Hillcrest Rehabilitation & Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lower Burrell, Pennsylvania.
- Location
- 100 Little Drive, Lower Burrell, Pennsylvania 15068
- CMS Provider Number
- 395208
- Inspections on file
- 47
- Latest survey
- April 17, 2026
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Hillcrest Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
Kitchen sanitation and refrigerator temperature monitoring deficiencies were identified in the main kitchen and on two nursing units. The walk-in cooler had dust, grime, and dark debris on the condenser unit, fan covers, and surrounding area, and the FSD confirmed the condition. The East unit refrigerator had an incomplete temp log and the Northwest unit refrigerator had no temp log, which the FSD also confirmed.
The facility failed to ensure PRN psychotropic medication regimens were supported by adequate documentation for three residents. One resident with anxiety and altered mental status received PRN Vistaril and Zyprexa, and two residents with diagnoses including dementia, anxiety, lung cancer, and respiratory failure received repeated PRN Ativan doses. In each case, the record lacked documentation of non-pharmacological interventions before administration, and two Ativan orders also lacked a 14-day stop date and documented rationale for continued use; the DON confirmed the missing documentation.
Failure to Assess Nutritional Status and Monitor Weights: The facility failed to complete required nutrition assessments and did not consistently obtain or act on weights for several residents. Records showed missing weights, incomplete RD documentation, inaccurate or unsupported MDS coding, and care plans that did not address significant weight changes or nutritional concerns for residents with diagnoses including HF, dementia, morbid obesity, respiratory failure, and adult failure to thrive.
Failure to Provide Appropriate Respiratory Care: Multiple residents with orders for oxygen, BiPAP, or nebulizer treatment had respiratory equipment left out of storage while not in use, including BiPAP masks, a nasal cannula, and a handheld nebulizer. One resident was observed receiving O2 via nasal cannula without a physician order, and the care plan did not address oxygen therapy. Staff confirmed the equipment was not stored as required and that the order and care plan were missing for the resident receiving oxygen.
Medication storage and security failures were observed in multiple areas of the facility. An LPN found several opened meds and supplies in medication carts and a med room that were not dated as required, along with non-medication items stored in the med room, and an East Hall med cart was left unlocked and unattended at the nurse's station.
A facility failed to coordinate hospice services for three residents and failed to obtain a hospice diagnosis for one resident. Records showed residents with diagnoses including brain dysfunction, Alzheimer’s disease, lung cancer, respiratory failure, heart failure, and other chronic conditions received hospice care, but their care plans lacked hospice agency contact information and 24-hour on-call access details; one hospice order also did not include a diagnosis. The DON and an LPNAC confirmed the deficiencies.
Failure to Offer COVID-19 Vaccination to Five Residents: The facility did not document that COVID-19 vaccination was offered to five residents whose MDSs showed they were not up to date. The records showed prior vaccine refusals or prior vaccination, but no later documentation that the vaccine was offered and either given or declined. The residents had diagnoses including HTN, HLD, anxiety, schizoaffective disorder, COPD, dementia, SOB, and depression.
Failure to Provide Effective Communication Training: The facility did not have credible annual in-service training on Effective Communication for five reviewed staff members, including NAs, an RN, and an LPN. Personnel file reviews showed the required training was missing for each employee, and the NHA confirmed the lapse during interview.
Failure to Provide Resident Rights Training: The facility did not have credible annual in-service training documentation on Resident Rights for five staff members, including NAs, an RN, and an LPN. Personnel file review showed the required training was missing for each employee, and the NHA confirmed the lapse during interview.
Failure to Provide Required Abuse, Neglect, and Exploitation Training: The facility did not have credible annual in-service training on abuse, neglect, and exploitation for five staff members, including NAs, an RN, and an LPN. Personnel files lacked documentation of the required training, and the NHA confirmed the lapse during interview.
Missing QAPI Training for Five Staff Members: The facility failed to provide annual QAPI in-service training for five staff members, including two NAs, an RN, and an LPN. Personnel files did not show credible QAPI training for the review period, and the NHA confirmed the lapse during interview.
Failure to Provide Required Infection Control Training: The facility failed to provide annual Infection Control in-service training for five staff members, including NAs, an RN, and an LPN. Personnel files did not show credible training for the review period, and the NHA confirmed the missing training during interview. The facility policy required regularly scheduled in-service classes and documentation of attendance.
The facility failed to provide annual Compliance and Ethics training for five staff members, including NAs, an RN, and an LPN. Review of personnel files showed no credible in-service training for the required period, and the NHA confirmed the lapse during interview.
The facility failed to provide required in-service training on dementia management and resident abuse prevention for five sampled staff members, including an RN, an LPN, and three NAs. It also failed to document that three sampled NAs received the required 12 hours of annual in-service education. The NHA confirmed the missing training and documentation during interview.
Behavioral Health training was not documented for five staff members, including NAs, an RN, and an LPN. Facility policy required regular in-service training, but personnel files for all five employees lacked credible annual Behavioral Health training for the review period, and the NHA confirmed the lapse during interview.
A resident admitted after left knee joint repair surgery with HTN and breast cancer did not receive several ordered meds, including an antibiotic, anti-inflammatory, antihypertensive, and lysine, because they were documented as unavailable and awaiting from pharmacy. The MAR and nursing notes did not show that the MD was appropriately notified of the missed doses, and an LPN confirmed the missed medication issue during interview.
A resident’s MDS incorrectly coded hospice care as present even though the clinical record did not show hospice admission during the assessment period. The resident had high blood pressure, anxiety, and a history of falling, and an LPN Assessment Coordinator confirmed the MDS did not accurately reflect the resident’s status.
A resident’s care plan was not updated to reflect a prophylactic Azithromycin order. The resident had diagnoses including HTN, COPD, and hyperlipidemia, but the current care plan did not include a focus, goal, or interventions for the antibiotic order, and the ADON/IP confirmed the omission.
Incomplete physician orders were found for two residents. One resident with diabetes had insulin and blood glucose monitoring orders, but the order did not include parameters for when to contact the physician for hypo- or hyperglycemia. Another resident had an azithromycin order for prophylaxis, but the order did not include a diagnosis. An LPN and the ADON/IP confirmed the missing order details.
The facility failed to complete ongoing accurate assessments for bedrail use for two residents. One resident had weakness, a right BKA, and bilateral enabler bars, while another had CVA with left-sided paralysis and a left enabler bar. Both residents’ last Enabler/Assist Rail/Device Evaluation - V2 assessments were completed about a year earlier, and the ADON confirmed assessments should be done quarterly.
Monthly MRRs were not reviewed by the attending physician for two residents. For one resident with HTN, HLD, and muscle weakness, pharmacist recommendations about sertraline and hydroxyzine lacked physician responses. For another resident with HTN, HLD, and schizoaffective disorder, pharmacist recommendations about olanzapine, Seroquel, and buspirone also lacked physician responses. The DON confirmed the MRRs were addressed by the facility and psych CRNPs instead of the attending physician.
Influenza Vaccine Not Offered to A Resident: Facility policy required annual influenza vaccination offers for residents without contraindications, but A resident with HTN, anxiety, and depression was coded on the MDS as not receiving the vaccine because it was not offered. The chart lacked documentation that the vaccine was offered, administered, or declined, and the IP confirmed the omission.
The facility failed to ensure that the East Hall crash cart was maintained in safe operating condition. Surveyors observed two expired ambu bags and masks in the cart, even though weekly crash cart checks were required on the checklist. The DON confirmed the expired equipment and the failure to ensure the cart was ready for use.
A resident with malnutrition, non-Alzheimer’s dementia, and adult failure to thrive experienced an unwitnessed fall and was found on the floor with bleeding from a frontal head area previously injured in a prior fall. Facility policy and the neuro check flowsheet required neurological assessments and documentation after unwitnessed falls or suspected head injuries, at specified time intervals. Although the area was cleansed, the NP assessed the resident, family and hospice were notified, and the hospice physician ordered transfer to the hospital for further head injury evaluation, record review showed no evidence that any neurological checks were initiated or documented. The DON and the Nursing Home Administrator confirmed that required neurological checks were not performed, resulting in a failure to provide necessary care and services.
A resident with diabetes, anemia, and hypertension was given 30 units of rapid-acting insulin (Humalog) instead of the prescribed long-acting insulin (Lantus) at bedtime. The LPN who administered the medication recognized the error, documented it, and notified the RN supervisor and physician. The facility's policy requiring verification of the correct medication before administration was not followed, resulting in a significant medication error.
The facility did not provide the required minimum number of nurse aides per resident on multiple day and evening shifts, as confirmed by census and staffing records. The Nursing Home Administrator acknowledged that the facility failed to meet the mandated NA staffing ratios, and there was no evidence of additional higher-level staff compensating for these shortages.
A resident with multiple medical conditions was found with an undated dressing on a forearm wound that had not been changed for two days. Review of the clinical record showed there was no physician order for wound care, and staff confirmed the lack of documentation and orders for the wound treatment.
Three residents with significant medical needs did not receive scheduled bathing assistance as required, with facility records showing multiple missed baths or showers and no documentation that services were provided, offered, or refused. The DON was unable to produce evidence that these ADL services were delivered as scheduled.
Facility staff did not meet required NA staffing ratios for multiple day, evening, and night shifts, with NA FTEs falling below mandated levels for the facility census. Additionally, the required LPN-to-resident ratio was not met on one evening shift, with insufficient LPN FTEs present. The DON confirmed these staffing shortages and the absence of compensating higher-level staff.
Administrative staff did not ensure the required 3.2 hours of direct nursing care per resident per day on multiple days, as confirmed by review of schedules and census data and acknowledged by the DON.
A resident with multiple medical conditions who required extensive two-person assistance for bed mobility suffered a left hip fracture after falling from bed when a nurse aide provided care alone, failed to use required fall mats, and did not follow standard safety procedures. Staff interviews and documentation confirmed that the care plan and physician orders were not followed, resulting in actual harm.
A resident with dementia and mobility needs sustained a left hip fracture after falling from bed when a NA left the resident's side during care. Required fall mats were not in place, and the care plan did not specify the needed assistance for bed mobility. Staff witness statements and documentation confirmed that supervision and accident prevention measures were not followed.
A resident alleged that staff left her on the floor for an hour after a fall, but the facility failed to document the grievance, investigate the allegation, or record findings and actions in the grievance log as required by policy.
A resident reported being left on the floor for an extended period after a fall, and the facility did not obtain required written witness statements from the resident or her roommate, resulting in an incomplete investigation and failure to follow the abuse/neglect policy.
A resident reported being left on the floor for an hour after a fall, but the facility failed to document the grievance, interview the resident and her roommate, or identify the staff involved, resulting in an incomplete investigation and lack of required reporting to the state agency.
The facility failed to properly date and store food products in the main kitchen, as observed during an inspection. Opened packages of dried pasta were found undated in the dry storage room, and in the walk-in cooler, cooked ground meat was placed next to an open and undated bag of raw chicken. These issues were confirmed by the Dietary Manager, highlighting a breach in safe food handling practices.
The facility failed to conduct care plan conferences and notify residents or their representatives in advance, as required by policy. Residents with various medical conditions, including depression, renal insufficiency, and COPD, were unaware of or had not participated in care plan meetings. The RNAC, an interim per diem employee, did not run these meetings, indicating a gap in responsibility.
The facility did not conduct or document resident council meetings for four months, failing to uphold residents' rights to organize and participate in such groups. Staff conducted room-to-room visits instead of group meetings, and residents reported not receiving feedback on their concerns. The Nursing Home Administrator confirmed these deficiencies.
A facility failed to conduct initial and ongoing assessments for the use of enabler bars for three residents, as required by their policy. The residents, with various medical conditions such as hypertension, hemiplegia, and diabetes, had enabler bars on their beds, but necessary evaluations were either outdated or missing, leading to a deficiency in care.
A facility failed to investigate and report an allegation of neglect involving a resident with atrial fibrillation and CHF. The resident was found with a bump on the shin and expressed fear during Hoyer lift use. Despite facility policy requiring investigation of such incidents, no investigation or report was made. The DON confirmed this oversight.
A facility failed to develop a baseline care plan for pain management for a resident admitted with multiple diagnoses, including fractures and neuropathy. Despite having physician orders for pain medication and a requirement to record pain scores, the resident's care plan lacked interventions for pain management, as confirmed by the Nursing Home Administrator.
The facility failed to meet professional standards in nutritional services due to the absence of an on-site Registered Dietitian (RD) over a six-month period. The RD worked remotely for eight hours a week and did not participate in care plan meetings or monitor food service operations as required. Interviews with staff revealed that the RD's absence affected the nutritional assessment process, leading to a deficiency in meeting residents' nutritional needs.
A resident with high blood pressure, heart failure, and dementia did not receive adequate assistance with ADLs, including scheduled showers and regular changing, as required by facility policy. The resident's family raised concerns about the lack of care, and the Nursing Home Administrator confirmed the deficiency.
A resident with dementia and multiple pressure ulcers did not receive necessary wound care services as per professional standards. The facility failed to document the stage of certain ulcers and did not follow the wound care provider's orders, including the use of Santyl and a wedge for repositioning. The Director of Nursing confirmed these deficiencies.
A facility failed to provide a resident with the necessary TLSO brace to maintain mobility, despite the resident's medical conditions requiring it. The resident's clinical record lacked an order or care plan for the brace, and staff confirmed its unavailability, leading to a deficiency in care.
A facility failed to timely assess the nutritional status of a resident, as required by their policy. The resident, with conditions including epilepsy and dysphagia, experienced an 11.8% weight loss over a short period, yet the first dietitian assessment occurred 40 days post-admission. Staff interviews revealed that assessments were not completed within the required timeframe, contributing to the deficiency.
The facility failed to provide appropriate respiratory care for two residents. One resident's oxygen tubing was not labeled with a date, contrary to physician orders, while another resident's nebulizer was neither labeled nor stored properly. These deficiencies were confirmed by nursing staff.
The facility failed to maintain consistent dialysis communication and care planning for a resident with renal insufficiency and diabetes. Despite physician orders for thrice-weekly dialysis, the resident's clinical record lacked a dialysis care plan and had incomplete communication forms for several dates. Interviews with an LPN and the DON confirmed these deficiencies.
The facility failed to ensure that pharmacy recommendations for a resident's medication regimen were reviewed by a physician. The resident had duplicate orders for Lidocaine gel and an order for oxycodone without non-pharmacological interventions. Recommendations were signed off by nursing staff instead of a physician.
A resident experienced significant medication errors due to incorrect dosages of Divalproex Sodium and Levetiracetam being administered, exceeding recommended limits. The error was identified after the resident's family reported increased lethargy, leading to a review of medication orders. Staff interviews revealed a lack of proper verification and clarification of orders upon admission, contributing to the error.
Kitchen Sanitation and Refrigerator Temperature Monitoring Deficiencies
Penalty
Summary
The facility failed to maintain kitchen equipment in a sanitary condition in the main kitchen walk-in cooler. During an observation with the Food Services Director in the main kitchen, the cold air condenser unit, two fan covers, and the area immediately surrounding the walk-in cooler were observed to have a build-up of dust, grime, and dark colored debris. The Food Services Director confirmed this condition during interview. The facility also failed to properly monitor refrigerator temperatures for two nursing units. On the East Nursing Unit, the refrigerator had an incomplete temperature log for April 2026, and on the Northwest Nursing Unit, the refrigerator had no temperature log for April 2026. The Food Services Director confirmed during interview that the facility failed to properly monitor refrigerator temperatures for these two units.
Unnecessary PRN Psychotropic Medication Use and Missing Documentation
Penalty
Summary
The facility failed to make certain resident medication regimens free from potentially unnecessary psychotropic medications without adequate indications for use for three residents. Facility policy stated that antipsychotic medications were to be used only when necessary for specific conditions, that staff were to gather and document information about behavior, mood, function, medical condition, symptoms, and risks, and that PRN psychotropic medications were not to be renewed beyond 14 days unless the practitioner evaluated the resident and documented the rationale for continued use. For one resident with diagnoses including anxiety disorder and altered mental status, the MAR showed PRN Vistaril and PRN Zyprexa were administered multiple times in April 2026. The record and progress notes did not include what non-pharmacological interventions were provided before the PRN medications were given. During interview, the DON confirmed that the facility failed to provide non-pharmacological interventions prior to giving the PRN medications. For a second resident with diagnoses including pneumonia, dementia, and anxiety disorder, the physician order for PRN Ativan did not include a 14-day stop date and there was no documented physician rationale for extending the medication beyond 14 days. The MAR showed the PRN Ativan was administered repeatedly throughout April 2026, and the record and progress notes again failed to include what non-pharmacological interventions were provided before administration. For a third resident with diagnoses including lung cancer, respiratory failure, and high blood pressure, the physician order for PRN Ativan also lacked a 14-day stop date and documented rationale, and the MAR showed the medication was given on several occasions in April 2026 without documentation of non-pharmacological interventions. The DON confirmed these failures during interview.
Failure to Assess Nutritional Status and Monitor Weights
Penalty
Summary
The facility failed to assess residents’ nutritional status as required and failed to properly monitor weight and nutrition status for four residents. Facility policy required a nutritional assessment for each resident, including current nutritional status and risk factors for impaired nutrition, and required weights on admission, weekly for four weeks, and monthly thereafter unless concerns were identified. The record review and staff interviews showed that these requirements were not consistently followed for Residents R5, R30, R40, and R50. Resident R5 was admitted with diagnoses including high blood pressure, anxiety, and a history of falling. Review of the weight record failed to reveal documented weights for June 2025 or July 2025. During interview, the DON confirmed the facility failed to properly monitor weight and status by failing to obtain and document weights for this resident. Resident R30 was admitted with diagnoses including heart failure, adult failure to thrive, and paroxysmal atrial fibrillation. The MDS coded weight loss of 5% or more in the last month or 10% or greater in the last six months. However, the Nutrition Evaluation and weight summary contained incomplete and inconsistent documentation, including missing weights for several months and no documented rationale for use of a dash in the MDS weight field. The clinical record also lacked a nutritional assessment explaining the resident’s nutritional status, and staff confirmed the record did not contain the required documentation. Resident R40 was admitted with diagnoses including rhabdomyolysis, morbid obesity, and respiratory failure. The record failed to show a Registered Dietitian nutritional assessment for the MDS, and the weight summary showed missing weekly and monthly weights, including no monthly weight obtained by the time of review. RD notes identified suspected entry errors and requested reweights, but the facility did not obtain the reweights. The resident’s care plan, updated 2/3/26, did not identify nutritional concerns related to significant weight loss or include interventions for that issue. Resident R50 was admitted with diagnoses including heart failure, dementia, and high blood pressure. The MDS coded significant weight loss, and the resident had an order for a 2.0 calorie nutritional supplement twice daily. The Nutrition Evaluation documented significant weight loss and later significant weight gain, but did not identify the dates and weights referenced, and the record lacked a January 2026 weight. The clinical nutrition documentation also showed a gap from 9/23/25 through 2/6/26, during which the resident’s nutritional status was not assessed by the RD, and the care plan did not identify significant weight changes as a nutrition focus or include the ordered supplement as an intervention.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
Appropriate respiratory care was not provided for multiple residents who had orders for oxygen therapy, BiPAP, CPAP/BiPAP support, or nebulizer treatment. Facility policies reviewed stated that nebulizer equipment was to be rinsed, disinfected, dried, and stored in a plastic bag with the resident’s name and date, that CPAP/BiPAP support was intended to improve oxygenation and promote comfort and safety, and that oxygen administration required verification of a physician order and review of the resident’s care plan. Resident R1 had diagnoses including respiratory failure and obstructive sleep apnea and a physician order for BiPAP 15/8 with 3 liters of oxygen every night shift. During observation, the BiPAP machine was on the bedside table and the mask was laying on the table, not stored in a bag while not in use. An LPN confirmed the mask was not stored in a plastic bag and that the facility failed to provide appropriate respiratory care. Resident R4 had diagnoses including respiratory failure and diabetes, with an order for oxygen at 4 liters per minute via nasal cannula as needed for shortness of breath. During observation, the nasal cannula was found lying on the floor next to the bed between the wall and concentrator, not stored in a bag while not in use, and an RN confirmed this. Resident R47 had COPD and an order for ipratropium-albuterol via handheld nebulizer every four hours as needed for wheezing. The nebulizer was observed sitting on the nightstand, not stored in a bag as required, and an LPN confirmed it should have been stored in a bag. Resident R54 had COPD, diabetes, and heart failure, with an order for BiPAP every night shift to keep oxygen saturation 90% and above. The BiPAP mask was observed on the nightstand, not stored in a bag as required, and an LPN confirmed this. Resident R61 was observed receiving 2 liters of oxygen via nasal cannula, but the clinical record did not contain a physician order for oxygen therapy and the care plan did not include goals or interventions related to oxygen therapy; an LPN and an LPN assessment coordinator both confirmed the lack of order and care plan.
Medication Storage and Security Failures
Penalty
Summary
The facility failed to properly store medications in two medication carts, one medication storage room, and failed to properly secure one medication cart while it was not in use. Facility policies stated that opened multi-dose containers must be dated and that medication carts, rooms, and supplies must be locked or attended by persons with authorized access. During an observation of the [NAME] Hall Medication Cart, a bottle of Lactulose was opened and not labeled with a date. An LPN confirmed the bottle was opened and lacked the required date label. During an observation of the North Hall Medication Cart, multiple items were found opened and not labeled with dates, including normal saline solution, mupirocin cream, plain packing strip, manuka honey, an albuterol inhaler, deep spray nasal saline, and Tums; a small package of Ritz Bit crackers was also present. In the East Medication Room, a tube of green pain relief gel, a vial of Tubersol, and a bottle of liquid gabapentin were opened and not labeled with dates, and non-medication items including a glass vase, ceramic snowman, Christmas hat, Christmas stocking, radio, and coffee cups were present. In addition, the East Hall Medication Cart was observed unlocked and unattended at the nurse's station, and an LPN confirmed the cart was not properly secured while not in use.
Hospice Coordination and Diagnosis Deficiencies
Penalty
Summary
The facility failed to obtain a diagnosis for hospice services for one resident and failed to ensure coordination of hospice services with facility services to meet end-of-life care needs for three residents. Facility policy stated that the facility is responsible for meeting residents’ personal and nursing needs in coordination with the hospice representative, communicating with the hospice provider, and documenting such communication so resident needs are addressed and met 24 hours per day. The coordinated care plan was also required to be revised and updated as necessary to reflect the resident’s current status, including diagnosis. Resident R9’s record showed diagnoses of non-traumatic brain dysfunction and Alzheimer’s disease, and the MDS indicated hospice care was received in the facility, but the comprehensive care plan did not include coordination of hospice services, including hospice contact information or how to access the hospice 24-hour on-call system. Resident R60’s record showed diagnoses of lung cancer, respiratory failure, and high blood pressure, and the MDS indicated hospice care was received in the facility, but the physician order to admit to hospice did not include a diagnosis for hospice services and the care plan lacked the diagnosis, hospice contact information, and 24-hour on-call access information. Resident R61’s record showed diagnoses of high blood pressure, hyperlipidemia, and anxiety, and the MDS indicated hospice care was received in the facility, but the care plan did not include hospice contact information or how to access the hospice 24-hour on-call system. The DON and LPNAC confirmed these failures during interview.
Failure to Offer COVID-19 Vaccination to Five Residents
Penalty
Summary
The facility failed to make certain that a COVID-19 vaccination was offered to five residents: R6, R8, R34, R37, and R65. Facility policy stated that everyone would be encouraged to remain up to date with recommended COVID-19 vaccine doses, and CDC guidance cited in the report stated that a 2025-2026 COVID-19 vaccine was recommended for people ages 6 months and older based on individual-based decision-making. Review of the clinical records showed that each of the five residents had an MDS coded “no” for being up to date with COVID-19 vaccination, with diagnoses including high blood pressure, hyperlipidemia, anxiety, schizoaffective disorder, COPD, dementia, shortness of breath, and depression. The records for R6, R8, R34, R37, and R65 did not include documentation that the COVID-19 vaccine was offered and administered or declined since the last recorded vaccination or refusal. R6 and R8 were last documented as refusing the vaccine in 2023, R34 and R65 were last documented as receiving the vaccine in 2022 and 2023 respectively, and R37 was last documented as refusing the vaccine in 2023. During interview, the Infection Preventionist confirmed that the facility failed to make certain that a COVID-19 vaccination was offered to these five residents.
Failure to Provide Effective Communication Training
Penalty
Summary
The facility failed to provide training on Effective Communication for five of five staff members reviewed: Nurse Aide (NA) Employee E4, NA Employee E5, Registered Nurse (RN) Employee E6, Licensed Practical Nurse (LPN) Employee E7, and NA Employee E8. Review of the facility’s In-Service Training Program policy for nurse aides indicated that all nurse aide personnel are to participate in regularly scheduled in-service training classes and that training attendance is to be entered on each employee’s Record of In-Service by the department supervisor or other designated person. Review of the personnel files showed that NA Employee E4, hired 3/20/24, did not have credible annual in-service training on Effective Communication from 1/1/25 through 12/31/25. Similar reviews of the files for NA Employee E5, RN Employee E6, LPN Employee E7, and NA Employee E8 also did not include credible annual in-service training on Effective Communication for that same period. During an interview on 4/16/26 at 2:15 p.m., the Nursing Home Administrator confirmed that the facility failed to provide training on Effective Communication for these five staff members.
Failure to Provide Resident Rights Training
Penalty
Summary
Staff members were not provided training on Resident Rights as required by facility policy and staff development requirements. Review of the facility’s In-Service Training Program policy showed that nurse aide personnel are to participate in regularly scheduled in-service training classes and that training attendance is to be recorded on each employee’s Record of In-Service. However, review of personnel files for NA Employee E4, NA Employee E5, RN Employee E6, LPN Employee E7, and NA Employee E8 did not include credible annual in-service training on Resident Rights for the period 1/1/25 through 12/31/25. The five employees identified had hire dates ranging from 3/20/24 to 3/9/81, and none of their personnel files contained the required Resident Rights in-service documentation for the annual period reviewed. During an interview on 4/16/26 at 2:15 p.m., the Nursing Home Administrator confirmed that the facility failed to provide training on Resident Rights for these five staff members.
Failure to Provide Required Abuse, Neglect, and Exploitation Training
Penalty
Summary
The facility failed to provide training on Abuse, Neglect, and Exploitation for five of five staff members: NA Employee E4, NA Employee E5, RN Employee E6, LPN Employee E7, and NA Employee E8. Review of the facility's In-Service Training Program policy indicated that nurse aide personnel are to participate in regularly scheduled in-service training classes, with notices posted on the employee bulletin board at least seven days before the class and attendance entered on each employee's Record of In-Service by the department supervisor or designee. Review of personnel files showed that NA Employee E4, hired 3/20/24; NA Employee E5, hired 10/22/19; RN Employee E6, hired 5/30/19; LPN Employee E7, hired 10/19/15; and NA Employee E8, hired 3/9/81 did not have credible annual in-service training on Abuse, Neglect, and Exploitation from 1/1/25 through 12/31/25. During an interview on 4/16/26 at 2:15 p.m., the Nursing Home Administrator confirmed that the facility failed to provide this training for all five staff members.
Missing QAPI Training for Five Staff Members
Penalty
Summary
Conduct mandatory training for all staff on the facility’s Quality Assurance and Performance Improvement (QAPI) Program was not completed for five of five staff members. Review of the facility’s In-Service Training Program policy showed that nurse aide personnel are to participate in regularly scheduled in-service training classes and that training attendance is to be recorded on each employee’s Record of In-Service. However, review of personnel files showed no credible annual in-service training on QAPI for NA Employee E4, NA Employee E5, RN Employee E6, LPN Employee E7, and NA Employee E8 for the 1/1/25 through 12/31/25 period. The personnel records identified the employees’ dates of hire as 3/20/24 for NA Employee E4, 10/22/19 for NA Employee E5, 5/30/19 for RN Employee E6, 10/19/15 for LPN Employee E7, and 3/9/81 for NA Employee E8. During an interview on 4/16/26 at 2:15 p.m., the Nursing Home Administrator confirmed that the facility failed to provide QAPI training for these five staff members.
Failure to Provide Required Infection Control Training
Penalty
Summary
The facility failed to provide Infection Control training for five of five staff members identified in the report: NA Employee E4, NA Employee E5, RN Employee E6, LPN Employee E7, and NA Employee E8. Review of the facility’s In-Service Training Program policy showed that nurse aide personnel are to participate in regularly scheduled in-service training classes and that attendance is to be recorded on each employee’s Record of In-Service. However, review of the personnel files for each of the five employees did not include credible annual in-service training on Infection Control for the period from 1/1/25 through 12/31/25. The personnel records reviewed showed that NA Employee E4 was hired on 3/20/24, NA Employee E5 on 10/22/19, RN Employee E6 on 5/30/19, LPN Employee E7 on 10/19/15, and NA Employee E8 on 3/9/81. During an interview on 4/16/26 at 2:15 p.m., the Nursing Home Administrator confirmed that the facility failed to provide Infection Control training for these five staff members. The cited regulations were 28 Pa. Code: 201.14(a) Responsibility of licensee and 28 Pa. Code: 201.20(a)(d) Staff development.
Missing Compliance and Ethics Training for Five Staff Members
Penalty
Summary
The facility failed to provide training on Compliance and Ethics for five of five staff members: NA Employee E4, NA Employee E5, RN Employee E6, LPN Employee E7, and NA Employee E8. Review of the facility's In-Service Training Program policy for nurse aides indicated that staff are to participate in regularly scheduled in-service training classes and that attendance is to be entered on the employee's Record of In-Service by the department supervisor or other designated person. Review of the personnel files for the five employees showed dates of hire ranging from 1981 to 2024, but none of the files contained credible annual in-service training on Compliance and Ethics for the period 1/1/25 through 12/31/25. During an interview on 4/16/26 at 2:15 p.m., the Nursing Home Administrator confirmed that the facility failed to provide Compliance and Ethics training for these five staff members.
Missing Dementia and Abuse Prevention Training
Penalty
Summary
The facility failed to provide training on Dementia Management and Resident Abuse Prevention for five of five sampled staff members, including three nurse aides, one RN, and one LPN. Review of the facility’s In-Service Training Program policy showed that nurse aide personnel are to participate in regularly scheduled in-service training classes and that annual in-services are to be no less than 12 hours per employment year. However, review of the personnel files for NA Employee E4, NA Employee E5, RN Employee E6, LPN Employee E7, and NA Employee E8 did not include credible annual in-service training on Dementia Management and Resident Abuse Prevention for the period reviewed. The facility also failed to ensure that three of three sampled nurse aides received a minimum of 12 hours of in-service education per year. Review of the nurse aide training records for NA Employee E4, NA Employee E5, and NA Employee E8 did not include credible documentation showing they received 12 hours of in-service training during the reviewed year. During interview, the Nursing Home Administrator confirmed that the facility failed to provide the required training on Dementia Management and Resident Abuse Prevention for the five staff members and failed to ensure the three sampled nurse aides received the required annual in-service hours.
Missing Behavioral Health Training for Five Staff Members
Penalty
Summary
Behavioral Health training was not provided for five of five staff members reviewed: NA Employee E4, NA Employee E5, RN Employee E6, LPN Employee E7, and NA Employee E8. Facility policy for the In-Service Training Program for nurse aides stated that all nurse aide personnel participate in regularly scheduled in-service training classes and that training attendance is entered on the employee's Record of In-Service. However, review of the personnel files for each of the five employees did not include credible annual in-service training on Behavioral Health for the period from 1/1/25 through 12/31/25. The personnel records showed that NA Employee E4 was hired on 3/20/24, NA Employee E5 on 10/22/19, RN Employee E6 on 5/30/19, LPN Employee E7 on 10/19/15, and NA Employee E8 on 3/9/81. During an interview on 4/16/26 at 2:15 p.m., the Nursing Home Administrator confirmed that the facility failed to provide training on Behavioral Health for these five staff members. The cited regulations were 28 Pa. Code: 201.14(a) Responsibility of licensee and 28 Pa. Code: 201.20(a)(d) Staff development.
Missed Ordered Medications and Lack of Physician Notification
Penalty
Summary
The facility failed to provide medications as ordered by the physician and failed to ensure the physician was appropriately notified of missed medication doses for one resident. Resident R21 was admitted following left knee joint repair surgery and had diagnoses including hypertension and breast cancer. Physician orders included cefadroxil 500 mg twice daily, celecoxib 200 mg twice daily, hydrochlorothiazide 25 mg at bedtime, and lysine 500 mg daily. The resident’s April 2026 MAR showed these medications were coded as "9 = other/see nursing notes" for scheduled doses, and the order administration notes for 4/2/26, 4/3/26, and 4/5/26 stated the medications were unavailable and awaiting from pharmacy. The nursing notes did not show that the physician was appropriately notified of the missed medication doses. The facility policy stated emergency pharmacy service was available on a 24-hour basis and that emergency medications could be obtained from the emergency supply, ADS, provider pharmacy, or backup pharmacy. During interview, an LPN stated that staff sometimes pull what they can from the emergency medication box and confirmed the facility failed to provide the ordered medications and ensure physician notification of the missed doses for Resident R21.
Incorrect Hospice Coding on MDS
Penalty
Summary
The facility failed to ensure that the MDS accurately reflected Resident R5’s status when Section O0110K1, Hospice care, was coded as “yes” even though the clinical record did not show that the resident was admitted to hospice services during the 14-day assessment period. Resident R5 was admitted to the facility with diagnoses of high blood pressure, anxiety, and a history of falling. Review of the record found no documentation supporting hospice enrollment for the assessment period, and during interview the LPN Assessment Coordinator confirmed that Resident R5 was incorrectly coded as receiving hospice services on the MDS and that the assessment did not accurately reflect the resident’s status.
Care Plan Not Updated for Ordered Prophylactic Antibiotic
Penalty
Summary
The facility failed to ensure that Resident R47’s care plan was updated and revised to reflect the resident’s specific care needs. Review of the facility’s Care Plans, Comprehensive Person-Centered policy showed that resident assessments are ongoing and care plans are revised as information and conditions change. Resident R47 was admitted on 6/15/24, and the MDS dated 2/10/26 identified diagnoses of hypertension, COPD, and hyperlipidemia. A physician order dated 12/24/25 directed Azithromycin 250 mg by mouth one time a day every Monday, Wednesday, and Friday for prophylaxis, but the current care plan did not include a focus, goal, or interventions for the Azithromycin oral tablets. During interview, the ADON/IP confirmed that the care plan failed to include a focus, goal, or intervention for the Azithromycin tablets.
Incomplete Physician Orders for Diabetes Monitoring and Antibiotic Therapy
Penalty
Summary
The facility failed to obtain physician orders for management of hypoglycemia and hyperglycemia for one resident with diabetes. The resident’s clinical record showed diagnoses of hypertension, diabetes, and heart failure, and physician orders included Basaglar insulin 20 units subcutaneously daily and morning blood glucose monitoring for diabetes. The blood glucose monitoring order did not include parameters for when to contact the physician regarding low or high blood sugar. During interview, an LPN confirmed the order lacked those parameters and stated she was not sure why they were not included. The facility also failed to procure complete physician’s orders for another resident. That resident’s record showed diagnoses of hypertension, COPD, and hyperlipidemia, and a physician order for Azithromycin 250 mg by mouth every Monday, Wednesday, and Friday for prophylaxis. The order did not include a diagnosis for the medication. During interview, the ADON/Infection Preventionist confirmed the order was missing a diagnosis and that the order was incomplete.
Failure to Reassess Bedrail Use and Risk
Penalty
Summary
The facility failed to conduct ongoing accurate assessments to ensure that bedrails were used to meet residents’ needs and to evaluate the risks associated with bedrail use for two residents. Facility policy titled Proper use of Bed Rails, dated 1/15/26, required resident assessment of risk from using bed rails, including risk of entrapment between the mattress and bed rail or in the bed rail itself, with reassessments at least quarterly, after a significant change in status, or when the type of bed, mattress, or rail changed. Resident R3 was admitted with diagnoses including high blood pressure, hyperlipidemia, and muscle weakness, and the care plan identified an ADL self-care deficit related to weakness/deconditioning and a right below-the-knee amputation, with bilateral enabler bars used to assist mobility. The last Enabler/Assist Rail/Device Evaluation - V2 assessment for R3 was completed on 4/11/25, yet bilateral enabler bars were observed on the bed during an observation on 4/13/26. Resident R7 was admitted with diagnoses including high blood pressure, hemiplegia, and CVA, and the care plan identified an ADL self-care deficit related to CVA with left-sided paralysis, with a physician order for a left enabler bar to assist with mobility and positioning. The last Enabler/Assist Rail/Device Evaluation - V2 assessment for R7 was also completed on 4/11/25, and a left enabler bar was observed on the bed during the same observation date. The ADON stated that enabler bar assessments should be done quarterly and confirmed the facility failed to conduct ongoing accurate assessments for these two residents.
Monthly MRRs Not Reviewed by Attending Physician
Penalty
Summary
The facility failed to provide evidence that medication regimen reviews were reviewed by the residents’ attending physician monthly for two residents, R3 and R8. Facility policy stated the consultant pharmacist performs a comprehensive monthly medication regimen review and reports findings and recommendations to the DON, attending physician, medical director, and, if appropriate, the administrator, with the physician expected to accept, act on, or reject the recommendation with an explanation. For Resident R3, who had diagnoses including high blood pressure, hyperlipidemia, and muscle weakness, the pharmacist’s 11/11/25 review recommended documenting the need for sertraline 200 mg daily without a gradual dose reduction, and the 2/26/26 review recommended reassessing hydroxyzine 25 mg twice daily and considering gradual dose reduction; the record did not include a response from the attending physician for either recommendation. For Resident R8, who had diagnoses including high blood pressure, hyperlipidemia, and schizoaffective disorder, the pharmacist’s 11/11/25 review recommended considering a dose reduction of olanzapine 2.5 mg daily, the 12/25/25 review recommended considering a dose reduction of Seroquel 12.5 mg twice daily, and the 3/30/26 review recommended considering a dose reduction of buspirone 5 mg twice daily. The clinical record did not include a response from the attending physician for any of these recommendations. During interview, the DON confirmed that the monthly medication regimen reviews were addressed by the facility and psych services CRNPs rather than the residents’ attending physician for Residents R3 and R8.
Influenza Vaccine Not Offered to Resident
Penalty
Summary
The facility failed to make certain that an influenza immunization was offered to Resident R65. Facility policy stated that all residents without medical contraindications were to be offered the influenza vaccine annually between October 1 and March 31, and that documentation of vaccination or refusal was to be placed in the resident’s medical record. Review of the clinical record showed Resident R65 was admitted to the facility and had diagnoses of high blood pressure, anxiety, and depression. The resident’s MDS dated 2/19/26 indicated that the influenza vaccine was not received in the facility for the current influenza season, with the reason coded as “not offered.” The resident’s record showed the last influenza vaccine was received on 10/17/24, and there was no documentation that an influenza vaccine had been offered, administered, or declined since that time. During an interview on 4/15/26 at 2:40 p.m., the Infection Preventionist confirmed that the facility failed to make certain that an influenza immunization was offered to Resident R65.
Expired Ambu Bags and Masks Found in East Hall Crash Cart
Penalty
Summary
The facility failed to make certain that equipment was in safe operating condition for one of two crash carts, the East Hall Crash Cart. Review of the Basic Crash Cart Checklist showed that a licensed nurse or designee was responsible for completing weekly checks of crash cart contents and submitting the checklist to the DON. During observation of the East Hall Crash Cart, surveyors found two ambu bags and masks that were expired. The DON later confirmed the observation and acknowledged that the facility failed to ensure the crash cart equipment was in safe operating condition.
Failure to Perform Neurological Checks After Unwitnessed Fall With Suspected Head Injury
Penalty
Summary
The facility failed to follow its neurological assessment policy and provide ordered care and services after an unwitnessed fall with suspected head injury for one of three reviewed residents. The facility’s policy, last reviewed on 2/20/25, required neurological checks following an unwitnessed fall or a fall with suspected head injury, with documentation of the date and time of each check, the person performing the assessment, and all assessment data. The facility’s neurological check flowsheet specified a standard frequency of every 15 minutes four times, every hour two times, and every four hours four times unless otherwise ordered by a physician. The resident involved was admitted on an unspecified date and had diagnoses including malnutrition, non-Alzheimer’s dementia, and adult failure to thrive, as documented on an MDS dated 12/9/25. On 12/12/25 at 11:20 a.m., the resident was found lying on the right side in front of a door with bleeding noted to the right frontal area at a site of a prior fall. The area was cleansed and bleeding stopped without difficulty, and the resident was assessed by a nurse practitioner; the family and hospice were notified, and the hospice physician ordered transfer to the hospital for further evaluation of a head injury. Review of the clinical record for that date showed no evidence that neurological checks were initiated or documented after this unwitnessed fall. In interviews, the DON and the Nursing Home Administrator confirmed that neurological checks were not performed and that the facility failed to provide the care and services needed for the resident to attain or maintain the highest practicable well-being.
Significant Medication Error: Wrong Insulin Administered
Penalty
Summary
A deficiency occurred when a resident with diagnoses of anemia, hypertension, and diabetes mellitus was administered the wrong type of insulin. According to the physician's order, the resident was to receive 30 units of insulin glargine (Lantus), a long-acting insulin, subcutaneously at bedtime. However, during a night medication pass, an LPN administered 30 units of insulin lispro (Humalog), a rapid-acting insulin, instead of the prescribed Lantus. The error was identified by the LPN, who documented the incident and notified the RN supervisor and physician. At the time of the incident, the resident's blood glucose was 170, blood pressure was 134/76, temperature was 97.5°F, heart rate was 74, and oxygen saturation was 98% on room air. The facility's medication administration policy requires staff to verify the right resident, medication, dosage, time, and route before administration, but this protocol was not followed, resulting in a significant medication error for the resident.
Plan Of Correction
Resident R1's orders were clarified, and the order was correct and in place at the time of survey. The residents had no negative outcome from receiving the incorrect insulin. Current residents' insulin orders were audited to ensure that the insulin order for each resident is correct. The DON, or designee, will inservice licensed staff on administering medications policy and administering insulin medication orders policy. The DON, or designee, will conduct an audit on diabetic insulin administration for accuracy of medication orders to ensure that they are given as ordered and documented in the administration record. Audits will be completed weekly for 2 weeks, then monthly for 2 months. Results of the audits will be reviewed at the Quality Assurance meetings until substantial compliance has been met.
Failure to Meet Minimum Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required minimum nurse aide (NA) staffing ratios as mandated by regulation. Specifically, for 14 out of 21 days reviewed, the facility did not provide at least one NA per 10 residents during the day shift. Additionally, on two days, the evening shift did not meet the minimum requirement of one NA per 11 residents. This was determined through a review of facility census data and nursing time schedules, which showed that the number of NA full-time equivalents (FTEs) present was consistently below the required levels for the census on those days. During an interview, the Nursing Home Administrator confirmed that the facility did not meet the minimum NA staffing requirements for the day and evening shifts as specified. There was no indication that additional higher-level staff were present to compensate for these staffing shortages. The deficiency was identified based on direct review of staffing records and census data, with no mention of specific residents or their conditions in the report.
Plan Of Correction
The residents had no negative outcome for not meeting the minimum of one nurse aide per 10 residents on day shift, one nurse aide per 11 residents on evening shift, and one nurse aide per 15 residents on night shift. The facility has hired additional staff, holds daily staffing meetings to track staffing, and has agency contracts to utilize for staffing needs. The Director of Nursing or designee will provide the staffing coordinator and HR with education on the Pennsylvania staffing requirements for ratios. The Staffing coordinator or designee will audit the staffing ratios 3 times weekly for 2 weeks and monthly times 1 month.
Failure to Provide Physician-Ordered Wound Care and Documentation
Penalty
Summary
The facility failed to provide appropriate care and treatment for a wound for one resident. According to the facility's policy, wound care must be performed with a physician's order, and all dressing changes must be documented with the date, time, staff involved, and type of dressing used. However, review of the clinical record for a resident admitted with diagnoses including high blood pressure, diabetes, and anxiety revealed no physician order for wound care from 9/26/25 to 10/6/25. During observation, the resident was found with an undated dressing on the left forearm, which the resident reported had not been changed since it was applied two days prior. Staff interviews confirmed the presence of the undated dressing and the absence of a physician order for wound care. The Nursing Home Administrator acknowledged that the facility did not provide appropriate care and treatment for the resident's wound.
Failure to Provide Scheduled Bathing Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically bathing and showering, for three residents who were dependent or required assistance. According to facility policy, residents unable to perform ADLs independently should receive services to maintain good nutrition, grooming, and personal and oral hygiene. Clinical records showed that these residents had significant medical conditions such as cerebral palsy, hemiplegia, dementia, anxiety, and depression, and were assessed as needing supervision, touching assistance, or being fully dependent for bathing. Each resident was scheduled for regular baths or showers twice weekly with staff assistance as indicated in their care plans. Documentation for the month reviewed revealed multiple missed scheduled baths or showers for all three residents, with no evidence that the services were provided, offered, or refused on those dates. In one instance, a nursing note indicated a resident was denied a shower after initially refusing and then requesting it later, citing lack of time. The Director of Nursing was unable to provide additional documentation to show that the residents were offered or received bathing assistance on the missed dates, confirming the failure to provide required ADL care.
Plan Of Correction
IA: Residents R1, R2, and R3 were reviewed for their shower/bath schedule and received a shower per schedule. Whole house audit was completed to ensure all residents' shower schedules are correct and meet the needs of the residents. Education: DON or designee will educate CNAs and licensed staff on the timely provision of activities of daily living (ADL) assistance and following assigned shower/bathing schedules. Audits: Showers will be audited 3 times weekly for 2 weeks and monthly times 1 month to ensure residents are receiving showers as assigned. F 0677
Failure to Meet Minimum Nurse Aide and LPN Staffing Ratios
Penalty
Summary
Facility administrative staff failed to meet required nurse aide (NA) staffing ratios on multiple occasions. Specifically, the facility did not provide the minimum of one NA per 10 residents during the day shift for 17 out of 21 days, one NA per 11 residents during the evening shift for 9 days, and one NA per 15 residents during the night shift for 5 days within the reviewed periods. Review of census data and nursing time schedules showed that the number of NA full-time equivalents (FTEs) present was consistently below the required levels for the respective shifts and census counts. The Director of Nursing confirmed these staffing shortages and acknowledged that there were no additional higher-level staff present to compensate for the deficiency. Additionally, the facility failed to provide the required minimum of one Licensed Practical Nurse (LPN) per 30 residents during the evening shift on one occasion. On that day, the number of LPN FTEs present was below the required amount based on the facility census. The Director of Nursing confirmed this LPN staffing shortage and also noted that there were no excess higher-level staff to offset the deficiency.
Plan Of Correction
The residents had no negative outcome for not meeting the minimum of one nurse aide per 10 residents on day shift, one nurse aide per 11 residents on evening shift, and one nurse aide per 15 residents on night shift. The facility has hired additional staff, holds daily staffing meetings to track staffing, and added additional agencies to utilize for staffing needs. Education: DON or designee will provide the staffing coordinator and HR with education on the Pennsylvania staffing requirements for ratios. Audits: Staffing coordinator or designee will audit the staffing ratios 3 times weekly for 2 weeks and monthly times 1 month. --- The residents had no negative outcome for not meeting the minimum of one LPN per 30 residents on evening shift. The facility has hired additional staff, holds daily staffing meetings to track staffing, and added additional agencies to utilize for staffing needs. Education: DON or designee will provide the staffing coordinator and HR with education on the Pennsylvania staffing requirements for ratios. Audits: Staffing coordinator or designee will audit the staffing ratios 3 times weekly for 2 weeks and monthly times 1 month.
Failure to Meet Minimum Nursing Care Hours Requirement
Penalty
Summary
Facility administrative staff failed to provide the minimum required 3.2 hours of direct general nursing care per resident per day on seven out of twenty-one reviewed days. Review of nursing time schedules and facility census data revealed that on these specific dates, the provided nursing care hours per patient day (PPD) fell below the regulatory minimum, with PPDs ranging from 2.91 to 3.16. The Director of Nursing confirmed during an interview that the facility did not meet the mandated nursing care hours on these days. No specific resident medical histories or conditions were mentioned in relation to the deficiency.
Plan Of Correction
IA: The residents had no negative outcome for not meeting the minimum 3.2 number of general nursing hours to each resident in a 24-hour period. The facility has hired additional staff, holds daily staffing meetings to track staffing, and added additional agencies to utilize for staffing needs. Education: DON or designee will provide the staffing coordinator and HR with education on the Pennsylvania staffing requirements for the 3.2 number of general nursing hours to each resident in a 24-hour time period. Audits: Staffing coordinator or designee will audit PPD 3 times weekly for 2 weeks and monthly times 1 month.
Failure to Follow Care Plan and Safety Protocols Results in Resident Hip Fracture
Penalty
Summary
A deficiency occurred when a resident with diagnoses including hypertension, heart failure, and dementia, who required extensive assistance of two staff for bed mobility, was not provided with the necessary goods and services as outlined in their care plan. The care plan specifically required the use of fall mats on both sides of the bed to minimize the risk of injury related to falls. However, during an episode of care, a nurse aide provided care alone and without the fall mats in place, despite physician orders and care plan directives. While the nurse aide was changing the resident, the bed was elevated to over two and a half feet, and the aide turned away from the resident to retrieve a brief. During this moment, the resident rolled out of bed and landed on the floor, resulting in an angulated left hip fracture. Multiple staff interviews confirmed that standard procedure is to roll residents toward the caregiver to prevent falls, and that the care plan requiring two-person assistance and fall mats was not followed at the time of the incident. Documentation and witness statements further indicated that the nurse aide did not maintain appropriate supervision and failed to follow established protocols for resident safety. The Director of Nursing and Nursing Home Administrator confirmed that the lack of adherence to the care plan and failure to provide required safety interventions constituted neglect, resulting in actual harm to the resident.
Failure to Provide Adequate Supervision and Accident Prevention During Bed Mobility
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and assistance to prevent accidents, resulting in actual harm. The resident, who had diagnoses including hypertension, heart failure, and dementia, required extensive assistance from two staff members for bed mobility, as documented in the Minimum Data Set. However, the care plan and physician orders did not clearly specify the required assistance for bed mobility, and fall mats, which were ordered to be placed bilaterally at the bedside, were not in place at the time of the incident. During care, a nurse aide was changing the resident and turned away to grab a brief, at which point the resident rolled out of bed and fell, sustaining a left hip fracture. The bed was elevated to over two and a half feet, and the fall mats were not present as required by the care plan and physician order. Witness statements from staff confirmed that the fall mats were not in place and that the nurse aide left the resident's side during care, contrary to facility policy and the resident's needs. The Director of Nursing also confirmed that the nurse aide's account of the incident was inconsistent with the physical evidence and that the aide failed to provide adequate supervision. The facility's policies on accident investigation and activities of daily living were not followed, contributing to the resident's fall and injury.
Failure to Document and Investigate Resident Grievance of Neglect
Penalty
Summary
The facility failed to properly document and process a resident grievance related to an allegation of neglect. Specifically, a resident reported that facility staff allowed her to remain on the floor for an hour after a fall. The facility's grievance log for the relevant month did not contain documentation of the date the grievance was received, a summary of the resident's allegation, steps taken to investigate, a summary of findings or conclusions, whether the grievance was substantiated, corrective actions implemented, or the date a written decision was issued. A review of the facility's grievance policy indicated that the Grievance Officer is required to submit a written report of findings to the Administrator upon receiving a grievance. However, interviews and document reviews confirmed that the facility did not follow this process for the resident's allegation. The Administrator in Training acknowledged that the required documentation and investigation steps were not completed or recorded in the grievance log.
Failure to Follow Abuse/Neglect Investigation Policy
Penalty
Summary
The facility failed to implement its Abuse Investigation and Reporting policy during an incident involving a resident who alleged neglect after a fall. According to the policy, all parties involved in an allegation are to be interviewed, and written, signed, and dated witness statements must be obtained. However, during the investigation of the incident where a resident reported being left on the floor for an hour after a fall, the facility did not obtain written witness statements from the resident or her roommate, resulting in an incomplete investigation. Facility documents submitted to the State Agency confirmed the lack of required documentation, and interviews with the Chief Nursing Officer and the resident identified specific staff members allegedly involved. The failure to follow established procedures meant that the investigation did not thoroughly identify or address the alleged perpetrators related to the neglect allegation.
Failure to Investigate Alleged Neglect After Resident Fall
Penalty
Summary
The facility failed to provide evidence of a thorough investigation into an allegation of neglect involving a resident who reported being left on the floor for an hour after a fall. The facility did not complete documentation of the resident's grievance, nor did they interview the resident or her roommate, resulting in an incomplete and inaccurate investigation. Additionally, the facility did not identify the alleged perpetrators or submit the required PB22 documents to the state agency. The investigation was further compromised by the facility's failure to implement a previously issued plan of correction related to ensuring residents are free from abuse and neglect. During interviews, the resident identified the staff members involved, including the DON and two nurse assistants. The lack of a thorough investigation prevented the facility from properly addressing and correcting the alleged neglect.
Improper Food Storage and Dating in Kitchen
Penalty
Summary
The facility failed to adhere to safe food handling practices as outlined in their Food Receiving and Storage policy. During an inspection, it was observed that the dry storage room contained two opened packages of dried pasta that were not dated. Additionally, in the walk-in cooler, a meal cart was found holding a metal tray with cooked ground meat placed next to an open and undated bag of raw chicken. These observations were confirmed by the Dietary Manager, Employee E7, indicating a failure to properly date and store food products, which could potentially lead to foodborne illness.
Failure to Conduct and Notify Residents of Care Plan Conferences
Penalty
Summary
The facility failed to conduct care plan conferences and ensure that residents or their representatives were notified in advance of these meetings for four residents. The facility's policy, dated 2/20/25, mandates that residents and their representatives be encouraged to participate in the development of the resident's care plan, with a seven-day notice provided for care plan conferences. However, interviews and record reviews revealed that residents R12, R36, and R39 were not aware of or had not participated in any care plan meetings. Resident R12, diagnosed with depression, renal insufficiency, and diabetes, had her care plans last revised on 2/14/25, but she stated she was unaware of any care plan meetings. Similarly, Resident R36, with high blood pressure, anxiety, and depression, and Resident R39, with hyperlipidemia, COPD, and major depressive disorder, also reported not attending or being aware of any care plan meetings. The Registered Nurse Assessment Coordinator (RNAC), who was an interim per diem employee, stated that she did not run the care plan meetings, indicating a possible gap in responsibility for organizing these conferences. The Nursing Home Administrator was informed of the facility's failure to conduct care plan conferences and notify residents or their representatives in advance. The deficiency was noted under 28 Pa. Code 201.29 (a) Resident rights and 28 Pa. Code 211.11 (e) Resident care plan.
Failure to Conduct and Document Resident Council Meetings
Penalty
Summary
The facility failed to uphold the residents' right to organize and participate in resident/family groups, as evidenced by the lack of documentation and follow-up from resident council meetings for four consecutive months. The facility's policy on grievances and complaints, dated February 20, 2025, mandates that all issues raised by resident or family groups be considered and responded to in writing. However, the review of resident council minutes for October and November 2024 revealed that staff conducted room-to-room visits instead of organizing a resident group meeting. Interviews with residents confirmed that no resident group meetings were held in October and November 2024, and they did not receive feedback or responses to their concerns. The Nursing Home Administrator acknowledged the failure to hold monthly resident council meetings and to document and follow up on resident concerns for the specified period.
Failure to Conduct and Document Enabler Bar Assessments
Penalty
Summary
The facility failed to conduct an initial Enabler/Assist Rail/Device Evaluation assessment for one resident and did not complete ongoing accurate assessments for three residents regarding the use of enabler/side rail assist bars. Specifically, Resident R30 did not have an initial assessment conducted, and Residents R7, R8, and R30 did not have ongoing assessments to ensure the enabler bars met their needs and addressed associated risks. Observations revealed that enabler bars were present on the beds of these residents, but the necessary evaluations were either outdated or missing. Resident R7, diagnosed with anemia, hypertension, and hemiplegia, had bilateral enabler bars on their bed, with the last evaluation completed nearly a year prior. Resident R8, with heart failure, hypertension, and diabetes, also had bilateral enabler bars, with the last assessment conducted over a year ago. Resident R30, diagnosed with hypertension, hyperlipidemia, and hemiplegia, had a right enabler bar without any recorded initial assessment. The facility's policy required assessments to determine the risks and benefits of using side rails, but these were not adequately performed or documented for the residents in question.
Failure to Investigate and Report Allegation of Neglect
Penalty
Summary
The facility failed to investigate and report an allegation of neglect involving a resident identified as R24. According to the facility's policy on identifying types of abuse, neglect is defined as the failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress. Resident R24, who was admitted with diagnoses of atrial fibrillation and congestive heart failure, was found to have a 7 x 5 cm bump on the right shin during a dressing change. The resident was unable to describe the cause of the injury but expressed fear when using the Hoyer lift. Despite this, the facility did not conduct an investigation or report the incident to the state survey agency. The Director of Nursing confirmed the failure to investigate and report the potential neglect incident.
Failure to Develop Baseline Care Plan for Pain Management
Penalty
Summary
The facility failed to develop a baseline care plan for pain management for one of its residents, identified as Resident R223. According to the facility's policy, a baseline care plan should be developed within 48 hours of a resident's admission to address their immediate needs. Resident R223 was admitted with several diagnoses, including a fracture of the right tibia and fibula, pain in the right ankle and joints of the right foot, and idiopathic progressive neuropathy. Despite these conditions and the resident's report of experiencing significant pain, the facility did not include a baseline care plan for pain management in the resident's care plan. The clinical records showed that Resident R223 had physician orders for pain management, including scheduled and as-needed doses of Acetaminophen and Oxycodone. The orders also required recording the resident's pain score every shift. However, during an interview, the Nursing Home Administrator confirmed that the baseline care plan for Resident R223 did not include interventions for pain management, indicating a failure to comply with the facility's policy and regulatory requirements.
Deficiency in Nutritional Services Due to Lack of On-Site Dietitian
Penalty
Summary
The facility failed to adhere to professional standards of quality in its nutritional services, as evidenced by the lack of a Registered Dietitian's (RD) active participation in essential duties over a six-month period. The RD, who began working remotely for the facility in late 2024, did not conduct in-person assessments, participate in care plan meetings, or monitor food service operations as required by the job description and state regulations. The RD worked only eight hours a week remotely and did not sign off on substitute menus or attend interdisciplinary meetings unless there was a specific concern. This lack of presence and involvement in the facility's operations led to a failure in meeting the nutritional needs of residents as per the facility's policies and state regulations. Interviews with facility staff, including the Dietary Manager and the Registered Nurse Assessment Coordinator, revealed that the RD's absence from the facility impacted the nutritional assessment process. The Dietary Manager indicated that resident meal preferences were managed by the Activities department, and the RNAC expressed uncertainty about the RD's presence in the building. The Nursing Home Administrator was informed of the deficiency, highlighting the facility's failure to have a Registered Dietitian on-site to fulfill the responsibilities outlined in the job description, which includes participating in interdisciplinary meetings and monitoring food service operations.
Failure to Provide ADL Assistance for a Resident
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADLs) for Resident R33, who was dependent on staff for toileting and required substantial assistance for showering. According to the facility's policy, residents unable to perform ADLs independently should receive necessary services to maintain good personal hygiene. However, a review of Resident R33's February 2025 shower documentation revealed that the resident did not receive scheduled showers on two occasions, and the toilet use documentation indicated that the resident was not changed at least every shift for 12 out of 28 days. Resident R33, who was admitted to the facility in April 2024, has diagnoses of high blood pressure, heart failure, and dementia, which affect their ability to perform self-care. The resident's family representative expressed concerns about the lack of bathing and changing, noting that staff had been informed multiple times about the need to prevent the resident from sitting in feces or a soiled brief. The Nursing Home Administrator confirmed the facility's failure to provide the necessary ADL assistance for Resident R33.
Failure to Provide Proper Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary services consistent with professional standards of practice for a resident with multiple pressure ulcers. Resident R27, who was admitted with diagnoses including dementia, morbid obesity, and muscle weakness, had several pressure ulcers upon admission. The facility did not document the stage of the sacrum and left rear thigh pressure ulcers. The care plan indicated a stage three pressure ulcer on the buttocks, and interventions included treatment per physician orders and repositioning assistance. However, the facility did not follow the wound care provider's orders, as the physician order did not include Santyl, which was necessary for the treatment. Additionally, the facility delayed implementing the wound care treatment ordered by the wound care provider for 29 days. The physician orders also failed to include an order for a wedge to assist with turning and repositioning, as recommended by the wound care provider. The Director of Nursing confirmed that the facility did not ensure residents received necessary services to promote healing and prevent infection, as required by professional standards of practice.
Failure to Provide Necessary Mobility Equipment
Penalty
Summary
The facility failed to ensure that a resident with limited mobility received the necessary services, equipment, and assistance to maintain or improve mobility. Resident R223, who was admitted with diagnoses including a fracture of the right tibia and fibula, pain in the right ankle and joints of the right foot, and idiopathic progressive neuropathy, was ordered to wear a TLSO brace when upright or out of bed. However, the resident reported that the brace had been missing for a couple of days, and this was confirmed by a Licensed Practical Nurse who stated that there was no TLSO brace available for the resident. Further review of Resident R223's clinical record revealed that there was no order or care plan for the TLSO brace, which was confirmed by the Director of Nursing. This oversight resulted in the resident not receiving the appropriate equipment and assistance needed to maintain or improve mobility, as required by the facility's obligations under 28 Pa. Code 211.12(d)(5) Nursing Services.
Failure to Timely Assess Nutritional Status
Penalty
Summary
The facility failed to timely assess the nutritional status of Resident R23, as required by their own policy. According to the facility's Nutritional Assessment policy, a dietitian is supposed to conduct a nutritional assessment for each resident upon admission within the current baseline assessment time frames. However, for Resident R23, who was admitted with diagnoses including epilepsy, dysphagia, hypertension, and hyperlipidemia, the first dietitian assessment was not conducted until 40 days after admission. This delay occurred despite the resident's hospital discharge summary indicating the need for nutritional monitoring due to increased nutritional demands. During the period from July 13 to July 30, Resident R23 experienced a significant weight loss of 11.8 percent, dropping from 242.2 lbs to 213.4 lbs. Despite this notable weight loss, there was no dietitian assessment related to this issue until August 22. Interviews with facility staff revealed that the dietitian assessments were not completed within the required 14-day timeframe, and there was uncertainty about the dietitian's presence in the facility on a daily basis. This lack of timely assessment and monitoring contributed to the deficiency identified by the surveyors.
Failure in Respiratory Care Management
Penalty
Summary
The facility failed to provide appropriate respiratory care related to oxygen management for two residents. Resident R41, who has a medical history of hypertension, respiratory failure, and coronary artery disease, was observed with oxygen administered via a nasal cannula. However, the oxygen tubing was not labeled with a date, which was confirmed by a registered nurse. This oversight was contrary to the physician's orders that required the oxygen tubing and canister to be changed every Saturday night shift. Similarly, Resident R274, diagnosed with diabetes, heart failure, and hypertension, was observed with a nebulizer that was not labeled with a date or stored in a bag. This was also confirmed by a registered nurse. The physician's orders for this resident included the administration of Ipratropium-Albuterol Inhalation Solution every six hours, but the lack of proper labeling and storage of the nebulizer indicated a failure in providing appropriate respiratory care.
Inconsistent Dialysis Communication and Care Planning
Penalty
Summary
The facility failed to ensure consistent dialysis communication and care planning for a resident requiring dialysis services. The resident, who was admitted with diagnoses of depression, renal insufficiency, and diabetes, had physician orders to attend dialysis three times a week. However, the clinical record review revealed the absence of a care plan for dialysis and incomplete communication forms for several dates in February and March. Interviews with a Licensed Practical Nurse and the Director of Nursing confirmed these deficiencies, indicating a lack of consistent communication and care planning for the resident's dialysis needs.
Failure to Ensure Physician Review of Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that irregularities identified in the Medication Regimen Reviews (MRR) by the pharmacy were reviewed by a physician for one of the residents. The facility's policy requires that a licensed pharmacist perform a monthly drug regimen review, and any irregularities should be reviewed by a physician who either accepts and acts upon the suggestions or provides an explanation for disagreeing. However, for Resident R12, this process was not followed. The resident had duplicate orders for Lidocaine gel, and the recommendation to discontinue one of the orders was signed off by the Director of Nursing instead of a physician. Additionally, another pharmacy review for the same resident indicated that there were no non-pharmacological interventions listed with an order for oxycodone, and it was recommended to consider adding such interventions. This recommendation was signed off by a Registered Nurse, who indicated the order was discontinued, but again, there was no physician review. The Nursing Home Administrator confirmed that the facility failed to ensure physician review of pharmacy recommendations for this resident.
Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. The resident, who was admitted with diagnoses including dementia, morbid obesity, and muscle weakness, was prescribed Divalproex Sodium and Levetiracetam for seizures. However, the dosages administered exceeded the recommended maximums. Specifically, the resident received 875 mg of Divalproex and 1750 mg of Levetiracetam, which were not aligned with the hospital's discharge orders. The error was identified when the resident's family reported increased lethargy, prompting a review of the medication orders. It was discovered that the orders entered by the Director of Nursing did not match the hospital's discharge instructions. The Licensed Practical Nurse had questioned the high dosages from the start, but the orders were not clarified until after the family raised concerns. The resident's condition was monitored, and medications were held due to the lethargy caused by the incorrect dosages. Interviews with staff revealed that there was a lack of proper verification and clarification of medication orders upon the resident's admission. The RN Supervisor confirmed that the facility failed to ensure the resident was free from significant medication errors. The Pharmacy Consultant Manager also noted that clarification was needed when multiple orders with different dosages were present, indicating a breakdown in communication and verification processes within the facility.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
