Hamilton Arms Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lancaster, Pennsylvania.
- Location
- 336 South West End Avenue, Lancaster, Pennsylvania 17603
- CMS Provider Number
- 395224
- Inspections on file
- 20
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Hamilton Arms Center during CMS and state inspections, most recent first.
A resident with Alzheimer's disease and dementia, whose son was designated as financial and healthcare POA, was switched to a new health insurance plan by facility staff after the original plan was discontinued. The Business Manager enrolled the resident in a different plan to maintain coverage but did not notify the POA, who later learned of the change from the insurance company and questioned the facility. The Administrator confirmed that the insurance change was made without informing the resident's appointed representative, resulting in a failure to honor the resident's right to representative notification.
A resident with CHF and significantly elevated BNP levels had multiple physician and NP orders for cardiology follow-up, with documentation that referrals were placed and the need for cardiology evaluation was discussed with facility staff. Despite nursing notes indicating calls to the cardiology office and messages left to schedule an appointment, there was no documentation that the consult was ever completed. The DON later reported that a cardiology visit had been scheduled but missed due to the resident being sick and could not provide supporting documentation, demonstrating a failure to carry out and document the ordered cardiology follow-up.
A resident with left-sided hemiplegia, requiring total assist for bed mobility, was left inadequately supervised during care by a CNA. The resident rolled out of bed and sustained a nondisplaced right ankle fracture, as confirmed by hospital evaluation. Facility staff and the DON confirmed that insufficient supervision during care led to the resident's fall and injury.
Two residents were inaccurately assessed as receiving anticoagulant medications in their MDS assessments, despite no evidence in their clinical records or physician orders to support this. These errors were confirmed by facility leadership through record review and staff interviews.
A resident with a pressure ulcer did not have required wound assessments, measurements, or treatment interventions documented in the clinical record, despite facility policy. Instead, staff relied on hospice documentation for monitoring and treatment, and the DON confirmed that this information was not entered into the facility's records.
Surveyors found that medications were not properly labeled and stored, including a medication refrigerator with unrecorded and elevated temperatures and an opened Lantus insulin pen on a medication cart that was not dated. Staff confirmed that these practices did not follow facility policy or regulatory requirements.
Five residents had personal refrigerators in their rooms without any temperature monitoring, cleaning logs, or evidence of maintenance according to food safety standards. The facility lacked a written policy and had not provided education to residents or families about safe food storage or refrigerator upkeep.
The facility did not follow physician orders for blood sugar checks and hypoglycemia management for two residents with diabetes and end stage kidney disease, and failed to complete required blood pressure monitoring for a resident with multiple cardiac conditions. Documentation was missing for physician notifications, timely interventions, and reassessments as required by orders.
The facility did not meet the required nurse aide staffing ratios, failing to provide the minimum number of nurse aides per residents during specific day and night shifts. The NHA confirmed the non-compliance during an interview.
The facility did not meet the required LPN to resident ratio on one day during the review period. On a specific day shift, the facility lacked the mandated minimum of one LPN per 25 residents. This was confirmed by the NHA during an interview.
The facility did not meet the required minimum nursing care hours for residents on two days, providing 3.13 and 3.07 direct care nursing hours per resident instead of the mandated 3.20 hours. This was confirmed by the NHA.
The facility did not effectively implement Enhanced Barrier Precautions (EBP) on two nursing floors. Observations revealed that resident rooms with EBP signage lacked available PPE. Interviews with staff, including an Infection Preventionist and the Nursing Home Administrator, indicated a lack of awareness and knowledge about PPE use and availability for EBP residents.
The facility did not provide necessary Medicare and Medicaid coverage notifications to residents. A resident did not receive a Notification of Medicare Non-Coverage (NOMNC), and three residents did not receive Advanced Beneficiary Notices of Non-Coverage (ABN). This was confirmed through documentation review and an interview with the Nursing Home Administrator.
A resident reported rough handling by CNAs, causing pain and anxiety. Although a grievance form was completed, the facility did not conduct an abuse investigation or report the allegation to the State Agency. The Nursing Home Administrator acknowledged the oversight.
A resident reported rough handling by CNAs, causing pain and anxiety. Although a grievance form was completed, the facility did not conduct an abuse investigation or report the allegation to the State Agency, as confirmed by the Nursing Home Administrator.
The facility failed to accurately complete MDS assessments for two residents. One resident's MDS inaccurately reported significant weight loss prior to admission, while another resident's MDS did not reflect hospice services despite a physician's order. These inaccuracies were confirmed by the Nursing Home Administrator and DON.
A resident with frequent constipation had multiple physician's orders for various medications, but the facility failed to clarify when each should be administered. Additionally, recommendations from a GI consult were not communicated to the attending physician, leading to a deficiency in care.
A resident did not receive timely dental services, including an annual exam and necessary care, despite authorization for such services. The resident reported missing fillings and issues with food getting stuck in their teeth. The DON confirmed the lack of a completed dental exam.
A resident expressed frustration over inadequate discharge preparation, lacking details on necessary durable medical equipment and follow-up care. The clinical record review showed missing information on primary care physician contacts, home health agency, and equipment arrangements, leading to a deficiency in ensuring a safe transfer.
Failure to Notify Resident Representative of Insurance Coverage Change
Penalty
Summary
The facility failed to honor a resident's right to have their appointed representative notified of changes affecting their care and finances when it changed the resident's health insurance coverage without informing the resident's power of attorney (POA). The resident had diagnoses including Alzheimer's disease and dementia, conditions that affect memory, thinking, and social abilities. The resident's profile and POA documents identified the resident's son as both financial and healthcare POA. The facility received a notification from the resident's insurance company indicating that the resident's current insurance plan was no longer offered, and subsequently enrolled the resident in a new health insurance plan. The Business Manager reported that the facility made the insurance change to ensure the resident would continue to have coverage, and confirmed that the new insurance coverage began on January 26, 2026, though the exact date of the change was not known. The Business Manager also stated that the resident's son, as POA, was notified of the change by the insurance company and then questioned the facility about why he had not been informed. The Nursing Home Administrator confirmed that the facility enrolled the resident in a different health insurance plan without notifying the POA. This sequence of actions and omissions resulted in the facility failing to ensure the resident's appointed representative was notified of the insurance coverage change.
Failure to Complete Ordered Cardiology Follow-Up for Resident With CHF
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for cardiology follow-up for a resident with congestive heart failure (CHF) and elevated BNP levels. Physician progress notes dated November 7, 2025, documented that the resident had CHF with BNP levels in the 1000s and that a cardiology follow-up was due, with a referral placed and discussed with the facility and scheduler. A physician order dated November 6, 2025, directed a cardiology follow-up, but there was no documented evidence that this consult was completed. The resident continued to experience shortness of breath and required supplemental O2, and a new medication was ordered while CHF remained the primary assessment. On December 8, 2025, nursing progress notes documented a new NP order for cardiology follow-up for CHF, and a corresponding physician order for cardiology follow-up was entered the same day. Physician progress notes on December 10, 2025, again stated that the resident needed cardiology follow-up and that this need had been discussed with the facility for scheduling. Nursing notes on December 11, 2025, indicated that cardiology had been called twice and messages left to schedule an appointment, with staff awaiting a return call. However, there was no documented evidence that the cardiology consult ordered on December 8, 2025, and referenced on December 11, 2025, was ever completed. During an interview, the DON stated that a cardiology consult had been scheduled but the resident could not attend due to illness and was unable to provide documentation of this, resulting in a failure to ensure that the cardiology follow-up orders were followed.
Failure to Provide Adequate Supervision During Care Resulting in Resident Fracture
Penalty
Summary
A resident with a history of cerebral infarction and left-sided hemiplegia required total assistance from one staff member for bed mobility and care, as documented in the care plan and Minimum Data Set. During care, a CNA rolled the resident onto their side to change them, removed the brief, and placed it on the floor. While the CNA was momentarily distracted, the resident rolled out of bed and fell to the floor. The resident was found lying on their left arm in a semi-prone position on the right side of the bed, with visible injuries including a bump on the forehead, a bruise on the left arm, and complaints of right ankle pain. Subsequent assessment and hospital evaluation revealed the resident sustained a nondisplaced fracture of the right ankle, with X-rays indicating possible fractures of the distal fibula and tibia, as well as severe diffuse osteopenia. Facility documentation and staff interviews confirmed that the resident did not receive adequate supervision during care, which resulted in actual harm. The Director of Nursing acknowledged that staff failed to provide the necessary supervision, leading to the resident's fall and injury.
Inaccurate MDS Assessments for Medication Administration
Penalty
Summary
The facility failed to ensure accurate assessments for two residents during the review period. For one resident, the Minimum Data Set (MDS) assessment indicated that the resident was receiving an anticoagulant under Section N0415, but a review of physician orders showed no evidence that the resident was actually receiving this medication. This discrepancy was confirmed by the Director of Nursing. Similarly, another resident's admission MDS assessment indicated receipt of an anticoagulant under Section N0410, but the clinical record did not support this, and the Nursing Home Administrator confirmed the MDS was coded incorrectly. These findings were based on clinical record reviews and staff interviews, demonstrating that the facility did not accurately document medication administration in the MDS assessments for these two residents.
Failure to Document Pressure Ulcer Assessment and Treatment in Clinical Record
Penalty
Summary
The facility failed to ensure that the clinical record accurately reflected the assessment and treatment of a pressure ulcer for one resident. According to facility policy, nursing staff are required to assess and document significant risk factors for pressure ulcers, as well as provide a full assessment of any pressure sores, including location, stage, measurements, and the presence of exudates or necrotic tissue. For a resident with a physician order for wound care to the buttocks, the clinical record showed an initial skin observation assessment noting an open area on the coccyx. However, subsequent facility documentation did not include required wound assessments, measurements, or treatment interventions. Instead, the facility relied solely on hospice documentation for monitoring and treatment of the pressure ulcer, without entering this information into the resident's clinical record. The DON confirmed that the facility did not document the wound and treatments in the clinical record, as required by policy.
Medication Labeling and Storage Deficiencies
Penalty
Summary
Surveyors identified deficiencies in the facility's medication labeling and storage practices. In the second-floor low side medication room, the medication refrigerator was observed to be at 50 degrees Fahrenheit, which is above the recommended storage temperature for most medications. Additionally, the Medication Storage Monthly Temperature Log for this refrigerator had multiple days in September where temperatures were not recorded, and the temperatures that were logged consistently showed the highest allowable reading of 46 degrees Fahrenheit. These findings indicate a failure to monitor and maintain appropriate storage conditions for medications as required by facility policy and professional standards. Further, on the second-floor high side, a medication cart was found to contain an opened Lantus insulin pen that was not dated. Staff interviews confirmed that opened medications are required to be dated upon first use, and that this procedure was not followed. The Nursing Home Administrator and DON acknowledged that the medication refrigerator log was incomplete, the high temperature was not addressed, and the opened insulin pen was not properly dated, all of which are contrary to facility policy and regulatory requirements.
Failure to Monitor and Maintain Personal Refrigerators for Food Safety
Penalty
Summary
Surveyors observed that five residents had personal refrigerators in their rooms, and there was no evidence of temperature logs or monitoring for these refrigerators. Additionally, there was no documentation or indication that the refrigerators were being cleaned or maintained according to professional food safety standards. An interview with the Nursing Home Administrator confirmed that the facility did not have a written policy regarding personal refrigerators, and no education had been provided to residents or their families about safe food storage, refrigerator cleaning, or temperature monitoring. These findings indicate that the facility failed to ensure food stored in personal refrigerators was maintained in accordance with professional standards for food safety, as required by regulation.
Failure to Follow Physician Orders for Blood Sugar and Blood Pressure Monitoring
Penalty
Summary
The facility failed to follow physician's orders for blood sugar monitoring and management for two residents and for blood pressure monitoring for one resident. For one resident with end stage kidney disease and diabetes mellitus, there were multiple instances where blood sugar readings were below the physician-ordered threshold, but there was no documented evidence that the physician was notified, that a rapidly absorbed glucose was provided, or that blood sugar was rechecked within the required timeframe. Similarly, another resident with end stage kidney disease and diabetes mellitus had several low blood sugar readings, but documentation did not show that the physician was notified or that the hypoglycemic protocol was followed as ordered, including timely reassessment after intervention. Additionally, a resident with a history of stroke, coronary artery disease, heart failure, hypertension, diabetes mellitus, and high cholesterol had physician's orders for blood pressure checks twice daily. However, the medication administration record showed missing documentation for required blood pressure checks on several occasions. Interviews with the Director of Nursing confirmed that the required monitoring and notifications were not completed as ordered for these residents.
Non-Compliance with Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide staffing ratios as per the regulation effective July 1, 2023. Specifically, the facility did not maintain a minimum of one nurse aide per 12 residents during the day and evening shifts, and one nurse aide per 20 residents overnight. During the period from January 11 to January 25, 2025, the facility was found to be non-compliant on January 19, 2025, for the day shift, and on January 22, 2025, for the night shift. The Nursing Home Administrator (NHA) confirmed during an interview on February 4, 2025, that the facility did not meet the minimum required staffing ratios on the identified dates.
Plan Of Correction
1. The facility failed to maintain nurse aide ratios on multiple days and shifts. 2. Facility will need to maintain a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening and 1 nurse aide per 15 residents overnight. Calculation of shift ratios will be completed and reviewed daily for accuracy by the scheduler or designee. 3. The scheduler and nursing supervisors will be educated on these ratios. For staff call offs, every effort will be made to replace the call off using resources available including communicating with staff to replace the vacancy. Staffing patterns are projected at least one week in advance to enable ongoing efforts to fill any vacant shifts. 4. Daily audits will be conducted for 1 month. Audits will be conducted by the scheduler or designee. Results of audits will be reviewed by the QAPI committee. 5. Date Certain is 4-4-25.
Failure to Meet LPN to Resident Ratio
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratio on one of the fourteen days reviewed. Specifically, on January 18, 2025, during the day shift from 7:00 a.m. to 3:00 p.m., the facility did not have the mandated minimum of one LPN per 25 residents. This deficiency was confirmed during an interview with the Nursing Home Administrator (NHA) on February 4, 2025, at 1:45 p.m., who acknowledged the shortfall in meeting the staffing requirements on the specified day.
Plan Of Correction
1. The facility failed to maintain LPN ratio on January 18th, 2025. 2. The facility will need to maintain a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight. Calculation of shift ratios will be completed and reviewed daily for accuracy by the scheduler or designee. 3. The scheduler and nursing supervisors will be educated on these ratios. For staff call offs, every effort will be made to replace the call off using resources available including communicating with staff to replace the vacancy. Staffing patterns are projected at least one week in advance to enable ongoing efforts to fill any vacant shifts. 4. Daily audits will be conducted for 1 month. Audits will be conducted by the scheduler or designee. Results of audits will be reviewed by the QAPI committee. 5. Date certain is 4-4-25.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the required minimum general nursing care hours for residents on two specific days. On January 18, 2025, the facility provided 3.13 direct care nursing hours per resident, and on January 22, 2025, it provided 3.07 direct care nursing hours per resident. These figures were below the mandated minimum of 3.20 hours of general nursing care per resident. This deficiency was confirmed during an interview with the Nursing Home Administrator (NHA) on February 4, 2025.
Plan Of Correction
1. The facility failed to maintain a minimum of 3.2 hours of direct resident care for each resident on multiple days and shifts. 2. Facility will need to maintain a PPD of 3.2 hours. Calculation of the PPD will be completed and reviewed daily for accuracy by the scheduler or designee. 3. The scheduler and nursing supervisor will be educated on the daily PPD. For staff call offs, every effort will be made to replace the call off using resources available including communicating with staff to replace the vacancy. Staffing patterns are projected at least one week in advance to enable ongoing efforts to fill any vacant shifts. 4. Daily audits will be conducted for 1 month. Audits will be conducted by the scheduler or designee. Results of audits will be reviewed by the QAPI committee. 5. Date certain is 4-4-25.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish effective Enhanced Barrier Precautions (EBP) on two nursing floors, as observed by surveyors. On the second-floor nursing unit, a resident room had signage indicating the resident was on EBP, but there was no evidence of Personal Protective Equipment (PPE) availability. An interview with Employee E3 revealed a lack of awareness regarding the appropriate PPE for EBP residents and where to obtain it. Similarly, on the first-floor nursing unit, a resident room also lacked visible PPE despite EBP signage. Licensed Employee E4 was similarly unaware of the necessary PPE and its location. The Infection Preventionist, Licensed Employee E5, stated that staff had been educated on PPE use for EBP residents. The Nursing Home Administrator confirmed that staff should be knowledgeable about PPE location and use for EBP residents.
Failure to Provide Required Coverage Notifications
Penalty
Summary
The facility failed to provide necessary notifications regarding Medicare and Medicaid coverage to residents, as required by regulations. Specifically, a Notification of Medicare Non-Coverage (NOMNC) was not provided to one resident, and Advanced Beneficiary Notices of Non-Coverage (ABN) were not provided to three residents. This deficiency was identified through a review of facility documentation and confirmed during an interview with the Nursing Home Administrator. The lack of these notifications means that residents were not informed about their coverage status and potential financial liabilities for services not covered by Medicare or Medicaid.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident who expressed concerns about the care provided by the nursing staff. The resident, who uses a cane and rollator for ambulation and has no family support except for a significant other, reported that the CNAs were rough during repositioning, causing pain and anxiety. This information was documented during a meeting with the social services department and physical therapy. Despite the completion of a grievance form by Social Services, no abuse investigation was conducted, and the allegation was not reported to the State Agency. The Nursing Home Administrator confirmed that an investigation and report should have been made.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to investigate an allegation of abuse involving a resident who expressed concerns about the care received. The resident, who ambulates with a cane and rollator, reported that the CNAs were rough during repositioning, causing pain and anxiousness. This concern was documented during a meeting with the social services department and physical therapy. Despite the grievance form being completed by Social Services, no abuse investigation was conducted, and the allegation was not reported to the State Agency. The Nursing Home Administrator confirmed that an investigation should have been conducted and reported, indicating a lapse in the facility's management of abuse allegations.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for two residents. For Resident 13, the Admission Nutrition Evaluation indicated a history of weight loss, but the MDS inaccurately reported a significant weight loss prior to admission, which was confirmed as incorrect by the Nursing Home Administrator. Resident 57's clinical record included a physician's order for hospice care, but the quarterly MDS failed to reflect that the resident was receiving hospice services, as confirmed by the Nursing Home Administrator and Director of Nursing.
Failure to Clarify and Implement Physician's Orders for Constipation Management
Penalty
Summary
The facility failed to clarify and implement physician's orders for a resident experiencing frequent constipation. The resident had multiple physician's orders for constipation management, including Colace, Dulcolax suppository, Polyethylene Glycol Powder, and Senna Plus. However, there was no order for Milk of Magnesia, which was referenced in the Dulcolax order, nor was there clarification on when each medication should be administered. Additionally, a gastrointestinal consult recommended a specific regimen involving Senna and Dulcolax, but these recommendations were not communicated to the resident's attending physician. Interviews with the Nursing Home Administrator and Director of Nursing confirmed the oversight in clarifying the physician's orders and implementing the GI consult recommendations. The clinical records did not show any action taken to address the GI consult's recommendations, leading to a deficiency in providing appropriate treatment and care according to the resident's needs and physician's orders.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide timely dental services for a resident, as evidenced by the lack of an annual dental exam and necessary dental care. The resident expressed concerns about missing fillings and the desire to have teeth pulled due to food getting stuck in the holes in their teeth. Despite authorization from the resident's responsible party for Direct Mobile Dental Services to perform an annual dental exam, x-rays, and cleanings in May 2023, there was no evidence in the clinical record that these services were provided. The Director of Nursing confirmed the absence of a completed dental exam for the resident.
Inadequate Discharge Preparation for Resident
Penalty
Summary
The facility failed to adequately prepare Resident R3 for a safe transfer or discharge from the nursing home. Resident R3, who was scheduled for discharge to home, expressed frustration and concern over the lack of information regarding necessary durable medical equipment such as a wheelchair, bedside commode, and hospital bed. The resident's clinical record indicated a Medicare cut letter stating that skilled nursing services would terminate on July 12, 2024, but the discharge planning summary assessment lacked essential details. The clinical record review revealed that the discharge summary did not include appointment or contact information for the primary care physician, nor did it provide details about the home health agency or durable equipment agency. Additionally, there were no documented discharge planning details regarding follow-up appointments, home health agency contacts, or durable medical equipment arrangements. An interview with the Director of Nursing confirmed these deficiencies, highlighting the facility's failure to ensure appropriate transfer and discharge preparation for Resident R3.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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