Gardens For Memory Care At Easton, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Easton, Pennsylvania.
- Location
- 500 Washington Street, Easton, Pennsylvania 18042
- CMS Provider Number
- 395708
- Inspections on file
- 18
- Latest survey
- April 10, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Gardens For Memory Care At Easton, The during CMS and state inspections, most recent first.
Surveyors identified multiple unsanitary food storage and handling practices in the kitchen and on two nursing units, including wall damage with a black substance near a refrigerator, flying insects in dry storage and the clean pan room, undated bulk thickener and soiled bulk flour containers, and dried food and liquid splatter on a juice refrigerator. During lunch tray-line service, two dietary staff worked with uncovered facial hair despite a policy requiring full hair restraints. In addition, microwaves in second- and third-floor resident pantries, used by staff to heat resident food, were found with black discoloration and a tan substance inside. An LPN and the dietary director confirmed the intended use of the microwaves and the requirement for facial hair restraints.
Surveyors found that the facility did not maintain a safe, clean, and sanitary environment on two nursing units. On one floor, marred wall trim, stained ceiling tiles, stained and displaced privacy and window curtains, a non-functioning towel dispenser, dark brown wall spots, a loose bathroom grab bar, a damaged ceiling tile, a cracked window header with hanging caulk, loose towel racks, and marred corridor and closet-adjacent walls were observed. In a common room, one chair had a broken spring sagging to the floor and another chair would not remain upright. On another floor, the corridor and room entrance floors were covered with a black substance, a privacy curtain between two beds was heavily stained, and dining room windows had visible dirt accumulation.
Surveyors identified infection control deficiencies when an LPN administered oral medications by pouring acetaminophen and senna tablets into an ungloved hand before placing them into pill cups for two residents, contrary to facility policy prohibiting staff from touching medications with their hands. Additional observations showed an EVS supervisor handling soiled linen while wearing gloves but no gown, and later returning washcloths that had fallen onto the floor back into a dryer instead of treating them as soiled, in violation of the facility’s laundry and linen policy requiring protective garments and maintenance of hygienically clean linen.
A resident with dementia, protein-calorie malnutrition, impaired vision, and documented need for assistance with eating was observed during a lunch meal without appropriate staff support. Despite a care plan calling for encouragement of intake, cueing, and reorientation, the resident struggled to pick up food, leaned over the tray to eat a sandwich directly from the plate, was unable to reach drinks, and did not properly manage a banana. Staff did not intervene to assist, cue, or adjust the meal setup for approximately 40 minutes, resulting in a failure to provide dining assistance in a dignified manner.
Surveyors found that staff did not follow physician orders for two residents. One resident with peripheral vascular disease had orders for daily TED stockings, but observations on multiple occasions showed the resident in bed and ambulating without the stockings, and there was no documentation of application or refusal. Another resident with hypertension had orders for carvedilol twice daily with specific SBP and HR hold parameters, yet MAR review showed the medication was given several times when SBP was below 110 mm/Hg and when HR was below 55, which the DON confirmed was outside ordered parameters.
A resident with dementia, memory impairment, a history of falls, and documented territorial and combative behaviors had an identified intervention for staff to hang a stop sign across the room doorway to deter wandering residents from entering after a prior incident in which the resident was found on the floor holding another resident’s ankle. During surveyor observations on multiple days, the stop sign was not present at the doorway, and the ADON confirmed it should have been in place, resulting in a deficiency for not maintaining the necessary device to help prevent incidents or accidents.
Surveyors observed that an LPN committed three medication administration errors during a single medication pass, resulting in a medication error rate above 5%. A resident with dementia and a psychotic disorder, who had orders for Depakote sprinkles DR, a senna-docusate combination tablet, and polyethylene glycol powder measured in a calibrated cup, instead received a crushed Depakote enteric-coated tablet, a senna-only tablet, and polyethylene glycol measured with a plastic spoon. These actions were inconsistent with the facility’s crushing-medications policy and its “do not crush” list, and the DON confirmed the errors.
Surveyors observed that trash and refuse were not properly disposed of or contained in the dumpster area. Debris including used face masks, used gloves, plastic utensils, and condiment packets was scattered near the dumpster, and a dietary employee transporting a full garbage can allowed multiple large pieces of plastic to blow out onto the ground. The employee retrieved only one piece of the blown trash, left the remaining debris on the ground, and left the dumpster lid open, resulting in improper management of garbage and refuse.
The facility failed to maintain a safe, clean, and comfortable environment on two nursing units. Observations revealed loose assist bars on toilets, soiled and damaged furnishings, and inadequate housekeeping in several rooms, including rooms 204, 307, 309, 311, 312, 313, and 314, as well as common areas like the dining room.
The facility did not provide devices for heating food in the service pantries of two nursing units, as observed on two separate days. A RN stated that all microwave ovens were removed from the pantries because resident families were frequently asking staff to reheat food.
The facility did not meet the required nurse aide (NA) to resident ratios on several occasions, failing to maintain the minimum staffing levels during day, evening, and night shifts over a 21-day period. This was confirmed by the facility's administrator after a review of nursing schedules.
The facility did not meet the required 3.2 hours of direct nursing care per resident on four specific days, with care hours ranging from 2.86 to 3.11. The administrator confirmed the shortfall during an interview.
A facility failed to implement safety interventions for a resident with behavioral symptoms, leading to an incident where one resident entered another's room, triggering a physical response. The resident with traumatic brain injury and dementia was supposed to have a stop sign on his door to prevent such incidents, but it was not in place, as confirmed by the Administrator. This deficiency was previously cited under relevant regulations.
A facility failed to implement safety measures for a resident at risk for falls and did not prevent another resident at risk for elopement from leaving a secured area. One resident was observed without prescribed fall mats, and another resident, identified as a high risk for elopement, was found outside the secured unit unsupervised due to a staff oversight.
Unsanitary Food Storage and Handling in Kitchen and Unit Pantries
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the main kitchen and on two nursing units. Review of the facility’s Dietary Dress Code Policy showed that all staff were required to fully cover their hair with a hair restraint when working with or around food. During a kitchen tour, surveyors observed a hole in the wall near a reach-in refrigerator with a black substance present, one flying insect in the dry storage area, and another flying insect in the clean pan room near the dish machine. A bulk container of thickener was undated and had white dried food debris along the outside of its lid, and the lid of a bulk flour container was also covered with white food debris. The juice refrigerator had dried food and liquid splatter on its side. During lunch meal tray-line service, two dietary employees were observed working with mustaches and parts of their beards uncovered, contrary to the facility’s policy requiring hair restraints for facial hair; the Director of Dietary confirmed they should have been wearing appropriate restraints. On the second-floor resident pantry, surveyors observed black discoloration inside the microwave, and on the third-floor resident pantry, a tan substance was seen on the interior of the microwave. An LPN confirmed that these unit microwaves were used by staff to heat resident food only. These observations formed the basis of the deficiency related to unsanitary food storage and handling practices in the dietary department and on the nursing units.
Failure to Maintain Safe, Clean, and Sanitary Environment on Two Nursing Units
Penalty
Summary
The facility failed to maintain a safe, clean, and sanitary environment on both the second and third floor nursing units, as identified during an environmental tour conducted by surveyors. On the second floor, the small dining room had marred wooden wall trim, and two stained ceiling tiles were observed in the corridor between specified rooms. In one resident room, the privacy curtain for one bed had a brown/dark gray stain, and the window curtain above the air-conditioning unit was off the rod and stained brown. Another room had a non-functioning towel dispenser and dark brown spots on the wall above one bed. A separate room had a loose bathroom grab bar, and there was a hole in a ceiling tile in front of another room. Additional observations included a cracked window header with hanging caulk above an air conditioning/heating unit, loose towel racks in a bathroom, marred corridor walls, and marred walls at the baseboards adjacent to closets in another room. On the second floor [NAME] Room, a black cushioned chair had a sagging seat cushion with a broken spring touching the floor, and a gray chair was broken so that its back would not remain in an upright position. On the third floor, the main corridor floor between specified rooms and inside the entrance to the residents' lounge dining room was covered with a black substance. The floors inside the entrances to several resident rooms were also covered with a black substance. A privacy curtain between two beds in another room had a large tan stain. In the main dining room on the third floor, the windows had an accumulation of dirt on their surfaces. These conditions were cited under CFR 483.10(i)(2) Safe Environment and related state regulations.
Infection Control Failures in Medication Administration and Linen Handling
Penalty
Summary
The deficiency involves failures in infection prevention and control during medication administration and linen handling. Facility policy for administering oral medications, last reviewed February 12, 2026, stated that employees were not to touch medications with their hands. However, during an observation on April 8, 2026, between 8:25 a.m. and 8:58 a.m., an LPN poured two tablets of acetaminophen 325 mg from a bottle into her ungloved hand before placing them into a pill cup and administering them to two residents, identified as Residents 24 and 81. The same LPN also poured one tablet of senna 8.6 mg into her ungloved hand before placing it into a pill cup and administering it to Resident 24. The DON confirmed that the LPN should not have touched the pills with bare hands. The facility also failed to follow its laundry and linen policy, last reviewed February 12, 2026, which required employees sorting or washing linen to wear a gown and gloves and to keep clean linen hygienically clean and protected from environmental contamination. On April 8, 2026, at 1:30 p.m., the EVS Supervisor was observed placing soiled linen into a clothes washer while wearing gloves but no gown. On April 10, 2026, at 12:25 p.m., the same EVS Supervisor opened a running clothes dryer, and three washcloths fell onto the floor; the EVS Supervisor then picked up the washcloths from the floor and put them back into the dryer. The Nursing Home Administrator confirmed that the EVS Supervisor should have worn a gown while handling soiled linen and that the washcloths that fell on the floor should have been treated as dirty and placed in a soiled linen bin.
Failure to Provide Timely, Dignified Dining Assistance
Penalty
Summary
Surveyors identified that staff failed to provide dining assistance in a manner that promoted and maintained dignity for one resident. The resident had dementia, protein-calorie malnutrition, impaired vision, cognitive impairment, and required staff assistance with eating per the clinical record and MDS assessment. The care plan documented self-care deficits and an increased risk for nutrition problems related to dementia, with interventions for staff to encourage food and fluid intake, provide cueing for eating, and reorient as needed. During a lunch observation, the resident was seated in the dining room with a tray containing a covered drink, a banana, and a ham and cheese sandwich. The resident had difficulty picking up food, leaned over the tray, and ate the sandwich directly off the plate without using his hands, attempted to reach drinks that were out of reach, and picked up the banana without peeling it further or attempting to eat it. Staff did not provide assistance, cueing, or improved meal setup until 40 minutes after the tray was received, and the Assistant DON later confirmed that staff should have assisted the resident with cueing and better meal setup.
Failure to Follow Physician Orders for Compression Therapy and Cardiac Medication Parameters
Penalty
Summary
The facility failed to follow physician orders for two residents. For one resident with peripheral vascular disease, a physician ordered the application of TED stockings each morning with removal at bedtime, beginning March 5, 2026. On multiple observations in early April 2026, this resident was seen both in bed and ambulating on the unit without the TED stockings in place. Clinical record review did not show evidence that the ordered treatment was provided or that the resident refused the TED stockings. In an interview, the Director of Nursing confirmed there was no documentation that the physician’s order had been followed or that the treatment was refused. For another resident with hypertension, a physician ordered carvedilol to be administered twice daily with specific hold parameters: do not administer if the systolic blood pressure was less than 110 mm/Hg or if the heart rate was less than 55 beats per minute. Review of the Medication Administration Records for March and April 2026 showed that staff administered carvedilol multiple times when the resident’s systolic blood pressure was below 110 mm/Hg and on several occasions when the heart rate was below 55 beats per minute. The Director of Nursing confirmed that the medication had been administered outside the physician-ordered parameters.
Failure to Maintain Required Safety Device for Resident With Behavioral and Fall Risks
Penalty
Summary
Surveyors identified a deficiency in accident prevention when a resident with dementia, mood disturbance, memory impairment, a history of falls, and documented behaviors of being territorial and combative did not have a required safety device in place. Clinical records showed that after an incident in which the resident was found lying on the floor by her bed holding the ankle of another resident who had walked into her room, staff documented an intervention to hang a stop sign across the doorway to deter wandering residents from entering. However, during observations on multiple days, the stop sign was not present at the resident’s doorway, and the Assistant Director of Nursing confirmed that it should have been in place. This failure to implement the planned intervention for a resident with known behavioral issues and fall history constituted the cited deficiency under 28 Pa. Code 211.12(d)(1)(5) related to nursing services and accident prevention.
Medication Pass Errors Result in >5% Medication Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5% on one nursing unit during a medication administration observation. On the specified date and time, surveyors observed 29 medication opportunities on the second floor and identified three medication errors, resulting in a 10.34% error rate. Facility policy on crushing medications, last reviewed in February 2026, required that medications only be crushed when appropriate and safe, consistent with physician orders, and that staff notify the physician if an order to crush conflicted with manufacturer instructions, such as for enteric-coated drugs. The facility’s own “do not crush” list identified Depakote tablets as not to be crushed due to their enteric-coated formulation. Clinical record review showed that Resident 24 had dementia with behavioral disturbance and a psychotic disorder and had physician orders for Depakote sprinkles oral capsule delayed release, a combination senna-docusate tablet (8.6 mg–50 mg), and 17 grams of polyethylene glycol powder to be measured in a calibrated cup. During the observed medication pass, an LPN crushed and administered a Depakote delayed release enteric-coated tablet instead of the ordered Depakote sprinkles, administered a senna 8.6 mg tablet instead of the ordered senna 8.6 mg–docusate sodium 50 mg combination tablet, and measured polyethylene glycol powder using a plastic spoon rather than the required calibrated cup. The DON confirmed that these three medication administration errors occurred.
Improper Disposal and Containment of Trash in Dumpster Area
Penalty
Summary
The facility failed to properly dispose of trash and refuse in the dumpster area. On April 7, 2026, at 11:00 a.m., surveyors observed multiple pieces of plastic and paper debris, including used face masks, used gloves, plastic spoons, and condiment packets, scattered in the area adjacent to the dumpster. Later that day, from 1:25 p.m. to 1:30 p.m., a dietary employee was seen transporting a wheeled garbage can full of trash across the parking lot to the dumpster. As the employee pushed and pulled the can, six large pieces of loose plastic blew out of the can toward the back of the dumpster. The dietary employee picked up only one of the six pieces of garbage that had blown from the can, then emptied the garbage can into the dumpster and left the area. The remaining five pieces of garbage were left on the ground, and the dumpster lid was left open. These observed actions and inactions resulted in trash and refuse not being properly contained or disposed of in accordance with facility management requirements under 28 Pa Code 201.18(b)(3).
Environmental Deficiencies in Resident Rooms and Common Areas
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment on two nursing units, specifically the second and third floors. Observations revealed several environmental issues, including loose and wobbly assist bars on toilets in rooms 204, 307, and 309, which could pose a safety risk to residents. Additionally, the towel racks in room 307 were loose, and there was a dried orange substance on the floor in front of the closets for beds three and four in room 309. The bathroom doorway in room 311 was soiled with a dried brown stain, and the heater was damaged. The window curtain in room 312 was soiled, and the fall mat had dust and several dried, gray spots on it, while the pedal to control bed height was covered with a layer of dust. Further observations included a soiled floor with a brown substance and a damaged heater with peeling paint by the heater in room 313. There was a cracked tile and peeling wallpaper near the window in the dining room, and the privacy curtain in room 314 (bed one) was soiled with brown stains. These findings indicate a failure to maintain a sanitary, orderly, and comfortable interior, as required by the regulations, and highlight the need for improved housekeeping and maintenance services to ensure a safe and homelike environment for residents.
Plan Of Correction
1. The facility has repaired the loose and wobbly assist bars in rooms 204, 307, and 309. The towel racks in room 307 were secured, and the scuffed and damaged table in the dining room across from room 215 was replaced. The dried orange substance in room 309, the brown stain in room 311, and the brown substance on the floor in room 313 were cleaned. Heater damages in rooms 311 and 313 were repaired. The soiled window curtain in room 312 and the privacy curtain in room 314 were removed and replaced with clean curtains. Additionally, the fall mat and bed pedal in room 312 were thoroughly cleaned and sanitized. The cracked tile and peeling wallpaper in the dining room were repaired, and the affected area was repainted. Peeling paint by the heater in room 313 will be repaired. 2. An environmental audit of all resident rooms and common areas was conducted to identify any similar environmental concerns. Any issues identified were immediately addressed. 3. All Maintenance Department staff will be reeducated on Weekly Environmental Safety Rounds. All Housekeeping staff will be reeducated on daily cleaning protocols. 4. Environmental audits will be completed weekly. Findings from audits will be reviewed during monthly Quality Assurance and Performance Improvement (QAPI) meetings, and QAPI will determine further action planning and discontinuation.
Absence of Food Heating Devices in Nursing Unit Pantries
Penalty
Summary
The facility failed to provide a device for heating food in the service pantries of two nursing units, specifically on the second and third floors. This deficiency was identified through observations conducted on April 29 and April 30, 2025, which revealed the absence of any devices to reheat food in the pantries of these units. During an interview on April 29, 2025, a Registered Nurse (RN) explained that the facility had removed all microwave ovens from the nursing unit pantries. The reason given for this action was that resident families were frequently requesting staff to reheat food, leading to the decision to remove the devices.
Plan Of Correction
1. Microwave ovens for heating food have been installed in both nursing unit pantries. 2. All residents residing were reviewed to ensure that the lack of heating devices in the pantries did not negatively impact their nutritional services or access to hot meals. No adverse outcomes were identified. 3. All Licensed nursing staff will be re-educated on the purpose of the pantry appliances and the proper use of the machines. 4. Audits to confirm that both pantries have microwave ovens for use will be completed weekly. Findings from audits will be reviewed during monthly Quality Assurance and Performance Improvement (QAPI) meetings, and QAPI will determine further action planning and discontinuation.
Failure to Meet Nurse Aide to Resident Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident ratios on multiple occasions over a period of 21 days. Specifically, the facility did not maintain the minimum ratio of one NA per ten residents during the day shift on nine separate days, one NA per eleven residents during the evening shift on three days, and one NA per fifteen residents during the night shift on five days. These deficiencies were identified through a review of nursing schedules for the periods of January 1 through 7, 2025, March 9 through 16, 2025, and April 24 through 30, 2025. The facility's administrator confirmed the failure to meet the required staffing ratios during an interview conducted on April 30, 2025.
Plan Of Correction
1. The facility has reviewed and adjusted staffing schedules to ensure compliance with minimum NA-to-resident ratios for all shifts. 2. A comprehensive review of the resident census and care needs was conducted to verify that current NA staffing levels meet or exceed regulatory requirements. A proactive system was developed to forecast NA staffing needs based on anticipated resident census and staff availability trends. 3. All nursing administrative staff will receive training on regulatory NA staffing requirements and the importance of timely shift coverage. 4. Daily audits of NA to resident ratios will be conducted weekly. Findings from audits will be reviewed during monthly Quality Assurance and Performance Improvement (QAPI) meetings, and QAPI will determine further action planning and discontinuation.
Deficiency in Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day. This deficiency was identified during a review of nursing schedules over a 21-day period, specifically on four days: March 15, April 25, April 26, and April 27, 2025. On these days, the facility provided 3.11, 3.05, 3.10, and 2.86 hours of care per resident, respectively, which were below the mandated minimum. The facility administrator confirmed the shortfall in nursing care hours during an interview conducted on April 30, 2025.
Plan Of Correction
1. The facility has reviewed and adjusted staffing schedules to ensure compliance with a minimum of 3.2 hours of direct care for each resident daily. 2. A comprehensive review of the resident census and care needs was conducted to verify that current nursing staffing levels meet or exceed regulatory requirements. A proactive system was developed to forecast nursing staffing needs based on anticipated resident census and staff availability trends. 3. All nursing administrative staff received training on regulatory minimum 3.2 hours of direct care for each resident daily. 4. Daily audits of a minimum of 3.2 hours of direct care for each resident daily will be conducted weekly. Findings from audits will be reviewed during monthly Quality Assurance and Performance Improvement (QAPI) meetings, and QAPI will determine further action planning and discontinuation.
Failure to Implement Safety Interventions for Residents
Penalty
Summary
The facility failed to ensure that safety interventions were in place for a resident at risk for behavioral symptoms. Resident 1, who had diagnoses including traumatic brain injury and dementia with behavioral disturbance, was supposed to have a stop sign on his door to prevent other residents from entering his room. This intervention was part of his care plan to prevent anxiety and ineffective coping when his belongings were touched. However, on November 24, 2024, Resident 1 exhibited physical behaviors towards another resident, Resident 2, after the latter entered his room. The stop sign, which was meant to deter wandering residents and prevent potential triggers for Resident 1's behaviors, was not in place at the time of the incident. Resident 2, who had diagnoses including dementia with mood and psychotic disturbance and anxiety, was noted to wander throughout the nursing unit and exhibited aggressive behaviors. On November 23, 2024, staff observed Resident 2 wandering into other residents' rooms. The lack of the stop sign on Resident 1's door, as confirmed by the Administrator on November 27, 2024, contributed to the incident where Resident 2 entered Resident 1's room, leading to Resident 1's physical response. This deficiency was previously cited on June 13, 2024, under CFR 483.25(d)(1)(2) and 28 Pa. Code 211.12(d)(1)(5).
Failure to Implement Safety Measures for Fall and Elopement Risks
Penalty
Summary
The facility failed to implement assessed safety measures for a resident at risk for falls and did not prevent another resident at risk for elopement from leaving a secured area without staff knowledge. Resident 20, who had Alzheimer's disease and a history of falls, was observed without the prescribed bilateral fall mats next to her bed, despite a physician's order and care plan intervention indicating their necessity. This oversight was noted during observations conducted over a three-hour period. Additionally, Resident 75, diagnosed with Alzheimer's disease and dementia with severe psychotic disturbance, was identified as a high risk for elopement. Despite interventions in place to distract her from wandering, the resident was found outside the secured nursing unit unsupervised. The incident occurred when a nurse aide left the unit without ensuring the door was locked, allowing the resident to exit. Witness statements confirmed the resident's exit-seeking behavior and the lack of staff awareness of her departure.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
