Gardens At Orangeville, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Orangeville, Pennsylvania.
- Location
- 200 Berwick Road, Orangeville, Pennsylvania 17859
- CMS Provider Number
- 395899
- Inspections on file
- 30
- Latest survey
- September 23, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Gardens At Orangeville, The during CMS and state inspections, most recent first.
Surveyors found that the facility did not maintain a clean and homelike environment, with soiled equipment, stained walls, foul odors, and unaddressed cleaning needs in resident areas. A resident with chronic kidney disease and paraplegia reported her wheelchair was not properly cleaned after an incident, and observations confirmed the presence of residue and damage to the wheelchair. Additional issues included soiled surfaces, odors, and cobwebs in common areas.
Several residents reported a lack of evening activities, expressing interest in options such as card clubs, arts and crafts, movie nights, and bingo after dinner. The activity calendar confirmed that all scheduled activities ended by mid-afternoon, and both the Activities Director and the Administrator acknowledged that no staff were assigned to facilitate evening programs, resulting in unmet resident needs.
Surveyors identified unsanitary conditions in the food and nutrition services department, including a hole in wall grout and accumulated dirt and debris in the kitchen. In a resident pantry area, several food items such as applesauce, canned pears, and milk were found without required date labeling. The FSD confirmed that food items should be dated to ensure safety, indicating a lapse in proper food storage and handling procedures.
A resident with COPD, who was cognitively intact, had $20.00 deducted monthly from her personal needs allowance (PNA) by the facility to pay off a debt, despite Medicaid covering her care costs. The resident was not informed that she was not required to use her PNA for this purpose, and the deductions continued for nearly two years, violating regulations on resident fund management and rights.
A resident with a history of stroke and moderate cognitive impairment, who had a physician order for a soft palm roll to prevent hand contracture, was frequently observed without the device in place and was non-compliant with its use. Staff confirmed the resident often removed the device, and the care plan did not address the resident's limited range of motion or non-compliance with the therapeutic device. The facility was unable to provide documentation of a care plan to address these needs.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a deficiency related to the facility's failure to follow the established care plan.
A resident with a PEG tube for enteral feeding was found to have an unlabeled and undated enteral syringe in use, with staff confirming the lack of labeling. Facility policy did not address requirements for labeling, dating, or disposal timeframes for enteral syringes, despite staff expectations. This resulted in a deficiency related to the handling and management of enteral feeding equipment.
A resident's nebulizer machine, including tubing and mask, was not maintained or replaced according to facility policy, with equipment remaining in the room months after treatments were discontinued and lacking proper dating. Staff confirmed the equipment had not been changed as required, and there was no current physician's order for its use.
Surveyors observed persistent musty urine odors in a resident's bathroom and widespread pest issues, including live and dead ants, spiders, centipedes, and other insects throughout a nursing unit. Multiple residents and a representative reported ongoing problems with odors and pests, and an LPN confirmed recurring ant infestations. The NHA acknowledged the facility's responsibility for ensuring a clean and homelike environment.
The facility failed to meet the required NA to resident ratios across multiple shifts, with staffing levels consistently below the required minimums for day, evening, and night shifts. The deficiency was confirmed by the Nursing Home Administrator, who acknowledged the shortfall in staffing levels.
The facility did not meet the required LPN to resident ratios on four shifts, with insufficient LPN staffing on the day, evening, and night shifts. No additional higher-level staff were available to compensate for these deficiencies, as confirmed by the Nursing Home Administrator.
The facility did not meet the required 3.2 hours of direct resident care per day, falling short on five out of seven days reviewed. Staffing levels were insufficient, with care hours ranging from 2.74 to 3.09 per resident. The Nursing Home Administrator confirmed the shortfall.
A facility failed to administer Torsemide as ordered for a resident with edema, despite documentation of its presence. Additionally, the resident missed a scheduled Pulmonary Medicine appointment due to the facility's failure to arrange transportation, as confirmed by the administrator.
The facility failed to ensure that the director of food and nutrition services, who was not a qualified dietitian, received frequent consultations from a qualified dietitian. The part-time Consultant RD worked remotely and did not have face-to-face interactions with residents or provide direct nutritional oversight. The nursing home administrator could not provide evidence of scheduled consultations between the director and the Consultant RD.
Residents reported significant delays in receiving assistance after ringing call bells, with wait times often exceeding 45 minutes. One resident, with chronic kidney disease and fibromyalgia, highlighted the issue, noting that staff appeared stressed and unpleasant when responding. A group interview revealed similar concerns, with residents experiencing long waits, particularly during low staffing periods, leading to incidents of soiling themselves. The NHA and DON acknowledged the issue but could not provide an explanation for the delays.
The facility did not maintain a clean and homelike environment in two nursing units. Observations included a bathroom with brown stains, a dusty air conditioning unit, a bed with a stained sheet and debris, and a hallway with stained trim and walls. The NHA confirmed the facility's responsibility for cleanliness.
The facility failed to ensure accurate MDS assessments for two residents, leading to discrepancies in their clinical records. One resident's assessment inaccurately indicated no anticoagulant medication was received, despite a physician's order for Apixaban. Another resident's discharge status was incorrectly documented as being discharged to a hospital, while the resident was actually discharged home. These inaccuracies were confirmed by facility staff.
A resident with severe cognitive impairment and osteoporosis sustained a laceration during a transfer from bed to wheelchair using a sit-to-stand lift. The injury was discovered after the transfer, and the facility's investigation could not determine the exact cause, though it was suggested the resident's leg might have hit the wheelchair. Both nurse aides involved had satisfactory transfer skills, but the facility failed to implement effective safety measures.
The facility failed to administer IV antibiotics as prescribed for two residents. One resident with chronic osteomyelitis missed multiple doses of Ampicillin and Vancomycin, with no documentation or physician notification. Another resident with a septic knee infection missed a dose of Cefazolin Sodium, also without documentation or notification. The facility's policy requiring eMAR documentation was not followed.
A resident with bipolar disorder and schizoaffective disorder was prescribed Depakote ER 250mg. The consultant pharmacist recommended a gradual dose reduction, but the attending physician did not respond appropriately. Instead, the psychiatric CRNP addressed the recommendation, and the physician cosigned without documenting the rationale for continued use. The DON confirmed the physician's failure to document justification in the clinical record.
A resident with acute respiratory failure and other conditions experienced multiple instances of inadequate nursing care. The resident was found in respiratory distress with low SPO2 levels and was sent to the hospital. Upon readmission, the resident expressed distress and had trouble breathing, but vital signs were not documented. Later, the resident exhibited bradycardia, and increased lung secretions were noted without proper assessment. Eventually, the resident was difficult to arouse with low BP and SPO2, leading to another hospital transfer.
The facility failed to plan menus that accommodate residents' food preferences, leading to dissatisfaction among residents. Despite voicing their preferences during Food Committee meetings, residents felt their input was not considered. A review of the 4-week menu cycle revealed repetitiveness and lack of variety, with beef and poultry served in consecutive meals multiple times. Interviews with the dietary manager and Nursing Home Administrator confirmed these issues.
The facility failed to honor a resident's right to refuse a prescribed therapeutic diet despite the resident being cognitively intact and informed of the risks. The attending physician did not address the resident's wishes for a liberalized diet, and the facility continued to enforce the diet without honoring the resident's decision.
The facility failed to provide adequate housekeeping services, resulting in unsanitary conditions in resident rooms and common areas. Two residents lodged a grievance about the cleanliness of their room, and observations confirmed issues such as a strong smell of urine, soiled rags, sticky floors, and dirty windows. The NHA confirmed that these areas were expected to be clean and sanitary, but the facility did not meet these standards.
The facility failed to ensure that the MDS Assessments accurately reflected a resident's discharge goals. Despite multiple records and staff interviews confirming the resident's wish to return home, the Admission MDS assessment inaccurately indicated that the resident's goal was to remain in the facility.
The facility failed to maintain an environment free of potential accident hazards on the 200-nursing unit. Observations revealed that the hallway from a resident room to 207 was obstructed with mechanical lifts, linen carts, soiled linen and trash hampers, and wheelchairs, blocking access to the corridor handrails intended for resident ambulation or mobility assistance. The Nursing Home Administrator confirmed the obstruction, and the maintenance director measured the distance of the obstructed hallway to be approximately 91 feet.
Failure to Maintain Clean and Homelike Environment Across Nursing Units
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment on both the West and East Nursing Units, as evidenced by multiple observations and resident reports. Specifically, the outer surface and surrounding floor of the ice machine in the East Nursing Unit were visibly soiled, and the wall fabric opposite the ice machine was stained and discolored. The vinyl baseboard molding in the area was also in need of repair. A strong urine-like odor was detected in the Short Hall of the East Nursing Unit, and the floors in a resident room were sticky and tacky, with a foul odor present in both the room and the adjacent hallway. Additionally, a large soiled brief was found in the bathroom sink between two resident rooms. In the dining/activity area of another unit, a buildup of cobwebs was observed behind the counter next to the refrigerator. A resident with chronic kidney disease and paraplegia, who was cognitively intact, reported that after a bowel movement in her wheelchair, staff cleaned her but missed areas of the wheelchair, which remained unclean. Upon inspection, the wheelchair's back support was found to have a rip in the fabric, forming a pocket that contained a thick brown and black residue. The Nursing Home Administrator confirmed that it is the facility's responsibility to provide services to maintain a clean and homelike environment for all residents.
Failure to Provide Evening Activities to Meet Resident Needs
Penalty
Summary
The facility failed to provide an ongoing program of activities that met the interests and supported the physical, mental, and psychosocial well-being of residents, specifically by not offering evening activities. During a resident group interview, four out of five residents expressed concerns about the lack of evening activities, with specific requests for the return of a recreation card club, arts and crafts, movie nights, and bingo after dinner. The residents indicated that there was little to do in the evenings and desired more structured activities during that time. A review of the Resident Activity Calendar for the month showed that the latest scheduled activity each day was at 2:00 PM, with no activities planned for the evening. The Director of Activities confirmed that there were no staff scheduled to facilitate evening programs and acknowledged that residents had requested such activities. The Nursing Home Administrator also confirmed the absence of structured evening activities, attributing it to staffing limitations. This lack of evening programming resulted in the facility not meeting the activity needs and interests of its residents.
Unsanitary Food Storage and Handling Practices Identified
Penalty
Summary
Surveyors observed that the facility failed to maintain sanitary conditions in the food and nutrition services department and a resident pantry area, which could lead to food contamination and microbial growth. Specifically, there was a three-quarter inch hole in the wall grout near the handwashing sink, and a build-up of dirt and debris was found along the perimeter of the kitchen and under the tray line counter area. These unsanitary conditions were directly observed during the initial tour with the foodservice director. Additionally, in the resident pantry area on the West Nursing Unit, two four-ounce containers of applesauce, two four-ounce containers of canned pears, and two covered eight-ounce glasses of milk were found without dates indicating when they were available for use. The food service director confirmed that food items were required to be dated to ensure quality and food safety. These findings demonstrate a failure to follow safe food storage and handling practices as required by professional standards and facility policy.
Improper Deduction of Medicaid Resident's Personal Needs Allowance for Facility Debt
Penalty
Summary
The facility failed to protect a resident's personal funds by charging her personal needs allowance (PNA) for services that are covered under Medicaid. The resident, who was cognitively intact and had a diagnosis of chronic obstructive pulmonary disease (COPD), was admitted with a monthly income from which the PNA was deducted, as required by Medicaid regulations. Despite this, the facility deducted an additional $20.00 each month from the resident's PNA to pay off a debt owed to the facility, as agreed upon in a payment agreement signed by the resident. The deductions were made over a period of nearly two years, totaling $460.00, with additional unclear debits also noted in the resident's account. Interviews with the resident and facility staff confirmed that the resident was not informed that she was not obligated to pay her outstanding balance from her PNA funds. The business office manager acknowledged the arrangement and the facility's role as the resident's representative payee, while the nursing home administrator confirmed the ongoing deductions and the lack of documentation showing the resident was properly informed of her rights regarding the use of her PNA. The facility's actions were found to be in violation of state regulations regarding the management of resident funds and resident rights.
Failure to Develop Person-Centered Care Plan for Limited Range of Motion and Device Non-Compliance
Penalty
Summary
The facility failed to develop a person-centered care plan to address a resident's limited range of motion in the left upper extremity and non-compliance with a physician-ordered therapeutic device. The resident, who had a history of cerebrovascular accident (stroke) and depression, was documented to have moderate cognitive impairment and impairment of the left upper extremity. Physician orders and occupational therapy recommendations specified the use of a soft palm roll to the left hand at all times, except during range of motion, hygiene, and skin checks, to maintain skin integrity and prevent further contracture. Despite these orders, observations revealed the resident was frequently found without the soft palm roll in place, and staff confirmed the resident often removed the device using her right hand. Review of the resident's care plan showed it did not address the limited range of motion or the resident's non-compliance with the prescribed soft palm roll. Interviews with staff, including an LPN and the DON, confirmed the resident's non-compliance and the absence of a care plan to address these issues. The Nursing Home Administrator was unable to provide documentation of a care plan that included interventions for the resident's limited range of motion or strategies to address non-compliance with the therapeutic device, resulting in a deficiency under nursing services regulations.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required.
Failure to Label and Date Enteral Feeding Syringes
Penalty
Summary
The facility failed to ensure that enteral feeding syringes in use were labeled and dated, and did not provide direction on the maximum time such syringes may remain in service. Observation revealed a 60 mL enteral syringe used for a resident's PEG tube was found on the room windowsill with a clear plastic bag beneath it containing tan residue; neither the syringe nor the bag was labeled or dated. Staff confirmed the syringe was opened but not labeled or dated. Review of the facility's policy showed it did not address labeling, dating, rinsing, or disposal timeframes for enteral syringes, despite staff and administration stating that syringes should be labeled and dated. The resident involved had diagnoses including dysphagia and non-traumatic intracerebral hemorrhage, and required a PEG tube for continuous enteral feeding. Physician orders directed staff to check PEG placement prior to each use and to administer water before and after medications. The lack of labeling and dating of the enteral syringe, as well as the absence of clear policy guidance on the handling and disposal of these syringes, constituted the deficiency identified during the survey.
Failure to Maintain and Remove Respiratory Equipment per Policy
Penalty
Summary
The facility failed to maintain respiratory equipment in accordance with its own Equipment Management Policy for one resident. The policy required that nebulizer machine tubing and masks be changed weekly and as needed to ensure sanitary conditions and safe function. Observation revealed that a nebulizer machine in a resident's room contained tubing and a mask that were not dated to indicate when they were last changed. The nebulizer bowl and tubing were marked with a date from three months prior, and staff confirmed that these items had not been replaced since that time, contrary to facility policy. Further review of the resident's clinical record showed that there was no current physician's order for nebulizer treatments, and the DON confirmed that the resident had previously received treatments earlier in the year, but the equipment was not removed from the room after treatments were discontinued. The respiratory equipment remained in the resident's room and was not maintained as required by policy, as confirmed by staff interviews and record review.
Failure to Maintain Clean and Homelike Environment Due to Persistent Odors and Pest Infestation
Penalty
Summary
The facility failed to maintain a clean and homelike environment on one of its nursing units, as evidenced by multiple observations and resident and staff interviews. In one resident's bathroom, a persistent, strong musty urine odor was noted, with the resident's representative confirming that the smell returns shortly after cleaning and negatively impacts the resident's living experience. Follow-up observation confirmed the odor remained present. Additionally, live and dead insects, including large black ants, spiders, flying insects, centipedes, and worms, were observed throughout the unit's common areas, hallways, and resident rooms. In one resident's room, several large black ants were seen crawling on the bedside table and personal items, and the resident reported that the ants had been present for several weeks, causing frustration and distress. An LPN confirmed the ongoing ant issue and removed contaminated items from the resident's bedside table. Further observations revealed several large spiders with extensive webs, dead ants, a flying insect, and a dead worm near the west exit area. Another resident reported frequently seeing and killing ants in her room, describing them as large black ants. A dead centipede was also found in the unit dining room. The Nursing Home Administrator confirmed the presence of live and dead pests during a subsequent tour and acknowledged the facility's responsibility to maintain a clean and homelike environment for residents.
Facility Fails to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident ratios across multiple shifts, as evidenced by a review of staffing records. Specifically, the facility did not provide the minimum required number of NAs on the day, evening, and night shifts for 18 out of 21 shifts reviewed. On the day shift, the facility consistently fell short of the required 1:10 NA to resident ratio, with staffing levels ranging from 5.66 to 7.72 NAs for resident censuses between 80 and 83. Similarly, the evening shift did not meet the 1:11 ratio, with staffing levels between 6.06 and 7.16 NAs for the same resident censuses. The night shift also failed to meet the 1:15 ratio, with staffing levels between 3.56 and 4.69 NAs. The deficiency was confirmed through an interview with the Nursing Home Administrator, who acknowledged the facility's failure to meet the required staffing levels. The report does not mention any additional higher-level staff being available to compensate for the staffing shortfall. This consistent understaffing across multiple shifts indicates a systemic issue in maintaining adequate staffing levels to meet regulatory requirements.
Plan Of Correction
Facility cannot retroactively correct this deficiency. New scheduling system in place to assist with replacing call offs and filling open shifts via automatic blasts to staff. The new scheduling system also has the ability to post open shifts to all staff including agency. Agency call offs are attempted to be replaced by the agency with additional bonus as needed. Recruitment of nursing staff will continue via facility website, Indeed, recruiting group, social media websites, local newspaper, job fairs, open house and off site recruiters. Agency utilized for open shifts. Retention efforts made with any resignation. Agency rates are reviewed weekly to ensure marketable and adjustments made as necessary. Text Blast for all open shifts. Facility recruiters have purchased list of nursing and aide staff to reach out to for recruitment. New onsite HR Director hired with extensive retention and recruitment experience. Calculation of daily PPD and shift ratios will be completed and reviewed daily for accuracy by the scheduler/back up scheduler, DON/ADON and NHA. All efforts will be made to meet PPD and staffing ratios. If call offs occur, all efforts will be made to attempt to fill that position. Daily PPD and ratios will be audited weekly x4, then monthly x2. Results to QA for review and recommendations.
Failure to Meet LPN to Resident Ratios
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios on four shifts out of 21 reviewed. Specifically, on March 27 and March 29, 2025, the day shift staffing was below the required 1 LPN per 25 residents, with 3.22 and 3.06 LPNs respectively, instead of the required 3.28 for a census of 82. On March 28, 2025, the evening shift had 2.69 LPNs instead of the required 2.73 for a 1:30 ratio, and the night shift had 1.88 LPNs instead of the required 2.05 for a 1:40 ratio. No additional higher-level staff were available to compensate for these deficiencies. The Nursing Home Administrator confirmed the facility's failure to meet the required LPN to resident ratios on these dates during an interview on April 1, 2025.
Plan Of Correction
Facility cannot retroactively correct this deficiency. New scheduling system in place to assist with replacing call offs and filling open shifts via automatic blasts to staff. New scheduling system also has the ability to post open shifts to all staff including agency. Agency call offs are attempted to be replaced by the agency with additional bonus as needed. Recruitment of nursing staff will continue via facility website, Indeed, recruiting group, social media websites, local newspaper, job fairs, open house and off site recruiters. Agency utilized for open shifts. Retention efforts made with any resignation. Agency rates are reviewed weekly to ensure marketable and adjustments made as necessary. Text Blast for all open shifts. Facility recruiters have purchased list of nursing and aide staff to reach out to for recruitment. New onsite HR Director hired with extensive retention and recruitment experience. LPN call outs are the issue with fulfilling this need consistently, so all efforts are made to replace this hole when it occurs. Calculation of daily PPD and shift ratios will be completed and reviewed daily for accuracy by the scheduler/back up scheduler, DON/ADON and NHA. All efforts will be made to meet PPD and staffing ratios. If call offs occur, all efforts will be made to attempt to fill that position. Daily PPD and ratios will be audited weekly x4, then monthly x2. Results to QA for review and recommendations.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident per day. This deficiency was identified through a review of the facility's staffing levels and confirmed by staff interviews. Specifically, on five out of the seven days reviewed, the facility's nursing care hours fell below the required minimum. On March 27, 2025, the facility provided 3.09 hours, on March 28, 2025, 2.74 hours, on March 29, 2025, 2.80 hours, on March 30, 2025, 2.85 hours, and on March 31, 2025, 3.05 hours of direct care per resident. An interview with the Nursing Home Administrator confirmed the facility's failure to consistently meet the required nursing care hours.
Plan Of Correction
Facility cannot retroactively correct this deficiency. New scheduling system in place to assist with replacing call offs and filling open shifts via automatic blasts to staff. New scheduling system also has the ability to post open shifts to all staff including agency. Agency call offs are attempted to be replaced by the agency with additional bonus as needed. Recruitment of nursing staff will continue via facility website, Indeed, recruiting group, social media websites, local newspaper, job fairs, open house and off site recruiters. Agency utilized for open shifts. Retention efforts made with any resignation. Agency rates are reviewed weekly to ensure marketable and adjustments made as necessary. Text Blast for all open shifts. Facility recruiters have purchased list of nursing and aide staff to reach out to for recruitment. New onsite HR Director hired with extensive retention and recruitment experience. Calculation of daily PPD and shift ratios will be completed and reviewed daily for accuracy by the scheduler/back up scheduler, DON/ADON and NHA. All efforts will be made to meet PPD and staffing ratios. If call offs occur, all efforts will be made to attempt to fill that position. Daily PPD and ratios will be audited weekly x4, then monthly x2. Results to QA for review and recommendations.
Failure to Administer Medication and Arrange Transportation
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of quality for a resident who was admitted with multiple diagnoses, including respiratory failure with hypoxia, COPD, congestive heart failure, and diabetes. A physician order dated December 17, 2024, required the administration of Torsemide, a diuretic, every 24 hours as needed for edema for three days. Despite documentation indicating the presence of edema on multiple shifts between December 17 and December 20, 2024, the medication was never administered. There was no nursing assessment describing the extent or location of the edema, nor was there any evidence that the physician was notified to clarify whether the medication should have been given. Additionally, the resident had a scheduled Pulmonary Medicine appointment on December 23, 2024, which was missed due to the facility's failure to arrange necessary transportation. An interview with the administrator confirmed these deficiencies, indicating that the facility did not ensure the resident received treatment and care in accordance with professional standards of practice and physician orders, potentially impacting the resident's health and well-being.
Deficiency in Nutritional Oversight and Consultation
Penalty
Summary
The facility failed to ensure that the full-time director of food and nutrition services, who was not a qualified dietitian or other clinically qualified nutrition professional, received frequently scheduled consultations from a qualified dietitian or other clinically qualified nutritional professional. The director of food and nutrition services had been employed for four years and had recently completed a course to become a certified dietary manager but had not yet passed the exam. Although the facility employed a part-time Consultant Registered Dietitian (RD) who worked remotely approximately 20 hours per week, there were no frequently scheduled consultations between the director and the Consultant RD. The Consultant RD confirmed that she completed all job tasks, including nutritional assessments, remotely with input from the interdisciplinary team, including nursing and the director of food and nutrition services. However, the Consultant RD did not have face-to-face interactions with residents, did not contact residents by phone before completing nutritional assessments, and had not been in the facility to observe residents' ability to eat or provide nutritional consultation. The nursing home administrator failed to provide documented evidence that the services of the Consultant RD included face-to-face interactions with residents to ensure appropriate nutritional oversight, nor that the director received frequently scheduled consultations from the Consultant RD.
Delayed Response to Resident Call Bells Due to Staffing Issues
Penalty
Summary
The facility failed to provide timely assistance to residents, compromising their quality of life and dignity. Resident 42, who is cognitively intact and suffers from chronic kidney disease and fibromyalgia, reported waiting 45 minutes to an hour for assistance after ringing the call bell, particularly during the second shift. The resident expressed frustration over the long wait times and noted that staff often appeared stressed and unpleasant when they finally responded. This issue was attributed to low nurse staffing, which occurred several times a week. During a group interview, four out of five residents expressed similar concerns about prolonged wait times for assistance. One resident reported waiting over 20 minutes when staffing was low, while another mentioned waiting over an hour, resulting in soiling themselves due to the delay. These residents indicated that the longest wait times occurred in the mornings and afternoons, and they felt the facility was understaffed multiple times a week. The Nursing Home Administrator and Director of Nursing acknowledged that residents should be treated with dignity and respect but could not explain the untimely responses to residents' requests for assistance.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment in two out of three nursing units, specifically the 100 and 200 Halls. Observations revealed several deficiencies: a bathroom with brown stains on the floor and doorframe, a window air conditioning unit with a large build-up of dust and black substances, a bed with a stained sheet and debris on the floor, and a hallway with stained and discolored floor trim and wall fabric. These observations were confirmed by the Nursing Home Administrator, who acknowledged the facility's responsibility to provide a clean environment for residents.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for two residents, leading to discrepancies in their clinical records. Resident 53, who was admitted with a diagnosis of Alzheimer's disease, had a physician's order for Apixaban, an anticoagulant medication, to be administered twice daily. Despite this, the resident's quarterly MDS assessment inaccurately indicated that no anticoagulant medication was received during the 7-day look-back period. This inaccuracy was confirmed by the Registered Nurse Assessment Coordinator (RNAC) during an interview. Similarly, Resident 70's discharge MDS assessment inaccurately documented the discharge status. The assessment stated that the resident was discharged to a short-term general hospital, whereas a discharge note revealed that the resident was actually discharged home, accompanied by her spouse. This discrepancy was confirmed by the Nursing Home Administrator. These inaccuracies in the MDS assessments reflect a failure in the facility's management and nursing services as per the cited Pennsylvania Code regulations.
Failure to Prevent Injury During Resident Transfer
Penalty
Summary
The facility failed to implement effective safety measures to prevent an injury during a transfer for a resident with severe cognitive impairment and osteoporosis. The resident required extensive-to-total assistance with mobility and transfers, as indicated in their care plan. On the day of the incident, the resident sustained a laceration on the right shin during a transfer from bed to wheelchair using a sit-to-stand lift. The injury was discovered after the transfer when blood was noticed on the resident's pants. The facility's investigation could not determine the exact cause of the injury, but it was suggested that the resident's leg might have hit the wheelchair during the initial transfer attempt. The resident was admitted to the emergency department for further evaluation, where the laceration was treated with sutures. Both nurse aides involved in the transfer had satisfactory competency evaluations for transfer skills and knowledge. Despite this, the Nursing Home Administrator confirmed that the facility is responsible for ensuring effective safety measures to prevent such accidents and injuries. The deficiency was identified under the Pennsylvania Code for nursing services and management.
Failure to Administer IV Antibiotics as Prescribed
Penalty
Summary
The facility failed to ensure the proper administration of physician-ordered intravenous antibiotics for two residents. Resident CR1, who was admitted with chronic osteomyelitis of the left ankle and foot, had orders for Ampicillin and Vancomycin to be administered at specific times. However, on multiple occasions, doses of these antibiotics were not administered as scheduled, and there was no documentation of the reasons for the missed doses or notification to the physician. Specifically, on November 10, 2024, two doses of Ampicillin were missed, and on November 13, 2024, a dose of both Ampicillin and Vancomycin was missed. The facility's policy requires documentation in the eMAR system after each medication administration, which was not adhered to in these instances. Similarly, Resident 122, admitted with a septic left knee prosthetic joint infection, had a physician order for Cefazolin Sodium to be administered every eight hours. On November 30, 2024, the 10:00 PM dose was not administered, and there was no documented evidence that the physician was notified of this missed dose. The Nursing Home Administrator confirmed the lack of documentation and adherence to the facility's policy, which mandates that medication administration be documented in the eMAR system to confirm compliance with physician orders.
Failure to Act on Pharmacist's Medication Review
Penalty
Summary
The attending physician failed to act upon pharmacist-identified irregularities in the medication regimen of a resident diagnosed with bipolar disorder and schizoaffective disorder. The resident was prescribed Depakote ER 250mg, a medication used to stabilize mood, and the consultant pharmacist recommended a review for a gradual dose reduction. However, the attending physician did not provide an appropriate response to this recommendation. Instead, the facility's consultant psychiatric CRNP responded to the pharmacy recommendation and signed off on it, while the attending physician merely cosigned without documenting the rationale and justification for the continued use of Depakote. An interview with the Director of Nursing confirmed that the CRNP was handling the pharmacy recommendations and that the attending physician failed to document the justification for the continued use of the medication in the resident's clinical record.
Failure to Timely Assess and Provide Care for Resident
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of quality for a resident who was admitted with acute respiratory failure, atrial fibrillation, bradycardia, and adult failure to thrive. On one occasion, the resident was found in respiratory distress with a blood oxygen level of 60%, and despite being administered oxygen, the level only increased to 78%. The resident was sent to the hospital for acute respiratory distress and pneumonia. Upon readmission, the resident expressed feeling like he was dying and had trouble breathing, but there were no documented vital signs at that time. Later, the resident exhibited bradycardia, and a stat EKG was ordered. Further documentation revealed that the resident had increased lung secretions, but no vital signs or physical assessment were documented at that time. Eventually, the resident was found difficult to arouse, with low blood pressure and low SPO2 levels, leading to another hospital transfer for acute respiratory failure with hypoxia. The Nursing Home Administrator and Director of Nursing confirmed that the facility staff failed to timely assess and provide care after a change in the resident's condition was noted.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to plan menus that accommodate residents' food preferences, leading to dissatisfaction among residents. This deficiency was identified through a review of the facility's grievance log, interviews with residents and staff, and an examination of the facility's planned menus. Residents B2, B3, B4, and B5 expressed concerns about the lack of variety and repetitiveness in the meals served. Despite voicing their preferences and suggestions during Food Committee meetings, residents felt their input was not considered in the menu planning process. Specific grievances included Resident B2's concern about the lack of variety and Resident B5's complaint about the overuse of eggs at breakfast. Interviews with the dietary manager and the Nursing Home Administrator confirmed these issues, revealing that the facility's cycle menus were developed by the corporate dietitian without adequately considering the residents' preferences. A detailed review of the facility's 4-week Spring/Summer menu cycle further highlighted the repetitiveness and lack of variety in meal planning. For instance, beef and poultry were served in consecutive meals multiple times, and similar meal patterns were observed across different weeks. The dietary manager acknowledged that residents' preferences were not always considered in menu development, and the Nursing Home Administrator confirmed the lack of variety and repetitiveness in the meals. This failure to accommodate residents' food preferences and provide appealing meal options led to dissatisfaction among the residents, as documented in the grievance log and resident interviews.
Failure to Honor Resident's Right to Refuse Treatment
Penalty
Summary
The facility failed to honor a resident's right to participate in their treatment and health care decision-making, including the right to refuse specific treatment. Resident B1, who was cognitively intact with a BIMS score of 15, expressed a desire to refuse the prescribed therapeutic diet despite being informed of the risks by the facility's Registered Dietitian (RD) and Assistant Director of Nursing (ADON). The resident, diagnosed with type two diabetes, cirrhosis of the liver, and major depressive disorder, stated a preference to eat whatever they wanted, acknowledging the risks involved. Despite this, the attending physician did not address the resident's wishes for a liberalized diet, and the facility continued to enforce the therapeutic diet without honoring the resident's decision to refuse it. During an interview with the Nursing Home Administrator (NHA), it was confirmed that the resident was capable of making their own decisions and that the facility failed to honor the resident's right to make informed decisions about their dietary treatment plan. The NHA acknowledged that the attending physician would not agree to liberalizing the diet, despite the resident's continued non-compliance and expressed wishes. This failure to respect the resident's autonomy and right to refuse treatment constitutes a deficiency in the facility's compliance with long-term care regulatory requirements.
Failure to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to provide adequate housekeeping services to maintain a clean and orderly environment for residents, specifically Residents B2 and B3. A grievance lodged by these residents on March 26, 2024, highlighted concerns about the cleanliness of their room, particularly on weekends. During an interview on April 16, 2024, both residents confirmed that their bathroom was not always cleaned, and the windows and window treatments in their room were very dirty. Observations on the same day revealed a strong smell of urine, a soiled rag on the bathroom floor, sticky floors, and yellow urine-like stains on the base of the toilet. Additionally, several soiled briefs were found in the bathroom garbage receptacle. The windows were heavily coated with a white film, and the window treatments were dusty. Similar cleanliness issues were observed in the west recreation lounge and another resident bathroom, where a pink substance was found in the sink and on the floor, and the base of the toilet had yellow stains. The windows and blinds in this room were also dirty and dusty. An interview with the Nursing Home Administrator (NHA) confirmed that resident rooms, bathrooms, and common areas were expected to be maintained in a clean and sanitary manner. However, the observations and grievances indicate that the facility failed to meet these standards, resulting in an unsanitary living environment for the residents. The findings were in violation of 28 Pa. Code 201.18 (e)(2.1) Management.
Inaccurate MDS Assessment for Resident Discharge Goals
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) Assessments accurately reflected the status of a resident. Specifically, Resident 62's Admission MDS assessment inaccurately indicated that her overall goal for discharge was to remain in the facility, despite multiple records and staff interviews confirming her goal was to return home after her therapeutic stay. The resident's clinical record, plan of care, and progress notes all indicated her wish to be rehabilitated and return to her daughter's home. This discrepancy was confirmed through interviews with the Social Services employee and the Nursing Home Administrator.
Obstructed Hallway Creates Accident Hazard
Penalty
Summary
The facility failed to maintain an environment free of potential accident hazards and obstacles to safe mobility on the 200-nursing unit. Observations on April 16, 2024, at approximately 10:35 AM and 10:50 AM revealed that the hallway from resident room [ROOM NUMBER] to 207 was obstructed with mechanical lifts, linen carts, soiled linen and trash hampers, and wheelchairs. These items blocked access to the corridor handrails, which are intended for resident ambulation or mobility assistance. The Nursing Home Administrator confirmed the obstruction at approximately 10:55 AM, and the maintenance director measured the distance of the obstructed hallway to be approximately 91 feet at 11:30 AM.
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Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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