Highlands Rehabilitation And Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Laporte, Pennsylvania.
- Location
- 918 Main Street, Laporte, Pennsylvania 18626
- CMS Provider Number
- 395683
- Inspections on file
- 25
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Highlands Rehabilitation And Healthcare during CMS and state inspections, most recent first.
The facility failed to maintain emergency lighting in the basement mechanical room, affecting one floor. The emergency light did not function properly when the power was turned off, although it worked with the test button. This was confirmed during an interview with the facility administrator.
The facility failed to maintain its sprinkler systems, with deficiencies found in five locations across three floors. Missing escutcheons were noted in the 3rd floor Oxygen Storage room and corridor, an unsealed ceiling tile penetration was found in the 1st floor Dietary area, and the Basement Level had missing escutcheons and lacked a wrench for sprinkler head replacement. These issues were confirmed with the facility administrator.
The facility failed to maintain the soiled linen and rubbish chutes as the 1st floor laundry chute door did not latch properly, affecting three of four floors. This was confirmed during an interview with the facility administrator.
The facility was found to be in violation of building construction requirements as it was observed to be three stories in height, exceeding the maximum allowable story height for its documented construction type, Type II (000). This deficiency was confirmed by the facility administrator during an exit conference.
The facility failed to maintain or improve the range of motion and mobility for four residents due to unclear restorative nursing policies and inadequate documentation. Residents required specific ROM exercises and ambulation assistance, but the frequency and shift-specific instructions were not provided, leading to incomplete care across shifts.
A facility failed to provide written notice of its bed-hold policy to a resident and their representative during a hospitalization. The resident was transferred to the hospital with stroke-like symptoms, and although the resident's sister was informed of the transfer, there was no evidence of written communication regarding the bed-hold policy. The Bed Hold Notice contained conflicting information, and the facility could not provide evidence of compliance with resident rights.
A facility failed to ensure an accurate MDS assessment for a resident with Schizophrenia. The resident's PASRR Level 1 and Level 2 evaluations indicated a mental health condition and eligibility for services, but the MDS inaccurately stated the resident was not considered to have a serious mental illness. This discrepancy was confirmed by the Nursing Home Administrator and DON.
The facility failed to revise care plans for three residents, leading to deficiencies in care. A resident's care plan did not include interventions to minimize anxiety and aggression, another resident's dental issues were not addressed in their care plan, and a third resident's care plan was not updated to reflect missing dentures. Interviews confirmed these deficiencies.
A facility failed to maintain a resident's ability to perform daily activities, specifically ambulation, due to inadequate staff follow-through. Despite a good prognosis with consistent support, the resident reported infrequent assistance with walking. Documentation showed multiple instances where the ambulation program was not attempted or marked as refused without re-approaching the resident, resulting in limited program completion.
A facility failed to implement physician-ordered supplemental oxygen for a resident, as staff did not routinely assess the resident's oxygen saturation levels to determine the need for supplemental oxygen. Despite a physician's order to administer oxygen at two liters per minute to maintain saturation levels above 90%, records showed no routine assessments were conducted. An observation revealed no supplemental oxygen in use, and no evidence of saturation assessments was found in the clinical record.
A facility failed to create an individualized care plan for a resident with dementia, despite the diagnosis being confirmed in an MDS assessment. The lack of a person-centered care plan was only addressed after a surveyor highlighted the issue, which was acknowledged by the facility's administration.
A resident's partial dentures went missing for eight months to a year, and the facility failed to provide timely replacement. Despite assessments by the facility's dental provider, there was no documentation of when the dentures were lost, and the facility lacked a policy for handling such incidents.
The facility failed to document that two residents with severe cognitive impairment or their representatives were educated on the risks and benefits of influenza and pneumococcal vaccinations. One resident's consent form lacked a signature, and the other resident's forms were undated, with no evidence of education provided to their responsible parties.
The facility failed to document that a resident's representative was educated on the risks and benefits of the COVID-19 vaccine, despite the resident's severe cognitive impairment. The resident, diagnosed with dementia, signed the consent form and received the vaccine without evidence of the responsible party's informed decision. The issue was confirmed by the infection preventionist and reported to the Nursing Home Administrator and DON.
The facility failed to provide timely written notifications to residents and their responsible parties regarding hospital transfers, as required by regulations. Five residents were transferred without proper documentation of notifications, including necessary information such as reasons for transfer, appeal rights, and contact details for the State Ombudsman. The Nursing Home Administrator confirmed the lack of compliance, and the facility did not submit transfer notices to the State Ombudsman until after the issue was identified during the survey.
A facility failed to complete a discharge summary within 30 days of a resident's death. A review of the resident's closed clinical record showed that while the resident was documented as deceased, the required discharge summary, including the final diagnosis and cause of death, was not completed in the specified timeframe. This deficiency was identified through record review and staff interviews.
The facility failed to meet the required nurse aide staffing levels during the evening and overnight shifts on specific days. Discrepancies in staffing calculations were identified, as staff were recorded as providing more hours than scheduled, leading to incorrect data. Despite multiple requests, accurate staffing information was not provided, confirming the shortfall in nurse aide staffing.
The facility did not meet the required LPN staffing levels on three separate days. During the day shift, the facility had insufficient LPNs for the resident census on two occasions, and during the overnight shift, the facility also fell short of the required LPNs for the resident census on one occasion. These deficiencies were identified through a review of nursing care hours and discussed with the Nursing Home Administrator and the DON.
The facility did not meet the required minimum of 3.2 hours of direct resident care per patient per day on four occasions. The review showed deficiencies in nursing care hours on specific days, with PPD hours falling short of the mandated requirement. These findings were discussed with the facility's administration.
A resident with dementia was found with a fractured arm after being pushed out of bed by her roommate, who has bipolar disorder. The incident was unwitnessed by staff, but the roommate later admitted to the act. The facility moved the aggressive resident to a different room and placed her on 15-minute checks, but failed to prevent the abuse.
The facility failed to maintain safe and comfortable temperature levels, with readings exceeding the recommended range on both the second and third floors. Residents expressed discomfort due to the heat, and the issue was attributed to the need for a replacement of the chiller and control panel. Approval for the chiller replacement was received, but no date was set for repairs, and approval for the control panel was pending.
The facility failed to ensure an effective infection control program for outbreak testing and transmission-based precautions. A resident had droplet precautions discontinued prematurely, and another resident had no documented evidence of transmission-based precautions. The facility did not initiate proper testing protocols after identifying symptomatic COVID-19 cases, leading to at least 55 reported cases.
The facility failed to implement their abuse policy and investigate an allegation of abuse between two residents. Despite a physical incident being reported and witnessed by a housekeeper, there was no documented evidence of an investigation or assessment of injuries. The housekeeper's statement was observed being written during the surveyor's visit, despite being dated for a previous year. Interviews with the Administrator and DON confirmed these findings.
A facility failed to administer the correct dosage of physician-ordered Morphine Sulfate for a resident. The MAR showed that a nurse administered 0.5 ml instead of the prescribed 0.75 ml on two occasions, with no evidence of as-needed doses being given. The Administrator confirmed no reported medication errors and verified the findings.
Emergency Lighting Deficiency in Mechanical Room
Penalty
Summary
The facility failed to maintain emergency lighting in the basement level mechanical room, affecting one of four floors. During an observation on January 29, 2025, at 10:50 am, it was noted that the emergency light did not function properly and failed to illuminate when the power was turned off in the room, although it worked when using the test button. This deficiency was confirmed during an interview with the facility administrator at the time of the exit conference on the same day.
Plan Of Correction
Emergency light in basement was rewired on 1/31/2025 and is now functioning properly. Maintenance director completed an audit to verify emergency lights in the facility are functioning properly. Maintenance Director was educated on maintaining emergency lighting by NHA. Maintenance director/designee will audit functionality of emergency lights weekly x4 and monthly x3 and report findings to monthly QAPI committee.
Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain its required sprinkler systems, as evidenced by observations and interviews conducted during a survey. The deficiencies were identified in five locations across three of the four floors of the facility. Specifically, on the 3rd floor, the Oxygen Storage room and a corridor near the Nurses' station were missing escutcheons. On the 1st floor, the Dietary area had an unsealed penetration of a ceiling tile near the dishwasher. In the Basement Level, the Maintenance Shop was missing an escutcheon, and the Tank Room's sprinkler box lacked a wrench for sprinkler head replacement. These deficiencies were confirmed during an exit conference with the facility administrator.
Plan Of Correction
Escutcheons were installed in the 3rd floor oxygen room, 3rd floor corridor, and maintenance shop on 2/3/2025. Ceiling tile in dietary was replaced on 1/30/2025. A sprinkler wrench was purchased and placed in the sprinkler box on 1/31/2025. The Maintenance Director audited facility sprinklers to verify escutcheons in place and ceiling tiles in the dietary department. The Maintenance Director was educated on maintaining the facility's sprinkler system by NHA. The Maintenance Director/designee will audit sprinklers to verify escutcheons are in place, the sprinkler box to verify the wrench is in place, and the dietary ceiling tiles weekly for 4 weeks and monthly for 3 months, and report findings to the monthly QAPI committee.
Failure to Maintain Laundry Chute Door Latching Mechanism
Penalty
Summary
The facility failed to maintain the soiled linen and rubbish chutes in compliance with NFPA 101 standards. During an observation on January 29, 2025, at 10:27 am, it was noted that the discharge laundry chute door on the 1st floor did not latch into the frame when tested. This issue affected three of the four floors in the facility. The deficiency was confirmed during an interview with the facility administrator at the time of the exit conference on the same day at 11:00 am.
Plan Of Correction
The laundry chute was repaired on 2/5/2025. Maintenance director/designee completed an audit to verify facility chutes function properly. Maintenance Director was educated on maintaining laundry chute latch by NHA. Maintenance director/designee will audit facility chutes to verify latching weekly x4 and monthly x3 and report findings to monthly QAPI committee.
Building Construction Type Violation
Penalty
Summary
The facility was found to be in violation of building construction requirements as it was observed to be three stories in height, which exceeds the maximum allowable story height for its documented construction type, Type II (000). According to the National Fire Protection Association (NFPA) 101 Life Safety Code, a Type II (000) building is not permitted to have any stories if it is non-sprinklered. This deficiency was identified during an observation on January 29, 2025, at 9:50 am. The facility administrator confirmed during an exit conference on the same day that the facility indeed exceeded the maximum allowable story height by one floor.
Plan Of Correction
FSES was completed on 8/26/2024. Facility will maintain an up to date FSES.
Failure to Maintain or Improve Residents' Range of Motion and Mobility
Penalty
Summary
The facility failed to provide adequate services to maintain or improve the range of motion (ROM) and mobility for four residents. The facility's policy on Restorative Nursing Services lacked specific guidelines on the frequency and expectations for completing restorative nursing program interventions. This lack of clarity contributed to the failure in implementing the necessary care for the residents. Resident 19 had a therapy restorative referral indicating a decrease in active ROM, requiring passive range of motion (PROM) exercises for their lower extremities. However, the frequency and specific shifts for these exercises were not documented, and the PROM task was only opened for completion during the day shift, leaving evening and night shifts without documentation of completion. Similarly, Resident 48 required ambulation assistance and PROM for their right elbow, but the frequency and specific shifts were not indicated, and the tasks were only documented during the day shift. Additionally, there was a failure to transition from an active ROM program to a PROM program as indicated by therapy. Resident 59's therapy referral indicated a decrease in ROM for their lower and right upper extremities, but the referral incorrectly implemented a program for the left upper extremity. The PROM task was only documented during day and evening shifts. Resident 74 required PROM exercises and orthotic application for their right hand, but the frequency and specific shifts were not indicated, and documentation was lacking for evening and night shifts. There was also no documentation for the application and removal of the orthotic, and several shifts were marked as not applicable or lacked documentation entirely.
Plan Of Correction
1. Residents 19, 48, 59, and 74 had their restorative programs reevaluated. 2. DON/designee audited current residents on a restorative program and were reevaluated with specific frequency. 3. Therapy/licensed staff will be re-educated on providing nursing with a frequency the restorative nursing program should be conducted. 4. NHA/designee will audit 5 random residents receiving restorative services to verify there is a frequency weekly x4 and monthly x3. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Failure to Provide Bed-Hold Policy Notice
Penalty
Summary
The facility failed to provide written notice regarding its bed-hold policy to a resident and the resident's representative during a hospitalization event. The resident, who was hospitalized with symptoms suggestive of a stroke, was transferred to the hospital from the facility. Nursing documentation indicated that the resident's sister was informed of the transfer, but there was no evidence that written information about the bed-hold policy was provided to her. A review of the Bed Hold Notice revealed inconsistencies, as it was documented that the resident was unable to sign, and the notice contained conflicting information about the resident's wishes regarding bed retention. The surveyor requested evidence of written communication to the resident's representative, but the facility could not provide it. This failure to provide written notice within 24 hours of the emergency transfer constitutes a deficiency in the facility's compliance with resident rights and responsibilities.
Plan Of Correction
1. Facility cannot retroactively correct bed hold notification to resident 63. 2. Business office manager/designee completed an audit of the last month of discharges and any missed bed hold notifications were addressed. 3. Nursing staff will be re-educated on providing bed hold notification to residents and resident representatives upon transfer out of the facility. 4. DON/designee will conduct random audits of transfers to verify proper bed hold notification weekly x4 and monthly x3. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Inaccurate MDS Assessment for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure a complete and accurate Minimum Data Set (MDS) assessment for one resident. Resident 34, who was admitted with a diagnosis of Schizophrenia, had a PASRR Level 1 form indicating a mental health condition that could lead to a chronic disability, necessitating a PASRR Level 2 evaluation. The PASRR Level 2 evaluation confirmed the presence of a mental health condition and eligibility for mental health services. However, the resident's last comprehensive MDS assessment inaccurately stated that the resident was not considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. This discrepancy was identified during a review of the resident's clinical record and confirmed by the Nursing Home Administrator and Director of Nursing.
Plan Of Correction
1. Resident 34's MDS was corrected. 2. Social services/designee completed an audit of residents with PASRR level 2 to verify Section A1500 is correct. 3. Social Service director was re-educated on completing accurate MDS assessments. 4. Social worker/designee will conduct random audits of PASRR level 2 residents to verify Section A1500 accuracy weekly x4 and monthly x3. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to revise the care plans for three residents, leading to deficiencies in their care. For Resident 79, the care plan did not include interventions to minimize anxiety and aggression by attempting care with one staff member or offering diet soda as suggested by the resident's daughter. Despite documentation indicating these suggestions, the care plan was not updated, and staff continued to provide care with two staff members without offering the diet soda. Resident 81's care plan was not developed to address dental health concerns despite multiple indications of dental issues, including tooth pain and decaying teeth. The facility's consultant dentist had documented these issues, but the registered nurse assessment coordinator did not review the dental progress notes when completing the MDS assessment, resulting in an inaccurate assessment that did not trigger a dental care plan. Resident 86's care plan was not revised to reflect the loss of her partial dentures, which had been missing for eight months to a year. Although the facility's consultant dental provider had assessed Resident 86 for new dentures, the care plan still indicated that she had partial dentures, failing to address her current needs. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed these deficiencies in care plan revisions.
Plan Of Correction
1. Resident 79's care plan was updated to include attempt care with 1 staff member and their tasks updated to include providing a diet coke. Resident 81's care plan was updated with a dental plan of care. Resident 86's care plan was updated with her current dental status. Resident 81's care plan was updated to include a dental plan. Resident 86's care plan was updated with her current dental status. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary. 2. Care conferences and consultant dental visit notes from the last 30 days were reviewed by RNAC/designee to verify any interventions/changes that were noted were added to the resident's care plan. 3. DON or designee will re-educate IDT and licensed staff on care planning and consultant dental visit interventions/changes. 4. DON or designee will complete random audits of care plan meetings and consultant dental visit notes to verify interventions/changes are discussed are added to the resident's care plan and captured on the MDS weekly X 4 then monthly X 3. Results of the audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Failure to Maintain Resident's Ambulation Program
Penalty
Summary
The facility failed to maintain or improve the ability of a resident to perform activities of daily living, specifically ambulation, due to insufficient staff follow-through. Resident 12, who was discharged from physical therapy with a home exercise program (HEP) and a good prognosis contingent on consistent staff support, reported that staff rarely assisted her with walking due to staffing shortages. Documentation revealed that on multiple occasions, staff marked the ambulation program as not applicable or noted the resident's refusal without re-approaching her to encourage participation. Throughout November 2024 to January 2025, there were numerous instances where Resident 12's ambulation program was either not attempted or marked as refused without further attempts to engage her. This lack of consistent follow-up and encouragement from staff resulted in the resident completing the program on only a fraction of the days reviewed. The deficiency was discussed with the Nursing Home Administrator and the Director of Nursing, highlighting the facility's failure to provide adequate care and services to maintain or improve the resident's functional abilities.
Plan Of Correction
1. Facility cannot retroactively provide restorative program to Resident 12 the days restorative was not completed. Resident 12 is currently receiving physical therapy. 2. DON/designee audited documentation from the last week of residents receiving restorative nursing program to verify residents are provided their program. 3. CNAs will be re-educated on the documentation of and providing restorative nursing services. 4. DON/designee will audit 5 random residents on a restorative nursing program weekly x4 and monthly x3. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Failure to Implement Physician-Ordered Supplemental Oxygen
Penalty
Summary
The facility failed to implement physician-ordered supplemental oxygen for a resident, identified as Resident 63, in accordance with professional standards of practice. A physician's order dated November 11, 2024, required staff to administer supplemental oxygen at two liters per minute as needed to maintain oxygen saturation levels above 90 percent. However, a review of the resident's medication and treatment administration records for November 2024, December 2024, and January 2025 revealed that staff did not routinely assess the resident's oxygen saturation levels to determine the need for supplemental oxygen. On January 13, 2025, an observation of Resident 63 showed no supplemental oxygen in use, and there was no evidence in the clinical record that staff had assessed the resident's oxygen saturation to confirm that supplemental oxygen was not needed. This deficiency was discussed with the Nursing Home Administrator and the Director of Nursing on January 14, 2025.
Plan Of Correction
1. Resident 63's order was revised to evaluate the need for supplemental oxygen. 2. DON/designee conducted an audit of residents receiving oxygen to verify evaluation is conducted when indicated. 3. Nursing staff will be re-educated on obtaining oxygenation saturation assessments if indicated. 4. DON/designee will audit 5 random residents on oxygen to verify evaluation of oxygenation saturation when indicated weekly x4 and monthly x3. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Failure to Implement Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized person-centered care plan for a resident diagnosed with dementia. The resident was admitted on October 31, 2024, with a diagnosis of dementia, which affects memory, language, problem-solving, and other cognitive abilities. The resident's most recent annual Minimum Data Set Assessment, dated November 6, 2024, confirmed the diagnosis of dementia. Despite this, the facility did not create a specific care plan to address the resident's cognitive loss until it was pointed out by a surveyor on January 15, 2025. This oversight was acknowledged by the Nursing Home Administrator and Director of Nursing during a review of the findings.
Plan Of Correction
1. Facility made revisions to individualize resident 43's care plan relating to her dementia. 2. Social services/designee reviewed residents with a dementia diagnosis to verify each had individualized dementia care plans. 3. Nursing staff and social services will be re-educated on implementing individualized person-centered care plans to address dementia and cognitive loss. 4. DON/designee will conduct random audits of 5 residents with dementia to verify their care plans are individualized weekly x4 and monthly x3. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Failure to Provide Routine Dental Services for Resident
Penalty
Summary
The facility failed to provide routine dental services for a resident, specifically concerning the replacement of missing partial dentures. Resident 86, who had partial dentures for both the upper and lower jaw, reported that her dentures had been missing for a period ranging from eight months to a year. Despite the resident's indication that the facility's consultant dental provider was supposed to be making new dentures, there was no documentation or grievance form available to confirm when the dentures went missing. An observation of Resident 86 revealed that she had natural teeth and was missing some teeth, which corroborated her claim of missing dentures. The clinical record review showed that the resident's plan of care, created upon admission, acknowledged her need for partial dentures. A progress note from the facility's consultant dental provider dated October 29, 2024, indicated that an assessment of the resident's bite for the molds of new partial dentures had been conducted, marking it as the second assessment. However, the facility lacked a policy or procedure to address the loss or damage of resident property, including dentures, as confirmed by the Nursing Home Administrator and the Director of Nursing. This deficiency highlights the facility's failure to ensure the timely replacement of essential dental appliances for the resident.
Plan Of Correction
1. Resident 86 has a follow up dental appointment to receive her new partials. 2. Social services/designee conducted an audit of residents with partial/ dentures to verify all are accounted for. Findings were addressed at the time of the audit. 3. Social services will be re-educated on notifying dental services within 3 days after partial/dentures are reported missing. 4. Unit manager/designee will conduct random audits of 5 residents with partial/ dentures to verify they are accounted for weekly x4 and monthly x3. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Failure to Document Immunization Education for Cognitively Impaired Residents
Penalty
Summary
The facility failed to ensure that residents' medical records included documentation that residents' representatives were provided education regarding the risks and benefits of immunizations. This deficiency was identified for two residents with severe cognitive impairment. Resident 21's clinical record showed no evidence that she or her responsible party received education about the risks and benefits of the influenza vaccination before it was administered. Despite a psychiatric note indicating that Resident 21 was awake, alert, and oriented, she was unable to confirm if she consented to the vaccination during an interview. Similarly, Resident 46's records revealed that she signed the consent forms for both influenza and pneumococcal vaccinations, but the forms lacked dates, and there was no evidence that her responsible party was informed about the risks and benefits of these vaccinations. Given Resident 46's diagnosis of dementia and severe cognitive impairment, she was not capable of making informed medical decisions independently. The facility's failure to provide the necessary education to the residents' representatives was confirmed by the infection preventionist during an interview.
Plan Of Correction
1. Facility cannot retroactively provide Influenza vaccine informed consent to resident 21 and 46's representatives. Facility cannot retroactively provide Pneumococcal vaccine informed consent to resident 46's representative. 2. Infection preventionist/designee conducted an audit of the last two weeks of influenza and pneumococcal vaccines given to verify resident representatives were provided the informed consent. 3. Infection preventionist will be re-educated on educating resident representatives on the Influenza and Pneumococcal vaccine informed consents prior to vaccination. 4. DON/designee will conduct random audits of Influenza and Pneumococcal vaccination consent forms weekly x4 and monthly x3. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Failure to Document COVID-19 Vaccine Education for Resident's Representative
Penalty
Summary
The facility failed to ensure that a resident's medical records included documentation that the resident's representative was provided education regarding the risks and benefits of receiving a COVID-19 immunization. This deficiency was identified for one of five residents reviewed for immunization concerns. Specifically, Resident 46, who had a severe cognitive impairment as indicated by a BIMS score of three, signed a consent form for the COVID-19 vaccine. However, the facility did not provide evidence that the resident's responsible party was educated about the vaccine's risks and benefits, which was necessary given the resident's incapacity to make informed medical decisions. The clinical record review revealed that Resident 46 had a diagnosis of dementia and was alert with confusion. Despite this, the resident signed the COVID-19 vaccine consent form, and the vaccine was administered. An interview with the facility's infection preventionist confirmed the lack of documentation regarding the education of the resident's responsible party. The Nursing Home Administrator and Director of Nursing were informed of these concerns, which were previously cited as a deficiency in February 2024.
Plan Of Correction
1. Facility cannot retroactively provide the COVID vaccine informed consent to resident 46's representative. 2. Infection preventionist/designee conducted an audit of the last two weeks of COVID vaccines given to verify resident representatives were provided the informed consent. 3. Infection preventionist will be re-educated on educating resident representatives on the COVID vaccine informed consent prior to vaccination. 4. DON/designee will conduct random audits of COVID vaccination consent forms weekly x4 and monthly x3. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Failure to Provide Required Transfer Notifications
Penalty
Summary
The facility failed to provide timely written notification to residents and their responsible parties regarding transfers to the hospital, as required by regulations. This deficiency was identified for five residents, who were transferred to the hospital due to changes in their conditions. The clinical records for these residents did not contain documentation of written notifications that included necessary information such as the reason for transfer, effective date, location, appeal rights, and contact information for the State Ombudsman and advocacy agencies. The Nursing Home Administrator confirmed that the facility did not provide the required written notices and had not submitted any transfer notices to the State Ombudsman for several months until after the survey process highlighted the issue. Specific cases included Resident 59, who was transferred on December 1, 2024, without the required written notification. Resident 91 and Resident 98 were also transferred without proper notification, and the State Ombudsman was not informed in a timely manner. Resident 63 experienced two hospitalizations, and in both instances, neither the resident nor the resident's representative received the required written notices. The facility was unable to provide evidence of compliance with notification requirements during interviews with the surveyor, indicating a systemic issue in adhering to regulatory standards for resident transfers.
Plan Of Correction
1. Facility cannot retroactively correct transfer notification to residents 59, 63, 91, 18, and 98. 2. Business office manager/designee completed an audit of the last month of discharges and any missed transfer notifications were addressed. 3. Nursing staff will be re-educated on providing notification to residents and resident representatives upon transfer out of the facility. 4. DON/designee will conduct random audits of transfers to verify proper notification weekly x4 and monthly x3. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Failure to Complete Discharge Summary Within 30 Days
Penalty
Summary
The facility failed to complete a discharge summary within 30 days of a resident's death, as required by regulation. A closed clinical record review for a resident revealed that nursing documentation noted the resident was without pulse or respirations and was pronounced deceased. However, the review also showed that no discharge summary, including the final diagnosis and cause of death, was completed within the required timeframe. This deficiency was identified during a closed clinical record review and confirmed through staff interviews.
Plan Of Correction
1. Facility cannot retroactively provide resident 100's discharge summary. 2. Medical records director/designee conducted an audit of the last 2 weeks of discharges to verify discharge summaries have been completed. 3. Providers will be re-educated on providing discharge summaries. 4. DON/designee will audit discharges to verify they have completed discharge summaries weekly x4 and monthly x3. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Deficiency in Nurse Aide Staffing Levels
Penalty
Summary
The facility failed to meet the required nurse aide staffing levels during the evening and overnight shifts for specific days reviewed. Specifically, the facility did not ensure a minimum of one nurse aide per 11 residents during the evening shift on two occasions and one nurse aide per 15 residents during the overnight shift on three occasions. This deficiency was identified through a review of nursing staffing hours and staff interviews conducted during an onsite survey. The survey revealed discrepancies in the staffing calculations, as staff were recorded as providing more hours of care than their scheduled shifts, leading to incorrect staffing data. Despite multiple requests from the surveyor, the facility was unable to provide accurate nurse staffing information. The review of nursing care hours for specific dates confirmed the shortfall in nurse aide staffing, which was discussed with the Nursing Home Administrator and the Director of Nursing.
Plan Of Correction
1. Facility cannot retroactively correct nurse aide staffing ratio. 2. Director of Nursing/Designee will conduct an initial audit of the past two weeks' schedule to determine if nurse aide ratio is in compliance. 3. Director of Nursing/Designee will re-educate the scheduler on the proper nurse aide staffing ratios. The facility will hold labor meetings Monday-Friday to verify ratios are made. 4. Director of Nursing/Designee will conduct random audits of nurse aide staffing weekly for four weeks, then monthly for two months thereafter to verify proper nurse aide ratios. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
LPN Staffing Deficiency on Day and Overnight Shifts
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) during specific shifts on three separate days. On two occasions during the day shift, the facility did not provide the minimum required number of LPNs per resident. Specifically, on October 6, 2024, and November 24, 2024, the facility had 4.03 and 4.0 LPNs respectively for a census of 103 residents, whereas 4.12 LPNs were required. Additionally, on October 12, 2024, during the overnight shift, the facility provided 2.06 LPNs for a census of 104 residents, falling short of the required 2.60 LPNs. These deficiencies were identified through a review of nursing care hours and were discussed with the Nursing Home Administrator and the Director of Nursing on January 16, 2025.
Plan Of Correction
1. Facility cannot retroactively correct LPN staffing ratio. 2. Director of Nursing/Designee will conduct an initial audit of the past two weeks schedule to determine if LPN ratio is in compliance. 3. Director of Nursing/Designee will re-educate the scheduler on the proper LPN staffing ratios. The facility will hold labor meetings Monday-Friday to verify ratios are made. 4. Director of Nursing/Designee will conduct random audits of LPN staffing weekly for four weeks, then monthly for two months thereafter to verify proper LPN ratios. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Deficiency in Meeting Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per patient per day (PPD) for four specific days across three different periods. The review of nursing staff care hours revealed deficiencies on October 6, 11, and 12, 2024, and November 24, 2024, with PPD hours recorded as 3.17, 3.08, 3.14, and 3.18, respectively. This shortfall was identified during a review of nursing staffing hours and confirmed through staff interviews. The findings were discussed with the Nursing Home Administrator and the Director of Nursing on January 16, 2025.
Plan Of Correction
1. Facility cannot retroactively correct staffing PPD. 2. Director of Nursing/Designee will conduct an initial audit of the past two weeks' schedule to determine if PPD is in compliance. 3. Director of Nursing/Designee will re-educate the scheduler on the proper PPD. The facility will hold labor meetings Monday-Friday to verify PPD is made. 4. Director of Nursing/Designee will conduct random audits of facility PPD weekly for four weeks, then monthly for two months thereafter to verify proper PPD hours. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Resident-to-Resident Abuse Incident
Penalty
Summary
Highlands Rehabilitation And Healthcare Center was found to be non-compliant with the requirement to protect residents from abuse, as evidenced by an incident involving two residents. Resident 1, who was admitted with unspecified dementia, was found on the floor with a fracture to her right arm after reportedly being pushed out of bed by her roommate, Resident 2. Resident 1 expressed fear and pain following the incident, which was unwitnessed by staff. The facility's documentation confirmed the injury and Resident 1's statement about being pushed. Resident 2, who has a diagnosis of bipolar disorder and was assessed with intact cognition, initially denied involvement but later admitted to pushing Resident 1. The incident occurred after Resident 2 was observed leaving the room and later admitted to the police and staff that she had pushed her roommate. The facility responded by moving Resident 2 to a different room and placing her on 15-minute checks for safety. Despite these measures, the facility failed to prevent the abuse from occurring. Interviews with staff revealed that Resident 2 had been acting differently due to the recent death of another resident she was close to. The Director of Nursing noted that Resident 2 was attention-seeking and initially denied the incident. The facility's investigation included witness statements from staff who confirmed Resident 2's admission of pushing Resident 1. The report highlights the facility's failure to protect Resident 1 from physical abuse by another resident, as required by federal and state regulations.
Plan Of Correction
1. R1 remains in the facility. Sling intact to right arm and pain controlled. She continues to have no recollection of the events and is happy in her new room. Social work visits completed. R2 remains in the facility. Medical follow up complete. ABT completed. Psych services continue to follow. Social work visits completed. She remains happy in her new room. 2. Residents on 3rd floor with a BIMS score of 8 or higher were interviewed/assessed for potential abuse. 3. DON/Designee reeducated abuse policies, investigation procedure and documentation process. Nurse aides and Licensed Nurses have been educated on documenting behaviors. 4. DON/SW/Designee will perform random audits of 5 resident's behaviors in nursing notes or EMAR/ETAR to ensure care plans updated weekly X 8, then monthly X 1. Results will be brought to QAPI.
Facility Fails to Maintain Safe Temperature Levels
Penalty
Summary
The facility failed to maintain comfortable and safe temperature levels between 71 and 81 degrees Fahrenheit on both the second and third floors. Observations on October 19, 2024, revealed that temperatures in various resident rooms and medication rooms exceeded the recommended range, with readings as high as 88 degrees Fahrenheit. Interviews with multiple residents confirmed that the facility was too warm, with several residents expressing discomfort and a preference for cooler temperatures. Fans were provided to help alleviate the heat, but residents reported that they were not very effective. The Director of Nursing and the maintenance director confirmed the warm temperatures and attributed the issue to the need for a replacement of the chiller and control panel. While approval had been received to replace the chiller, there was no scheduled date for the repairs, and approval for the control panel replacement was still pending. This deficiency was previously cited on February 9, 2024, under the regulation 483.10(i)(1)-(7) for maintaining a safe, clean, comfortable, and homelike environment.
Failure to Implement Effective Infection Control Program
Penalty
Summary
The facility failed to ensure an effective infection control program for outbreak testing and transmission-based precautions on one of its nursing units. The policy for COVID-19 testing requires immediate testing and follow-up tests 48 hours apart until no new cases are detected for 14 days. Additionally, residents with COVID-19 should be on transmission-based precautions for at least 10 days. However, Resident 1, who tested positive and was symptomatic, had droplet precautions discontinued after only seven days. Resident 2, who also tested positive and was symptomatic, had no documented evidence of how long transmission-based precautions were maintained, nor was there a physician order to start or discontinue droplet precautions. The facility did not initiate either contact tracing or a broad-based testing approach after identifying symptomatic COVID-19 cases starting on March 26, 2024. The facility's infection control preventionist quit at the end of March 2024, and a new infection control preventionist did not initiate facility-wide COVID-19 testing until April 3, 2024. Between March 26, 2024, and April 20, 2024, the facility reported at least 55 resident and staff cases of COVID-19 to the Department of Health. Interviews with the Administrator and Director of Nursing confirmed these findings, indicating a significant lapse in the facility's infection control measures during this period.
Failure to Implement Abuse Policy and Investigate Allegation
Penalty
Summary
The facility failed to implement their abuse policy regarding investigating an allegation of abuse for two residents. According to the facility's Abuse Policy, allegations must be reported to the Administrator or other officials, and an investigation must be initiated immediately. However, the facility did not provide documented evidence that an investigation was started regarding a physical incident between two residents. Nursing documentation indicated that one resident struck another in the face, which was witnessed by a housekeeper and reported to the Director of Nursing. Despite this, there was no documented evidence that the injured resident was assessed for injuries or that an investigation was initiated. The surveyor observed the housekeeper writing a statement about the incident during the on-site visit, despite the statement being dated for a previous year. The housekeeper confirmed that she had initially written a statement when the incident occurred but was unsure what happened to it after submission. Interviews with the Administrator and Director of Nursing confirmed these findings, indicating a failure to follow the facility's abuse policy and properly document and investigate the incident.
Failure to Administer Correct Dosage of Pain Medication
Penalty
Summary
The facility failed to provide the highest practicable care regarding the administration of physician-ordered pain medications for one resident. A review of the resident's closed clinical record revealed a physician's order for Morphine Sulfate 20mg/ml, 0.75 ml to be administered every four hours around the clock for pain. However, the Medication Administration Record (MAR) for April 2024 showed that a registered nurse only administered 0.5 ml of Morphine Sulfate on two occasions, instead of the prescribed 0.75 ml. There was no documented evidence that any as-needed doses of Morphine Sulfate were administered during the nurse's shift. An interview with the Administrator confirmed that there were no reported medication errors for April 2024 and verified the findings for the resident.
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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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