Green Valley Skilled Nursing And Rehabilitation Ce
Inspection history, citations, penalties and survey trends for this long-term care facility in Pottsville, Pennsylvania.
- Location
- 1 Matthew Drive, Pottsville, Pennsylvania 17901
- CMS Provider Number
- 396086
- Inspections on file
- 19
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Green Valley Skilled Nursing And Rehabilitation Ce during CMS and state inspections, most recent first.
The facility failed to provide an ongoing program of activities to meet residents' needs, as three residents expressed concerns about the lack of activities on Sundays and Mondays. The activity calendar and staffing records confirmed no scheduled activities or assigned staff on these days. Residents had previously raised these issues during council meetings, but no action was taken.
The facility failed to monitor and address significant weight loss in two residents, leading to a deficiency in nutritional care. One resident experienced a 12.4 lb. weight loss over nine days, and another lost 38 lbs. over several months. Required reweights were not conducted, and physicians were not notified. Additionally, recommended nutritional interventions were not implemented, and there was a discrepancy in fluid restriction status.
A physician failed to act on pharmacist-identified medication irregularities for three residents with various mental health diagnoses. Despite multiple medication regimen reviews, the facility lacked documentation of the pharmacist's recommendations and the physician's responses, as confirmed by the Nursing Home Administrator.
A resident with severe cognitive impairment was improperly restrained using furniture to create a makeshift playpen, without a physician's order or consent. The facility failed to follow its policies on restraint utilization and resident rights, leading to a deficiency.
A facility failed to ensure accurate MDS assessments for a resident with paranoid schizophrenia and major depressive disorder. Despite a positive PASRR Level 1 screen and confirmation of eligibility for Level II services, the MDS assessment inaccurately reported the resident's mental illness status. This was confirmed by the RN assessment coordinator.
A facility failed to follow physician orders for a resident's PICC line management. The resident, with a PICC line for antibiotic therapy due to knee issues, had orders for specific antibiotics and saline flushes. However, the Medication Administration Record showed the PICC line was not consistently flushed as required, confirmed by the DON.
A resident with congestive heart failure did not receive proper maintenance of their oxygen equipment, as the facility failed to change the oxygen tubing weekly per policy. Observations over several days showed the tubing was not replaced, and the DON confirmed the oversight.
A facility failed to maintain a system of records for controlled drugs, specifically Oxycodone, for a resident with diabetes and prostate cancer. The resident was discharged with 10 Oxycodone tablets, but there was no documented accountability record as required by facility policy. The DON confirmed the lack of documentation, which is necessary to prevent unauthorized use and ensure accurate accounting.
A facility failed to document the clinical rationale for increasing an antipsychotic medication for a resident with severe cognitive impairment. Despite a psychiatric team meeting, there was no evidence of alternative treatments considered or resident involvement in the decision-making process. The DON confirmed the lack of documentation and the facility's responsibility to prevent unnecessary psychotropic medication.
The facility failed to maintain proper signage for the emergency generator's remote manual stop station, as observed during a survey. The absence of identifying signage was confirmed by the Administrator and Maintenance Director, indicating non-compliance with NFPA standards.
The facility was found deficient in maintaining proper signage for the Fire Department Connection of the sprinkler system. An observation revealed the absence of identifying signage, which was confirmed during an interview with the Administrator and Maintenance Director.
A resident with cerebral ischemia and dementia, requiring assistance from two staff members for transfers, sustained a sprained ankle when a nurse aide transferred the resident alone. The incident occurred during a transfer from the toilet to a wheelchair, resulting in the resident's left knee giving out and subsequent fall. The injury led to pain, swelling, and a decline in mobility and independence in activities of daily living. Interviews confirmed the failure to follow the care plan and physician orders for safe transfers.
The facility failed to employ a full-time qualified director of food and nutrition services in the absence of a full-time qualified dietitian. The current food service director is enrolled in an online course to become a certified dietary manager and is not yet qualified. The facility employs a part-time consultant dietitian who works approximately four hours per week. The previous full-time qualified food service director left the facility, and the position has not been filled.
The facility failed to maintain acceptable practices for food storage and service, including the use of unpasteurized eggs and improper dating of food items in the resident pantry refrigerator. These actions increased the risk of food-borne illness.
The facility failed to accommodate a resident with COPD and a bariatric wheelchair, preventing her from participating in activities due to the narrow width of the Activity Room door. Despite being aware of the issue and having a pending work order, the problem was not resolved, leading to the resident's inability to engage in her preferred activities.
The facility failed to follow its abuse prohibition procedures for screening and training a rehired nurse aide. The employee was rehired without an employment application, background check, contact with previous employers, or verification of certification. Additionally, the employee did not receive the required orientation training.
A resident who required two-person assistance for transfers was transferred by a single nurse aide, resulting in a sprained ankle. The incident was not reported to the State Survey Agency within the required time frames, violating the facility's abuse prohibition policy.
A resident with multiple diagnoses, including depression and dementia, expressed a desire to harm herself, but the facility failed to provide therapeutic social services or follow up on the resident's distress. The Director of Social Services was unaware of the statement, and no documentation of therapeutic intervention was found.
The facility failed to maintain accurate and complete clinical records for a resident with congestive heart failure, diabetes, chronic kidney disease, and GERD, who experienced weeping in her left lower extremity. Despite the resident's condition being noted, there was a lack of timely and accurate documentation regarding the facility's response and communication with the physician.
Lack of Scheduled Activities on Sundays and Mondays
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet the needs, interests, and preferences of residents, as evidenced by concerns raised by three out of four residents during a group interview. The residents expressed dissatisfaction with the lack of activities on Sundays and Mondays, which was confirmed by a review of the activity calendar and staffing documentation showing no scheduled activities or assigned activity staff on these days throughout February 2025. The residents had previously raised these concerns during Resident Council meetings, but no action had been taken to address the issue. Resident 4, who is cognitively intact, expressed a preference for hymn singing on Sundays and desired at least one program on Sundays and Mondays. Resident 6, with moderate cognitive impairment, and Resident 8, also cognitively intact, indicated an interest in additional bingo activities and leading activities themselves. The Nursing Home Administrator confirmed the absence of activity staff on Sundays and Mondays and acknowledged the facility's responsibility to ensure residents' needs and preferences are met, as per 28 Pa. Code 201.29 (a) Resident rights.
Failure to Monitor and Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to monitor and address significant weight loss in two residents, leading to a deficiency in nutritional care. Resident 36 experienced a 12.4 lb. weight loss over nine days and a subsequent 7 lb. weight loss, yet the facility did not conduct required reweights or notify the physician and resident representative as per their policy. The Director of Nursing confirmed these lapses, acknowledging that the weight loss was not communicated to the physician each time it was noticed. Resident 20 also experienced a significant weight loss of 38 lbs. over several months. Despite a dietary referral and recommendations for daily weights and nutritional interventions, the facility did not conduct reweights or implement the recommended health shake. Additionally, there was a discrepancy in the resident's fluid restriction status, which had been discontinued but was still referenced in dietary notes. The Director of Nursing confirmed these failures, including the lack of communication with the physician and resident representative regarding the weight loss.
Failure to Act on Pharmacist Recommendations
Penalty
Summary
The deficiency involves the failure of a physician to act upon pharmacist-identified irregularities in the medication regimens of three residents. Resident 11, who was admitted with diagnoses including anxiety disorder, major depressive disorder, and dementia, had medication regimen reviews conducted on multiple occasions. Despite the pharmacist making recommendations during these reviews, the facility was unable to provide documentation of these recommendations or any response from the physician. Similarly, Resident 24, diagnosed with dementia and major depressive disorder, and Resident 4, diagnosed with paranoid schizophrenia and major depressive disorder, also had medication regimen reviews where the pharmacist made recommendations. However, the facility failed to document these recommendations or any physician response. The Nursing Home Administrator confirmed the lack of documentation for the pharmacist's recommendations and the physician's actions, which constitutes a deficiency under the relevant Pennsylvania Code sections.
Improper Use of Physical Restraints on a Resident
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints that were not required to treat a medical symptom. The resident, who was severely cognitively impaired and had a history of osteoarthritis and acute respiratory failure, was found on the floor near her bed and later placed in a makeshift playpen created by surrounding her with furniture. This action was taken without a physician's order, consent from the resident or her representative, or documented evidence that less restrictive measures had been attempted and failed. The resident's care plan included interventions for altered sleep and wake cycles, communication problems, and behavior issues related to suicidal ideation. Despite these interventions, the resident was found on the floor and later placed in a wheelchair at the nurse's station. When the resident expressed discomfort and requested to return to bed, she was instead placed on a mattress on the floor in the common area, surrounded by furniture to prevent her from moving. Witness statements from staff members confirmed the use of furniture as a restraint, with one staff member describing the action as abusive. The facility's Director of Nursing and Nursing Home Administrator acknowledged the lack of a documented physician order, care plan intervention, or consent for the use of the furniture as a restraint. The facility's policies on restraint utilization and resident rights were not followed, leading to the deficiency.
Inaccurate MDS Assessment for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the status of a resident. The resident in question was admitted with diagnoses of paranoid schizophrenia and major depressive disorder. A review of the resident's Pennsylvania Preadmission Screening Resident Review Identification (PASRR) Level 1 form indicated a positive screen for serious mental illness, necessitating a Level II evaluation. A subsequent letter from the Pennsylvania Department of Human Services confirmed the resident's eligibility for Level II services, requiring the facility to provide or arrange for mental health services. However, the significant change MDS assessment inaccurately reported that the resident was not considered a state Level II PASRR for serious mental illness. This inaccuracy was confirmed during an interview with the registered nurse assessment coordinator.
Failure to Follow PICC Line Management Orders
Penalty
Summary
The facility failed to provide person-centered care and adhere to physician orders for the management of a PICC line for a resident. The resident, who was admitted with a PICC line for antibiotic therapy due to a right total knee replacement and a left knee infection, had specific physician orders for the administration of Vancomycin HCL and Cefazolin Sodium. Additionally, there was an order for a Normal Saline flush to be used intravenously every shift before and after the administration of IV antibiotics. Upon review of the resident's February 2025 Medication Administration Record, it was found that the PICC line was not consistently flushed before and after the administration of each IV antibiotic as per the physician's orders and facility policy. This was confirmed during an interview with the Director of Nursing, who acknowledged the lack of documented evidence for the required flushing of the PICC line. This deficiency was noted under the 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
Failure to Maintain Oxygen Equipment
Penalty
Summary
The facility failed to maintain respiratory equipment in accordance with its policy, affecting one resident who required oxygen therapy. The facility's policy, last reviewed on December 14, 2024, mandates that oxygen tubing and humidifier bottles be changed weekly to ensure optimal functioning. However, observations revealed that the oxygen tubing attached to the resident's oxygen concentrator was not replaced as required. The tubing was dated January 20, 2025, and remained unchanged during observations on February 25, 26, and 27, 2025. The resident involved had been admitted with a diagnosis of congestive heart failure and had physician orders for oxygen therapy to manage shortness of breath. Despite the resident's need for respiratory support, the facility did not adhere to its policy of weekly tubing changes. The Director of Nursing confirmed the oversight, acknowledging that the tubing had not been replaced per the facility's guidelines, thus failing to maintain the resident's oxygen equipment properly.
Failure to Document Controlled Medication Accountability
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not maintaining a system of records for the receipt and disposition of controlled drugs, specifically Oxycodone, for one resident. The facility's policy requires that all controlled medications be accounted for, inventoried, and destroyed in the presence of two licensed clinicians, with documentation on the accountability record. However, for Resident 43, who was admitted with diagnoses including diabetes and prostate cancer, there was no documented evidence of a controlled medication accountability record for the Oxycodone 2.5 mg tablets prescribed for pain or dyspnea. Upon discharge, Resident 43 was sent home with medications, including 10 Oxycodone tablets, but the facility failed to provide documentation of the accountability record for these controlled medications. An interview with the Director of Nursing confirmed the absence of this documentation, which is required to prevent unauthorized use or misappropriation and ensure accurate accounting and disposition of controlled drugs.
Lack of Documentation for Antipsychotic Medication Increase
Penalty
Summary
The facility failed to ensure proper documentation and justification for the increase of an antipsychotic medication for a resident diagnosed with a psychotic disorder and dementia. The resident, who was admitted with severe cognitive impairment, had a care plan addressing potential physical aggression and impaired cognitive function. Despite a psychiatric interdisciplinary team meeting where new recommendations were made, the clinical record lacked documented evidence of the clinical rationale for increasing the resident's antipsychotic medication, alternative treatment options considered, or involvement of the resident or their representative in the decision-making process. The Director of Nursing confirmed the absence of documentation supporting the rationale for the dosage increase and acknowledged the facility's responsibility to ensure residents are free from unnecessary psychotropic medication. The medication administration records showed that the resident received the additional dose of Quetiapine Fumarate daily for a month, but there was no evidence of a clinical rationale or discussion of alternative interventions. This deficiency was identified through clinical record review and staff interviews, highlighting a failure in the facility's medication management practices.
Emergency Generator Signage Deficiency
Penalty
Summary
The facility failed to maintain proper signage for the emergency generator's remote manual stop station. During an observation conducted on February 12, 2025, at 1:05 PM, it was noted that the stop station lacked identifying signage. This deficiency was identified as affecting the entire component of the emergency generator system. An interview conducted during the exit conference with the Administrator and Maintenance Director on the same day confirmed the absence of the required signage. The lack of signage was acknowledged by the facility's representatives, indicating a failure to comply with the necessary maintenance and testing protocols as outlined in NFPA standards.
Plan Of Correction
The maintenance has installed a sticker identifying the remote manual stop station for the emergency generator. The NHA and maintenance director will tour the facility and grounds to identify any other locations which may need additional or new signage to maintain compliance. The NHA and maintenance director will review life safety regulations for signage to ensure that the facility is in compliance. The maintenance director will audit the sticker weekly with his generator checks to ensure the sticker remains in place. Results of the audit will be forwarded to the QAPI committee for review.
Deficiency in Fire Department Connection Signage
Penalty
Summary
The facility failed to maintain proper signage for the Fire Department Connection associated with the installed sprinkler system. During an observation on February 12, 2025, at 12:55 PM, it was noted that the Fire Department Connection lacked identifying signage. This deficiency was confirmed during an interview with the Administrator and Maintenance Director at the exit conference on the same day at 1:30 PM.
Plan Of Correction
The maintenance director has installed a reflective sign identifying the location of the fire department hookup. The NHA and maintenance director will tour the facility and grounds to identify any other locations which may need additional or new signage to maintain compliance. The NHA and maintenance director will review life safety regulations for signage to ensure that the facility is in compliance. The maintenance director will audit the fire department connection sign with his generator checks to ensure the sign remains in place. Results of the audit will be forwarded to the QAPI committee for review.
Inadequate Transfer Assistance Leads to Resident Injury and Decline
Penalty
Summary
The facility neglected to provide the necessary care and services to prevent physical harm to Resident 33, resulting in a sprained ankle and subsequent decline in activities of daily living. Resident 33, admitted with diagnoses of cerebral ischemia and dementia, had a care plan indicating the need for assistance from two staff members for transfers due to impaired balance and cognitive impairment. Despite physician orders and care plans specifying the requirement for two staff members during transfers, Employee A1, a nurse aide, transferred Resident 33 alone, leading to the ankle injury on February 29, 2024. The incident occurred during a transfer from the toilet to a wheelchair when Resident 33's left knee gave out, causing Employee A1 to lower the resident to the floor. Subsequent assessments revealed left ankle tenderness, edema, and pain, with the resident unable to bear weight on the ankle. Despite receiving Tylenol for pain management, Resident 33 continued to experience ankle pain and required a Hoyer lift for transfers until the swelling decreased. Physical therapy sessions post-injury noted the resident's complaints of left foot/ankle pain impacting transfer and ambulation abilities, leading to a decline in mobility and independence in activities of daily living. Interviews with Resident 33's family member and the Nursing Home Administrator confirmed the facility's failure to ensure the resident's safety, with Employee A1 neglecting to follow the care plan and physician orders for safe transfers. The family member expressed concerns about the setback in Resident 33's physical rehabilitation post-injury, affecting the resident's ability to walk and delaying potential discharge home. The Nursing Home Administrator acknowledged the deficiency in ensuring Resident 33's safety and the subsequent decline in the resident's activities of daily living due to the sprained ankle caused by inadequate transfer assistance.
Failure to Employ Qualified Food Service Director
Penalty
Summary
The facility failed to employ a full-time qualified director of food and nutrition services in the absence of a full-time qualified dietitian. An interview with the food service director (FSD) revealed that she was currently enrolled in an online course to become a certified dietary manager and was not yet qualified for the position according to regulatory criteria. The facility employed a part-time consultant dietitian who worked approximately four hours per week. Review of monthly time sheets confirmed this arrangement. The nursing home administrator confirmed that the previous full-time qualified food service director's last day of employment was on October 20, 2023, and that the facility did not currently employ a full-time qualified food service director.
Failure to Maintain Food Storage and Service Standards
Penalty
Summary
The facility failed to maintain acceptable practices for the storage and service of food, which increased the risk of food-borne illness. During an initial tour of the food and nutrition services department, it was observed that two cases of fresh shell eggs, which were not pasteurized, were present on a shelf in the walk-in refrigerator. The food service director (FSD) confirmed that these unpasteurized eggs were being used to serve dippy eggs and that they were ordered by mistake instead of pasteurized shell eggs from the food supplier. This practice is against CMS guidance and increases the risk of residents contracting Salmonella Enteritis. Further observations in the resident pantry refrigerator revealed several food storage and sanitation concerns. A thawed 4-ounce nutritional shake and a 10-gallon plastic bag containing 4-ounce nutritional shakes were not dated with a thaw or discard date, despite manufacturer instructions to use them within 14 days after thawing. Additionally, two plastic storage containers of applesauce, two 46-ounce bottles of thickened juice, and a 60-ounce bottle of apple juice were opened but not dated. A spill was also observed under the plastic pull-out crisper drawer of the refrigerator. The FSD confirmed that food and beverages were to be stored and thawed according to acceptable practices and that the food and nutrition services department and resident pantry were to be maintained in a sanitary manner to prevent potential contamination.
Failure to Accommodate Resident's Participation in Activities
Penalty
Summary
The facility failed to provide reasonable accommodations for Resident 41, who has chronic obstructive pulmonary disease (COPD) and uses a bariatric wheelchair with a 40-inch width. Despite being cognitively intact and having a care plan that included participation in activities such as bingo, arts and crafts, and spiritual services, Resident 41 was unable to attend many activities because her wheelchair could not fit through the 36-inch wide Activity Room door. This issue was confirmed by the Director of Maintenance, who had been aware of the problem and had a pending work order to address it, which had not been completed by the time of the survey. Resident 41 expressed frustration during an interview, stating that she had to sit in the hallway to listen to spiritual services because her wheelchair would not fit through the door. The Nursing Home Administrator confirmed that the facility failed to make reasonable accommodations to allow Resident 41 to participate in her chosen activities. The deficiency was identified under 28 Pa. Code 201.29 (a) Resident rights.
Failure to Implement Abuse Prohibition Procedures for Rehired Employee
Penalty
Summary
The facility failed to implement their established abuse prohibition procedures for fully screening and training one employee out of five reviewed. Specifically, Employee 1, a nurse aide, was rehired on December 23, 2023, without documented evidence of an employment application, a PA State Police criminal background check, contact with previous employers to screen for history of abuse or mistreatment, or verification of the employee's nurse aide certification. Additionally, there was no documentation that Employee 1 received orientation training, including abuse training, as required by the facility's policy. An interview with the Business Office Manager confirmed that the facility did not have an application packet for Employee 1's rehire and that the necessary background checks and verifications were not completed. The Business Office Manager also confirmed that Employee 1 did not receive the required orientation training upon rehire. This failure to follow established procedures for screening and training employees led to the deficiency identified in the report.
Failure to Timely Report Resident Neglect
Penalty
Summary
The facility failed to timely report an instance of resident neglect to the State Survey Agency. The incident involved Resident 33, who required the assistance of two staff members for transfers. On February 29, 2024, Employee A1, a nurse aide, attempted to transfer Resident 33 alone, resulting in the resident's left knee giving out and her being lowered to the floor. Initially, no injuries were reported, but later that day, Resident 33 experienced left ankle tenderness, edema, and pain, and was unable to bear weight on her ankle. A subsequent facility incident report confirmed that Employee A1 was aware of the two-person transfer requirement but chose to perform the transfer alone, leading to Resident 33's sprained ankle. The incident was not reported to the State Survey Agency within the required time frames. The facility's abuse prohibition policy mandates that all incidents of suspected neglect be thoroughly investigated and reported to the Pennsylvania Department of Health within five calendar days. Despite this policy, the neglect incident involving Resident 33 was not reported in a timely manner. The Nursing Home Administrator confirmed that the facility staff failed to ensure that Resident 33 received the necessary services to avoid physical harm and acknowledged the delay in reporting the neglect to the State Survey Agency.
Failure to Provide Therapeutic Social Services
Penalty
Summary
The facility failed to provide therapeutic social services to promote the mental and psychosocial well-being of a resident diagnosed with malignant neoplasm of the colon, COPD, depression, and dementia. The resident, who was moderately cognitively impaired with a BIMS score of 10, expressed a desire to harm herself by asking for scissors or a razor to slit her wrists. This statement of distress was documented in a behavior note, but there was no follow-up or provision of therapeutic social services documented in the resident's clinical record. An interview with the Director of Social Services revealed that she was unaware of the resident's statement and had not provided any follow-up or therapeutic social services. The Nursing Home Administrator confirmed the lack of documented evidence of therapeutic social services being provided to the resident following her statement of wanting to harm herself. This failure to address the resident's expressed distress constitutes a deficiency in providing medically-related social services to help the resident achieve the highest possible quality of life.
Failure to Maintain Accurate and Complete Clinical Records
Penalty
Summary
The facility failed to maintain accurate and complete clinical records consistent with professional standards of practice by not timely and accurately documenting the response to a change in a resident's condition. Resident 40, who was admitted with diagnoses including congestive heart failure (CHF), diabetes, chronic kidney disease, and gastro-esophageal reflux disease (GERD), experienced weeping in her left lower extremity. Despite the resident's condition being noted in nursing documentation, there was a lack of timely and accurate documentation regarding the facility's response and communication with the physician about the resident's condition. On March 23, 2024, a nursing note indicated that the resident's left lower leg was weeping, but there was no immediate follow-up or documentation of physician notification. By March 26, 2024, the resident's condition had not improved, and she expressed concerns about her weeping legs and recent weight gain. The resident was unsure if the physician was aware of her condition. A nursing note later that day mentioned the physician was informed, but there was no corresponding physician progress note to confirm this. The Director of Nursing (DON) acknowledged the lack of documentation regarding the physician's visit and orders for the resident's leg dressings. The resident continued to express concerns about her condition, and the facility's failure to document timely and accurate responses to the resident's change in condition was confirmed by the Nursing Home Administrator (NHA). This deficiency highlights the facility's failure to ensure proper documentation and communication regarding the resident's care needs.
Latest citations in Pennsylvania
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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