Green Meadows Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Malvern, Pennsylvania.
- Location
- 283 East Lancaster Avenue, Malvern, Pennsylvania 19355
- CMS Provider Number
- 395519
- Inspections on file
- 21
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Green Meadows Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to keep the automatic sprinkler system free of extraneous weight, with multiple wires and flex conduit observed attached to or laying across sprinkler piping in several areas above the ceiling. Facility leadership confirmed these items were present and supported by the sprinkler system.
The facility did not provide documentation verifying that annual inspections and testing of electrical receptacles in resident care areas were completed, as required by NFPA 99. This deficiency was confirmed by both the Administrator and the Director of Maintenance, and affected all smoke zones within the component.
Fifteen rooms on a dementia care unit were found without fresh water or with water cups dated weeks prior, while other rooms had currently dated water. Staff interviews confirmed knowledge of the hydration lapse, and facility leadership was unaware until informed by surveyors.
Three resident rooms lacked privacy curtains, and eighteen rooms had soiled or stained privacy curtains on the 1st floor dementia care unit. This failure to provide adequate privacy and maintain clean equipment was confirmed by facility leadership.
A resident's clinical record and care plan indicated Full Code status, while a POLST signed by the resident reflected a DNR preference. The DON confirmed the inconsistency, showing the facility did not ensure the resident's advance directives were accurately documented.
A resident's MDS assessment was inaccurately coded to indicate the presence of an indwelling catheter, despite no clinical evidence supporting this. Staff confirmed the error during an interview, acknowledging the assessment did not accurately reflect the resident's status.
A resident with major depressive disorder was prescribed Mirtazapine, but staff did not monitor for side effects or document the medication's effectiveness. The DON confirmed that no such monitoring was conducted.
A resident with encephalopathy and an order for a Kennedy Cup was repeatedly observed drinking from a regular cup with a straw instead of the prescribed assistive device. Staff interviews confirmed knowledge of the resident not using the Kennedy Cup as ordered, and the care plan documented the need for meal assistance due to intellectual disability.
Two residents did not receive their prescribed medications as ordered because the facility was waiting for pharmacy delivery, as confirmed by the DON. The medications included treatments for hypertension, hyperlipidemia, COPD, post-surgical aftercare, and hypopituitarism, and were not available for administration as scheduled.
The facility failed to meet required staffing levels for nurse aides on several occasions, with insufficient coverage during day, evening, and night shifts. These deficiencies were confirmed by staffing documents and the DON.
The facility did not meet the required 3.2 hours of direct nursing care per resident per day on several occasions in February 2025. The nursing hours ranged from 2.80 to 3.19, as confirmed by the DON.
The facility did not comply with its food labeling and storage policy, as observed in the dry storage area of the kitchen. Eight opened bags of uncooked pasta lacked labels with the food item name and use-by date and were not properly sealed. The Dietary Director confirmed these deficiencies, which violated the facility's 2017 policy.
A facility failed to document catheter care for a resident with a suprapubic catheter, as required by their policy. The policy mandates catheter care every shift and as needed, with documentation and reporting of any concerns. However, a review of the resident's clinical record showed no evidence of such documentation, a deficiency confirmed by the DON.
A resident's UA C+S test results were finalized but not reported to the physician for three days, delaying treatment for a urinary tract infection. The DON confirmed the delay in communication.
Sprinkler System Not Maintained Free of Extraneous Weight
Penalty
Summary
Surveyors determined that the facility failed to maintain the automatic sprinkler system free of extraneous weight in three of twelve smoke compartments. During observations conducted above the ceiling in multiple areas, including the 2nd floor above the Nurses' Station, the North Hall by a resident room, and the 3rd floor above the Nurses' Station, various items such as multiple wires and flex conduit were found laying across or attached to the sprinkler piping system and its brackets. These findings were confirmed during an interview with the Administrator and Director of Maintenance, who acknowledged the presence of these items attached to and supported by the sprinkler pipe system. No information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
Remove existing wiring (various items) from sprinkler piping, in the locations noted, and install separate hanging devices as needed using an above ceiling permit program. Education of the requirements will be provided to the appropriate staff. Audits of above ceiling work will be conducted, monthly x3. Findings will be reviewed in monthly QAPI meetings.
Failure to Document Annual Electrical Receptacle Inspections
Penalty
Summary
Surveyors determined that the facility failed to provide documentation verifying that annual inspections and testing of electrical receptacles in resident care areas had been completed. During a document review, it was found that there was no evidence to confirm that electrical receptacles had been tested within the last 12 months in any of the twelve smoke zones of the component. This lack of documentation was identified during a review conducted between 9:30 AM and 10:35 AM on December 18, 2023. At the exit conference, both the Administrator and the Director of Maintenance confirmed that there was no documentation available to show that the required annual electrical inspections had been performed. The deficiency specifically relates to the absence of records for the testing of electrical receptacles in resident care areas, as required by NFPA 99 standards.
Plan Of Correction
Facility will ensure documentation of annual inspections of electrical receptacles in resident care areas is completed and will include in building Management Software task list as an annual inspection. Education on the inspection of and documentation of electrical receptacles utilizing the annual inspection report in building Management Software task list will be provided to the appropriate staff. Audits will be completed semi-annually to check on schedule and confirm results are filed in life safety book. Findings will be reviewed in monthly QAPI meetings.
Failure to Provide Adequate Hydration to Residents
Penalty
Summary
Surveyors observed that the facility failed to provide adequate hydration to residents in fifteen out of thirty-two rooms on the first floor dementia care unit. During observations conducted over three consecutive days, it was found that rooms 100 through 115 either had no cups of fresh water available for residents or the cups present were dated between November 14 and December 1, indicating that the water had not been replaced for an extended period. In contrast, rooms 116 through 132 had currently dated cups with fresh water. Specific rooms, such as 113 and 114, were noted to have water cups dated as far back as November 14, and room 101 had a cup dated December 1. All other rooms in the 100 to 115 range had no water cups at all. Interviews with staff confirmed awareness of the lack of fresh water in these rooms. A registered nurse acknowledged knowledge of the issue, and when the findings were presented to the Nursing Home Administrator and Director of Nursing, they denied prior knowledge of the hydration lapse and indicated they would investigate. The deficiency was cited under federal and state regulations requiring facilities to ensure residents are offered sufficient fluid intake to maintain proper hydration and health.
Plan Of Correction
The facility cannot retroactively correct this issue. All residents were provided fresh water cups for hydration. A facility-wide audit was conducted by the DON/Designee to assure that residents were provided fresh water cups for hydration. The DON/Designee educated nursing staff on the importance of assuring that residents were provided fresh water cups for hydration. Random room audits will be conducted to assure that residents are provided fresh water cups for hydration. Audits will be done weekly for four weeks, then monthly for three months or until compliance is achieved. Results will be discussed at the monthly QAPI.
Deficiency in Resident Room Privacy and Cleanliness
Penalty
Summary
Surveyors observed that three out of thirty-two resident rooms on the 1st floor dementia care unit did not have privacy curtains, and eighteen rooms had privacy curtains that were soiled or had brown stains. These observations were made over a three-day period. The lack of privacy curtains and the presence of soiled curtains were confirmed during interviews with the Nursing Home Administrator and the Director of Nursing. The deficiency was identified as a failure to provide adequate privacy and maintain clean equipment in resident rooms, as required by regulations.
Plan Of Correction
Soiled curtains were immediately replaced with clean privacy curtains and privacy curtains were hung in rooms that were missing privacy curtains. Facility-wide audit conducted by NHA/Designee to ensure resident rooms have privacy curtains and are free from soilage. NHA/Designee provided education to housekeeping and maintenance staff on assuring that resident rooms have privacy curtains in place and free from soilage. NHA/Designee will audit random rooms to ensure privacy curtains are present and free from soilage. Audits will be done weekly x4 then monthly x2 or until compliance is achieved. Results will be discussed at monthly QAPI.
Failure to Ensure Consistent Advance Directives for Code Status
Penalty
Summary
The facility failed to ensure that advance directives regarding code status were accurately reflected in the clinical record for one resident. Specifically, a review of the resident's clinical record showed a physician's order and care plan indicating Full Code status, while a Physician's Order for Life Sustaining Treatment (POLST) signed by the resident indicated a Do Not Resuscitate (DNR) status. This discrepancy meant that the resident's wishes as documented in the POLST were not aligned with the orders and care plan maintained by the facility. The Director of Nursing confirmed during an interview that the clinical record did not match the POLST signed by the resident. The deficiency was identified through clinical record review and interviews, and it was determined that the facility did not ensure appropriate advance directives were in place and consistent for the resident involved.
Plan Of Correction
Resident 114 code status was reviewed with resident/representative and confirmed desire for DNR status. Care plan, Physician order, and POLST reviewed and revised. Facility-wide audit of POLST, Physician order, and care plan was done to assure clinical record and POLST are consistent with residents' wishes. DON/Designee educated licensed nursing staff and social services staff on the importance of assuring POLST, Physician order, and care plan are consistent with residents' wishes. Random audits will be conducted of resident's clinical record to assure that POLST, Physician order, and care plan are consistent with residents' wishes. Audits will be done daily x 5 days, then weekly x 4, then monthly x 2 or until compliance is achieved. Results will be discussed in monthly QAPI meeting.
Inaccurate MDS Assessment for Catheter Status
Penalty
Summary
A deficiency was identified when a review of a resident's admission Minimum Data Set (MDS) assessment indicated that the resident had an indwelling catheter, as documented in section H, Bladder and Bowel. However, further examination of the clinical record revealed no evidence that the resident actually had an indwelling catheter at the time of the assessment. This discrepancy was confirmed during an interview with a licensed staff member, who acknowledged that the MDS had been coded incorrectly and that the resident did not have an indwelling catheter. The failure to accurately assess and document the resident's status resulted in an inaccurate MDS assessment for this individual.
Plan Of Correction
Resident 29 was discharged. Section H of MDS submitted within the last 14 days will be reviewed to assure clinical record and MDS coding is consistent with resident assessment of bowel and bladder. Administrator/Designee will educate clinical reimbursement staff on ensuring MDS coding is consistent with clinical record for resident assessment of bowel and bladder status. Random audits of Section H of MDS submitted will be conducted to assure clinical record and MDS coding is consistent with resident assessment of bowel and bladder. Audits will be done weekly x4, then monthly x2 or until compliance is achieved. Results will be discussed in monthly QAPI meeting.
Failure to Monitor Antidepressant Therapy
Penalty
Summary
The facility failed to ensure that appropriate monitoring for side effects and effectiveness was conducted for an anti-depressant medication prescribed to a resident diagnosed with major depressive disorder. The resident had a physician's order for Mirtazapine to treat depression, but a review of the clinical record did not show any evidence that staff monitored for side effects or documented the effectiveness of the medication. An interview with the Director of Nursing confirmed that no monitoring for side effects or effectiveness of the anti-depressant was performed. This lack of monitoring was identified through clinical record review and was previously cited in earlier surveys.
Plan Of Correction
Resident 35's clinical record was revised to show evidence of monitoring of side effects of the anti-depressant medication and its effectiveness. DON/Designee conducted a facility-wide audit of current residents on antidepressant medications to ensure monitoring of side effects and its effectiveness are in place. DON/Designee educated nursing staff on the importance of monitoring side effects and its effectiveness for residents on antidepressant medications. DON/Designee will randomly audit residents with antidepressant medication to ensure effectiveness and side effects are monitored. Audits will be done weekly x4 then monthly x2 or until compliance is achieved. Results will be discussed at monthly QAPI.
Failure to Provide Prescribed Assistive Drinking Device
Penalty
Summary
A deficiency was identified when a resident with a medical diagnosis of encephalopathy and an order for a regular diet with a Kennedy Cup, built-up fork, and spoon was not provided with the prescribed assistive drinking device. The resident's physician order, dated May 21, 2025, specified the use of a Kennedy Cup, which is a spill-proof cup with a secure lid and J-shaped handle, to assist with drinking. Observations conducted over three consecutive lunch services revealed that the resident was instead drinking from a regular cup with a straw, contrary to the physician's order. Interviews with facility staff, including the unit manager RN, confirmed awareness that the resident was not using the Kennedy Cup as ordered. The Nursing Home Administrator and Director of Nursing were not aware of the resident's lack of access to the prescribed assistive device until the issue was presented to them. The resident's care plan indicated a need for assistance with meals due to intellectual disability and a stable weight, further supporting the necessity for the assistive device. The failure to provide the required Kennedy Cup constituted noncompliance with regulations regarding assistive devices for eating and drinking.
Plan Of Correction
The facility cannot retroactively correct this issue. Resident 7 was given a Kennedy cup for all meals. DON/Designee conducted a facility-wide audit of residents who have orders for adaptive equipment to ensure appropriate adaptive equipment was in place during meals. DON/Designee educated Nursing/Dietary staff on the importance of assuring that assistive devices ordered are in place during meals. DON/Designee will conduct meal observations weekly x 4 then monthly x 3 or until compliance is achieved to verify adaptive equipment ordered is present during meals. Results will be discussed at the monthly QAPI.
Failure to Provide Timely Pharmacy Services
Penalty
Summary
The facility failed to ensure that pharmaceutical services were provided in a timely manner to meet the needs of two residents. For one resident admitted with multiple diagnoses including hypertension, hyperlipidemia, COPD, and post-surgical aftercare, physician admission orders were written for several medications to begin on a specified date. However, review of the Medication Administration Record (MAR) showed that these medications were not administered as ordered, and staff notes indicated they were waiting for delivery from the pharmacy. Similarly, another resident admitted with hypopituitarism had physician orders for Desmopressin Acetate and Hydrocortisone to begin on a specified date. The MAR revealed these medications were also not administered as ordered, with staff documentation stating they were awaiting pharmacy delivery. The Director of Nursing confirmed that both residents did not receive their prescribed medications on time due to unavailability from the pharmacy.
Staffing Deficiencies in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides (NAs) on multiple occasions between February 1, 2025, and February 21, 2025. Specifically, the facility did not provide the mandated one NA per 10 residents during the day shift on five days, one NA per 11 residents during the evening shift on two days, and one NA per 15 residents during the night shift on four days. These deficiencies were confirmed by a review of staffing documents and an email confirmation from the Director of Nursing (DON) on March 8, 2025.
Plan Of Correction
1. Review staffing needs, workload, and determining units with the current gaps. 2. Distribution of Assignments: Review staff assignments and the rotation schedule involved with each. 3. Weekend Staffing Log: Assure all weekend shifts are covered and all steps needed for call offs. 4. Identify recruitment strategies. Continue to develop effective recruitment strategies to attract qualified candidates. This includes flyers, sign on/referral bonus, advertising job openings, utilizing on-line job portals, and word of mouth. 5. Streamline onboarding and "processing" process for the facility. This includes looking at any inefficiencies to ensure process is candidate friendly and focuses on selecting the best-suited individuals for the positions. 6. Retention Events: Access the factors that contribute to turnover and taking steps to improve employee retention. Performance review and evaluation: Assuring timely performance reviews are completed and staff are evaluated properly. 7. Training and Development of Staff utilizing facility training portal and in-services. Also partnering with leadership to set up workshops for employee development. 8. Communication: Continue to work on communication channels within the organization. Encourage staff members to provide feedback, share concerns and suggest improvements related to staffing to help identify potential issues early on and facilitate collaborative problem solving.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to consistently meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day. A review of the facility's staffing levels revealed that on multiple dates in February 2025, the facility's nursing hours fell below the required minimum. Specifically, on February 8, 9, 10, 11, 13, 14, 15, 16, 17, and 19, the direct care nursing hours per resident ranged from 2.80 to 3.19, all below the mandated 3.2 hours. This deficiency was confirmed by the Director of Nursing via email on March 8, 2025.
Plan Of Correction
1. Review staffing needs, workload, and determining units with the current gaps. 2. Distribution of Assignments: Review staff assignments and the rotation schedule involved with each. 3. Weekend Staffing Log: Assure all weekend shifts are covered and all steps needed for call offs. 4. Identify recruitment strategies. Continue to develop effective recruitment strategies to attract qualified candidates. This includes flyers, sign on/referral bonus, advertising job openings, utilizing on-line job portals, and word of mouth. 5. Streamline onboarding and "processing" process for the facility. This includes looking at any inefficiencies to ensure process is candidate friendly and focuses on selecting the best-suited individuals for the positions. 6. Retention Events: Access the factors that contribute to turnover and taking steps to improve employee retention. Performance review and evaluation: Assuring timely performance reviews are completed and staff are evaluated properly. 7. Training and Development of Staff utilizing facility training portal and in-services. Also partnering with leadership to set up workshops for employee development. 8. Communication: Continue to work on communication channels within the organization. Encourage staff members to provide feedback, share concerns and suggest improvements related to staffing to help identify potential issues early on and facilitate collaborative problem solving.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to adhere to its policy on food labeling and storage, as observed during a tour of the main kitchen's dry storage area. Eight opened bags of uncooked pasta were found without labels indicating the food item name and use-by date, and they were not properly sealed. This was in violation of the facility's policy dated 2017, which mandates that all food should be dated upon receipt and properly labeled before storage. The Dietary Director confirmed that the pasta should have been labeled and sealed according to the policy.
Lack of Documented Catheter Care for Resident
Penalty
Summary
The facility failed to provide documented evidence of consistent and adequate catheter care for a resident with a suprapubic catheter. The facility's policy, implemented on March 1, 2024, requires catheter care to be performed every shift and as needed, with documentation of the care provided and any concerns reported to the nurse on duty. However, a review of the clinical record for the resident revealed no documented evidence of catheter care being provided. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the lack of documentation for the resident's catheter care.
Delay in Reporting Lab Results to Physician
Penalty
Summary
The facility failed to report laboratory results to the ordering physician in a timely manner for one resident. Resident 22 had a physician order for a urine analysis and culture sensitivity (UA C+S) test on September 11, 2024, to determine if there was a urinary tract infection. The laboratory report was finalized and available on September 15, 2024. However, the results were not communicated to the physician until September 18, 2024, as noted in the resident's progress notes. This delay in reporting led to a delay in the physician ordering antibiotics to treat the urinary tract infection. The Director of Nursing confirmed the delay in reporting the results during an interview on October 9, 2024.
Latest citations in Pennsylvania
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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