Hcc At White Horse Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Newtown Square, Pennsylvania.
- Location
- 535 Gradyville Road, Newtown Square, Pennsylvania 19073
- CMS Provider Number
- 395833
- Inspections on file
- 16
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Hcc At White Horse Village during CMS and state inspections, most recent first.
The facility failed to maintain and inspect its sprinkler system, affecting the entire facility. Documentation was missing for a 3-year dry system full flow test and a 5-year internal valve and pipe inspection. This was confirmed during an interview with the Administrator and Maintenance Director.
The facility did not maintain and inspect portable fire extinguishers as required by NFPA 10. Documentation review revealed the absence of certification for the technician performing annual maintenance. This issue was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility failed to maintain the fire resistance rating of common wall fire separations, affecting one of three levels. The rated double doors near the basement loading dock did not fully close and positively latch when tested. This was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility did not maintain emergency battery back-up lighting in operable condition, affecting one of three floors. An observation revealed that the emergency light near the generator in the South Hall basement Generator Room failed to illuminate when tested. This was confirmed during an exit interview with the Administrator and Maintenance Director.
A heater fan was found blocking access to an electrical panel in the basement next to the kitchen storage room, compromising safety protocols. This was confirmed during an interview with the Administrator and Maintenance Director.
The facility failed to maintain smoke doors according to NFPA 101 standards, as observed when the double corridor smoke doors at room 108 did not close smoke tight. This issue was confirmed during an interview with the Administrator and Maintenance Director.
The facility was found to be in violation of NFPA standards due to improper use of surge protectors. A refrigerator and a microwave were plugged into surge protectors in the basement level offices, which is unauthorized. This was confirmed during an exit interview with the Administrator and Maintenance Director.
The Healthcare Center at White Horse Village was found deficient in its Emergency Preparedness Plan, failing to address the resident population, persons at-risk, and continuity of operations. This was confirmed during a survey and an exit interview with the Administrator and Maintenance Director.
The facility failed to develop emergency preparedness policies and procedures that include a system of medical documentation to preserve patient information, protect confidentiality, and maintain record availability. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility's emergency preparedness plan was found deficient due to missing policies and procedures for using volunteers and integrating State and Federally designated health care professionals during emergencies. This deficiency, affecting the entire facility, was confirmed during a document review and exit interview with the Administrator and Maintenance Director.
The facility failed to provide documentation on its role under a waiver declared by the Secretary, as required by section 1135 of the Act. This deficiency was confirmed during a document review and an exit interview with the Administrator and Maintenance Director, affecting the entire facility's emergency preparedness.
The facility's emergency preparedness communication plan was found lacking a method for sharing patient information and medical documentation with other health care providers, affecting the entire facility. This deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director.
The facility's emergency preparedness communication plan was found lacking as it did not include a means of providing information about the ASC's needs and its ability to provide assistance to the authority having jurisdiction. This deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director.
The facility did not maintain an emergency preparedness communication plan that includes a method for sharing information with residents and their families. This deficiency was identified during a document review and confirmed in an interview with the Administrator and Maintenance Director.
The facility failed to store food in a sanitary manner, as required by policy. Surveyors found expired lime juice and illegible dates on liquid egg cartons in the main kitchen walk-in refrigerator. Additionally, unsealed frozen salmon was observed in the walk-in freezer. The Nursing Home Administrator and staff confirmed the issues, and the expired items were discarded.
Failure to Maintain and Inspect Sprinkler System
Penalty
Summary
The facility failed to maintain and inspect its sprinkler system as required, affecting the entire facility. During a document review on January 13, 2025, it was found that the facility could not provide documentation for a 3-year dry system full flow test and a 5-year internal valve and pipe inspection. This deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director.
Plan Of Correction
The proper documentation for the 3-year dry system full flow test and 5-year internal valve and pipe inspection was obtained from Metropolitan Fire Protection Co., Inc. The documentation will be kept on file and included in each annual documentation set as needed. Monthly audits will be done by the Maintenance Manager to ensure all documentation is current. All audits will be reviewed by the Director of Facilities and Plan Operations and submitted to the Quality Assurance Performance Improvement Committee monthly ongoing.
Failure to Maintain and Inspect Portable Fire Extinguishers
Penalty
Summary
The facility failed to maintain and inspect portable fire extinguishers in accordance with NFPA 10, affecting the entire facility. During a documentation review, it was found that the facility could not provide the certification for the technician responsible for the annual maintenance of the portable fire extinguishers. This deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director.
Plan Of Correction
The proper documentation was obtained from Clark Fire Protection. The certificate will be kept on file and updated as needed. Monthly audits will be done by the Maintenance Manager to ensure all documentation is current. All audits will be reviewed by the Director of Facilities and Plan Operations and submitted to the Quality Assurance Performance Improvement Committee monthly ongoing.
Fire Resistance Deficiency in Facility
Penalty
Summary
The facility failed to maintain the fire resistance rating of common wall fire separations, specifically affecting one of the three levels within the facility. During an observation on January 13, 2025, at 9:00 a.m., it was noted that the rated double doors near the basement loading dock did not fully close and positively latch when tested. This deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director at 10:15 a.m. on the same day.
Plan Of Correction
Rated Double Door has been adjusted to ensure the doors are smoke tight, close and positively latch to maintain their fire rating. Maintenance will conduct weekly audits for 4 weeks, then monthly audits to ensure doors are smoke tight. All audits will be reviewed by The Senior Director of Property and Facilities and submitted to the Quality Assurance Performance Improvement Committee on a monthly basis for 12 months.
Emergency Battery Back-Up Lighting Failure
Penalty
Summary
The facility failed to maintain emergency battery back-up lighting in operable condition, affecting one of three floors. During an observation on January 13, 2025, at 9:30 a.m., it was noted that the emergency battery back-up light nearest the generator in the South Hall basement Generator Room did not illuminate when tested. This deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director on the same day at 10:15 a.m.
Plan Of Correction
The emergency battery back-up light was replaced and tested as fully operable. Maintenance will conduct weekly audits for 4 weeks, then monthly audits to ensure the battery back-up light is fully operational. All audits will be reviewed by The Senior Director of Property and Facilities and submitted to the Quality Assurance Performance Improvement Committee on a monthly basis for 12 months.
Obstructed Access to Electrical Panel
Penalty
Summary
The facility failed to maintain clear accessibility to an electrical panel, which is a requirement for safety and compliance. During an observation on January 13, 2025, at 8:50 a.m., it was noted that a heater fan was obstructing access to an electrical panel located in the basement, adjacent to the kitchen storage room. This obstruction could potentially hinder quick access to the panel in case of an emergency, which is a critical safety concern. The deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director on the same day at 10:15 a.m. The interview verified that the blockage of the electrical panel was unauthorized, indicating a lapse in the facility's adherence to safety protocols. This oversight affected one of the three levels in the facility, highlighting a specific area where compliance with safety regulations was not met.
Plan Of Correction
The heater fan was removed at the time of survey on 1/13/2025 to ensure clear access to an electrical panel. Maintenance will conduct a daily audit for 30 days, then weekly audits are ongoing to ensure clear access to the electrical panel. Housekeeping, Laundry, Transportation, Maintenance, and Dining Staff will be in-serviced on keeping the electrical panels clear at all times. All audits will be reviewed by The Senior Director of Property and Facilities, and results submitted to the Quality Assurance Performance Improvement Committee on a monthly basis ongoing.
Smoke Doors Not Closing Smoke Tight
Penalty
Summary
The facility failed to maintain smoke doors in compliance with NFPA 101 standards, specifically affecting one of the three levels. During an observation on January 13, 2025, at 10:15 a.m., it was noted that the double corridor smoke doors at room 108 did not close smoke tight. This deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director at the same time and date.
Plan Of Correction
Both sets of doors have been adjusted to ensure doors are smoke tight and maintain their fire rating. Maintenance will conduct weekly audits for 4 weeks, then monthly audits to ensure doors are smoke tight. All audits will be reviewed by The Senior Director of Property and Facilities, and results submitted to the Quality Assurance Performance Improvement Committee on a monthly basis ongoing.
Improper Use of Surge Protectors in Facility
Penalty
Summary
The facility failed to comply with the National Fire Protection Association (NFPA) standards regarding the use of surge protectors, as observed during a survey. Specifically, the deficiency was noted on the basement level of the facility, where a refrigerator was plugged into a surge protector inside the Driver's Office, and a microwave was plugged into a surge protector inside the Security Office. These actions were identified as improper and unauthorized uses of surge protectors, which do not meet the required safety standards for electrical equipment in patient care areas. The deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director.
Plan Of Correction
The refrigerator and microwave plugs were removed from surge protectors at the time of inspection. The staff were in-serviced on proper use of outlet strips for electronics only. Maintenance will conduct weekly audits for 4 weeks, then monthly audits to ensure outlet strips are not used improperly. All audits will be reviewed by The Senior Director of Property and Facilities and submitted to the Quality Assurance Performance Improvement Committee on a monthly basis for 12 months. Emergency Plan - Plan of Correction
Deficiency in Emergency Preparedness Plan
Penalty
Summary
The Healthcare Center at White Horse Village was found to have deficiencies in its Emergency Preparedness Plan during a survey conducted on January 13, 2025. The facility failed to ensure that its policies and procedures adequately addressed the resident population, including persons at-risk, the type of services the facility could provide in an emergency, and the continuity of operations, including delegations of authority and succession plans. This deficiency was identified through a document review and confirmed during an exit interview with the Administrator and the Maintenance Director. The survey revealed that the facility's Emergency Preparedness Plan did not include the necessary documentation to address these critical areas, affecting the entire facility. The lack of documentation was confirmed during the exit interview, indicating a failure to comply with the requirements set forth in 42 CFR 483.73(a)(3). This deficiency has the potential for minimal harm, as it pertains to the facility's ability to effectively manage emergencies and ensure the safety and well-being of its residents.
Plan Of Correction
Facility established policy to define the patient population served, patients at risk and the types of services that the community can provide in an emergency to ensure continuity. The Senior Director of Property and Facilities will ensure the Emergency Operations Manual and related policies are reviewed on an annual basis. Results of review will be submitted by The Senior Director of Property and Facilities to the Quality Assurance and Performance Improvement Committee on an annual basis.
Deficiency in Emergency Preparedness Documentation
Penalty
Summary
The facility was found to be deficient in developing and implementing emergency preparedness policies and procedures that include a system of medical documentation. This system is required to preserve patient information, protect the confidentiality of patient information, and secure and maintain the availability of records. During a document review conducted on January 13, 2025, it was revealed that the facility failed to establish such a system, affecting the entire facility. An exit interview with the Administrator and the Maintenance Director confirmed the lack of documentation. This deficiency indicates that the facility did not comply with the regulatory requirements for emergency preparedness, specifically in maintaining a system that ensures the protection and availability of patient records. The absence of these policies and procedures could potentially impact the facility's ability to manage patient information effectively during emergencies.
Plan Of Correction
Facility established a policy for protection of privacy with appropriate users and disclosures of protected Health information during an emergency. The Senior Director of Property and Facilities will ensure the Emergency Operations Manual and related policies are reviewed on an annual basis. Results of review will be submitted by The Senior Director of Property and Facilities to the Quality Assurance and Performance Improvement Committee on an annual basis.
Deficiency in Emergency Preparedness Plan
Penalty
Summary
The facility was found deficient in its emergency preparedness plan due to the absence of policies and procedures addressing the use of volunteers and other emergency staffing strategies during an emergency. Specifically, the plan lacked documentation on the process and role for integrating State and Federally designated health care professionals to address surge needs during an emergency. This deficiency was identified during a document review conducted on January 13, 2025, at 8:00 a.m. During an exit interview with the Administrator and the Maintenance Director later that morning, the lack of documentation was confirmed. The deficiency affects the entire facility, as the emergency preparedness plan is a critical component in ensuring adequate staffing and resource allocation during emergencies. The absence of these policies and procedures indicates a gap in the facility's ability to effectively manage and respond to emergency situations.
Plan Of Correction
Facility established policy for the use of volunteers in an emergency or other staffing strategies. The Senior Director of Property and Facilities will ensure the Emergency Operations Manual and related policies are reviewed on an annual basis. Results of review will be submitted by The Senior Director of Property and Facilities to the Quality Assurance and Performance Improvement Committee on an annual basis.
Lack of Emergency Preparedness Documentation Under Waiver
Penalty
Summary
The facility failed to provide the necessary policy and procedure documentation regarding its role under a waiver declared by the Secretary, in accordance with section 1135 of the Act. This deficiency was identified during a document review conducted on January 13, 2025, at 8:00 a.m. The review revealed that the facility did not have an Emergency Preparedness Plan that included the required documentation concerning the roles under a waiver declared by the Secretary. An exit interview with the Administrator and the Maintenance Director confirmed the absence of this critical documentation. The lack of documentation affects the entire facility, as it pertains to the provision of care and treatment at an alternate care site identified by emergency management officials. This deficiency highlights a significant gap in the facility's emergency preparedness policies and procedures.
Plan Of Correction
Facility established policy to establish roles for providing care during emergencies under blanket or specific $1135 waivers. The Senior Director of Property and Facilities will ensure the Emergency Operations Manual and related policies are reviewed on an annual basis. Results of review will be submitted by The Senior Director of Property and Facilities to the Quality Assurance and Performance Improvement Committee on an annual basis.
Deficiency in Emergency Preparedness Communication Plan
Penalty
Summary
The facility's emergency preparedness communication plan was found to be deficient as it did not include a method for sharing information and medical documentation for patients with other health care providers. This deficiency was identified during a document review conducted on January 13, 2025, at 8:00 a.m. The absence of this critical component in the communication plan affects the entire facility, as it is essential for maintaining the continuity of care during emergencies. During an exit interview with the Administrator and the Maintenance Director on the same day at 10:30 a.m., it was confirmed that the facility lacked the necessary documentation to support the sharing of patient information and medical documentation. This oversight in the emergency preparedness communication plan indicates a failure to comply with the regulatory requirements, which mandate the inclusion of such methods to ensure effective communication and continuity of care in emergency situations.
Plan Of Correction
The facility established policy to share appropriate information from the facility's emergency plan with residents and their representatives. The Senior Director of Property and Facilities will ensure the Emergency Operations Manual and related policies are reviewed on an annual basis. Results of the review will be submitted by the Senior Director of Property and Facilities to the Quality Assurance and Performance Improvement Committee on an annual basis.
Deficiency in Emergency Preparedness Communication Plan
Penalty
Summary
The facility's emergency preparedness communication plan was found to be deficient as it did not include a means of providing information about the Ambulatory Surgical Center's (ASC) needs and its ability to provide assistance to the authority having jurisdiction, the Incident Command Center, or designee. This deficiency was identified during a document review conducted on January 13, 2025, at 8:00 a.m. During an exit interview with the Administrator and the Maintenance Director on the same day at 10:30 a.m., it was confirmed that the facility lacked the necessary documentation in its emergency preparedness communication plan. This oversight affects the entire facility, as it fails to comply with the requirement to maintain a comprehensive communication plan that includes the ASC's needs and capabilities.
Plan Of Correction
Facility established policy to provide information about the community's occupancy, needs and its ability to provide assistance, to authorities having jurisdiction. The Senior Director of Property and Facilities will ensure the Emergency Operations Manual and related policies are reviewed on an annual basis. Results of review will be submitted by The Senior Director of Property and Facilities to the Quality Assurance and Performance Improvement Committee on an annual basis.
Deficiency in Emergency Preparedness Communication Plan
Penalty
Summary
The facility failed to maintain and update an emergency preparedness communication plan that includes a method for sharing information from the emergency plan with residents and their families or representatives. During a document review on January 13, 2025, at 8:00 a.m., it was revealed that the emergency communications plan lacked this essential component, affecting the entire facility. This deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director on the same day at 10:30 a.m., where the lack of documentation was acknowledged.
Plan Of Correction
Facility established policy to share appropriate information from the facility's emergency plan with residents and their representatives. The Senior Director of Property and Facilities will ensure the Emergency Operations Manual and related policies are reviewed on an annual basis. Results of review will be submitted by The Senior Director of Property and Facilities to the Quality Assurance and Performance Improvement Committee on an annual basis.
Deficiency in Food Storage Practices
Penalty
Summary
The facility failed to store food in a sanitary manner in the kitchen, as observed during a survey. The facility's policy requires all food items in the refrigerator or freezer to be covered, labeled, dated, and discarded once expired. However, during an inspection of the main kitchen walk-in refrigerator, surveyors found an opened container of expired lime juice without a date of first use and three unopened expired containers of lime juice. Additionally, a case of liquid egg cartons was found with illegible dates, and a box with a bag of unsealed frozen salmon was observed in the walk-in freezer. The Nursing Home Administrator and Employee E3 confirmed the illegible dates and expired items, which were discarded at the time of the findings. Employee E3 stated that the expired eggs had recently arrived from the distributor and were dated at the facility. The Nursing Home Administrator confirmed that all food should be sealed, labeled, and dated appropriately, and discarded once expired.
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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