Harmon House Health & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mount Pleasant, Pennsylvania.
- Location
- 601 South Church Street, Mount Pleasant, Pennsylvania 15666
- CMS Provider Number
- 395726
- Inspections on file
- 39
- Latest survey
- January 13, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Harmon House Health & Rehab Center during CMS and state inspections, most recent first.
A resident who was cognitively intact, incontinent, and at risk for pressure ulcers developed full-thickness moisture-associated skin damage to the sacrum and had a physician’s order for daily cleansing and Medi-honey application. Although treatment was documented on the TAR prior to discharge, the discharge instructions marked wound care as not applicable, and the drug disposition form did not show that Medi-honey was sent home. The resident was discharged home with home health after staff reviewed medications and instructions with family, but there was no documentation that wound care instructions or Medi-honey were provided, as confirmed by the NHA.
The facility failed to follow CDC-based COVID-19 infection control practices by not promptly testing symptomatic residents who had standing orders allowing COVID-19 testing as needed and by not ensuring proper PPE use in a COVID-19-positive room. One resident experienced fever, respiratory symptoms, and systemic complaints without being tested until later, when a rapid test was finally done and was positive. Another resident had several days of cough, congestion, malaise, and remaining in bed before a rapid COVID-19 test was ordered and found positive, despite active COVID-19 cases in the building. A third resident with cough, body aches, malaise, and wheezing was tested and found positive, and transmission-based precautions were ordered. During the outbreak, a laundry aide entered the shared COVID-19-positive room of two residents wearing only a surgical mask, despite posted droplet precautions and an isolation station with N95s, gowns, gloves, and eye protection, contrary to the facility’s stated requirement that all staff don full PPE when entering COVID-19-positive rooms.
A resident with an indwelling catheter, wound infection, MS, and a Stage 4 pressure ulcer required Enhanced Barrier Precautions per physician's orders. Although appropriate signage was present and the need for infection control was documented, there was no evidence that a comprehensive, individualized care plan addressing these precautions was developed, as confirmed by the DON.
A resident with impaired mobility and pain risk did not receive diclofenac sodium topical gel as ordered, as an LPN failed to use the dosing card to measure the prescribed amount, instead applying unmeasured amounts to the resident's knee. The DON confirmed the medication should have been measured to ensure the correct dose.
Staff failed to follow Enhanced Barrier Precautions and proper hand hygiene while providing high-contact care to a resident with an indwelling catheter, wound infection, and Stage 4 pressure ulcer. Two nurse aides wore only gloves, not gowns, during care activities such as wound dressing changes and incontinent care, and did not perform hand hygiene at appropriate times, contrary to facility policy and infection control guidelines.
A resident with quadriplegia and multiple sclerosis was injured during an improper transfer when a nurse aide attempted to use a mechanical lift without the required two-person assistance. The sling pad slipped, causing the resident to fall and sustain a head laceration requiring staples. The nurse aide was aware of the facility's policy but failed to follow it, resulting in the incident.
A resident with quadriplegia and multiple sclerosis was injured during a transfer using a Hoyer lift when only one nurse aide assisted, contrary to the facility's policy requiring a two-person assist. The sling pad slipped, causing the resident to hit his head and sustain a laceration requiring staples.
A facility failed to maintain the confidentiality of residents' medical information, resulting in the unauthorized disclosure of health information for two residents. Resident 6's information was mistakenly given to a family member of another resident, who then shared it with an outside physician. Additionally, Resident 7's information was erroneously provided to the same family member upon their return to the facility.
A resident with multiple sclerosis and quadriplegia required a condom catheter, which was not documented as being changed daily according to facility policy. The issue was identified when the resident's wife requested daily changes, revealing a lack of specific physician's orders and documentation on the MARs.
The facility failed to provide written notification to residents and their legal guardians regarding the reasons for hospitalization for seven residents. These residents, who had various medical conditions, were transferred to the hospital due to changes in their conditions, but there was no documented evidence of written notices being provided to their responsible parties. This deficiency was confirmed by the Nursing Home Administrator and violated resident rights and discharge policy regulations.
The facility failed to complete comprehensive admission and annual MDS assessments within the required timeframe for five residents. The assessments were completed between 17 to 21 days after admission, exceeding the 14-day requirement. This deficiency was confirmed through clinical records and staff interviews.
The facility failed to complete quarterly MDS assessments within the required timeframe for five residents, with each assessment being completed one day late. This non-compliance was confirmed by the Nursing Home Administrator.
The facility failed to follow physician's orders for four residents, leading to deficiencies in care. A resident did not receive required assessments every shift, another had insulin held incorrectly, a third received an antibiotic for too long, and a fourth was given blood pressure medication when it should have been held. These issues were confirmed by the DON.
The facility failed to document the administration of controlled medications for two residents. One resident, who was cognitively intact and frequently in pain, had oxycodone doses signed out without evidence of administration. Another resident, cognitively impaired and frequently anxious, had diazepam doses signed out with no documentation of administration. These discrepancies were confirmed by the DON.
A resident with decreased mobility was found with the call bell out of reach, contrary to her care plan and facility policy. Interviews with an LPN and the DON confirmed the call bell should have been accessible.
A resident, who was cognitively impaired and dependent on staff, refused their prescribed antidepressant medication on multiple occasions. The facility's policy required notifying the physician of such refusals, but there was no documented evidence that this was done. The DON confirmed the lack of notification.
The facility failed to accurately complete MDS assessments for two residents. One resident was incorrectly coded for PTSD instead of a traumatic brain injury, while another resident's anticoagulant medication was not coded despite being administered. These errors were confirmed by the RNAC and DON.
A facility failed to change a resident's midline catheter dressing when it became loose, as required by policy. The resident, who was receiving IV antibiotics for bacteremia, had a compromised dressing observed on multiple occasions. Staff interviews confirmed the dressing should have been changed but was not.
The facility failed to administer oxygen as prescribed for two residents. One resident with asthma and respiratory failure received oxygen at 4 liters per minute instead of the ordered 2 liters. Another resident on hospice care with pneumonitis received oxygen at 3 liters per minute instead of the prescribed 2 liters. These discrepancies were confirmed by LPNs and the DON, indicating non-compliance with physician orders.
A facility failed to secure a medication cart, leaving it unlocked and unattended while a nurse administered medications. An unmarked medication cup with various tablets and an expired bottle of Rolaids were found in the cart. The LPN and DON confirmed these issues, indicating lapses in medication security and management.
The facility failed to maintain sanitary conditions in food service, as a dietary aide was observed without a beard guard, and the sanitizer level in the sink was consistently above the recommended range. This was confirmed by the Dietary Manager and Nursing Home Administrator.
The facility's QAPI committee failed to maintain compliance with regulations, resulting in repeated deficiencies in areas such as physician notification, quality of care, intravenous therapy, medication accountability, and infection control. Despite plans of correction involving audits and reviews, the committee was ineffective in addressing these issues.
An LPN failed to perform hand hygiene before administering oral medications and eye drops to a resident, contrary to the facility's infection control policy. The resident had a physician's order for Restasis for dry eyes. Both the LPN and the DON confirmed the lapse in protocol.
Failure to Provide Wound Care Instructions and Supplies at Discharge
Penalty
Summary
The deficiency involved the facility’s failure to provide complete discharge information and necessary wound care supplies to a resident being discharged home. The facility’s discharge planning policy required development and implementation of a discharge plan that focused on the resident’s discharge goals, preparation for transition to post-discharge care, and reduction of preventable readmissions. The resident’s admission MDS showed the resident was cognitively intact, incontinent of bowel and bladder, and at risk for developing pressure ulcers, with no existing pressure ulcers at that time. On a later date, the resident developed full-thickness moisture-associated skin damage on the sacrum measuring 6.2 x 3.6 x 0.2 cm, and a physician’s order was initiated for daily cleansing of the sacrum with soap and water, patting dry, and application of Medi-honey once a day. The TAR documented that Medi-honey was applied on two consecutive days prior to discharge. On the day of discharge, nursing documentation indicated the resident was discharged home, medications were reviewed with a family member, and discharge instructions were provided. However, the written discharge instructions, which indicated the resident was being discharged home with home health, did not reflect that the resident was receiving wound care, as the wound care section was marked “N/A.” The drug disposition form showed that medications were sent home with the resident, but there was no documentation that Medi-honey was provided. In an interview, the Nursing Home Administrator confirmed there was no documented evidence that the resident or family received Medi-honey or wound care instructions upon discharge, despite the active physician’s order for daily wound treatment to the sacrum.
Failure to Follow COVID-19 Symptom Testing Protocols and PPE Requirements During Outbreak
Penalty
Summary
The deficiency involves the facility’s failure to follow CDC-based infection prevention and control guidelines for early detection, testing, and appropriate PPE use during a COVID-19 outbreak. CDC guidance cited in the report emphasizes routine assessment of all residents for COVID-19 symptoms, prompt testing of anyone with even mild symptoms regardless of vaccination status, and use of N95 respirators, gowns, gloves, and eye protection for all HCP entering rooms of residents with suspected or confirmed COVID-19. The facility had 18 residents develop COVID-19 between late December and early January and 11 active cases at the time of the on-site visit, yet staff practices and testing decisions did not consistently align with these guidelines. For Resident 4, who had a standing physician order allowing COVID-19 testing as needed per protocol, nursing documentation on one date showed a low-grade fever, body aches, chills, shortness of breath, and a dry cough. Despite these symptoms and the standing order, no COVID-19 test was performed at that time. Later in the month, the resident again exhibited symptoms including headache, fatigue, malaise, cough, and a temperature of 100.4°F, at which point a rapid COVID-19 test was performed and was positive, and isolation/combined droplet/contact precautions were ordered. During interview, the IP and DON stated that symptomatic residents would typically be tested, but that this depended on the practitioner, and the DON confirmed that Resident 4 had standing orders for testing that were not used on the earlier symptomatic date. For Resident 10, who also had a standing order permitting COVID-19 testing as needed, multiple nursing notes over several days documented cough, congestion, malaise, pale skin, and remaining in bed due to not feeling well, while the facility already had active COVID-19 cases. COVID-19 testing was not obtained until several days after the onset of these symptoms, when the CRNP was notified and ordered a rapid COVID-19 swab that resulted positive, and isolation/combined droplet/contact precautions were then ordered. For Resident 11, a nursing note documented that the resident did not feel well, had a moist productive cough, body aches, malaise, and expiratory wheezing; a rapid COVID-19 swab was ordered and was positive, and transmission-based precautions were ordered. Additionally, an observation showed a laundry aide entering the shared COVID-19-positive room of Residents 10 and 11 wearing only a surgical mask, despite droplet precaution signage and an isolation station with N95 masks, gowns, gloves, and eye protection at the door. The laundry aide acknowledged he should have gowned and possibly worn an N95 and confirmed he did not initially realize the PPE was available, while the IP confirmed that all staff entering COVID-19-positive rooms were required to don gloves, an N95, eye protection, and a gown.
Failure to Develop Comprehensive Care Plan for Enhanced Barrier Precautions
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan with specific and individualized interventions for a resident who required Enhanced Barrier Precautions. The facility's policy required that each resident have a care plan with measurable goals and timetables to address their medical, nursing, mental, and psychosocial needs as identified in the comprehensive assessment. For the resident in question, the quarterly MDS assessment documented significant care needs, including an indwelling catheter, a wound infection, Multiple Sclerosis, and a Stage 4 pressure ulcer in the sacral region. Physician's orders specified the use of Enhanced Barrier Precautions, and signage was observed outside the resident's room indicating the required infection control measures for high-contact care activities. Despite these documented needs and orders, there was no evidence in the clinical record that a comprehensive care plan addressing the resident's Enhanced Barrier Precautions had been developed. This was confirmed by the Director of Nursing during an interview, who acknowledged the absence of such documentation. The deficiency was cited under 28 Pa. Code 211.12(d)(5) Nursing Services.
Failure to Measure and Administer Topical Medication per Physician Order
Penalty
Summary
A deficiency was identified when staff failed to follow physician's orders and manufacturer’s directions for administering diclofenac sodium topical gel 1 percent to a resident. The physician's order specified that four grams of the gel should be applied to the resident's right knee four times daily, and the manufacturer's instructions required the use of a dosing card to measure the correct amount. During a medication administration observation, an LPN applied the gel to the resident's knee without using the dosing card, instead squeezing unmeasured amounts onto her gloved finger and applying it to the resident’s knee. The resident involved had impaired mobility and was at risk for pain, as documented in the care plan and Minimum Data Set assessment. The LPN confirmed in an interview that she did not use the dosing card, believing it was only provided with prescription strength gel, not the over-the-counter version supplied by the facility’s pharmacy. The DON also confirmed that the gel should have been measured to ensure the correct dose was administered as ordered.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to follow established infection control guidelines from CMS and CDC, as well as its own policy, during the care of a resident with an indwelling catheter, wound infection, Multiple Sclerosis, and a Stage 4 pressure ulcer. The resident had physician's orders for Enhanced Barrier Precautions (EBPs), which require staff to wear gloves and gowns during high-contact care activities. Despite clear signage and policy, two nurse aides entered the resident's room wearing only gloves and proceeded to provide high-contact care, including rolling the resident, removing soiled dressings, providing incontinent care, and handling a mechanical lift sling, without donning gowns as required. Additionally, one of the nurse aides failed to remove gloves and perform hand hygiene after removing wound dressings and providing incontinent care, before continuing with other care tasks. Both aides only removed their gloves and used hand gel after several care activities had already been performed. These actions were confirmed by the Director of Nursing to be inconsistent with facility policy and infection control guidelines, specifically regarding the use of gowns and proper hand hygiene during care for residents on EBPs.
Improper Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that residents were free from abuse or neglect, as evidenced by an incident involving a resident who was transferred incorrectly, resulting in a fall and a head laceration requiring staples. The facility's policy on mechanical lifts required a two-person assist for all mechanical lifts, including Hoyer lifts. However, during the transfer of a resident with quadriplegia and multiple sclerosis, Nurse Aide 1 attempted to transfer the resident alone using a mechanical lift. This resulted in the sling pad slipping from under the resident, causing him to hit his head on the headboard and sustain a laceration. The resident, who was cognitively intact and dependent on staff for daily care needs, was transferred to the emergency room where he received three staples to the back of his head. The incident report confirmed that Nurse Aide 1 was aware of the facility's policy requiring two-person assistance for transfers but failed to adhere to it. The Director of Nursing confirmed that Nurse Aide 1 should have had a second person assist with the transfer, as per the facility's policy.
Failure to Follow Transfer Protocols Results in Resident Injury
Penalty
Summary
The facility failed to maintain a safe environment for a resident who was dependent on staff for care, including transfers and bed mobility, due to quadriplegia and multiple sclerosis. The facility's policy required a two-person assist for all mechanical lifts, including Hoyer lifts. However, an incident occurred where the resident was transferred using a Hoyer lift by only one nurse aide. During the transfer, the sling pad slipped from under the resident, causing him to hit his head on the headboard and sustain a laceration that required staples. The resident was cognitively intact and understood by others, as indicated in a recent Minimum Data Set assessment. The incident report confirmed that the transfer was conducted by a single staff member, contrary to the facility's policy. The Director of Nursing confirmed that two people should have been involved in the transfer, highlighting the failure to adhere to established safety protocols for resident transfers using mechanical lifts.
Confidentiality Breach of Residents' Health Information
Penalty
Summary
The facility failed to maintain the confidentiality of residents' medical information, affecting two of the seven residents reviewed. The incident involved the unauthorized disclosure of health information for two residents. Specifically, Resident 6's health information was mistakenly provided to a family member of another resident, Resident 1, who then shared it with an outside physician. Additionally, when the family member returned to the facility, they requested Resident 1's health information but were erroneously given Resident 7's health information instead. The facility's policy on privacy, dated January 22, 2024, stipulates that protected health information should only be used and disclosed as permitted under HIPAA rules. However, the investigation dated September 15, 2024, revealed that these policies were not adhered to, resulting in the breach of confidentiality for Residents 6 and 7. The Nursing Home Administrator confirmed the breach during an interview, acknowledging that the health information of Residents 6 and 7 was improperly disclosed to Resident 1's family member.
Incomplete Documentation of Condom Catheter Care
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented for a resident who required the use of a condom catheter. The facility's policy stated that condom catheters should be changed daily and as needed. However, a review of the resident's Medication Administration Records (MARs) for several months revealed no documented evidence that the catheter was being changed daily as per the policy. This discrepancy was identified when the resident's wife requested daily changes, leading to the realization that there was no specific physician's order for this practice. The resident, who had multiple sclerosis and quadriplegia, was understood to require an external catheter due to neuromuscular dysfunction of the bladder. Despite the care plan and physician's orders indicating the need for catheter care every shift, the lack of documentation on the MARs until a specific order was obtained highlighted a gap in adherence to the facility's policy. Interviews with staff confirmed that the catheter was being changed during routine catheter care, but this was not properly documented until the issue was addressed following the family's request.
Failure to Notify Residents and Guardians of Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents and their legal guardians regarding the reasons for hospitalization, as required by regulations. This deficiency was identified for seven residents during a review of clinical records and staff interviews. The residents involved were cognitively intact and required assistance with daily care needs, with various medical conditions such as diabetes, myocardial infarction, pressure sores, dementia, chronic obstructive pulmonary disease, and infections. For each of the seven residents, nursing notes documented instances where they were transferred to the hospital due to changes in their medical conditions, such as shortness of breath, increased confusion, unresponsiveness, and infections. Despite these transfers, there was no documented evidence that written notices were provided to the residents' responsible parties, explaining the reasons for the transfers. This lack of documentation was confirmed during an interview with the Nursing Home Administrator. The specific cases included residents being sent to the hospital for issues like a large area under a cast needing debridement, an unstageable diabetic pressure ulcer, and abnormal lab results indicating renal failure. The facility's failure to provide the required written notifications violated resident rights and discharge policy regulations, as outlined in 28 Pa. Code 201.25 and 28 Pa. Code 201.29(f)(g).
Late Completion of MDS Assessments
Penalty
Summary
The facility failed to ensure that comprehensive admission and annual Minimum Data Set (MDS) assessments were completed within the required time frame for five residents. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, an admission MDS assessment must be completed no later than 14 days following admission. However, the assessments for Residents 12, 53, 65, 69, and 77 were completed beyond this timeframe, with delays ranging from 17 to 21 days after admission. The deficiency was confirmed through a review of clinical records and staff interviews, which revealed that the comprehensive MDS assessments for these residents were completed late. The Nursing Home Administrator acknowledged the late completion of these assessments during an interview. This failure to adhere to the mandated assessment schedule was identified as past non-compliance.
Failure to Timely Complete MDS Assessments
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed within the required timeframe for five residents. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, the assessment reference date (ARD) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type, and the assessment must be completed no later than 14 calendar days after the ARD. However, the assessments for Residents 2, 17, 47, 59, and 72 were completed 15 days after their respective ARDs, exceeding the allowed timeframe. The specific instances of non-compliance included Resident 2's assessment, which was completed one day late, and similar delays for Residents 17, 47, 59, and 72. These delays were confirmed during an interview with the Nursing Home Administrator. The deficiency was identified as past non-compliance, indicating that the facility had previously failed to adhere to the required timelines for completing MDS assessments.
Failure to Follow Physician's Orders for Medication and Assessments
Penalty
Summary
The facility failed to adhere to physician's orders for four residents, leading to deficiencies in care. For Resident 17, the facility did not consistently perform the required full head-to-toe assessments with vital signs every shift, as ordered by the physician. Documentation showed that the assessment was only completed once, despite the order for it to be done per shift. Resident 37, who was moderately cognitively impaired and had diabetes, had their insulin held on multiple occasions when their blood sugar levels were above the threshold that required holding the medication, contrary to the physician's orders. Resident 40, who was cognitively intact and receiving antibiotics, was administered Cipro for 11 days instead of the prescribed 10 days, resulting in two additional doses. Resident 46, who was cognitively impaired and had hypertension, received metoprolol tartrate on several occasions when their systolic blood pressure was below the threshold that required holding the medication, as per the physician's orders. These actions were confirmed through interviews with the Director of Nursing, who acknowledged the discrepancies between the physician's orders and the care provided.
Failure to Document Administration of Controlled Medications
Penalty
Summary
The facility failed to maintain accountability for controlled medications for two residents, as revealed through a review of policies, clinical records, and staff interviews. For one resident, who was cognitively intact and frequently experienced pain, there were physician's orders for oxycodone to be administered as needed. However, the controlled drug record indicated that doses were signed out on several occasions, but there was no documented evidence in the clinical record that these doses were actually administered. This discrepancy was confirmed by the Director of Nursing during an interview. Similarly, another resident, who was cognitively impaired and frequently experienced anxiety, had physician's orders for diazepam to be applied as needed. The controlled drug record showed that doses were signed out on specific dates, but again, there was no documented evidence in the clinical record that these doses were administered. This lack of documentation was also confirmed by the Director of Nursing. These findings indicate a failure to adhere to the facility's policy and applicable laws regarding the documentation and administration of controlled substances.
Failure to Ensure Call Bell Accessibility
Penalty
Summary
The facility failed to reasonably accommodate the needs of a resident by not ensuring that the call bell was within reach. Resident 8, who required maximum assistance for transfers and toileting due to decreased mobility, was observed on June 24, 2024, with the call bell hanging off the back of the bed onto the floor, out of her reach. The resident's care plan specified that the call bell should be within reach, and the facility's policy, dated August 14, 2023, also required that the call light be within easy reach. Interviews with a Licensed Practical Nurse and the Director of Nursing confirmed that the call bell should have been accessible to the resident.
Failure to Notify Physician of Medication Refusal
Penalty
Summary
The facility failed to notify a resident's physician in a timely manner about a change in the resident's condition, specifically the refusal of medication. According to the facility's policy dated August 14, 2023, the physician should be notified if a resident refuses medication for more than 24 hours. Resident 52, who was cognitively impaired and dependent on staff assistance, was receiving an antidepressant, Lexapro, as per physician's orders dated June 23, 2023. The resident refused the medication on multiple occasions in June 2024, specifically on the 1st, 2nd, 3rd, 4th, 17th, and 18th. However, there was no documented evidence that the physician was informed of these refusals. This was confirmed during an interview with the Director of Nursing on June 26, 2024.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to complete accurate comprehensive Minimum Data Set (MDS) assessments for two residents. For one resident, the MDS assessment incorrectly indicated a diagnosis of post-traumatic stress disorder (PTSD) in Section I16100, despite a social service note stating that the resident had not experienced or witnessed a life-threatening or traumatic event. The Registered Nurse Assessment Coordinator confirmed that the section should have been coded for a traumatic brain injury instead. For another resident, the MDS assessment failed to code for anticoagulant medication in Section N0415E1, even though the resident had been receiving Warfarin, an anticoagulant, as per physician's orders during the seven-day look-back period. The Director of Nursing confirmed that the resident had received the medication and should have been coded accordingly.
Failure to Change Compromised IV Dressing
Penalty
Summary
The facility failed to adhere to its policy regarding the timely changing of IV dressings for a resident, leading to a deficiency. The policy required that midline catheter dressings be changed weekly and whenever the dressing's integrity was compromised, such as when it became wet, loose, or soiled. Additionally, staff were expected to assess the midline insertion site with each medication administration. However, observations on multiple occasions revealed that the midline dressing on a resident's right arm was loose and had lost its integrity, indicating that the dressing was not changed as required by the facility's policy. The resident involved was moderately cognitively impaired and had medical conditions including bilateral stasis leg ulcers and bacteremia, for which they were receiving intravenous antibiotics. Despite the physician's orders for the administration of Zosyn three times a day, the compromised dressing was not addressed promptly. Interviews with a Licensed Practical Nurse and the Director of Nursing confirmed that the dressing was visibly loose and should have been changed when its integrity was compromised, but it was not, leading to the deficiency finding.
Failure to Administer Oxygen as Prescribed
Penalty
Summary
The facility failed to ensure that residents received oxygen as ordered by the physician for two residents. Resident 8, who was cognitively intact and had diagnoses including asthma and respiratory failure, was observed receiving oxygen at a flow rate of 4 liters per minute instead of the prescribed 2 liters per minute. This discrepancy was confirmed by both a Licensed Practical Nurse and the Director of Nursing, indicating a failure to adhere to the physician's orders. Similarly, Resident 70, who was severely cognitively impaired and on hospice care with diagnoses including pneumonitis and anxiety, was observed receiving oxygen at a flow rate of 3 liters per minute instead of the ordered 2 liters per minute. This was also confirmed by a Licensed Practical Nurse and the Director of Nursing. These findings demonstrate a failure to provide respiratory care in accordance with physician orders, as required by the facility's policy and state regulations.
Medication Security and Management Deficiencies
Penalty
Summary
The facility failed to ensure the security and proper management of medications in one of the four medication carts reviewed. During an observation, it was noted that the lower level medication cart was left unlocked and unattended while a nurse was administering medications to residents in a room with the door shut, blocking the nurse's view of the cart. This lack of supervision could potentially lead to unauthorized access to medications. Additionally, an undated and unmarked medication cup containing various tablets was found in the top drawer of the cart, indicating a lapse in proper medication labeling and handling procedures. Further inspection of the stock drawer in the same medication cart revealed an opened bottle of Rolaids with an expiration date that had already passed. Interviews with the LPN and the Director of Nursing confirmed these findings, acknowledging that the medication cart should have been kept in full view while in use, and that expired medications and unmarked medication cups should not have been present in the cart. These observations highlight deficiencies in the facility's adherence to pharmacy and nursing service regulations.
Sanitation Deficiencies in Food Service
Penalty
Summary
The facility failed to ensure that food was prepared and served under sanitary conditions, as required by professional standards for food service safety. Observations in the main kitchen revealed that a dietary aide did not have a beard guard covering his beard, which was confirmed by the Dietary Manager. Additionally, the sanitizer level in the three-compartment sink was consistently recorded at 500 parts per million (ppm) on multiple dates, exceeding the manufacturer's recommended level of 200-400 ppm. This was confirmed by the Nursing Home Administrator, who acknowledged that the sanitizer level was not within the recommended range on the specified dates.
Repeated Deficiencies in Quality Assurance Processes
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations, as evidenced by repeated deficiencies identified in multiple surveys. These deficiencies included issues with notifying the physician or responsible party about changes in a resident's condition, quality of care, intravenous therapy, accountability of controlled medications, proper storage and labeling of medications, food preparation and storage under sanitary conditions, and infection control practices. Despite developing plans of correction that included audits and reporting results to the QAPI committee, the facility was unable to effectively address these recurring issues. The deficiencies were identified in surveys conducted on various dates, including July 20, September 18, and October 25, 2023, as well as the current survey ending June 27, 2024. The facility's plans of correction consistently involved completing audits and reviewing the results as part of quality assurance, but the QAPI committee was ineffective in implementing these plans to ensure ongoing compliance with the regulations. The repeated nature of these deficiencies indicates a systemic issue within the facility's quality assurance processes.
Infection Control Lapse in Medication Administration
Penalty
Summary
The facility failed to adhere to proper infection control practices during medication administration, as observed during a survey. The facility's policy, dated August 14, 2024, required staff to perform hand hygiene before administering medications, including eye drops. However, on June 26, 2024, an LPN was observed administering oral medications and eye drops to Resident 15 without performing hand hygiene. Resident 15 had a physician's order for Restasis, an eye medication for dry eyes, to be administered twice daily. The LPN confirmed during an interview that she did not perform hand hygiene as required. The Director of Nursing also confirmed the lapse in protocol during a subsequent interview.
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Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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