Holland Center For Rehabilitation And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Holland, Pennsylvania.
- Location
- 280 Middle Holland Road, Holland, Pennsylvania 18966
- CMS Provider Number
- 395432
- Inspections on file
- 28
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Holland Center For Rehabilitation And Nursing during CMS and state inspections, most recent first.
A resident who was cognitively intact but totally dependent for transfers, with documented gait abnormalities, recurrent falls, and a care plan requiring a mechanical lift (Hoyer lift) for all transfers, was assisted by a CNA using a walker and no lift. The CNA, working alone and unaware of the mechanical-lift requirement, attempted to stand the resident from a wheelchair to transfer to bed, during which the resident fell to the floor. The resident, previously identified as at risk for falls and with reduced balance, strength, and activity tolerance, sustained multiple right ankle and lower leg fractures and a tibiotalar dislocation that required surgical repair, demonstrating failure to follow the established care plan and transfer interventions.
A resident with multiple psychiatric and neurological diagnoses, identified as high risk for elopement, was able to leave the secured unit without a care plan or interventions in place. The resident followed a dietary staff member through locked doors, navigated the facility, and exited through an unsecured door, ultimately being found confused and barefoot in a parking lot. Facility staff confirmed that required supervision and safety measures were not implemented.
The facility did not maintain its fire alarm system in proper working order, as the fire alarm panel was observed to be in trouble mode during both the initial survey and a follow-up revisit. This issue was confirmed by facility leadership on both occasions.
Surveyors identified that fire-rated doors in the basement elevator lobby area had multiple penetrations and extensive damage, compromising the required fire resistance rating for common wall separations. Facility leadership confirmed these deficiencies during interviews.
Surveyors identified deficiencies in electrical system maintenance, including an open junction box with exposed wiring and electrical panels blocked by storage or with a broken latch, which remained unresolved upon revisit.
The facility did not complete required criminal background checks before hiring three new employees, as mandated by its abuse prevention policy. Background checks were conducted only after employment had begun, contrary to policy requirements designed to prevent abuse, neglect, and exploitation.
A resident with dementia and behavioral health needs was involved in an incident where a nurse aide slapped the resident after being struck. The witnessing aide did not immediately report the alleged abuse to the supervisor, resulting in a delay of about 24 hours before the incident was reported to facility leadership and the state health department.
A resident admitted with severe protein-calorie malnutrition, anorexia, depression, and muscle weakness did not have a baseline care plan developed or implemented to address nutrition needs within 48 hours of admission, as required by facility policy. This omission was confirmed by the DON and documented in the clinical record.
The facility did not develop or implement complete care plans for three residents, omitting necessary interventions for nebulizer treatments, oxygen therapy, and pressure ulcer prevention. Physician orders and resident needs were not reflected in the care plans, and staff confirmed these omissions during interviews.
Two residents did not receive respiratory care as ordered by their physicians. One resident with Parkinson's Disease and syncope was not receiving prescribed continuous oxygen, while another with chronic pulmonary disease and respiratory failure was given a lower oxygen flow rate than ordered, and had a dirty oxygen concentrator filter and unreadable tubing label. These deficiencies were confirmed by nursing staff during observation.
The facility did not complete required performance reviews or skills evaluations for nurse aides, as confirmed by record review and DON interview. No documentation of competencies or annual performance reviews was found, and the facility lacks related policies and procedures.
A resident with a documented PTSD diagnosis did not have this information communicated to nursing staff, resulting in a lack of appropriate trauma-informed care. The DON and Administrator were also unaware of the diagnosis, and there was no system in place for the psychologist to report new diagnoses to facility staff.
A resident admitted with a traumatic subdural hematoma and other medical conditions did not receive several prescribed medications for multiple days because the medications were not available from the pharmacy. Nursing documentation showed the medications were not administered, and there was no evidence the physician was informed of the ongoing issue. The DON confirmed there was no policy or protocol in place to ensure timely medication administration or to address situations when medications are unavailable.
A facility was cited for a medication error rate of 12% after a resident did not receive multiple scheduled medications, including gabapentin and metformin, at the prescribed times, with some doses delayed by several hours and without physician notification. Additionally, a nurse was observed preparing to crush medications that should be administered whole, such as Metoprolol ER, Finasteride, and Clopidogrel, contrary to best practices and facility policy.
Survey results were not easily accessible to residents or visitors, as the binders were kept behind the nursing stations on both nursing floors, and one binder contained outdated information. During a resident council meeting, several alert and oriented residents indicated they were unaware of the most recent Department of Health Survey results.
A facility failed to maintain accurate medical records for residents with indwelling urinary catheters. Documentation inconsistencies were found, with residents marked as both continent and incontinent, despite catheter use. The DON confirmed that records should have indicated continence not rated due to the catheter, and documentation was required once per shift, which was not consistently done.
A resident with multiple medical conditions did not receive prescribed Morphine and Oxycodone-acetaminophen for pain management due to the facility's failure to administer the medications as ordered. The resident reported the issue to local authorities and requested emergency transport to the hospital for proper care. The DON confirmed the lapse in medication administration.
A resident with a history of Alzheimer's, diabetes, and high blood pressure experienced respiratory distress, but the LTC facility failed to provide timely assessment and emergency transport. Despite the spouse's concerns, the resident's condition was not promptly addressed, leading to delayed oxygen administration and non-emergency transport. The resident suffered cardiac arrest in the parking lot and was pronounced deceased later that evening.
A resident did not receive prescribed pain medications, including Lyrica, Morphine Sulfate, and Oxycodone, due to issues with pharmacy services. This resulted in severe pain and affected the resident's activities and sleep. The facility's failure to administer medication as ordered was confirmed by the Assistant Director of Nursing.
The facility did not conduct monthly drug regimen reviews for a resident and failed to ensure physician acknowledgment of a pharmacist's recommendations for another resident. A resident's medication regimen review was not completed upon admission, and another resident's continued use of Pantoprazole was not evaluated by a physician despite pharmacist recommendations.
The facility failed to report healthcare-associated infections (HAIs) to the Pennsylvania Patient Safety Reporting System (PA-PASR) for two months. Documentation showed 14 HAIs in May and 5 in June, but no evidence of reporting was found. The DON confirmed the facility did not review or report these infections as required by the MCARE Act.
The facility failed to maintain an effective antibiotic stewardship program over five months, lacking necessary protocols and monitoring systems. Documentation for antibiotic orders from February to June 2024 was incomplete, missing symptoms, stop dates, and reviews for appropriateness. The Director of Nursing confirmed these deficiencies, violating resident care policies and nursing services regulations.
The facility failed to offer or provide the pneumococcal vaccine to five residents, as required by its policy. Despite the policy stating that residents should be assessed and offered the vaccine within thirty days of admission, records showed no evidence of this occurring. The Assistant DON confirmed the oversight, indicating a lapse in following the facility's vaccination protocol.
A facility failed to offer a resident the opportunity to develop an advance directive upon admission, as required by policy. The resident's hospital records indicated a DNR/DNI status, but this was not implemented in the facility, and the family was not given a chance to formulate an advance directive. The Assistant Director of Nursing confirmed these oversights, which violated specific Pennsylvania Code regulations related to management, resident rights, and nursing services.
The facility failed to develop and implement baseline care plans within 48 hours of admission for several residents, including those with specific medical needs like sacral wounds and urinary catheters. Additionally, the facility did not provide written summaries of these care plans to the residents or their representatives, as required by policy.
A facility failed to create a care plan for a resident at risk of elopement, who was diagnosed with dementia and dehydration. Despite the resident's wandering and exit-seeking behavior, and a social service note indicating the resident's desire to go home, no interventions were implemented. This was confirmed by the ADON.
A facility failed to accurately assess and obtain informed consent for bed rail use for a resident with dementia. The resident's care plan indicated cognitive impairments, but the risk evaluation did not reflect this, and there was no evidence of informed consent or discussion of risks and benefits with the resident or representative. The ADON confirmed these deficiencies.
A resident's lab results were delayed, leading to a failure in timely communication of critical findings. The resident, suspected of anemia, had blood work ordered, but results were not promptly reported. The facility did not notify the physician of abnormal results until the following day, despite low hemoglobin and high BUN levels. Staff interviews confirmed issues with timely lab result receipt.
The facility did not adhere to professional standards for food storage and safety. Observations revealed expired and undated food items in the refrigerator, and the walk-in refrigerator door was left open, causing a temperature above the required level. The Food Service Manager attributed the issue to delivery staff leaving the door open.
The facility failed to properly dispose of garbage, as observed in the receiving and garbage disposal areas. A dumpster was found with its lid open, leaking a brown liquid that attracted flies. A follow-up observation revealed the liquid was still present, along with kitchen trash on the floor.
A resident with dementia was inaccurately assessed for elopement risk, as the facility failed to document dementia as a predisposing condition. Despite the resident's wandering and exit-seeking behavior, the elopement assessment did not reflect the true risk, resulting in a lower score than warranted.
The facility failed to adhere to infection control protocols, as staff were observed not using PPE correctly and mishandling soiled linens. A nurse used the same gown for two residents on Enhanced Barrier Precautions (EBP), and an aide provided care without a gown. Additionally, a staff member was seen carrying soiled linen without a bag, violating facility policy.
The facility did not provide mandatory training on its QAPI program for staff, as shown by the absence of training records in the personnel files of five employees, including nurse aides and licensed nurses. This deficiency was confirmed through various reviews and interviews, and acknowledged by the facility's administrator.
The facility failed to develop a baseline care plan for a resident with heart failure, omitting necessary interventions like compression stockings and daily weight monitoring. This was confirmed by the DON.
A resident did not receive prescribed medications and treatments due to unavailability and lack of emergency supply use. The facility also failed to obtain required weights and inform the physician of significant weight gain. Additionally, the order for compression stockings was incorrect and needed clarification.
Failure to Follow Care-Planned Mechanical Lift Transfer Resulting in Fall and Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate assistance and supervision with assistive devices during transfers for a resident identified as being at risk for falls and totally dependent for transfers. Facility policy on comprehensive person-centered care plans required the interdisciplinary team to develop and implement care plans with measurable objectives and interventions based on comprehensive assessments, and the accident/incident policy required investigation and analysis of resident vulnerabilities. For this resident, the admission MDS documented cognitive intactness and total dependence for transfers, requiring assistance of staff for all transfers between bed and chair. A physical therapist’s assessment documented abnormalities of gait and mobility, a history of recurrent falls, and that the resident was at risk for falls and required a mechanical lift (Hoyer lift) for all transfers. The therapist noted that nursing was notified of the resident’s total dependence transfer status, and subsequent therapy documentation continued to identify total dependence with use of a mechanical lift. Physician and physiatrist notes described the resident as cognitively intact, alert, oriented, and able to follow commands. The comprehensive care plan identified the resident as at risk for accident hazards due to reduced balance, strength, and activity tolerance, with reduced ability to perform functional mobility and ADLs, and specifically directed use of a mechanical lift for all transfers, with nursing staff educated on this intervention to prevent falls. On the day of the incident, the resident was seated in a wheelchair and activated the call light requesting to return to bed. A nursing assistant (Employee E5) responded, reported the resident wanted to go back to bed, and placed a walker in front of the resident. While assisting the resident to stand from the wheelchair in preparation for a transfer to bed, and doing so alone without use of the mechanical lift or assistance of a second staff member, the resident fell to the floor. The nursing assistant later stated they were unaware the resident required a mechanical lift and two-person assistance for transfers. Blood was observed on the floor near the resident after the fall. The resident was sent to the emergency room and diagnosed with a comminuted distal fibular shaft fracture, a transverse fracture of the medial malleolus, and dislocation of the tibiotalar joint of the right leg, requiring surgical repair. The therapy director confirmed that the care plan required a mechanical lift for transfers and that nursing staff failed to implement this intervention.
Failure to Supervise High-Risk Resident Leads to Elopement
Penalty
Summary
The facility failed to provide adequate supervision and implement necessary interventions to prevent an unauthorized leave from the nursing unit, resulting in a resident elopement. A resident with diagnoses including chronic schizophrenia, bipolar disorder, anxiety disorder, and seizure disorder was admitted from a behavioral health hospital with a history of aggression and suicidal and homicidal ideations. Upon admission, the resident was assessed as high risk for elopement, but there was no documentation that a care plan addressing elopement or wandering risk was developed or implemented. The responsible nurse confirmed that interventions such as wander guard placement, supervision, and diversional activities were not put in place for this resident. On the day of the incident, the resident was able to leave the locked nursing unit by following a dietary staff member through code-alarmed doors and then used an elevator to access other parts of the facility. The resident abandoned their wheelchair, took a rollator walker, and exited the building through an unlocked door in the independent living section, eventually being found barefoot in a parking lot. Staff interviews and documentation confirmed that the resident was confused and lacked identification at the time. The facility's failure to follow its own policy for identifying and managing residents at risk for elopement directly contributed to the resident's unauthorized exit from the facility.
Failure to Maintain Fire Alarm System in Proper Operating Condition
Penalty
Summary
The facility failed to maintain its fire alarm system in proper operating condition, as evidenced by the fire alarm panel being in trouble mode during both the initial survey and a subsequent onsite revisit. On May 28, 2025, observation revealed that the fire alarm panel, located in the front lobby office area, was in trouble mode at the time of the survey. This condition was confirmed during the exit interview with the Administrator and Maintenance Director. During a follow-up onsite revisit on July 16, 2025, the fire alarm panel remained in trouble mode, and this was again confirmed by the Administrator and Maintenance Director during the exit interview. No information regarding residents or their medical conditions was provided in the report.
Plan Of Correction
The facility fire panel has been repaired so that it is not in trouble mode. The facility will call our fire protection company to repair if the panel should go into trouble mode. The Maintenance Director and/or designee will perform audits weekly, for four weeks and monthly for two months to ensure that the fire panels are not in trouble. Results of the audits will be reported to QAPI.
Failure to Maintain Fire-Resistant Door Barriers
Penalty
Summary
Surveyors observed that the facility failed to maintain the required fire resistance rating for common wall fire separations in one of three levels. Specifically, during an inspection, deficiencies were identified with fire-rated doors in the basement elevator lobby area. One double fire door had several penetrations on the door leaf and in the metal door frame, and another fire door showed penetrations and extensive damage at each hinge location. These conditions were directly observed by surveyors during their walkthrough. The deficiencies were confirmed in interviews with the Administrator and Maintenance Director, who acknowledged the issues with the fire doors. The report does not mention any specific patients or residents affected, nor does it provide details about their medical history or condition at the time of the deficiency. The focus of the findings is on the physical environment and the failure to maintain fire-resistant barriers as required by NFPA 101 standards.
Plan Of Correction
The fire door with penetrations has been replaced. Other fire doors in the center will be checked to ensure that they are free of penetrations. The Maintenance Director and/or designee will perform audits weekly, for four weeks and monthly for two months to ensure that the fire doors are free from penetrations. Results of the audits will be reported to QAPI.
Electrical System Deficiencies: Exposed Wiring and Inaccessible Panels
Penalty
Summary
Surveyors observed that the facility failed to maintain proper protection of electrical wiring in multiple areas. Specifically, an open junction box with exposed wiring was found in the basement phone room. Additionally, in the storage room across from the Health Care Administrator's office, two electrical panels (DP 2 and DP 4) were blocked by storage items within three feet, and one of the panels (DP 4) had a broken latch, making it difficult to open. During a follow-up onsite revisit, it was determined that the issue with the missing latch on the DP 4 electrical panel door had not been corrected, and the panel was still not secured properly. These deficiencies were confirmed during exit interviews with the Administrator and Maintenance Director. No information about residents or their medical conditions was included in the report.
Plan Of Correction
1) The electrical panel labeled DP 4 has been repaired so that it can latch and be easily opened. Storage has been removed from in front of electrical panel DP 2 and DP 4. 2) Other electrical panels have been checked to ensure that there is no storage and that the latch can close and be easily opened. 3) The Maintenance Director and/or designee will perform audits weekly, for four weeks and monthly for two months to ensure that the electrical panels can latch and easily open, and that there is no storage within three feet of the panels. Results of the audits will be reported to QAPI.
Failure to Complete Pre-Employment Background Checks
Penalty
Summary
The facility failed to develop and implement an abuse prohibition policy that ensured a thorough investigation of prospective employees' employment history, specifically by not conducting required criminal background checks prior to hiring. Review of personnel files for three newly hired employees revealed that their criminal background checks were completed after their hire dates, contrary to facility policy which mandates background checks before employment. This was confirmed through staff interviews and review of the facility's Abuse Prevention Program policy, which requires that no individual be employed without a completed background check to ensure they have not been found guilty of abuse, neglect, exploitation, or misappropriation of property.
Failure to Immediately Report Alleged Abuse
Penalty
Summary
An incident occurred involving a resident with dementia, psychotic disturbance, mood disturbance, and anxiety, who required assistance with personal care. During the incident, the resident became agitated, removed her pants, and urinated in the hallway. While staff attempted to assist her back to her room, the resident slapped a nursing aide, who then retaliated by slapping the resident across the face. The aide who witnessed the event did not immediately report the incident to the nursing supervisor, instead waiting until the following day to do so. This delay in reporting resulted in the facility failing to immediately notify the Pennsylvania Department of Health of the alleged abuse, as required by policy and regulation. The internal investigation and suspension of the involved staff were also delayed by approximately 24 hours due to the late report. The deficiency was identified through review of facility policies, clinical records, and staff interviews, confirming that the facility did not ensure immediate reporting of the abuse allegation.
Failure to Develop Baseline Care Plan for Nutrition Needs
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident within 48 hours of admission, as required by facility policy. The resident was admitted with diagnoses including severe protein-calorie malnutrition, anorexia, depression, and muscle weakness. Despite the resident's significant nutritional needs and self-reported weight loss, there was no documented evidence in the clinical record that a baseline care plan addressing nutrition was created or put into place. This was confirmed during an interview with the Director of Nursing, who acknowledged the absence of a baseline care plan related to the resident's nutrition diagnosis.
Failure to Develop Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, as required by policy. For one resident with chronic pulmonary disease and respiratory failure, there was a physician order for weekly nebulizer mask and tubing changes, but the care plan did not address nebulizer treatments. The resident reported issues with the nebulizer, and the assistant director of nursing confirmed the absence of a related care plan. Another resident with Parkinson's disease and syncope had physician orders for continuous and as-needed oxygen administration, but the care plan lacked any focus, interventions, or goals related to oxygen therapy, as confirmed by a registered nurse. A third resident, admitted with pressure ulcers and at risk for further injury, had a physician order for PR boots to be worn in bed to elevate the heels. The resident was observed not wearing the boots and stated noncompliance, while documentation from the wound team noted this noncompliance. However, the treatment administration record inaccurately documented the resident as compliant, and the care plan did not address the use of boots or the resident's noncompliance. These findings were based on policy review, clinical record review, observations, and staff interviews.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for two residents. For one resident with Parkinson's Disease and a history of syncope, physician orders required continuous oxygen administration at 2 liters, as well as oxygen as needed. However, during observation, the resident was not receiving oxygen as ordered, and this was confirmed by a registered nurse at the time of the observation. Another resident with chronic pulmonary disease and respiratory failure with hypoxia had a physician order for continuous oxygen at 3 liters per minute via nasal cannula. Upon observation, the resident was receiving only 2 liters of oxygen, and the oxygen concentrator's filter was found to be dirty. Additionally, the oxygen tubing was labeled with an unreadable bandage, making it unclear when it was last changed. These findings were confirmed by a licensed nurse during the survey.
Failure to Complete Nurse Aide Performance Reviews and Skills Evaluations
Penalty
Summary
The facility failed to complete required performance reviews and skills evaluations for nurse aides, as evidenced by a review of personnel records and staff interviews. Specifically, the personnel file for one nurse aide hired in March 2024 did not contain documentation of a skills evaluation or post-orientation performance evaluation. An interview with the DON confirmed that the facility does not conduct competencies or performance reviews for staff and lacks a policy or procedure for staff competencies or performance reviews. It was further confirmed that none of the nurse aides have annual performance reviews completed.
Failure to Communicate PTSD Diagnosis to Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff were informed of a resident's diagnosis of post-traumatic stress disorder (PTSD), resulting in a lack of appropriate treatment and services for the resident. The resident, who is a veteran, was admitted with a documented diagnosis of PTSD, as noted in psychological progress notes by a nurse practitioner. These notes indicated that the resident experienced PTSD symptoms, including nightmares several times per month, but was not seeking treatment for them. The PTSD diagnosis was listed under 'Other Diagnoses' in the progress notes. Despite this documentation, the registered nurse responsible for assessing residents and developing care plans was unaware of the PTSD diagnosis, as the psychological notes were not communicated to him. Additionally, both the Director of Nursing and the Administrator confirmed they were not aware of the resident's PTSD diagnosis or symptoms. It was acknowledged that there was no established communication system for the psychologist to report new diagnoses to facility staff, resulting in the failure to provide trauma-informed care as outlined in the facility's policy.
Failure to Provide and Administer Prescribed Medications to New Admission
Penalty
Summary
A newly admitted resident with a diagnosis of traumatic subdural hematoma and additional medical needs was not provided with several prescribed medications, including Heparin Sodium, Dronabinol, Modafinil, and Mekinist, for multiple days following admission. Nursing notes and the electronic medication administration record (EMAR) documented that these medications were not administered because they were not available from the pharmacy. The facility failed to ensure timely acquisition and administration of these medications, and there was no evidence that the attending physician was made aware of the ongoing unavailability of the medications. Further, an interview with the Director of Nursing revealed that the facility did not have a policy or procedure in place to ensure residents receive their prescribed medications or a protocol to follow when medications are not available from the pharmacy or not administered. This lack of established processes contributed to the resident not receiving necessary medications as ordered by the physician.
Medication Error Rate Exceeds 5% Due to Untimely and Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required by regulation, with a documented error rate of 12%. For one resident, medications were not administered in a timely manner or as ordered by the physician. Specifically, a resident with multiple chronic conditions, including neuropathy and diabetes, did not receive their scheduled morning medications until several hours late. The 8:00 a.m. dose of gabapentin was not given until 12:31 p.m., and other medications such as metformin and a lidocaine patch were also administered significantly later than prescribed. There was no evidence that the physician was notified of these delays or that there were orders permitting the altered administration times. Additionally, during medication administration observation, a registered nurse was found preparing to crush medications for another resident that should not be crushed, including Metoprolol Succinate ER, Finasteride, and Clopidogrel Bisulfate. Crushing these medications can alter their effectiveness and safety, as confirmed by literature and the nurse at the time of observation. These actions were in direct violation of the facility's own medication administration policy, which requires medications to be given safely, timely, and as prescribed.
Survey Results Not Readily Accessible to Residents and Visitors
Penalty
Summary
The facility failed to ensure that the most recent Department of Health Survey results were readily accessible to residents and visitors on both the first and second nursing floors. During a facility tour with the Director of Social Services, it was observed that the survey results binder was placed behind the nursing station, requiring individuals to request access, rather than being easily available. Additionally, the binder on the second floor contained outdated information, with the most recent survey results dated January 22, 2019. In a resident council meeting, several alert and oriented residents reported being unaware of the recent Department of Health Survey results.
Inaccurate Documentation of Catheter Care and Urinary Continence
Penalty
Summary
The facility failed to maintain complete and accurate medical records for four residents concerning catheter care and urinary continence. The documentation for these residents, who were utilizing indwelling urinary catheters, was found to be incorrect or incomplete. For instance, Resident R1's records showed inconsistencies in documenting urinary continence, with entries indicating both continence and incontinence, despite the presence of a catheter. Similar issues were observed with Resident R2, where documentation inconsistencies were noted, including instances of being marked as both continent and incontinent. Resident R4's records also exhibited discrepancies, with missing documentation for several shifts and incorrect entries regarding continence status. This resident was using an indwelling catheter prior to discharge, yet the records did not consistently reflect this. Resident R5's documentation was similarly flawed, with entries showing both continence and incontinence, and missing records for certain shifts, despite the use of a catheter prior to discharge. The Director of Nursing confirmed that during the documented periods, each resident was using an indwelling catheter, and the documentation should have reflected this by marking continence as not rated due to the catheter. Additionally, it was confirmed that bladder function should be documented at least once per shift, which was not consistently done, leading to the identified deficiencies.
Failure to Administer Pain Medication
Penalty
Summary
The facility failed to meet professional standards of practice by not providing routine and emergency pain medication to a resident, identified as Resident R1. The resident, who had a history of cerebral infarction, hypertension, malignant neoplasm of the ovary, hemiparesis, central pain syndrome, and leukemia, was admitted to the facility from the hospital. Physician's orders required the administration of Morphine sulfate twice daily and Oxycodone-acetaminophen as needed for pain management. However, the facility did not administer the 9:00 p.m. dose of Morphine sulfate on August 2, 2024, and failed to provide the as-needed Oxycodone-acetaminophen on August 2 and 3, 2024. The deficiency was further highlighted when Resident R1 reported to the nursing staff that she needed her pain medication, but was informed that the facility did not have the prescribed medication available. As a result, the resident called the local police and emergency ambulance transport, reporting neglect and requesting to be taken back to the hospital to receive the necessary pain medication. The Director of Nursing confirmed that the nursing staff failed to administer the prescribed medications as ordered by the physician for pain management on the specified dates.
Failure to Timely Assess and Transport Resident in Respiratory Distress
Penalty
Summary
The facility failed to timely assess a resident, identified as Resident R158, for respiratory distress and did not ensure timely emergency transportation services, resulting in an Immediate Jeopardy situation. Resident R158, who had a history of Alzheimer's disease, type 2 diabetes, and high blood pressure, was admitted to the facility for rehabilitative services following an abscess incision and drainage. On the day of the incident, the resident's spouse expressed concerns about his breathing to the nursing staff, but these concerns were not promptly addressed. A licensed nurse, Employee E13, overheard the spouse's concerns and instructed the charge nurse to assess the resident's lungs and call the physician, but then left the unit. Another nurse, Employee E4, was approached by the spouse during shift change but did not immediately recognize the urgency of the situation. It was not until 7:00 p.m. that Employee E4 assessed the resident and found his oxygen saturation levels critically low, prompting her to administer oxygen and contact the physician. However, she opted for non-emergency transport, which delayed the resident's transfer to the hospital. The Nursing Supervisor, Employee E5, was informed of the situation and instructed Employee E4 to administer oxygen and call the physician. Despite these instructions, the resident was not transferred until 8:10 p.m., and he experienced cardiac arrest in the facility's parking lot. Emergency services were only contacted after the resident coded, and he was pronounced deceased later that evening. The facility's failure to provide timely assessment and emergency transport for Resident R158 led to the identification of an Immediate Jeopardy situation.
Failure to Administer Pain Medication as Prescribed
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, as evidenced by the lack of administration of prescribed pain medications. The resident, who experienced severe pain in the lower back and legs, reported not receiving her prescribed pain medications, including Lyrica, Morphine Sulfate, and Oxycodone, for extended periods. This failure to administer medication as ordered by the physician resulted in the resident experiencing a pain level of 10 out of 10, affecting her daily activities and sleep. The Medication Administration Record for July 2024 showed multiple instances where the resident did not receive her prescribed medications. The Assistant Director of Nursing confirmed the resident's claims, attributing the issue to problems with pharmacy services, which led to medications not being delivered on time. This deficiency highlights a significant lapse in the facility's ability to manage and administer pain medication as per physician orders, directly impacting the resident's well-being.
Failure to Conduct Monthly Drug Regimen Reviews and Physician Acknowledgment
Penalty
Summary
The facility failed to ensure that a drug regimen review was conducted at least monthly for its residents, as required by its policy. Specifically, for Resident R13, there was no evidence of a medication regimen review completed upon admission since June 8, 2024. The facility was unable to provide documentation of the medication regimen review when requested, indicating a lapse in adherence to their established procedures for medication management. Additionally, the facility did not ensure that the attending physician reviewed or responded to the pharmacist's recommendations. In the case of Resident R9, the consultant pharmacist recommended an evaluation for the continued use of Pantoprazole 40mg daily due to potential risks associated with long-term use, such as increased risk of fractures, Vitamin B12 malabsorption, hypomagnesemia, and CDAD. However, there was no evidence of physician acknowledgment or response to these recommendations, highlighting a breakdown in communication and follow-up on medication-related concerns.
Failure to Report Healthcare-Associated Infections
Penalty
Summary
The facility failed to conduct a review of reportable infections to the Pennsylvania Patient Safety Reporting System (PA-PASR) and report as required for two of the six months reviewed, specifically May 2024 and June 2024. According to the Medical Care Availability and Reduction of Error (MCARE) Act, nursing homes are required to electronically report healthcare-associated infection (HAI) data to the Department and the Authority using nationally recognized standards based on CDC definitions. The facility documentation revealed that in May 2024, there were 14 in-house acquired infections, and in June 2024, there were 5 in-house acquired infections. However, there was no evidence that these infections were reported to PA-PASR as required. An interview with the Director of Nursing on July 11, 2024, confirmed that the facility did not review the HAI infections to determine if they met the criteria for reporting to PA-PASR. This oversight indicates a failure to comply with the reporting requirements set forth by the MCARE Act, which mandates that nursing homes report HAIs to the Pennsylvania Patient Safety Authority and the Department of Health. The lack of documentation and reporting of these infections suggests a gap in the facility's infection control and reporting processes.
Deficient Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program over a five-month period, as evidenced by a lack of antibiotic use protocols and monitoring systems. The facility's policy, dated December 2016, did not include a system for antibiotic use protocols, which is a critical component of an effective antibiotic stewardship program. This deficiency was identified through a review of facility documentation, policies, and staff interviews, revealing that the facility did not adhere to CDC guidelines for antibiotic stewardship in nursing homes. During the months of February to June 2024, the facility's infection surveillance tool failed to document symptoms, stop dates, total days of therapy, outcomes, and adverse events for all antibiotic orders. Specifically, in February, there were 17 antibiotic orders; in March, 15 orders; in April, 21 orders; in May, 37 orders; and in June, 12 orders, all lacking necessary documentation. Additionally, there was no antibiotic review conducted to determine the appropriateness of the antibiotic usage during these months. The Director of Nursing confirmed these findings during an interview on July 11, 2024. The lack of documentation and review indicates a significant gap in the facility's antibiotic stewardship program, failing to ensure that antibiotics were prescribed and administered under appropriate guidance. This deficiency is in violation of 28 Pa. Code 211.10(d) regarding resident care policies and 28 Pa. Code 211.12(d)(1)(5) concerning nursing services.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to offer and/or provide the pneumococcal immunization to five residents, as revealed by a review of clinical records and staff interviews. The facility's policy, dated October 2019, mandates that residents be assessed for eligibility to receive the pneumococcal vaccine series prior to or upon admission. If eligible, the vaccine should be offered within thirty days of admission unless medically contraindicated or previously administered. However, the records for five residents showed no evidence of the vaccine being offered or administered, despite the policy requirements. The Assistant Director of Nursing confirmed that these residents did not receive the pneumococcal vaccine, nor was it offered to them. The residents involved were of varying ages, and their immunization records lacked documentation of the pneumococcal vaccine. This deficiency was identified during a survey, and it was noted that the facility did not adhere to its own vaccination protocol, which includes documenting the date of vaccination, lot number, expiration date, person administering, and site of vaccination in the resident's medical record.
Failure to Implement Advance Directive for Resident
Penalty
Summary
The facility failed to ensure that a resident was offered the opportunity to develop an advance directive, as required by their policy. Upon admission, the resident should have been provided with written information about their rights to refuse or accept medical treatment and to formulate an advance directive. However, the clinical record for the resident did not include a completed section for code status, nor was there evidence of a physician order for a code status. This oversight occurred despite the hospital records indicating the resident's code status as Do Not Resuscitate/Do Not Intubate (DNR/DNI). The Assistant Director of Nursing confirmed that the resident's DNR/DNI status from the hospital was not implemented in the facility, and the resident's family was not given the opportunity to formulate an advance directive. This failure to act according to the facility's policy and the resident's documented wishes represents a deficiency in honoring the resident's rights. The report cites specific Pennsylvania Code regulations related to management, resident rights, and nursing services that were not adhered to in this case.
Failure to Develop and Implement Baseline Care Plans
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed and implemented within 48 hours of admission for several residents, as required by their policy. Specifically, the care plans for residents with specific medical needs, such as a sacral wound, indwelling urinary catheter, and skin conditions, lacked documented goals or interventions. For instance, a resident with a suspected deep tissue injury on the sacrum did not have any goals or interventions documented in their care plan. Similarly, another resident requiring urinary catheter care every shift had no corresponding care plan documentation. Additionally, the facility did not provide written summaries of the baseline care plans to the residents or their representatives, as evidenced by the lack of documentation in the clinical records. This was noted for residents with various diagnoses, including altered mental status, dementia, dehydration, anemia, and chronic kidney disease. Despite requests for evidence of baseline care plans and their distribution to residents or representatives, the facility was unable to provide such documentation, indicating a systemic issue in meeting regulatory requirements for resident care planning.
Failure to Develop Elopement Prevention Care Plan
Penalty
Summary
The facility failed to develop a person-centered care plan addressing the risk of elopement for a resident diagnosed with altered mental status dementia and dehydration. The resident, admitted with impaired cognitive function and dementia, was identified as at risk for elopement due to ambulatory and disoriented behavior. Despite the resident's wandering and exit-seeking behavior noted in progress notes and observations, and a social service note indicating the resident's desire to go home, the facility did not implement a care plan or interventions to prevent elopement. This deficiency was confirmed through an interview with the Assistant Director of Nursing.
Failure to Conduct Accurate Bed Rail Assessments and Obtain Informed Consent
Penalty
Summary
The facility failed to conduct accurate assessments and obtain informed consent for the use of bed rails for a resident. The resident, who was admitted with diagnoses including altered mental status, dementia, and dehydration, had a care plan indicating impaired cognitive function. An observation revealed that the resident's bed had bilateral upper side rails. A review of the side rail/entrapment risk evaluation showed that the resident used the side rails for support and wanted them raised. However, the assessment inaccurately documented the resident's cognitive impairments, failing to identify the risk associated with dementia and impaired thought processes. Additionally, there was no documented evidence that the facility informed the resident or their representative of the risks and benefits of using bed rails, nor was there any informed consent obtained prior to their use. An interview with the Assistant Director of Nursing confirmed the inaccuracies in the bed rail evaluation and the lack of informed consent. The facility's actions were found to be in violation of specific Pennsylvania Code regulations regarding the responsibility of the licensee, nursing services, and resident care policies.
Delayed Lab Results for Resident
Penalty
Summary
The facility failed to ensure timely laboratory services for a resident, identified as R94, which resulted in a delay in obtaining critical blood test results. The resident's daughter expressed concern about her mother's increased confusion and a recent fall, suspecting anemia, and requested blood work on a Sunday. The blood was collected the following Monday morning, but the results were not available promptly. The physician had ordered a complete blood count (CBC), complete metabolic panel (CMP), and magnesium test to be conducted on July 8, 2024. However, the results were not reported until late that evening, and the facility did not notify the physician of the abnormal results until the next day. The laboratory results revealed that the resident had a low hemoglobin level of 7.4, indicating anemia, and an elevated BUN level of 50, suggesting possible dehydration or kidney function issues. Despite these critical findings, there was no evidence in the clinical record that the facility communicated these results to the physician in a timely manner. Interviews with staff, including a Licensed Practical Nurse and the Assistant Director of Nursing, confirmed issues with the timely receipt of lab results, which should have been available on the same day as collection. This deficiency was noted under several Pennsylvania Code regulations related to resident care policies and nursing services.
Food Storage and Safety Deficiency
Penalty
Summary
The facility failed to ensure that food was stored and served in accordance with professional standards for food service safety. During an initial tour of the Food Service Department, it was observed that the refrigerator contained hot dog buns with a use-by date that had already passed, a vegetable tray and a tray of cake with no date, and a fresh fruit cup and lettuce with use-by dates of the previous day. Additionally, the walk-in refrigerator door was not completely closed, resulting in a temperature reading of 24 degrees Fahrenheit, which is above the required 0 degrees or below for freezer storage. Employee E19, the Food Service Manager, explained that the high temperature was due to the delivery staff leaving the freezer door open after a delivery that morning.
Improper Garbage Disposal
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed in the receiving and garbage disposal areas. On July 9, 2024, at 10:30 a.m., a surveyor, along with Employee E19, the Food Service Manager, noted that one dumpster had its lid open, exposing its contents. Additionally, a brown-colored liquid was leaking from the dumpster, creating a stagnant pool on the floor outside, which attracted flies. A follow-up observation on June 10, 2024, at 1:55 p.m. with regional dietary staff and Employee E19 revealed that the brown liquid was still present next to the dumpster, and kitchen trash was found on the floor nearby.
Inaccurate Elopement Assessment for Resident with Dementia
Penalty
Summary
The facility failed to accurately complete an elopement assessment for a resident diagnosed with dementia, which is a predisposing condition for elopement risk. The resident was admitted with diagnoses including altered mental status and dementia, yet the elopement assessment inaccurately documented 'none present' for predisposing diseases. This oversight resulted in a total assessment score that did not reflect the resident's true risk for elopement, as a score above 10 was considered at risk, but the resident's score was only 8. Further review of the resident's records and observations revealed behaviors consistent with elopement risk, such as wandering and exit-seeking behavior. Progress notes indicated the resident's wandering behavior and desire to leave the facility, yet these were not accurately reflected in the elopement assessment. The resident was ambulatory and displayed impaired cognitive function, which should have been considered in the assessment to accurately determine the risk of elopement.
Infection Control Deficiencies in PPE and Linen Handling
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observations and staff interviews. The facility's policy on Enhanced Barrier Precautions (EBP) was not properly implemented, as staff were observed not adhering to the required use of personal protective equipment (PPE). Specifically, a licensed nurse was seen tending to two residents on EBP while wearing the same gown, which is against the facility's policy. Additionally, an aide was observed providing incontinence care to a resident on EBP without wearing a gown, despite a sign indicating the need for such precautions. Further deficiencies were noted in the handling of soiled linens. A therapy staff member was observed leaving a resident's room with soiled linen in hand, without using a bag or container, contrary to the facility's policy on laundry handling. This was confirmed by a Licensed Practical Nurse, who acknowledged that used linen should be bagged prior to transport. These observations indicate a lack of adherence to infection control protocols, potentially compromising the safety and sanitary conditions within the facility.
Lack of QAPI Training for Staff
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) program included mandatory training for staff, as evidenced by the lack of training documentation in the personnel files of five employees. Specifically, the personnel files of nurse aides and licensed nurses, identified as Employees E6, E7, E8, E9, and E10, showed no evidence of training related to the facility's QAPI program. This deficiency was confirmed through observations, clinical record reviews, facility documentation, and interviews with staff and residents, and was acknowledged by the facility's administrator.
Failure to Develop Baseline Care Plan for Heart Failure
Penalty
Summary
The facility failed to develop a baseline care plan for a resident diagnosed with heart failure, encephalopathy, chronic kidney disease, and high blood pressure. Upon admission, the resident's physician noted the need for elevated legs at rest, the use of compression stockings in the morning and removal before bed, daily vitals, and weekly weights. The care plan did not include these specific interventions for managing heart failure, such as the use of compression stockings for edema and daily weight monitoring. This deficiency was confirmed during an interview with the Director of Nursing.
Failure to Follow Physician Orders and Provide Appropriate Care
Penalty
Summary
The facility did not follow or clarify physician orders for medication and treatments for a resident diagnosed with encephalopathy, chronic kidney disease, unspecified heart failure, and high blood pressure. Specifically, the resident did not receive Ticagrelor, Clonidine HCl, and Doxazosin Mesylate as prescribed on multiple occasions due to the medications being unavailable. The nursing staff failed to utilize the facility's emergency supply of these medications. Additionally, the facility did not obtain the required weights on admission and 24 hours post-admission, and there was no clinical evidence that the physician was informed of a significant weight gain of 3.5 pounds in 24 hours. The order for compression stockings was also found to be incorrect and needed additional clarification. The Director of Nursing confirmed that the orders were missing parameters and that the physician was not informed of the resident's weight gain. The facility also failed to document when the compression stockings were donned or removed and did not specify the parameters to alert the physician of weight gain. These deficiencies were identified during a review of the resident's records and interviews with staff, indicating a failure to provide appropriate treatment and care according to physician orders and the resident's needs.
Latest citations in Pennsylvania
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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