Friendship Village Of South Hi
Inspection history, citations, penalties and survey trends for this long-term care facility in Pittsburgh, Pennsylvania.
- Location
- 1290 Boyce Road, Pittsburgh, Pennsylvania 15241
- CMS Provider Number
- 395688
- Inspections on file
- 25
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Friendship Village Of South Hi during CMS and state inspections, most recent first.
A resident with a traumatic brain injury, subdural hematoma, and cervical fracture reported to an RN that during care he was boosted in bed, his head struck the headboard, and he experienced increased numbness and tingling in his left forearm and fingers, with pins and needles in his upper extremities and feet. The RN documented the complaint and noted no obvious head injury, no increased pain, and an intact CTO brace with a missing foam piece, and the resident’s care plan called for caution during transfers and bed mobility. However, nursing staff did not enter an incident report or initiate an investigation of this allegation of potential rough handling/abuse as required by facility policy and state law, and the event was not reported to administration until the family later raised concerns, at which point leadership confirmed the failure to immediately report and investigate.
Grievance boxes on three nursing units were mounted at heights between 55 and 61 inches, making them inaccessible to residents in wheelchairs. On one unit, an armchair further blocked access to the box. The Nursing Home Administrator confirmed the lack of accessibility, which did not comply with facility policy or federal accessibility requirements.
Thirteen residents with significant medical needs did not receive timely assistance with ADLs, as evidenced by prolonged call light response times ranging from 20 minutes to over an hour. Multiple residents and families reported repeated delays, and facility records confirmed these extended wait times, despite residents' dependence on staff for essential care.
Surveyors found that two medication rooms contained multiple expired medical supplies and medications, including dressings, ointments, and syringes, as well as personal belongings of former residents. The DON confirmed that the facility failed to ensure proper storage and disposal of these items, contrary to facility policy.
A resident who required a two-person assist for transfers was moved by a single CNA, resulting in a deep skin tear on the right shin that required 17 sutures. The resident, with multiple medical conditions and non-weight bearing status, was injured when their leg struck the wheelchair leg rest holder during the transfer. The CNA did not check the resident's transfer status as documented in the Kardex, leading to neglect and actual harm.
A resident with severe cognitive impairment and multiple diagnoses was found to have their bed placed against the wall without a physician's order or documented medical reason. Facility policy and state regulations require written authorization for physical restraints, but no such documentation was present in the clinical record or care plan, and staff confirmed the lack of compliance.
A resident with Alzheimer's and other medical conditions was administered Seroquel, a psychotropic medication, both as a scheduled and PRN order for agitation and depression. The PRN order exceeded the facility's 14-day policy limit, and there was no documented clinical rationale or evidence of behaviors to justify continued use. Staff confirmed the failure to ensure the medication regimen was free from unnecessary psychotropic medication.
A resident who required a two-person assist for transfers due to multiple medical conditions was transferred by a single CNA, contrary to the care plan and Kardex instructions. During the transfer, the resident's leg struck the wheelchair leg rest holder, causing a deep skin tear that required 17 sutures. The CNA did not verify the resident's transfer status before performing the transfer alone, resulting in actual harm.
The facility did not post the required contact information for Adult Protective Services (APS) and other pertinent State agencies and advocacy groups, making this information inaccessible to residents and their representatives. This was confirmed during observations and an interview with the NHA.
The facility did not display required written information about how to apply for and use Medicare and Medicaid benefits, or how to receive refunds for previous payments covered by these benefits. This was confirmed during observations and an interview with the NHA.
The facility did not revise or update care plans for two residents to reflect their current care needs. One resident's care plan lacked interventions for a bed placed against the wall, which acted as a physical restraint, while another resident's care plan did not accurately reflect their level of independence with oral care and lacked documentation of personal hygiene services. Facility leadership confirmed these deficiencies.
The facility did not provide or document required training on the Quality Assurance and Performance Improvement (QAPI) Program for staff. Review of records and staff interviews confirmed the absence of QAPI-related education, and the administrator acknowledged the deficiency.
The facility failed to provide four residents the opportunity to formulate an advance directive, as required by policy. Despite being admitted with various health conditions, their clinical records lacked documentation of being offered this right. The DON and NHA confirmed this deficiency during an interview.
The facility did not notify the State Ombudsman Office of resident transfers and discharges for over four years, from 2019 to 2024. This was confirmed through document reviews and interviews, with the Nursing Home Administrator acknowledging the lapse. The State Ombudsman Office had not received notifications since 2019, violating resident rights as per PA Code: 201.29(f)(g).
Failure to Immediately Report and Investigate Resident Allegation of Rough Handling
Penalty
Summary
The deficiency involves the facility’s failure to immediately report and investigate a resident’s allegation of potential abuse/neglect as required by policy and state law. Facility policy (RISKWATCH Incident/Accident Occurrence Reporting System) required that incidents such as alleged abuse, rough handling, equipment-related incidents involving a resident, and injuries of unknown origin be entered completely and accurately by the licensed nurse or first responder prior to the end of the shift and as close to the time of the incident as possible, with documentation on the 24-hour report and alert monitoring per change of condition standards. A resident with diagnoses including traumatic subdural hematoma, displaced fracture of the seventh cervical vertebra, and traumatic brain injury reported to an RN that during care the previous night, when he was being boosted in bed, his head hit the headboard and he was experiencing increased numbness and tingling in his left forearm and first and second fingers, with pins and needles in the left upper extremity, right hand, and both feet. The RN documented that there was no obvious head injury or increased pain and that the cervical-thoracic orthosis brace was intact, though missing a foam piece underneath the bottom portion. Despite this report from the resident, and the resident’s plan of care indicating he had potential/actual impairment related to a cervical collar and impaired mobility requiring use of caution during transfers and bed mobility to prevent striking extremities against hard or sharp surfaces, the nursing staff did not make an incident report or initiate an investigation at that time. The Nursing Home Administrator confirmed that the resident and family reported the event to nursing staff on the date of the RN’s note without staff making a report in accordance with facility policy and state requirements. An investigation was not initiated until later, after the family emailed facility administration with concerns related to the event. The Nursing Home Administrator and Director of Nursing acknowledged that the facility failed to immediately report and investigate the resident’s allegation in response to allegations of abuse, neglect, exploitation, or mistreatment.
Grievance Boxes Inaccessible to Residents
Penalty
Summary
The facility failed to ensure that grievance boxes were accessible to residents on three nursing units: Dogwood, Pinewood, and Specialty Care. Observations revealed that the grievance boxes were mounted at heights of approximately 55 inches, 61 inches, and 60 inches above the floor, respectively, which placed them out of reach for residents using wheelchairs. Additionally, on the Specialty Care unit, an armchair was found blocking access to the grievance box, further limiting accessibility. Interviews with the Nursing Home Administrator confirmed that the grievance boxes were not accessible to residents in these locations. The facility's policy supports residents' and family members' rights to voice grievances without discrimination or reprisal, and federal regulations require that grievance procedures be accessible to all residents, including those with disabilities. However, the facility did not comply with these requirements, as evidenced by the placement and obstruction of the grievance boxes.
Failure to Provide Timely Assistance with Activities of Daily Living
Penalty
Summary
The facility failed to provide necessary care and services to thirteen out of twenty-four residents who required assistance with activities of daily living (ADLs). Facility policy states that residents unable to perform ADLs independently must receive appropriate care to maintain nutrition, grooming, and hygiene. However, multiple residents and their families reported excessive wait times for staff assistance after activating call lights, with documented delays ranging from 20 minutes to over an hour. These concerns were corroborated by group interviews, resident council minutes, and grievance records, all indicating ongoing dissatisfaction with response times. Clinical record reviews revealed that affected residents had significant medical conditions such as malignant neoplasm of the colon, diabetes mellitus, dementia, hip fractures, Parkinson's disease, and other chronic illnesses. Many required substantial or maximal assistance with personal hygiene, mobility, and toileting, as indicated by their Minimum Data Set (MDS) assessments. Despite these needs, call light audits consistently showed prolonged response times, with several instances exceeding 30 minutes and some over an hour, directly impacting residents who were dependent on staff for essential care. Interviews with residents, family members, and facility leadership confirmed the pattern of delayed responses. Residents expressed frustration and described frequent experiences of waiting extended periods for help, particularly with ADLs. The facility's own documentation, including call light logs and grievance records, substantiated these reports. The deficiency was acknowledged by both the Nursing Home Administrator and the Director of Nursing, who confirmed that necessary care and services were not consistently provided to the identified residents.
Improper Storage and Disposal of Medications and Medical Supplies
Penalty
Summary
The facility failed to ensure that medical supplies and medications were properly stored and disposed of in two out of three medication rooms, as required by facility policy and regulatory standards. During observations, multiple expired medical supplies and medications were found in both the Secure Care Unit and Dogwood Unit medication rooms. Items identified included expired calcium alginate dressings, gelling fiber dressings, a latex Foley catheter, Bacitracin zinc ointment, and various other medical supplies and medications with expiration dates ranging from 2021 to 2025. Additionally, the facility policy required contacting the dispensing pharmacy for instructions regarding the return or destruction of discontinued, outdated, or deteriorated medications or biologicals, but this was not followed as evidenced by the presence of these expired items. Further, in the Dogwood medication room, personal belongings of former residents, such as hearing aids, eyeglasses, a cell phone, and other miscellaneous articles, were found stored under the sink. These items belonged to residents who had been discharged from the facility as far back as 2020. The Director of Nursing confirmed during an interview that the facility did not ensure proper storage or disposal of medical supplies, medications, and personal items in the medication rooms.
Failure to Follow Transfer Protocols Resulting in Resident Harm
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for transfers and required the assistance of two staff members, was transferred by a single CNA. The resident had significant medical conditions, including COPD, heart failure, and diabetes, and was non-weight bearing on the left lower extremity. The resident's care plan and Kardex clearly indicated the need for a two-person assist for all transfers, and the facility's policies required staff to follow these directives to prevent harm. During the transfer from wheelchair to bed, the CNA performed the transfer alone, contrary to the resident's documented needs. As a result, the resident sustained a deep skin tear on the right shin, which was discovered after the transfer when the resident's pants were removed. The wound was significant, measuring 4.5 cm by 5 cm by 1 cm, with exposure of adipose tissue, and required 17 sutures at the hospital. The incident was attributed to the resident's leg striking the wheelchair leg rest holder during the improper transfer. Staff interviews confirmed that other nurse aides were able to describe how to access and follow a resident's required transfer status. The Nursing Home Administrator acknowledged that the facility failed to protect the resident from neglect, as the CNA did not check the transfer status on the Kardex and did not provide the required level of assistance, resulting in actual harm to the resident.
Failure to Ensure Resident Free from Physical Restraint Without Physician Order
Penalty
Summary
A deficiency was identified when a resident with Alzheimer's disease, high blood pressure, and lumbar radiculopathy was found to have their bed placed against the wall without a physician's order or documented medical justification. The facility's policy requires that residents be free from physical restraints unless authorized in writing by a physician for a specific and limited period or in emergencies. In this case, there was no documentation in the resident's clinical record, plan of care, or progress notes to support the use of the bed against the wall as a restraint or to indicate a medical reason for this intervention. The resident in question had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Despite this, there was no evidence of a physician's order or care plan goal related to the bed placement. During staff interviews, it was confirmed that the facility failed to ensure the resident was free from the use of a physical restraint without proper authorization, as required by both facility policy and state regulations.
Failure to Prevent Unnecessary Use of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary psychotropic medication. According to the facility's policy, psychotropic medications should only be used when nonpharmacological interventions are clinically contraindicated and must be supported by documented clinical rationale. For one resident with diagnoses including Alzheimer's disease, high blood pressure, and lumbar radiculopathy, the clinical record showed ongoing orders for Seroquel (Quetiapine) both as a scheduled and PRN medication for agitation and depression. The PRN order for Seroquel exceeded the 14-day limit set by policy, and there was no documentation of behaviors or clinical justification for continued use during the specified period. Additionally, a new PRN order for Seroquel was written at the request of the resident's family, again without documented evidence of behaviors or clinical rationale in the progress notes. Staff interviews confirmed that the facility did not ensure the resident's medication regimen was free from unnecessary psychotropic medication, as required by both facility policy and regulatory standards.
Failure to Provide Adequate Supervision During Resident Transfer Resulting in Harm
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for transfers and required a two-person assist as documented in the care plan and Kardex, was transferred by a single CNA. The resident had significant medical conditions, including COPD, heart failure, diabetes, and was non-weight bearing on the left lower extremity. The care plan specifically indicated the need for caution during transfers to prevent skin injuries, and the Kardex clearly stated the requirement for a two-person assist for transfers. During the transfer from wheelchair to bed, the CNA performed the task alone, contrary to the documented requirements. The resident's right shin struck the wheelchair leg rest holder during the transfer, resulting in a deep skin tear. The injury was discovered after the transfer when the resident's pants were removed, revealing a large, deep skin tear with exposure of adipose tissue. The wound measured 4.5 cm by 5 cm, was 1 cm wide and deep, and required immediate medical attention. The incident was reported by the CNA and assessed by nursing staff, who confirmed the extent of the injury. The resident was sent to the hospital, where the wound required 17 sutures. Documentation and staff interviews confirmed that the CNA did not check the resident's transfer status prior to the transfer and did not follow the required two-person assist protocol, directly leading to the resident's injury.
Failure to Post Required State Agency and APS Contact Information
Penalty
Summary
The facility failed to post required information for Adult Protective Services (APS) and other pertinent State agencies and advocacy groups in a manner accessible and understandable to residents and their representatives. During observations conducted in the building, it was found that there was no posted list containing the names, addresses (mailing and email), and telephone numbers of State agencies such as the State Survey Agency, State licensure office, APS, the Office of the State Long-Term Care Ombudsman, the protection and advocacy network, home and community-based service programs, and the Medicaid Fraud Control Unit. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the absence of the required postings.
Failure to Display Medicare and Medicaid Benefit Information
Penalty
Summary
The facility failed to display written information for residents and their responsible persons regarding how to apply for and use Medicare and Medicaid benefits, as well as how to receive refunds for previous payments covered by these benefits. During observations conducted in the building, it was noted that this required information was not posted. Additionally, during an interview, the Nursing Home Administrator confirmed that the facility did not have the necessary written information displayed as required by regulations. No information was provided to residents or applicants for admission about these benefits or the refund process.
Failure to Revise and Update Care Plans for Two Residents
Penalty
Summary
The facility failed to revise and update care plans for two of eighteen residents to accurately reflect their current status, as required by facility policy and state regulations. For one resident with Alzheimer's, high blood pressure, and lumbar radiculopathy, the care plan did not include goals or interventions related to the resident's bed being placed against the wall, which created a physical restraint on one side. There was also no physician order for this intervention, and the care plan did not address this aspect of the resident's care. For another resident with non-Alzheimer's dementia, high blood pressure, and depression, the care plan indicated total dependence on staff for oral care. However, nursing progress notes documented that the resident was independent in oral care, and there was a lack of documentation regarding the provision and assistance level of personal hygiene services on multiple dates. Interviews with the resident and family confirmed that oral care was not provided daily or routinely. The DON and Nursing Home Administrator acknowledged the failure to update care plans for these residents.
Lack of Documented QAPI Training for Staff
Penalty
Summary
The facility failed to provide documented training on its Quality Assurance and Performance Improvement (QAPI) Program for staff, as required by its own Facility Assessment and state regulations. Review of facility documents and education records did not show evidence of QAPI-related training for staff. During interviews, the Nursing Home Administrator was unable to provide documentation or confirm that any staff education included QAPI content, and ultimately acknowledged that the required training had not been conducted or documented. This deficiency was identified through review of records and staff interviews, with no additional information or documentation available to demonstrate compliance.
Failure to Provide Opportunity for Advance Directives
Penalty
Summary
The facility failed to provide the opportunity for four residents to formulate an advance directive, which is a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated. This deficiency was identified through a review of facility policy, clinical records, and staff interviews. The facility's policy, dated 10/1/24 and 1/4/24, states that residents have the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. The clinical records of four residents, who were admitted with various diagnoses including diabetes, anxiety, high blood pressure, dementia, muscle weakness, and a history of falls, did not contain an advance directive or documentation that they were given the opportunity to formulate one. During an interview, the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed the absence of such documentation in the clinical records of these residents, indicating a failure to uphold the residents' rights as per 28 Pa. Code: 201.29(b)(d)(j) regarding resident rights.
Failure to Notify State Ombudsman of Transfers and Discharges
Penalty
Summary
The facility failed to notify the State Ombudsman Office of resident transfers and discharges for a period exceeding four years, from September 2019 through September 2024. This deficiency was identified through a review of facility documents, information from the State Ombudsman Office, and staff interviews. The facility was unable to provide documented evidence of compliance with the notification requirement during this time frame. The State Ombudsman Office confirmed that they had not received the required notifications since August 2019. The Nursing Home Administrator acknowledged the failure to report these transfers and discharges as required by the Pennsylvania Code: 201.29(f)(g) concerning resident rights.
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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