedule and did not document numerous administrations in the MAR. Additionally, lorazepam was administered without an active physician order, indicating a failure to ensure medications were only given with valid orders.
A facility failed to maintain the confidentiality of a resident's medical records, as a paper with the resident's name and clinical findings was visible from the hallway. The paper, which included treatment instructions for the resident's tracheostomy, was improperly placed outside the resident's room instead of being secured.
The facility did not complete the required TB screening for two new employees, as per its infection control plan. Employee 3 had no documentation of a TST or TB blood assay test prior to hire, while Employee 7 had only one TST from a previous employer. The Nursing Home Administrator confirmed the oversight and stated that both employees were removed from the floor and sent for a TB blood assay test.
A facility failed to ensure verbal medication orders were countersigned by the prescribing physician within 48 hours, as required by state regulations. A resident with hypertension and bipolar disorder had verbal orders for lorazepam and clonazepam entered without the necessary physician counter-signature. The facility's policy did not include the requirement for physician signatures on verbal orders, and the Director of Nursing acknowledged the expectation for compliance with state regulations.
A facility failed to notify a resident's representative of a critically low hemoglobin level, as required by their policy. The resident, diagnosed with anemia and atrial fibrillation, had a hemoglobin level of 6.0, significantly below the normal range. The Assistant Director of Nursing confirmed that the representative should have been informed, but no documentation of such notification was found.
A facility failed to follow physician orders for a resident with anemia and Afib, leading to continued administration of Coumadin despite orders to discontinue blood thinners. The facility also lacked documentation of INR results, and the physician assistant was unaware of elevated INR levels.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed and provided consent for psychotropic medications, as evidenced by record reviews for two residents. One resident had diagnoses including major depressive disorder with psychotic features and generalized anxiety disorder and had physician orders for quetiapine and lorazepam, with a history of being on these types of medications for several months. The resident’s clinical record contained a Psychotropic Medication Treatment Consent form that incorrectly listed the treatment reason as Tracheotomy/Brain Damage, left the medication section blank, and was signed by the resident’s representative. The record did not contain documentation that the resident or representative had been educated on the risks, benefits, side effects, or other adverse reactions associated with the ordered antipsychotic and antianxiety medications. Another resident had diagnoses including schizoaffective disorder bipolar type, generalized anxiety disorder, and major depressive disorder, and had physician orders for olanzapine, buspirone, and escitalopram. This resident’s Psychotropic Medication Treatment Consent form had both the condition being treated and the medications being used left blank, although it was signed by the resident’s representative. The clinical record similarly lacked documentation that the resident or representative had been informed of the risks and benefits, including side effects and adverse reactions, of the antipsychotic, antianxiety, and antidepressant medications. During an interview, the NHA stated that the facility’s practice was to obtain a psychotropic consent at admission only and not to obtain additional consents, and that staff would review medication changes with representatives and document these discussions in progress notes; however, no such documentation was found for these two residents.
Failure to Obtain Physician Response to Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that monthly Medication Regimen Review (MRR) recommendations made by the consultant pharmacist were reviewed and acted upon by the attending physician or prescriber, as required by facility policy. The policy titled "Medication Regimen Review (Monthly Report)" stated that recommendations are to be acted upon and documented by facility staff and/or the prescriber. For three residents, documentation showed that nursing staff acknowledged and implemented pharmacist recommendations, but there was no evidence that a physician had reviewed or addressed the identified irregularities. For one resident with heart failure and respiratory failure, the consultant pharmacist recommended on December 10, 2025, that additional monitoring be added for an anticonvulsant medication; a nurse signed the recommendation and documented "added to order," but there was no physician signature or documentation of physician review. For a second resident with heart failure and respiratory failure, the pharmacist recommended on October 17, 2025, that a PRN antianxiety medication either be limited to 14 days or have a documented rationale and duration; a nurse signed and documented "14-day added to order" without any physician signature or evidence of physician review. For a third resident with a fracture of the first thoracic vertebra and respiratory failure, the pharmacist recommended on December 10, 2025, additional monitoring for an antipsychotic medication; a nurse signed and documented "AIMS" without a physician signature or documentation that the physician reviewed or acted on the irregularity. In an interview, the DON stated they would expect the regulation to be followed.
Failure to Update Care Plans to Reflect Current Respiratory and Fall-Prevention Interventions
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised to reflect residents' current clinical status for two residents. For one resident with chronic respiratory failure and dependence on a respirator, physician orders documented a tracheostomy type and size of #8 Portex starting March 19, 2025. However, the resident’s comprehensive plan of care continued to list a trach type and size of 7 XLT-D cuffed under the care area for ineffective airway clearance related to disease process with vent support as needed and trach. In an interview, the Nursing Home Administrator and DON acknowledged that the resident’s trach size and type had changed and that the care plan was not updated, and the DON stated she would expect care plans to be updated timely. For another resident with chronic respiratory failure and hypertension who had an unwitnessed fall on September 24, 2025, the fall report documented an intervention to place bilateral fall mats on either side of the bed. The comprehensive care plan included a focus area for risk of falls with an intervention for bilateral fall mats and instructions to ensure placement every shift, last revised October 21, 2025. Observations of the resident’s room on two separate days did not reveal bilateral fall mats, and a housekeeper reported not having seen any fall mats in the room. The DON stated in interviews that the fall mats had been reviewed and discontinued around the time of the resident’s most recent hospitalization in November 2025 and that she would expect the care plan to be updated, indicating the care plan was not revised to reflect the discontinuation of the fall mats.
Failure to Verify G-Tube Placement Prior to Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medications administered via a gastrostomy tube were provided in accordance with professional standards and facility policy. The facility’s Medication Administration policy, last reviewed on December 31, 2025, required that gastrostomy tube placement be confirmed by auscultation with air prior to medication administration. Resident 46’s clinical record showed diagnoses including acute and chronic respiratory failure with hypoxia, ventilator dependence, and the presence of a gastrostomy tube. The physician’s order for this resident directed that feeding tube placement be confirmed prior to every instillation of tube feeding, medications, water, etc., each shift, and that placement be confirmed per policy. During a medication administration observation for Resident 46 on January 22, 2026, at 8:45 AM, a Registered Nurse (Employee 3) administered medications through the resident’s gastrostomy tube without confirming tube placement beforehand. In a subsequent interview, Employee 3 stated that the facility previously had a policy requiring verification of gastrostomy tube placement before medication administration but believed that policy was no longer in effect. In an interview later that morning, the DON confirmed that Employee 3 should have verified the gastrostomy tube placement before administering the medications, indicating that the nurse’s actions did not follow the current policy and physician order.
Failure to Reinstate Vitamin C Order for Pressure Ulcer Treatment
Penalty
Summary
The facility failed to ensure necessary treatment and services were provided, consistent with professional standards of practice, to promote healing of a pressure ulcer for one resident. Facility policy on Wound Care and Pressure Ulcer Care required staff to check the physician’s order for specific wound care and medication instructions. The resident had diagnoses including a stage 3 pressure ulcer, chronic respiratory failure, and hypertension. Wound Evaluation & Management Summaries over multiple dates documented recommendations from the wound provider for a dietician consult and vitamin C 500 mg BID as part of the wound care plan. Dietitian notes from multiple weekly wound meetings documented that the resident was taking vitamin C as an intervention for wound healing. However, review of the physician’s orders showed that the order for ascorbic acid (vitamin C) 500 mg BID for wounds, which began in mid-September, was discontinued in early October when the resident went to the hospital and was never re-entered upon the resident’s return. During an interview, the DON stated that the vitamin C order was discontinued when the resident was hospitalized and was not reinstated afterward, despite the wound doctor’s continued recommendation, and acknowledged that physician recommendations were expected to be implemented.
Improper Labeling and Failure to Discard Expired Tuberculin Vials in Medication Room
Penalty
Summary
Surveyors identified a deficiency in the facility’s medication management practices related to labeling and discarding multi-dose vials. Review of the facility’s Pharmacy Services policy, last reviewed December 31, 2025, showed that all opened multi-dose vials were required to be dated at the time they were opened. Product information for tuberculin skin testing solution indicated that the solution expires 30 days after the initial puncture into the vial. During observation of the first floor medication room with a staff member on January 21, 2026, surveyors found two opened vials of tuberculin skin testing solution, one without any open date and another labeled with an open date of December 4, 2025, which was beyond the 30‑day use period. In an interview, the DON and Assistant DON acknowledged that multi-dose vials should be dated when opened and confirmed that the vial dated December 4, 2025, was expired and should have been discarded. No specific residents or their clinical conditions were mentioned in relation to this deficiency. The findings were limited to the medication storage and labeling practices in one of two medication rooms observed (the first floor medication room), where the presence of an undated vial and an expired vial of tuberculin skin testing solution demonstrated noncompliance with the facility’s own policy and accepted professional standards for medication labeling and expiration dating.
Improper Infection Control During G-Tube Medication Administration
Penalty
Summary
A deficiency occurred when a nurse failed to follow infection prevention and control practices during medication administration for Resident 33, who received medications via a gastrostomy tube. During a medication pass observation, the nurse entered the resident’s room, donned a gown and gloves, and placed the resident’s prepared medication cups on the room’s heating unit. The nurse then used both gloved hands to pick up a fall mat from the floor beside the bed and lean it against the wall, and subsequently placed the cups of prepared medications on top of the upright fall mat. The nurse proceeded to administer the medications through the resident’s gastrostomy tube while also holding the end of the tube feeding administration tubing, which connects directly to the gastrostomy tube, in her left gloved hand. In an immediate interview, the nurse acknowledged that she had touched the fall mat on the floor with her gloved hands and then continued with medication administration without changing gloves or performing hand hygiene. In a later interview, the Nursing Home Administrator and the DON confirmed that the nurse should have removed her gloves, cleansed her hands, and applied clean gloves prior to administering the medications through the gastrostomy tube.
Failure to Document Controlled Substance Administration per Professional Standards
Penalty
Summary
The facility failed to ensure that care and services were provided in accordance with professional standards of practice for one resident. Facility policy required that the Controlled Drug Record be signed by the nurse at the time the drug is given, and that administration be documented on the medication administration record (MAR). For a resident with quadriplegia and hypotension who had physician orders for oxycodone as needed for pain, review of records showed discrepancies between the controlled drug record and the MAR. Specifically, oxycodone was documented as being dispensed 17 times, but only 8 administrations were signed off on the MAR. Additionally, some administrations were recorded on the MAR either before or well after the medication was documented as dispensed, and several dispensed doses were not signed off on the MAR at all. Interviews with the DON, Assistant DON, and Nursing Home Administrator confirmed that staff are expected to document on both the controlled drug record and the MAR when administering controlled substances. However, they were unable to provide an explanation for the discrepancies or missing documentation. This failure to accurately document the administration of controlled substances did not comply with facility policy or professional standards of nursing practice.
Incomplete Documentation of Laboratory Results in Resident Record
Penalty
Summary
The facility failed to ensure that a resident's medical record was complete and accurately documented in accordance with accepted professional standards. Specifically, for a resident with diagnoses including congestive heart failure and hypertension, there was a physician order for laboratory tests including a CBC, BMP, and urinalysis. While the results for the CBC and urinalysis were documented in the clinical record, there was no documentation of the BMP results. Nursing progress notes indicated that the CBC and urinalysis results were received and reviewed, but did not mention the BMP. Interviews with the LPN and physician revealed that the BMP was not viable due to insufficient blood, and the provider was made aware of this at the time. However, there was no documentation in the resident's clinical record that the provider was notified about the non-viable BMP or that a decision was made not to redraw the test. The Nursing Home Administrator confirmed that such conversations should have been documented in the clinical record, but this was not done.
Failure to Perform Required Generator Load Bank Test
Penalty
Summary
The facility failed to maintain its emergency generator system as required by NFPA standards. Specifically, the facility did not perform the mandatory 3-year, 4-hour load bank test on the generator, which is crucial for ensuring the generator's capability to supply emergency power within the required 10 seconds. This deficiency was identified during a document review and interview conducted on January 23, 2025, between 9:15 AM and 10:30 AM. The Director of Maintenance confirmed during an interview that the load bank test had not been performed. This oversight indicates a lapse in the facility's adherence to the maintenance and testing schedule outlined in NFPA 110, which mandates regular inspections and testing to ensure the reliability of emergency power systems. The failure to conduct this test could potentially compromise the facility's ability to provide essential power during emergencies.
Plan Of Correction
1. Facility has contracted with an outside vendor to complete the 4 hour load bank test, to be completed by Compliance date. 2. Maintenance Director or Designee will ensure the generator load bank scheduling will be reviewed yearly for documentation of the 3 year, 4-hour load bank test on the generator was performed as required. 3. Maintenance Director will report findings to the QAPI committee.
Deficiency in Common Wall Door Maintenance
Penalty
Summary
The facility failed to maintain the integrity of common wall doors on the second floor, as observed during a survey on January 23, 2025. Specifically, the common wall door at the bridge to the elevator had gaps greater than 1/8 inch, which exceeds the allowed gap margins. This deficiency was confirmed through an interview with the Director of Maintenance, who acknowledged that the door did not meet the required standards. Additionally, another observation on the same day revealed that common wall doors on the second floor by the East Lounge also had gaps greater than 1/8 inch and lacked manual positive latching. These doors were only held closed by a coded magnetic release, which allowed them to open freely when the fire alarm was activated. The Director of Maintenance confirmed these findings, indicating that the doors did not comply with the necessary safety requirements.
Plan Of Correction
1. The distance between the common wall doors by the East lounge have been adjusted and corrected to meet one-eighth-inch requirement. 2. Door was adjusted to ensure manual positive latching. 3. Facility Maintenance Director or his designee will audit random doors for gaps for the next 3 months and then quarterly. 4. Maintenance Director will report findings to the QAPI committee.
Obstructed Exit Access on Second Floor
Penalty
Summary
The facility failed to maintain clear and unobstructed exit access on one of its two floors, as required by NFPA 101 Means of Egress standards. During an observation conducted on January 23, 2025, between 12:15 PM and 12:45 PM, it was noted that the corridor on the second floor was obstructed at several locations. Specifically, between Resident Rooms 201 and 202, a soiled-linen and a trash container were blocking the corridor. Outside Resident Room 202, a clean-linen cart was found obstructing the passageway. Additionally, outside Resident Room 208, a clean-linen, a soiled-linen, and a trash container were also obstructing the corridor. An interview with the Director of Maintenance confirmed these obstructions, indicating a failure to keep the means of egress free from impediments as required by the relevant safety codes.
Plan Of Correction
1. Hallways on 2nd floor have been cleared of identified obstructions. 2. All other floors have been cleared of possible obstructions. 3. Facility Maintenance Director or his designee will perform random audits weekly for the next 3 months and then quarterly. The audits will be conducted not less than monthly, at random times and dates.
Stairtower Door Gap Exceeds Allowable Limit
Penalty
Summary
The facility failed to maintain the stairtower doors within the allowed gap margins on one of two floors. During an observation on January 23, 2025, at 12:10 PM, it was noted that the 2nd floor stairtower door, located by the elevator, had gaps greater than 1/8 inch. This observation was confirmed through an interview with the Director of Maintenance at the same time.
Plan Of Correction
1. The distance between the stair tower doors have been adjusted and corrected to meet one-eighth-inch requirement. 2. Facility Maintenance Director or his designee will audit random doors for gaps for the next 3 months and then quarterly. 3. Maintenance Director will report findings to the QAPI committee.
Failure to Test Emergency Lighting
Penalty
Summary
The facility failed to meet the requirement for emergency lighting as outlined in NFPA 101. Specifically, the facility did not perform functional tests of the battery-powered emergency lighting source located in the Generator Room, which serves the entire component. During a document review conducted on January 23, 2025, it was revealed that there was no documentation verifying that the Generator Room's battery back-up emergency lighting was tested for 90 minutes annually. This deficiency was confirmed through an interview with the Director of Maintenance, who acknowledged the lack of recorded annual testing.
Plan Of Correction
1. The Generator Room battery back-up emergency lighting was tested 90 minutes to ensure lighting during power outage. 2. Back up lighting unit will be added to the facility Preventative Maintenance log to ensure the working condition and will be audited monthly. 3. Maintenance Director will report findings to the QAPI committee.
Failure to Update and Revise Care Plans for Residents
Penalty
Summary
The facility failed to review and revise the care plans for four residents, leading to deficiencies in their care. Resident 2, who was dependent on a ventilator and had a history of falls, had an outdated care plan that did not reflect the intervention for bilateral fall mats after an unwitnessed fall. The RNAC acknowledged that the physician's order was not updated, which prevented the care plan from being revised accordingly. The DON confirmed that the care plan should have been updated with the fall intervention. Resident 26's care plan was not updated to reflect the discontinuation of Amphetamine-Dextroamphetamine, and the care plan for anti-anxiety medications lacked detailed interventions and monitoring guidelines. The care plan for anti-psychotic medication was also not individualized. The DON and Nursing Home Administrator both recognized that the care plan should have been revised during the care plan meeting. Resident 29's care plan did not initially include the use of bilateral thick fall mats, despite having an order for them and their presence since admission. The care plan was only updated after the surveyor's observation. Resident 37's care plan still included a resolved blister wound, which had not been revised since March 2024. The DON acknowledged that the care plan should have been updated to reflect the resolution of the wound.
Plan Of Correction
Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. One: actions taken for situation identified: 1) The Facility recognizes that it cannot retroactively correct the situation for resident R2, R26, R29, R37. 2) The Facility updated R2, R26, R29, R37 care plans to reflect current resident orders and plan of care. 3) All resident care plans were reviewed to ensure that care plans to reflect current resident orders and plan of care. Two: system changes and measures that will be taken: 1) All Licensed and IDC staff will be in-serviced on initiating, updating and resolving care plan items. 2) Care plans will be monitored at Daily Clinical meetings and updated as necessary. Three: monitoring mechanism to assure compliance: 1) The Director of Nursing or her designee will conduct audits on 5 (5) random residents 3x week for 4 weeks for compliance with careplans, then five (5) random residents 1x week for 2 months. 2) The Director of Nursing will report findings at Continuous Quality Improvement Committee meetings.
Failure to Document and Administer Care as Ordered
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for three residents. Resident 9, who had a tracheostomy and was dependent on a ventilator, had an order for triple antibiotic ointment to be applied to moisture-associated skin damage at the tracheostomy site every shift. However, there was no clinical documentation of any skin damage or assessments from September 24, 2024, to January 8, 2025. The Director of Nursing (DON) confirmed the absence of documentation and noted that the physician assessed the site on January 8, 2025, finding no skin damage and discontinued the ointment. Resident 14, diagnosed with COPD and hypertension, had multiple treatment orders for pressure areas and wounds on the left buttock and thigh. The treatment administration records (TAR) for October, November, and December 2024 showed several instances where treatments were not documented as completed. The DON believed the treatments were completed but acknowledged the lack of documentation, which should have been recorded on the TAR. Resident 17, with Type 2 Diabetes Mellitus and end-stage renal disease, had orders for blood sugar checks and medication administration. The medication administration records for October, November, and December 2024, and January 2025, revealed multiple instances where blood sugar checks were not documented, and a high blood sugar reading was not followed up with physician notification. Additionally, Midodrine was administered despite a blood pressure reading that should have prompted holding the medication. The DON confirmed these discrepancies and expected staff to document medication administration and follow-up communication with the physician as ordered.
Plan Of Correction
Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. One: actions taken for situation identified: 1) The Facility recognizes that it cannot retroactively correct the situation for resident R9, R14, R17. 2) The Facility reviewed R9, and had a new skin assessment completed, site has been healed and treatment d/cd. R14 was assessed and is still receiving treatment to her open areas. R17 chart was reviewed for missing documentation and medication administration. 3) All current residents were reviewed for vital signs, incomplete documentation and correct skin assessments and orders relating to those skin assessments. Two: system changes and measures that will be taken: 1) All Licensed staff will be in-serviced on documentation accuracy, including vital signs, notifying physician on follow up and on lab values and abnormal lab values, accurate skin assessments and treatment orders. 2) Documentation will be monitored at Daily Clinical meetings and staff will be notified as necessary for corrections. Three: monitoring mechanism to assure compliance: 1) The Director of Nursing or her designee will conduct audits on five (5) random residents 3x a week for 4 weeks for compliance with documentation accuracy, including vital signs, notifying physician on follow up and on lab values and abnormal lab values, accurate skin assessments and treatment orders, and careplans, then five (5) random residents 1 x a week for 2 months. 2) The Director of Nursing will report findings at Continuous Quality Improvement Committee meetings.
Failure to Provide Appropriate Catheter Care
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent urinary tract infections for a resident with an indwelling catheter. The resident, who had diagnoses including obstructive uropathy, congestive heart failure, and muscle weakness, had specific physician orders for catheter care. These orders included documenting foley output every shift, performing catheter care every shift, and changing the foley flush kit every night shift. However, the facility did not consistently document the completion of these orders. From April 2024 through December 2024, there were multiple instances where foley output was not documented, catheter care was not completed, and the foley flush kit was not changed as ordered. As a result of these lapses in care, the resident received antibiotic treatment for urinary tract infections on two occasions, from July 15-22, 2024, and November 3-15, 2024. The Director of Nursing confirmed that the facility's process and physician orders were not followed as expected. This deficiency was identified during a review of the facility's policy, the resident's clinical record, and through staff interviews, highlighting a failure to adhere to the care plan designed to prevent infections related to the indwelling catheter.
Plan Of Correction
Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. One: actions taken for situation identified: 1) The Facility recognizes that it cannot retroactively correct the situation for resident R37. 2) The Facility reviewed R37, for missing documentation. 3) All current residents with Catheters were reviewed for incomplete documentation, Foley care, output, and Foley Flush Kit changes. Two: system changes and measures that will be taken: 1) All Licensed staff will be in-serviced on documentation accuracy, Foley care, documentation of output and Foley Flush Kit changes. 2) Documentation will be monitored at Daily Clinical meetings and staff will be notified as necessary for corrections. Three: monitoring mechanism to assure compliance: 1) The Director of Nursing or her designee will conduct audits on 5 random residents 3x a week for 4 weeks for compliance with Foley care, documentation, output and direct observation of residents that have orders for Foley Flush Kits were done, then five (5) random residents 1x week for 2 months. 2) The Director of Nursing will report findings at Continuous Quality Improvement Committee meetings.
Failure to Discontinue Unnecessary Antibiotic Ointment
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications, specifically regarding the use of an antibiotic ointment. The facility's policy requires a thorough evaluation of each resident's drug regimen to promote positive outcomes and minimize risks. However, for one resident with cerebral palsy, chronic respiratory failure, a tracheostomy, and ventilator dependence, there was an ongoing order for triple antibiotic ointment to be applied to the tracheostomy stoma site. This order was in place from September 24, 2024, without any documented clinical assessment or evidence of skin damage that would necessitate its use. The facility's consultant pharmacist reviewed the resident's medication regimen multiple times between October and December 2024 but did not identify the lack of clinical documentation supporting the use of the antibiotic ointment. During an interview, the Director of Nursing confirmed the absence of documentation for skin damage and acknowledged that the ongoing use of the ointment should have been identified and addressed earlier. The resident's physician eventually assessed the tracheostomy site and discontinued the ointment after finding no skin damage.
Plan Of Correction
Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. One: actions taken for situation identified: 1) The Facility recognizes that it cannot retroactively correct the situation for resident R9. 2) The Facility reviewed R9, and had a new skin assessment completed, site has been healed and treatment d/cd. 3) All current residents were reviewed for correct skin assessments and orders relating to those skin assessments. Two: system changes and measures that will be taken: 1) All Licensed staff will be in-serviced on documentation accurate skin assessments and treatment orders. 2) Documentation will be monitored at Daily Clinical meetings and staff will be notified as necessary for corrections. 3) Education will be provided to consultant pharmacist re: reviewing all medications to include ointments and treatment medications and Pharmacy Recommendations will be reviewed to ensure that ointments and treatment medications are reviewed by the Pharmacist. Three: monitoring mechanism to assure compliance: 1) The Director of Nursing or her designee will conduct audits on 5 random residents 3x a week for 4 weeks for compliance with treatments for skin assessments then five (5) random residents 1x week for 2 months. 2) The Director of Nursing or her designee will conduct random audits for ointments and treatment medications to compare Physician orders against Pharmacy Reviews and will review 5 random residents pharmacy recommendations monthly for compliance with treatments for skin assessments and pharmacy recommendations, then five (5) random residents for 2 months. Pharmacy recommendations are received monthly. 3) The Director of Nursing will report findings at Continuous Quality Improvement Committee meetings.
Failure to Manage Psychotropic Medications and Documentation
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications. The clinical record review revealed that a resident with diagnoses of hypertension and bipolar disorder was prescribed clonazepam and lorazepam, both benzodiazepines, for anxiety and restlessness. These medications were continuously reordered without documented clinical rationale for their duplicative use, despite a pharmacy recommendation to consolidate the medications. The provider disagreed with the recommendation, citing perceived benefits over risks, but no documented review of the risks and benefits was found. Additionally, the facility did not adhere to the prescribed administration schedule for lorazepam. The Controlled Drug Record showed instances where lorazepam was administered less than six hours apart, contrary to the physician's orders. Furthermore, there were discrepancies between the Controlled Drug Record and the electronic Medication Administration Record (MAR), with numerous administrations not recorded in the MAR. The facility also administered lorazepam to the resident during a period when there was no active physician order for the medication. This occurred on multiple occasions, indicating a failure to ensure that medications were only administered with a valid physician order. The Director of Nursing confirmed that it was the facility's expectation for staff to follow prescribed time frames and document all medication administrations accurately.
Plan Of Correction
Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. One: actions taken for situation identified: 1) The Facility recognizes that it cannot retroactively correct the situation for resident R26. 2) The Facility reviewed R26, but resident has since discharged and no longer resides at the facility. 3) All current residents were reviewed for duplicate therapy and Physician documentation for Risk/Benefit and orders and signed Physician orders. 4) All current residents were reviewed for Medication Administration and Controlled drug record for correct administration times frames as prescribed and for missing documentation. Two: system changes and measures that will be taken: 1) All Licensed staff and Medical Director and Medical Providers will be in-serviced on documentation Psychotropic drug use, Duplicate Therapy, correct administration times frames as prescribed and for missing documentation. 2) Documentation will be monitored at Daily Clinical meetings for accuracy. 3) Pharmacy Consultant to review for accuracy and discrepancies. 4) Medical Director and his staff will be in-serviced on documentation for Risk/Benefits of use. Three: monitoring mechanism to assure compliance: 1) The Director of Nursing or her designee will conduct audits on 5 random residents 3x a week for 4 weeks for compliance with Psychotropic drug use, then five (5) random residents 1x week for 2 months. 2) The Director of Nursing will report findings at Continuous Quality Improvement Committee meetings.
Confidentiality Breach of Resident's Medical Records
Penalty
Summary
The facility failed to ensure the confidentiality of a resident's personal and medical records, specifically for one resident diagnosed with quadriplegia and tracheostomy status. During an observation, it was noted that a paper containing the resident's first name and clinical assessment findings was taped to the wall outside the resident's room, visible from the hallway. This paper included information pertinent to the resident's treatment, such as suctioning instructions for the tracheostomy, and was dated January 4, 2025. During a staff interview, the Nursing Home Administrator acknowledged that the paper should have been placed on the back of the resident's door to prevent it from being in plain sight from the hallway.
Plan Of Correction
Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. One: actions taken for situation identified: 1) The Facility recognizes that it cannot retroactively correct the situation for resident R18. 2) The Facility immediately removed the written paper on January 7, 2025. 3) All resident rooms were inspected for any personal identifying information outside of their rooms. Two: system changes and measures that will be taken: 1) All staff will be educated on the privacy of our residents. 2) Any privacy concerns will be addressed by Nursing Administration. Three: monitoring mechanism to assure compliance: 1) The Director of Nursing or her designee will conduct audits on 5 random residents 3x a week for 4 weeks for compliance with privacy outside of their rooms, then five (5) random residents 1x a week for 2 months. 2) The Director of Nursing will report findings at Continuous Quality Improvement Committee meetings.
Failure to Complete TB Screening for New Employees
Penalty
Summary
The facility failed to adhere to its tuberculosis (TB) infection control plan by not completing the required TB screening for two employees, identified as Employees 3 and 7. According to the facility's policy, new employees must have either two negative tuberculin skin tests (TSTs) administered not more than three weeks apart or a negative TB blood assay test not more than one year old, along with a completed Baseline TB Individual Risk Assessment and Symptoms Questionnaire. However, the personnel file for Employee 3, who was hired on November 6, 2024, did not contain any documentation of a TST or TB blood assay test prior to hire. Similarly, Employee 7, hired on December 17, 2024, had only one TST documented from a previous employer, dated April 3, 2024, which was negative. There was no additional documentation of a second TST or a TB blood assay test prior to their employment at the facility. During an interview, the Nursing Home Administrator confirmed the lack of documentation and stated that both employees had been removed from the floor and sent for a TB blood assay test, pending negative results before returning to work. The administrator acknowledged the expectation that all new hires should be appropriately screened for TB according to the facility's policy.
Plan Of Correction
Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. One: actions taken for situation identified: 1) The Facility recognizes that it cannot retroactively correct the situation for Employee 3 and 7. 2) The Facility removed both employees from the schedule until their TB screening was completed and reviewed. 3) All current employees were reviewed for accurate TB screening requirements. Two: system changes and measures that will be taken: 1) HRA, DON, ADON, Department Heads and Infection Preventionist will be in-serviced on Facility TB policy. 2) Infection Preventionist will review all new employees for correct and accurate TB screening before new employees are allowed to start. Three: monitoring mechanism to assure compliance: 1) The Director of Nursing or her designee will conduct audits weekly audits of all new hires for 4 weeks and then monthly for 2 months for accuracy. 2) The Director of Nursing will report findings at Continuous Quality Improvement Committee meetings.
Failure to Countersign Verbal Medication Orders
Penalty
Summary
The facility failed to ensure that verbal orders for medications were countersigned by the prescribing physician within the required 48-hour timeframe, as mandated by state regulations. This deficiency was identified during a review of clinical records, facility policy, and staff interviews. Specifically, the facility's policy titled "Verbal Orders, Physician Orders and Diagnostic/Lab Results," last reviewed in December 2024, did not include language requiring the physician to sign verbal orders. This oversight was evident in the case of one resident, who had verbal orders for lorazepam and clonazepam entered into their clinical record without the necessary counter-signature from the prescribing physician. The resident in question, identified as Resident 26, had a medical history that included hypertension and bipolar disorder. On December 30, 2024, verbal orders were entered for lorazepam and clonazepam, both of which are schedule IV controlled medications. However, these orders lacked the required counter-signature by the prescribing physician. During a staff interview, the Director of Nursing confirmed that it was the facility's expectation for verbal orders to be signed by the physician as required by state regulation, highlighting a lapse in adherence to this policy.
Plan Of Correction
Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. One: actions taken for situation identified: 1) The Facility recognizes that it cannot retroactively correct the situation for resident R26. 2) The Facility reviewed R26, but resident has since discharged and no longer resides at the facility. 3) All current residents were reviewed to ensure that all verbal orders are being countersigned by the physician. Two: system changes and measures that will be taken: 1) All Licensed staff and Physician and Medical Providers will be in-serviced on Physician verbal orders and Physician countersigning orders. 2) Documentation will be monitored at Daily Clinical meetings and staff will be notified as necessary for corrections. Three: monitoring mechanism to assure compliance: 1) The Director of Nursing or her designee will conduct audits on 5 random residents 3x week for 4 weeks for compliance with verbal orders then five (5) random residents 1x week for 2 months. 2) The Director of Nursing will report findings at Continuous Quality Improvement Committee meetings.
Failure to Notify Resident's Representative of Critical Lab Value
Penalty
Summary
The facility failed to notify the emergency contact person of a critical lab value for a resident, which was a deficiency identified during a review of facility policy, clinical records, and staff interviews. The facility's policy, titled Notification of Change in Status, requires that patients and/or family members be informed of any changes in treatments or status, including non-life-threatening situations such as changes in treatment or medication and test results. However, the review of Resident 1's clinical record revealed that the resident's representative was not notified of a critically low hemoglobin level of 6.0, which was significantly below the reference range of 12.8-16.6. Resident 1 had diagnoses of anemia and atrial fibrillation, conditions that could be significantly impacted by such a low hemoglobin level. Despite the critical nature of this lab result, there was no documentation in the clinical record indicating that the resident's representative was informed. During an interview, the Assistant Director of Nursing acknowledged that the representative should have been notified. A follow-up interview with the Nursing Home Administrator and the ADON did not provide any additional information regarding the notification failure.
Failure to Follow Physician Orders for Blood Thinner Management
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for a resident diagnosed with anemia and atrial fibrillation. The physician had ordered the discontinuation of blood thinners and specific lab tests following an episode of hematuria. However, the clinical record showed that the resident continued to receive Coumadin, a blood thinner, despite the physician's order to discontinue all blood thinners. There was no evidence that the order was clarified with the physician to determine which specific medications should be discontinued, and no order was found to hold aspirin, which was documented as being held. Additionally, the facility did not have the INR lab results from the scheduled blood draw on record, and the physician assistant was unaware of the elevated INR result of 4.2. The facility was unable to provide evidence that the INR result was communicated to them by the lab. This lack of communication and failure to follow physician orders contributed to the deficiency in meeting the resident's care needs.
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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