Horsham Center For Jewish Life
Inspection history, citations, penalties and survey trends for this long-term care facility in North Wales, Pennsylvania.
- Location
- 1425 Horsham Road, North Wales, Pennsylvania 19454
- CMS Provider Number
- 396078
- Inspections on file
- 43
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Horsham Center For Jewish Life during CMS and state inspections, most recent first.
A resident who was alert, oriented, and fully dependent on staff for ADLs, including bathing and personal hygiene, was observed to be unkempt with unwashed, matted, and oily hair and facial hair. The resident reported receiving only bed baths because she could not stand and stated her hair had not been washed since admission. Review of the care plan showed identified ADL needs due to activity intolerance, but documentation over a 30-day period reflected only bed baths, with no evidence that showers were offered or refused and no record of hair washing since admission. Staff were unable to produce additional documentation to show that appropriate ADL and hygiene care had been provided.
A resident experienced a significant change in condition characterized by large amounts of rectal bleeding, blood on bedding and the floor, and symptoms of weakness, pallor, and increased confusion, leading a medical provider to order an emergency hospital transfer. Although facility policy required prompt notification of the resident’s representative for significant changes and transfers, the resident’s legally designated representative was not informed until approximately six hours after the event. The unit manager arranged EMS and transfer paperwork, assuming the bedside nurse would notify the family, while the bedside nurse assumed the unit manager had already done so and did not verify that contact occurred. The administrator later confirmed there was a lapse in timely notification and a communication breakdown related to unclear assignment of responsibility for notifying the resident’s representative.
The facility did not ensure that the results of investigations into suspected abuse, neglect, or misappropriation were reported within the required timeframe for two residents. One cognitively intact resident and her son reported missed nebulizer treatments, with no evidence that the investigation results were reported as required. Another resident with severe dementia was found with unexplained bruising, and the facility failed to document or report the investigation results to the appropriate authorities.
A resident was served food and beverages at temperatures outside the acceptable range, as confirmed by the Food Service Director during a test tray review. Meal trays were transported using open carts, and items such as eggs, coffee, orange juice, and chocolate milk were found to be not palatable due to improper temperatures.
A resident with multiple medical conditions was found with a bruise of unknown origin on the back of the head. Although facility policy requires thorough investigation and interviews with all relevant staff, the nurse aide assigned to the resident the day before the bruise was discovered was not interviewed, resulting in an incomplete investigation.
The facility did not provide timely access to medical records for three residents after receiving signed requests, resulting in significant delays beyond the timeframes required by facility policy and state regulations. The Medical Records Director confirmed that the records were not released promptly, as verified through staff interviews and documentation review.
A resident with dementia who exhibited ongoing agitation, verbal aggression, and confusion did not receive timely behavioral health care as required by their care plan. Despite repeated incidents and documented requests for a psychiatric consult, there was no evidence that the resident was seen by psychiatric services, and staff confirmed the consult was not completed.
A resident with COPD was transferred using a mechanical sit-to-stand lift by a single nurse aide, contrary to facility policy requiring two staff for such transfers. During the transfer, the resident's arm was bumped into a doorway, resulting in injury. Documentation and interviews confirmed the policy was not followed.
Residents reported that food was unpalatable, sometimes overcooked or undercooked, and often served cold. During a group interview, several residents agreed there were ongoing issues with food quality, including an incident where chicken was served partially raw. A test tray observation with the Dietitian confirmed that food items were served at temperatures too cool to be palatable.
A resident with dementia, Parkinson's disease, anxiety, and depression was found to have a bed alarm in use without documented evaluation for its necessity. Physician orders and care plans indicated daily use of bed and chair alarms, but clinical records lacked evidence of assessment for these devices. This was confirmed by a unit manager RN, resulting in a deficiency for not ensuring the resident was free from physical restraints.
A resident receiving tube feeding was found with a bottle of Jevity 1.5 enteral feed that had not been discarded within the required 24-hour period, as confirmed by the unit manager. This failure to follow proper enteral feeding protocols resulted in a deficiency related to safe feeding tube practices.
A resident with physician orders for oxygen therapy and regular tubing maintenance was observed disconnected from the oxygen tube, with the concentrator running and the tubing lying on the floor. This was confirmed by an LPN at the time of observation.
A resident with PTSD, anxiety disorder, and bipolar disorder was admitted, but the care plan did not address the resident's actual PTSD condition or identify past experiences and possible triggers for re-traumatization. This deficiency was confirmed by the Social Service Director.
A resident with renal dialysis dependence and obstructive uropathy had an order for Enhanced Barrier Precautions every shift. During care, an ophthalmologist provided an eye examination without wearing a required protective gown, in violation of infection control protocols.
A resident with multiple medical conditions was discharged against medical advice (AMA) without the physician being informed. The family declined transfer training, and the interdisciplinary team disagreed with the discharge. The physician was unaware of the situation until after the resident had left, and stated that documentation of the family's refusal should have been made instead of an AMA discharge.
A resident's dental procedure was delayed because the facility failed to withhold Xarelto as instructed. The unit manager missed the special instruction, leading to the rescheduling of the procedure.
A resident with a fracture and Parkinson's disease experienced a delay in orthopedic follow-up due to a missed appointment. The facility was reminded of the appointment by the resident's family, but transportation was not arranged in time, leading to an eight-week gap instead of the recommended four weeks. The responsible unit manager was terminated for unsatisfactory performance.
The facility failed to maintain and test its generator system according to NFPA standards, specifically lacking documentation for a required 3-year, 4-hour load test. This deficiency affects the entire facility, as the generator is crucial for maintaining electrical systems during outages. The absence of documentation was confirmed during an interview with the Administrator and Maintenance Director.
The facility did not comply with Pennsylvania Act 48 for carbon monoxide detector maintenance. The carbon monoxide detector in the basement laundry had not had its battery changed since June 2023, exceeding the annual requirement. This was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility was found to have improperly installed an Alcohol Based Hand Rub Dispenser (ABHR) directly above a light switch and electrical outlet in the basement kitchen, violating NFPA 101 safety standards. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility failed to properly install sprinkler system components, affecting one of four levels. Missing sprinkler protection was observed over a combustible material at the main entrance's exterior portico ceiling. Additionally, a pendant sprinkler was installed in the Synagogue telephone room, but the area lacked a ceiling assembly, resulting in incomplete sprinkler coverage. These deficiencies were confirmed during an exit interview with the Administrator and Maintenance Director.
The facility failed to maintain its sprinkler system, with boxes stored too close to a sprinkler and a missing drywall section replaced with cardboard around another sprinkler. Documentation for the annual inspection of the clean agent suppression system was missing, and corrective actions for previously identified valve issues were not documented.
The facility was found to have an unsealed penetration around data wires above the smoke doors on the first floor, section D-1, compromising the smoke barrier's integrity. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility failed to maintain electrical wiring protection, affecting two levels. A junction box in the basement chiller room ceiling was missing its protective cover, and a damaged duplex receptacle on the third floor in the C/D Kitchenette exposed inner wiring. These issues were confirmed during an exit interview with the Administrator and Maintenance Director.
The facility was found to be in violation of NFPA standards when an orange extension cord was improperly plugged into a surge protector inside an electrical panel on the second floor. This was observed in the C/D Corridor Storage Room and confirmed during an exit interview with the Administrator and Maintenance Director.
The facility failed to maintain proper oxygen storage in the basement, with combustible boxes stored next to oxygen cylinders and empty cylinders not separated from full ones. These deficiencies were confirmed during an exit interview with the Administrator and Maintenance Director.
The facility did not maintain the integrity of a fire extinguisher housing, as a broken housing box was observed on the second floor across from a resident room. This was confirmed by the Administrator and Maintenance Director.
The facility failed to maintain operable emergency lighting, as the back-up battery lighting fixture in the generator enclosure did not illuminate when tested. This issue was confirmed during an interview with the Administrator and Maintenance Director.
A resident with end-stage renal disease requiring dialysis experienced harm due to the facility's failure to monitor and assess their dialysis access site. After surgery on the resident's fistula, the facility did not obtain physician orders for care and monitoring, and ongoing swelling and infection were not communicated to the physician. Incomplete documentation and communication with the dialysis center contributed to the resident's emergent hospital transfer for a swollen, infected fistula and deep vein thrombosis.
The facility was found to have insufficient nursing staff, resulting in delayed call bell responses and medication administration. Residents reported long wait times for assistance, affecting their care, including shower schedules. A nursing aide felt overwhelmed with a caseload of 13 residents, and only two aides were working during the day shift. The shortage of staff was linked to increased falls as residents attempted to use the bathroom without assistance.
The facility failed to provide palatable and appropriately heated food and drink for several residents. Complaints included cold meals, poor taste, and non-compliance with dietary needs. A test tray confirmed that certain food items were outside acceptable temperature ranges, supporting residents' dissatisfaction.
A resident with a history of Alzheimer's and gastrostomy status repeatedly dislodged their peg tube, but the facility failed to update the care plan to address this behavior. Despite multiple incidents, the care plan was not revised, as confirmed by the DON.
The facility failed to obtain a specialist consultation for a resident with lymphedema and did not administer insulin as ordered for another resident with diabetes. One resident expressed a preference for a lymphedema specialist, but no follow-up was documented despite an active order. Another resident's insulin was administered hours later than prescribed, potentially affecting their health.
The facility failed to provide proper respiratory care for three residents with Chronic Respiratory Failure. One resident lacked a physician's order for oxygen therapy, while all three had oxygen concentrators with filters containing a buildup of grey, fuzzy substance. The Unit Manager confirmed the need for cleaning these filters.
The facility did not complete annual performance evaluations for three nurse aides, as required by its policy. The evaluations for Employees E11, E12, and E13 were missing, despite the policy mandating evaluations at the end of a 90-day probationary period and annually thereafter. This deficiency was identified during a review of facility documentation.
A facility failed to create an individualized care plan for a resident with dementia, despite their policy requiring such plans. The resident, admitted with a dementia diagnosis, was receiving antipsychotic medications, but lacked a care plan with measurable goals and interventions. The DON confirmed the necessity of care plans for dementia patients.
The facility failed to maintain proper communication and documentation with a dialysis provider for residents receiving dialysis. A resident with end-stage renal disease was hospitalized due to a severe infection, with incomplete communication records between the facility and the dialysis center. Another resident's dialysis logs were missing documentation from both the dialysis center and facility staff, indicating lapses in maintaining accurate records.
The facility failed to provide required in-service training for a nurse aide, Employee E14, as per their policy which requires at least 12 hours of training annually based on performance reviews. During a review, the facility could not provide documentation of completed training for this employee.
Horsham Center for Jewish Life failed to notify the Office of the State Long-Term Care Ombudsman about emergency hospital transfers for two residents. One resident experienced an unwitnessed fall and was transferred for evaluation, while another had multiple incidents requiring hospital visits, including pulling out medical devices. The facility did not comply with notification requirements, as confirmed by the Assistant Administrator.
A facility failed to document the disposition of a resident's personal property after their death. The deficiency was identified during a review of the resident's closed clinical record, which lacked documentation on the final disposition of their belongings. This oversight was confirmed in an interview with the Nursing Home Administrator and the DON.
A housekeeping staff member was observed sleeping on a couch in a common area of Unit D2, wearing earbuds and unresponsive to a surveyor's presence. This occurred in view of residents and visitors, and was confirmed by the Unit Manager and Nursing Home Administrator as unprofessional behavior that did not uphold resident dignity.
The facility did not meet the required nurse aide staffing levels during the day shift on two occasions. With a census of 300 residents, only 26.90 nurse aides were available instead of the required 30. On another occasion, with 309 residents, 29.83 nurse aides were present instead of the needed 30.90. No additional higher-level staff were available to cover the shortfall.
A resident with a history of suicidal ideation was able to access a razor and self-harm due to inadequate supervision and failure to remove hazardous materials from their environment. Despite being on 1:1 supervision, the resident was left unsupervised in the bathroom, where they found the razor. The facility's policies on safety and supervision were not effectively implemented, leading to an Immediate Jeopardy situation.
A resident with a history of suicidal ideation accessed hazardous materials, including a razor, due to lapses in supervision and room searches by staff. The resident used the razor to cut their wrist, resulting in an Immediate Jeopardy situation. The facility's management failed to ensure a safe environment, contributing to the incident.
A resident with a history of anxiety and depression expressed suicidal thoughts to staff, but the facility failed to provide adequate supervision. Despite clear indications of distress, the resident was not placed on 1:1 monitoring, leading to an intentional acetaminophen overdose. The nursing supervisor and staff did not take appropriate action, resulting in the resident's hospitalization.
A resident with a history of depression and anxiety expressed suicidal ideations and reported ingesting Tylenol, but the facility failed to notify the physician. Despite multiple staff members being aware of the resident's threats and actions, there was no evidence of physician notification or implementation of specific care instructions during the shift.
A resident with a history of passive suicidal ideation did not have a comprehensive person-centered care plan addressing these thoughts, despite multiple expressions of feeling better off dead to the facility's psychologist and unit manager. The resident, who was cognitively intact and had several medical conditions, did not have any goals or interventions in their care plan to address these ideations, contrary to the facility's policy requiring ongoing assessments and care plan revisions.
A resident with multiple diagnoses, including Parkinson's disease, did not receive medications at the prescribed times, as required by the facility's policy. The Medication Administration Audit Report for July 2024 showed that medications such as Selegiline, Carbidopa-Levodopa, and Amantadine HCI were administered late on several occasions, contrary to physician orders.
A resident with a history of depression expressed suicidal ideations and claimed to have ingested Tylenol pills. Despite notifying the nursing supervisor, there was a delayed response, and the resident was not placed on 1:1 observation. The resident eventually called 911 and was transported to the hospital, revealing deficiencies in the facility's management and response to the crisis.
A facility failed to document a resident's mental health concerns accurately. The resident, with a history of anxiety and depression, left voicemails for the unit manager expressing thoughts of being better off dead. The unit manager did not document the voicemails or actions taken, only notifying a psychologist. This lack of documentation constitutes a deficiency in maintaining accurate medical records.
Failure to Provide and Document Required ADL Assistance and Hygiene Care
Penalty
Summary
The facility failed to provide adequate ADL assistance, including bathing and hair care, to a resident who was fully dependent on staff for all ADLs. The resident’s admission MDS dated January 13, 2026 documented that the resident was alert and oriented, had one Stage III pressure ulcer and six unstageable pressure areas, and was totally dependent on staff for toileting, showering/bathing, dressing, and required substantial/maximal assistance with personal hygiene. The resident’s care plan, initiated on January 14, 2026, identified inability to perform ADLs due to activity intolerance and included interventions for staff assistance. Despite this, an observation and interview on April 6, 2026 at 11:30 a.m. revealed the resident appeared unkempt, with facial hair on the upper lip and hair that appeared unwashed, matted, and oily. During the interview, the resident reported that staff did not offer showers and that she received only bed baths because she was unable to stand. She further stated that her hair had not been washed since admission nearly three months earlier. In a subsequent interview on April 8, 2026 with the ADONs and the unit manager/LN, it was confirmed that documentation for the prior 30 days (March 10 through April 4, 2026) showed only bed baths were provided, with no evidence that showers were offered or refused. There was also no documentation that the resident’s hair had been washed at any time since admission. Staff were given an opportunity to provide additional documentation but none was produced, confirming the lack of documented ADL assistance consistent with the resident’s assessed needs and care plan.
Failure to Promptly Notify Resident Representative of Significant Change and Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a resident’s legally designated representative of a significant change in condition and an emergency hospital transfer. Facility policy dated February 2024 required notification of the resident and/or representative for any significant change in condition, including hospital transfer. The resident had a Power of Attorney designation on file for a family member dated August 1, 2023. On January 9, 2025, at 9:31 a.m., a medical provider documented that an aide reported large amounts of blood on the floor, wheelchair, and bathroom floor. On evaluation, the resident was in bed with a blood-covered gown, dried blood on sheets, and a large amount of blood on the floor and wheelchair cushion, appearing awake, alert, weak, pale, and with some increased confusion, and was noted to have a rectal bleed. The provider reviewed the situation with the unit manager and agreed to transfer the resident to the emergency room for further evaluation. A nursing note authored by a licensed nurse at 4:02 p.m. the same day, approximately six hours after the change in condition and transfer, documented that the resident was sent to the hospital for rectal bleeding and transferred for gastrointestinal bleeding, and that the resident’s niece was contacted at that time to provide an update and address questions and concerns. The unit manager reported that she was on duty, received notification of the change in condition, contacted emergency services, and completed transfer paperwork, and stated that she believed the bedside nurse would notify the family. She confirmed that she did not speak with the family member until five to six hours after the transfer and then learned the representative had not been notified immediately. The bedside nurse confirmed she was assigned to the resident, responded to the room when called by an aide, and found the provider already assessing the resident and deciding on hospital transfer. She acknowledged it was her responsibility to notify the representative but assumed the unit manager had done so and did not verify that notification occurred. The Nursing Home Administrator confirmed there was a lapse in timely notification to the resident’s representative and a communication breakdown due to failure to clearly assign responsibility for notification.
Failure to Timely Report Investigation Results of Suspected Abuse, Neglect, or Misappropriation
Penalty
Summary
The facility failed to ensure that the results of all investigations into suspected abuse, neglect, or misappropriation were reported within five working days to the administrator or designated representative and to other officials as required by State law. For one resident, who was cognitively intact and had a history of chronic obstructive pulmonary disease, asthma, and malignant neoplasm, a grievance was filed by the resident and her son regarding missed nebulizer treatments. They reported that treatments were not administered as ordered, and that records falsely indicated administration. There was no evidence that the results of the investigation into this grievance were reported to the appropriate authorities within the required timeframe. For another resident with heart failure and severe dementia, who was on 1:1 observation due to behavioral concerns, a nursing note documented unexplained bruising. The facility's investigation did not provide a documented explanation for the bruising, and there was no evidence that the injury of unknown origin or the results of the investigation were reported to the State Survey Agency as required. These findings were confirmed through interviews with facility leadership and review of facility documentation and policies.
Failure to Serve Food and Drink at Palatable Temperatures
Penalty
Summary
The facility failed to provide food and drink at palatable temperatures for one of five residents reviewed. During an observation, resident meal trays were transported from the kitchen to the nursing unit using open carts. A test tray review with the Food Service Director revealed that the eggs were served at 116°F, coffee at 123°F, orange juice at 51°F, and chocolate milk at 46°F. These temperatures were confirmed by the Food Service Director to be outside the acceptable range, resulting in food and drink that were not palatable.
Incomplete Investigation of Bruise of Unknown Origin
Penalty
Summary
The facility failed to conduct a complete and thorough investigation into a bruise of unknown origin found on a resident. The facility's policy requires that all allegations be thoroughly investigated, including reviewing documentation, medical records, and interviewing all relevant staff members who had contact with the resident during the period in question. In this case, a nurse aide discovered a dark purple bruise on the back of the resident's head, which caused mild pain when touched. The resident had multiple diagnoses, including cerebral infarction, anxiety, depression, dementia, hypertension, and diabetes. During the investigation, statements were collected from various staff members who worked on the relevant shifts, but the nurse aide who was assigned to the resident on the day prior to the discovery of the bruise was not interviewed. This omission was confirmed by the Assistant Director of Nursing. The failure to interview all pertinent staff, as required by facility policy, resulted in an incomplete investigation of the incident.
Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to provide timely access to medical records requested by or on behalf of residents, as required by its own policy and state regulations. Specifically, for three residents, the facility received signed, written requests for the release of medical records but did not fulfill these requests within the timeframes outlined in the facility's policy. The policy states that residents may access their records within 24 hours (excluding weekends and holidays) of a written request and may obtain photocopies with at least 48 hours' advance notice. However, documentation showed significant delays in providing the requested records, with some requests taking several weeks to be fulfilled. During an interview, the Medical Records Director acknowledged that the records for the three residents were not released to the requestors in a timely manner. The deficiency was identified through staff interviews, review of facility policy, and examination of facility documentation, confirming that the facility did not adhere to its own procedures or regulatory requirements regarding resident access to medical records.
Failure to Provide Timely Behavioral Health Services
Penalty
Summary
A deficiency occurred when a resident with dementia, identified as being at risk for verbal aggression, did not receive timely behavioral health care as required. The resident's care plan included interventions such as a psychiatric or psychogeriatric consult as indicated. Over a period of time, the resident exhibited multiple episodes of agitation, verbal aggression, wandering, and combative behavior, including incidents where the resident was uncooperative with therapy, called 911 while confused, and was verbally aggressive toward staff and family. Despite these ongoing behavioral health concerns, documentation showed that a referral for a psychiatric consult was sent, but there was no evidence that the resident was seen by psychiatric services. Further review of facility records revealed that the resident was not listed to be seen by the psychiatric provider, and electronic communication logs indicated that requests for consultation went unanswered for 30 days, with a follow-up message sent 12 days prior to the survey. Staff interviews confirmed that the resident had not been seen by psychiatric services, despite the ongoing behavioral health issues and the care plan's directive for such intervention. This failure to provide necessary behavioral health care and services in a timely manner resulted in the deficiency.
Mechanical Lift Transfer Performed by Single Staff Member Resulted in Resident Injury
Penalty
Summary
A deficiency occurred when a nurse aide operated a mechanical sit-to-stand lift alone to transfer a resident diagnosed with chronic obstructive pulmonary disease. According to facility policy, at least two nursing staff are required to safely move a resident with a mechanical lift. The nurse aide transported the resident by herself into the bathroom, during which the resident's arm was bumped into the doorway. Documentation and staff interviews confirmed that the transfer was performed without the required second staff member present. The incident was discovered through a review of the resident's clinical record and an incident investigation report, which included statements from the involved staff. The administrator confirmed that the nurse aide was alone during the transfer and that the incident resulted in the resident's arm being injured when it was bumped on the door. The facility's policy and the events leading up to the incident were verified through interviews and documentation review.
Failure to Provide Palatable and Properly Heated Food
Penalty
Summary
The facility failed to provide food and drink that was palatable, attractive, and served at a safe and appetizing temperature. Multiple residents reported that the food did not taste good, was sometimes overcooked or undercooked, and was occasionally served cold. During a group interview, several residents agreed that there were ongoing problems with the food, including an incident where chicken was served partially raw with visible blood. Observations during a test tray with the Dietitian confirmed that food items, including pasta, green beans, and salmon, were served at temperatures below what is considered palatable, and the Dietitian acknowledged that the food was too cool. Facility documentation, resident interviews, and direct observation all supported the finding that the facility did not meet dietary service requirements for food quality and temperature.
Failure to Evaluate Use of Bed and Chair Alarms as Physical Restraints
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including unspecified dementia, Parkinson's disease with dyskinesia, anxiety disorder, and depression, was found to have a bed alarm in place. The resident's clinical record included physician orders for the use of a bed alarm and care plan documentation for both bed and chair alarms. The Minimum Data Set assessment indicated daily use of these alarms, and the resident required partial to moderate assistance with bed mobility and transfers. Despite the use of these alarms, there was no documented evidence in the clinical records that the resident had been evaluated for the use of a chair or bed alarm. This lack of evaluation was confirmed during an interview with the unit manager, a registered nurse. The failure to assess the need for these devices resulted in the facility not ensuring the resident was free from physical restraints, as required.
Failure to Discard Expired Enteral Feeding Bottle
Penalty
Summary
The facility failed to ensure proper enteral feeding practices for a resident receiving tube feeding. Specifically, a physician's order directed that Jevity 1.5 be administered once daily at a specified rate until a total daily volume was reached. However, during an observation, it was found that the bottle of Jevity 1.5 in the resident's room was dated eight days prior to the observation, indicating it had not been discarded within the required 24-hour period. The unit manager confirmed that enteral feed bottles must be discarded every 24 hours, but this protocol was not followed for the resident in question.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for one resident. Physician orders for the resident included checking and changing oxygen tubing weekly and as needed, every night shift, every Saturday, and ensuring the tubing was dated, as well as administering oxygen at two liters to maintain an SPO2 greater than 90 every shift for shortness of breath. During an observation, the resident was found disconnected from the oxygen tube while the oxygen concentrator was running, and the oxygen tubing was observed lying on the floor. This finding was confirmed at the time with a licensed nurse.
Failure to Provide Trauma-Informed, Culturally Competent Care for Resident with PTSD
Penalty
Summary
The facility failed to provide culturally competent, trauma-informed care for a resident diagnosed with post-traumatic stress disorder (PTSD), anxiety disorder, and bipolar disorder. Review of the clinical record and care plan revealed that although the resident's PTSD diagnosis was documented, the care plan did not address the resident's actual condition by identifying past experiences or possible triggers that could cause re-traumatization. This omission was confirmed during an interview with the Social Service Director, who acknowledged that the care plan lacked necessary details regarding the resident's PTSD and associated triggers.
Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program related to Enhanced Barrier Precautions for one resident. Specifically, a resident with diagnoses of dependence on renal dialysis and obstructive and reflux uropathy had a physician order for Enhanced Barrier Precautions to be implemented every shift. During an observation, an ophthalmologist was seen providing eye examination care to the resident without wearing a protective gown, which is required as part of the personal protective equipment (PPE) under Enhanced Barrier Precautions. This lapse was confirmed with the staff member involved at the time of the observation. The deficiency was identified through observations, review of facility policies and documentation, clinical record review, and staff interviews, and was cited under 28 Pa Code 201.14(a) and 28 Pa Code 201.18(d).
Failure to Communicate Resident Discharge Information to Physician
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the physician before a resident was discharged against medical advice (AMA). The resident, who was cognitively intact and had multiple medical conditions including a fracture, Parkinson's disease, dysphagia, type 2 diabetes, and lack of coordination, was discharged AMA due to the family's non-cooperation in receiving transfer training. The interdisciplinary team did not agree with the resident leaving the facility without the family being trained for safe transfer. The physician was not informed about the AMA status or the family's non-compliance before the resident left the facility. The physician only received a message requesting a callback, but by the time the call was returned, the resident had already left. The physician stated that if informed, they would have recommended documenting the family's refusal rather than proceeding with an AMA discharge. The Director of Nursing and the Administrator confirmed that the physician should have been involved in the decision-making process.
Failure to Withhold Medication Delays Dental Procedure
Penalty
Summary
The facility failed to ensure that routine dental services were provided in a timely manner for a resident. The resident was scheduled for a dental procedure to extract a tooth, which required the withholding of the medication Xarelto for three days prior to the procedure. However, the Medication Administration Record showed that Xarelto was administered without any documentation indicating the need to hold it. An interview with the unit manager and the Director of Nursing revealed that the unit manager missed the special instruction to withhold the medication, resulting in the rescheduling of the procedure.
Failure to Ensure Timely Orthopedic Follow-Up
Penalty
Summary
The facility failed to ensure the timely provision of professional services for a resident who was receiving orthopedic care. The resident, diagnosed with a fracture of the right lower leg, Parkinson's disease, and lack of coordination, sustained a fall resulting in a distal right fibula fracture. Following a follow-up appointment on December 23, 2024, the orthopedic service recommended another follow-up in four weeks. However, the next appointment was scheduled for February 10, 2025, resulting in an eight-week gap instead of the recommended four weeks. The delay was due to a missed appointment initially scheduled for January 20, 2025. The facility was reminded of this appointment by the resident's family on January 19, 2025, but transportation arrangements were not made in time, necessitating a rescheduling. The unit manager, who was responsible for the oversight, failed to act on the reminder and was later terminated for unsatisfactory performance in following up with families and residents. This oversight led to the deficiency in providing timely professional services to the resident.
Generator Maintenance Deficiency
Penalty
Summary
The facility failed to maintain and test its generator system in compliance with NFPA standards, specifically the requirement for a 3-year, 4-hour load test. During a document review on February 10, 2025, it was discovered that the facility could not provide documentation to confirm that this critical test had been conducted. This deficiency affects the entire facility, as the generator is essential for ensuring the safety and functionality of the electrical systems during power outages. The absence of this documentation was confirmed during an exit interview with the Administrator and Maintenance Director.
Plan Of Correction
3 year, 4 hour load test was completed on 2/26/25. All generator tests will be scheduled in TELS for timely completion. Maintenance staff will be in-serviced on timely completion of generator tests and documentation. The maintenance director/designee will do a random audit to ensure that generator tests and documentation are completed timely, findings reported to QAPI.
Carbon Monoxide Detector Battery Maintenance Deficiency
Penalty
Summary
The facility failed to comply with Pennsylvania Act 48 regarding the maintenance of carbon monoxide detectors. During an observation on February 10, 2025, at 11:30 a.m., it was noted that the carbon monoxide detector in the basement laundry area had not had its battery changed since June 8, 2023. This exceeds the annual requirement for battery replacement. The deficiency was confirmed during an exit interview with the Administrator and Maintenance Director on the same day at 1:45 p.m.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance. Battery was changed on the carbon monoxide detector in the basement laundry. All carbon monoxide detectors were checked for batteries not exceeding annual requirements. The maintenance director will in-service maintenance staff on maintaining the required regulation set forth in PA Act 48 for carbon monoxide detectors. Carbon monoxide detectors were added to the tasks in TELS to ensure batteries are changed timely. Any findings will be reported to the QAPI committee.
Improper Installation of ABHR Above Electrical Outlet
Penalty
Summary
The facility failed to comply with the requirements for the installation of Alcohol Based Hand Rub Dispensers (ABHR), as observed during a survey. Specifically, an ABHR was installed directly above a light switch and a duplex electrical outlet in the basement kitchen. This placement does not meet the safety standards outlined in NFPA 101, which require that dispensers are not installed within 1 inch of an ignition source. The deficiency was confirmed during an exit interview with the Administrator and Maintenance Director.
Plan Of Correction
ABHR dispenser was removed from the basement kitchen above light switch and duplex electrical outlet. All ABHR dispensers were checked for appropriate placement in accordance with guidelines. Maintenance Director will in-service all maintenance staff on proper installation and placement of ABHR dispenser. Random weekly audit of ABHR dispensers for placement will be completed for 3 weeks and findings reported to QAPI.
Incomplete Sprinkler System Installation
Penalty
Summary
The facility failed to properly install sprinkler system components, affecting one of four levels. During an observation on February 10, 2025, at 1:10 p.m., it was noted that there was missing sprinkler protection over a combustible material at the main entrance's exterior portico ceiling. Additionally, at 1:15 p.m. on the same day, it was observed that a pendant sprinkler was installed in the Synagogue telephone room, but the area lacked a ceiling assembly, resulting in incomplete sprinkler coverage. These deficiencies were confirmed during an exit interview with the Administrator and Maintenance Director on February 10, 2025, at 1:45 p.m.
Plan Of Correction
A. Facility is submitting time limit waiver to obtain quotes for the portico sprinkler install or proof of sufficient fire safety rating. B. The sprinkler pendant was removed, and proper upright sprinkler head was installed in the synagogue telephone room. Sprinkler heads/pendants will be checked for proper installation. Maintenance director will in-service maintenance staff on proper sprinkler system components/installation. Random weekly audit of sprinkler heads/pendants will be completed X 3 weeks and findings will be reported to QAPI.
Deficiencies in Sprinkler System Maintenance and Documentation
Penalty
Summary
The facility failed to maintain its automatic sprinkler system components, affecting two of four levels. On February 10, 2025, an observation revealed that stored boxes were placed within 18 inches of a sprinkler in the second floor C Corridor Storage Room, which was confirmed during an exit interview with the Administrator and Maintenance Director. Additionally, a missing section of drywall ceiling was replaced with white cardboard surrounding a sprinkler in the first floor Main Lobby next to the front desk, potentially affecting the sprinkler's activation. This was also confirmed during the exit interview. Further document review on the same day revealed that the facility could not provide the annual inspection documentation for the clean agent suppression system in the Basement IT Room. Additionally, a report from October 19, 2022, indicated that three butterfly valves needed replacement during a 5 Year Internal Valve Inspection, but evidence of corrective action and retesting was not available at the time of the survey. These issues were confirmed during the exit interview with the Administrator and Maintenance Director.
Plan Of Correction
A. Stored boxes were removed from the second floor C storage room to ensure proper clearance of sprinkler heads and signage/tape installed. B. White cardboard was removed from the sprinkler head on first floor main lobby next to front desk and was fixed using 5/8 sheetrock. C. Annual inspection of the clean agent suppression system by basement IT will be completed by 4/3/2025. D. 3 butterfly valves will be reinspected, and retest will be completed by 4/3/2025. All storage areas are checked to ensure proper clearance of sprinkler heads and sprinkler heads will be checked for anything that could negatively impact operation. All inspections and documentation were completed to ensure sprinkler system is in accordance with NFPA 25. Maintenance director will in-service maintenance staff on maintaining automatic sprinkler system components in accordance with NFPA 25. Random weekly audits of sprinkler system components will be completed X 3 weeks and findings reported to QAPI.
Unsealed Penetration in Smoke Barrier Wall
Penalty
Summary
The facility failed to maintain smoke barrier walls free of unsealed penetrations, which is a requirement for ensuring a 1/2-hour fire resistance rating. During an observation on February 10, 2025, at 12:20 p.m., a surveyor identified an unsealed penetration around data wires located above the smoke doors on the first floor, section D-1. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director later that day at 1:45 p.m.
Plan Of Correction
The penetration around data wires above smoke doors on D1 was sealed using LC Endothermic Firestop Sealant. System number CAJ0047 with an F rating of 2 hours and a T rating of 2 hours. The maintenance team filled the void in accordance with manufacturers specifications. The maintenance department will check behind work orders/vendors to ensure all penetrations are sealed properly. The maintenance director will in-service staff on maintaining smoke barrier walls free of unsealed penetrations. Random weekly audits of smoke barrier walls will be conducted X3 weeks and findings will be reported to QAPI.
Electrical Wiring Protection Deficiency
Penalty
Summary
The facility failed to maintain the protection of electrical wiring, which affected two of the four levels. During an observation on February 10, 2025, at 12:00 p.m., it was noted that a junction box in the basement chiller room ceiling was missing its protective cover, leaving the inner wiring exposed. Additionally, at 12:05 p.m. on the same day, a damaged duplex receptacle was observed on the third floor in the C/D Kitchenette, also exposing the inner wiring. These deficiencies were confirmed during an exit interview with the Administrator and Maintenance Director at 1:45 p.m. on February 10, 2025.
Plan Of Correction
The junction box in the basement chiller room ceiling was repaired. The duplex receptacle on the third floor C/D kitchenette was replaced. All electrical panels and wiring will be inspected and repairs made as needed. Maintenance will be in-serviced on electrical requirements in accordance with NFPA 99. Random weekly audit of electrical panels and receptacles will be conducted X3 weeks and findings reported to QAPI.
Improper Use of Extension Cord in Electrical Panel
Penalty
Summary
The facility failed to comply with the National Fire Protection Association (NFPA) standards regarding the use of electrical devices. During an observation on February 10, 2025, at 11:45 a.m., it was found that an orange extension cord was improperly plugged into a surge protector inside an electrical panel labeled PNL-MEC09, located in the C/D Corridor Storage Room on the second floor. This setup was not in accordance with the NFPA guidelines, which prohibit the use of extension cords as a substitute for fixed wiring and require that they be removed immediately after their temporary use. The deficiency was confirmed during an exit interview with the Administrator and Maintenance Director on the same day at 1:45 p.m.
Plan Of Correction
Extension cord was removed from inside the electrical panel on the C/D corridor storage room. Facility will prohibit the improper use of electrical devices in the facility. Maintenance staff will be in-serviced on proper use of electrical devices. A random weekly audit X3 weeks to ensure no improper use of electrical devices, findings reported to QAPI.
Oxygen Storage Deficiencies in Basement
Penalty
Summary
The facility failed to maintain proper oxygen storage requirements, as observed during a survey on February 10, 2025. In the basement oxygen storage room, combustible boxes were stored directly next to oxygen cylinders, which is a violation of safety protocols. This improper storage poses a risk as oxidizing gases should not be stored with flammable materials, and there should be a separation of at least 20 feet, or 5 feet if the area is sprinklered, from combustibles. Additionally, the facility did not separate empty portable oxygen cylinders from full ones in the same storage room. This lack of segregation can lead to confusion and potential safety hazards, as it is essential to clearly distinguish between full and empty cylinders to ensure proper usage and storage. These deficiencies were confirmed during an exit interview with the Administrator and Maintenance Director.
Plan Of Correction
Combustible boxes were removed from the oxygen storage room next to cylinders located in the basement. Empty portable oxygen cylinders were separated from full cylinders in the basement storage room. All oxygen storage areas will be checked for proper storage of cylinders. The maintenance director will in-service Material Management on proper oxygen storage requirements. The maintenance director/designee will audit O2 storage areas for proper storage of cylinders weekly X3 and report findings to QAPI.
Fire Extinguisher Housing Integrity Issue
Penalty
Summary
The facility failed to maintain the integrity of a fire extinguisher housing, as observed on February 10, 2025. During an inspection, it was noted that the fire extinguisher housing box located on the second floor, across from resident room A201, was broken. This observation was confirmed during an exit interview with the Administrator and Maintenance Director on the same day.
Plan Of Correction
The broken fire extinguisher housing box by A201 was replaced. All fire extinguisher housing boxes were checked to ensure integrity. The maintenance director will in-service maintenance staff to ensure NFPA 101 Portable fire extinguishers. A random weekly audit of portable fire extinguishers and housing will be checked for integrity X3 weeks, and findings will be reported to QAPI.
Emergency Lighting Deficiency in Generator Enclosure
Penalty
Summary
The facility failed to maintain emergency lighting in operable condition, as evidenced by an observation made on February 10, 2025. During the inspection, it was noted that the emergency back-up battery lighting fixture within the generator enclosure did not illuminate when tested. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director on the same day.
Plan Of Correction
Emergency lighting fixture within the generator enclosure was repaired. All emergency lighting was checked to ensure working properly when tested. Maintenance director will in-service maintenance staff to maintain emergency lighting in operable condition. Random weekly audit to check emergency lighting is in operable condition for 3 weeks and report findings to QAPI.
Failure to Monitor Dialysis Access Leads to Harm
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received services consistent with professional standards of practice. The resident, identified as R104, was admitted with end-stage renal disease and required hemodialysis three times a week. After a surgical procedure on the resident's right arm fistula, which is used for dialysis access, the facility did not obtain the attending physician's orders for the care and monitoring of the fistula upon the resident's return from the hospital. Nursing documentation revealed that the resident's right arm was swollen and showed signs of infection, yet there was no evidence that the resident's physician was notified of these ongoing issues. The facility's policy on hemodialysis catheter access and care emphasizes the importance of preventing infection and maintaining catheter patency. However, the facility did not adhere to these guidelines, as evidenced by the lack of regular assessments and documentation of the resident's condition. The resident's nursing notes indicated ongoing erythema and swelling at the surgical site, but the facility failed to document any assessment or evaluation of the surgical wound from December 6 to December 9, 2024. Additionally, there was incomplete communication between the facility and the dialysis center, with missing or incomplete data in the dialysis communication books. As a result of these deficiencies, the resident experienced actual harm, requiring an emergent transfer to the hospital due to a swollen, infected fistula with purulent drainage and the development of a non-occlusive right brachial deep vein thrombosis. The facility's failure to properly monitor and assess the resident's condition led to this adverse outcome, highlighting significant lapses in the care and communication processes related to the resident's dialysis treatment.
Plan Of Correction
Resident 104 orders were reviewed and physician orders for monitoring of AV site are present. Residents currently receiving dialysis services orders were reviewed for appropriate monitoring of dialysis sites. Dialysis representative re-educated licensed staff on monitoring of dialysis sites and complications of dialysis to observe for. Unit manager/designee will complete random audits of residents currently receiving dialysis services to ensure monitoring of dialysis site weekly x4 then monthly x2 and report findings to QAPI committee monthly.
Insufficient Nursing Staff Leads to Delayed Care
Penalty
Summary
The facility was found to have insufficient nursing staff to meet the needs of its residents, as evidenced by observations and interviews with residents and staff. On February 4, 2025, a call bell light in room 304 was observed to be on for over 30 minutes without being answered, indicating a delay in response time. Resident R180 reported that delayed call bell responses were common and attributed this to nurse aides leaving or being reassigned to other units. Multiple residents expressed concerns about the lack of nurse aides, which affected their care, including shower schedules and timely assistance. A nursing aide, Employee E16, reported feeling overwhelmed with a caseload of 13 residents and noted that only two aides were working during the day shift, which she felt was insufficient. Further interviews revealed that residents were concerned about the timeliness of call bell responses and medication administration due to inadequate staffing. During a resident council meeting, several residents reported that the biggest issue in the facility was the shortage of nursing aides and nurses, leading to long wait times for assistance and delayed medication administration. The lack of sufficient staff was also linked to an increase in falls, as residents attempted to use the bathroom without assistance. The facility's failure to provide adequate nursing staff was in violation of regulatory requirements, as it did not ensure the safety and well-being of its residents.
Plan Of Correction
Residents R180, R46, R155, R247, R75, R78, R137, R32, R134, R11, R161 and R7 had no ill effects from this alleged deficient practice. The facility cannot retroactively correct this alleged deficient practice. Staff Development Nurse/designee educated the nursing staff on the call bell policy. Licensed staff were educated on medication administration policy with emphasis on timeliness. Facility department heads/designee will complete random call bell audits on units weekly x4 then monthly x2 and report findings to QAPI meeting monthly.
Food Temperature and Palatability Deficiency
Penalty
Summary
The facility failed to provide food and drink that was palatable and served at appropriate temperatures for 15 out of 35 residents reviewed. Multiple residents reported that the food was often served cold, lacked flavor, and was not appetizing. Specific complaints included cold scrambled eggs, meals not aligning with dietary needs such as diabetic and kosher requirements, and dissatisfaction with the quality and taste of the food. Observations during a test tray conducted with the Dietitian confirmed that certain food items, such as Brussels sprouts and skim milk, were outside the acceptable temperature range, and the macaroni and cheese was noted to be bland. Interviews with residents revealed consistent dissatisfaction with the food service, with reports of cold meals and poor taste being common. One resident mentioned that the food did not adhere to kosher laws, while another expressed concern about the nutritional content of meals, particularly for a diabetic diet. The Dietitian confirmed that the food items tested were not palatable due to being outside the acceptable temperature range, further supporting the residents' complaints.
Plan Of Correction
Residents R114, R55, R406, R10, R268, R204, R31, R18, R285, R407, R22, R221, R182, R28, and R118 were seen by dietician to review likes/dislikes and discuss issues with food palatability. The facility has contracted with new food service provider. Dietician re-educated dietary staff on appropriate food temperatures. Social Services/designee will audit random residents weekly x4 then monthly x2 on palatability and taste of food and report findings to QAPI committee monthly.
Failure to Update Care Plan for Resident's Peg Tube Behavior
Penalty
Summary
The facility failed to ensure that care plans were updated in a timely manner for a resident who exhibited behaviors of dislodging a peg tube. The resident, admitted on August 14, 2023, had a medical history including benign neoplasm of the stomach, Alzheimer's disease, gastrostomy status, unspecified protein-calorie malnutrition, and attention-deficit hyperactivity. Despite multiple incidents where the resident dislodged the peg tube, including documented occurrences on March 18, June 11, and December 12, 2024, there was no care plan developed to address this behavior. The facility's policy requires that comprehensive, person-centered care plans be developed and revised as residents' conditions change. However, the care plan for this resident was not updated to reflect the behavior of pulling out the peg tube. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the need for the care plan to be revised to address the resident's behavior.
Plan Of Correction
Resident R237 care plan updated to include a comprehensive care plan for identified behaviors. Residents with peg tubes were reviewed for past 14 days for resident behaviors and care plans checked to ensure a comprehensive care plan addressing the behaviors was completed. Staff development/designee re-educated licensed staff on formation of comprehensive care plan when resident observed pulling at peg tube are exhibited. Random audits of residents with peg tube for pulling behaviors care plans will be completed weekly x4 then monthly x2, for a comprehensive care plan for behaviors is in place. Results will be reported to QAPI committee monthly.
Failure to Obtain Specialist Consultation and Administer Insulin as Ordered
Penalty
Summary
The facility failed to obtain a consultation with a specialist and administer insulin medications as ordered by the physician for two residents. Resident R40, who has a medical history of multiple sclerosis, paraplegia, lymphedema, and muscle weakness, expressed a preference for seeing a lymphedema specialist over the past seven months. Despite an active physician order for a lymphedema therapy consult dated August 31, 2024, there was no documented evidence of follow-up or appointment scheduling. A physician note from January 23, 2025, indicated that Resident R40 was refusing diuretics and ace wrapping, and expressed frustration that no action was being taken regarding her condition. The unit clerk, Employee E9, attempted to locate a treatment center but was unsuccessful, and no further action was documented. Resident R94, with a medical history of chronic kidney disease and type 2 diabetes mellitus with diabetic neuropathy, had a physician order for insulin Aspart to be administered before meals at 11:00 a.m. However, a facility audit revealed that the insulin was administered at 2:04 p.m. on February 2, 2025, by a licensed nurse, Employee E10, which did not align with the physician's order. This failure to administer medication as prescribed could potentially impact the resident's health and well-being.
Plan Of Correction
Resident R40 has lymphedema assessment pending by facility lymphedema specialist. Resident 94 had no ill effects from insulin administration. Resident charts audited for outpatient specialty orders for the past 14 days to ensure appointments are scheduled. All residents have the potential to be affected by this alleged deficient practice. Staff Development Nurse/designee educated licensed staff on timely scheduling of appointments and assuring appointments are scheduled when ordered. Staff Development Nurse/designee re-educated licensed staff on administration of medications timely and documenting when administering medications. Unit Manager/designee will audit orders weekly x4 weeks then monthly x2 for outpatient specialist appointment orders and that they are scheduled timely and report findings to QAPI committee monthly. Unit manager/designee will complete random audit weekly of administration records to ensure that insulin is administered timely and report findings to QAPI committee monthly.
Deficiency in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for three residents diagnosed with Chronic Respiratory Failure with hypoxia. Resident 406's clinical record did not contain a physician's order for oxygen therapy, yet the resident was observed wearing oxygen. Additionally, the oxygen concentrator in Resident 406's room had a filter with an abundance of grey, fuzzy substance. Resident 18 had a physician's order for oxygen at 2 liters per minute continuously, but the oxygen concentrator filter in their room also had a buildup of whiteish, grey, fuzzy substance. Similarly, Resident 114 was observed with an oxygen concentrator filter containing a buildup of grey, fuzzy substance. During an interview, the Unit Manager acknowledged that the filters in these rooms needed cleaning, indicating a lapse in maintaining equipment hygiene.
Plan Of Correction
Resident 406 oxygen orders are completed and concentrator filter was cleaned upon discovery. Resident R18 and Resident R114 oxygen concentrator filters were cleaned upon discovery. Oxygen concentrators currently in use were checked and filters cleaned as needed. Staff development nurse/designee re-educated licensed staff on cleaning of filters per orders. Unit Manager/designee will audit random oxygen concentrators weekly to ensure that filters are clean and report findings to QAPI committee monthly.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to ensure that annual performance evaluations were completed for three out of nine nurse aides reviewed, specifically Employees E11, E12, and E13. According to the facility's policy, revised in September 2020, a performance evaluation should be conducted at the end of an employee's 90-day probationary period and at least annually thereafter. However, during a review of the facility's documentation, it was found that the facility could not provide completed performance evaluations for Employees E11 and E12 when requested on February 5, 2025. Additionally, on February 7, 2025, the facility was unable to provide a completed performance evaluation for Employee E13. This deficiency was identified based on the facility's failure to adhere to its own policy and regulatory requirements for regular in-service education and performance reviews.
Plan Of Correction
Employee E11, E12 and E13 evaluations were completed. All nurse aide employee files reviewed for annual evaluations and completed if necessary. Administrator/designee re-educated HR director on Performance Evaluation policy. HR director/designee will audit random nurse aide employee files monthly x3 to ensure that 90 day probationary eval (if needed) and yearly evaluation is completed and report findings to QAPI committee monthly.
Failure to Implement Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized person-centered care plan for a resident diagnosed with dementia, identified as Resident R46. The deficiency was identified through a clinical record review and staff interview, which revealed that Resident R46, admitted on December 21, 2023, with a diagnosis of dementia, did not have a care plan with measurable goals and interventions to address their dementia care needs. The facility's dementia policy, dated November 2018, requires the interdisciplinary team to create a resident-centered care plan to maximize function and quality of life for individuals with confirmed dementia. Despite this policy, the review of the Minimum Data Set (MDS) indicated that Resident R46 was receiving antipsychotic medications, yet there was no corresponding care plan addressing their dementia care. The Director of Nursing confirmed that residents diagnosed with dementia should have a care plan in place.
Plan Of Correction
Resident 46 care plan was reviewed and updated as needed. Residents with a diagnosis of dementia care plans were reviewed for care plan with measurable goals and interventions to address their care and treatment needs. Staff development nurse/designee re-educated licensed nurses and social services on comprehensive care plans to address individualized needs of residents with dementia. Unit managers and social services will audit random care plans with residents with a diagnosis of dementia to ensure that they have an individualized care plan to address dementia care weekly x4 and monthly x2 and report findings to QAPI committee monthly.
Deficient Communication and Documentation for Dialysis Residents
Penalty
Summary
The facility failed to maintain proper communication and documentation between the facility and a dialysis provider for three residents receiving dialysis. Resident R104, who was admitted with end-stage renal disease, experienced a severe infection at the fistula site and was hospitalized. The facility's records showed incomplete or missing communication with the dialysis center, and the Unit Manager was unable to provide detailed information about the resident's condition or the progression of the infection. Similarly, Resident R139's records revealed incomplete documentation of dialysis sessions. Out of nineteen log pages, only eleven were completed, with one page lacking any clinical information from the dialysis center and ten pages missing post-dialysis documentation from the facility's evening staff. The Unit Manager confirmed these documentation lapses, indicating a failure in maintaining accurate and complete records for residents undergoing dialysis.
Plan Of Correction
Resident R104, R139 and R230 dialysis communication books were reviewed. Residents on dialysis communication books were reviewed and dialysis centers for residents were called to review procedure for post dialysis communication. Staff development nurse/designee re-educated licensed staff on completion of dialysis communication book and checking communication book upon return from dialysis. Unit managers/designee will randomly audit dialysis communication books weekly x 4 then monthly x2 to ensure communication sheets are completed during visits and report results to QAPI committee monthly.
Deficiency in Required In-Service Training for Nurse Aide
Penalty
Summary
The facility failed to ensure that required in-service training was provided for one nurse aide, identified as Employee E14, out of nine nurse aides reviewed. The facility's policy, revised in August 2022, mandates that in-service training should be based on the outcome of the annual performance review and should not be less than 12 hours per employment year. However, during a review of the regular in-service education records on February 5, 2025, the facility was unable to provide documentation of completed in-service education for Employee E14. This deficiency was identified through a review of facility-provided documentation and staff interviews.
Plan Of Correction
Employee 14 education reviewed and 12 hours have been completed. Current Nurse aide education records were reviewed to ensure completion of yearly training requirements. Administrator educated Staff Development Nurse on 12 hour training requirement yearly for CNA's and need to address any weaknesses identified in yearly evaluation. Staff Development Nurse will randomly audit current CNA in-services monthly x 3 to ensure that 12 hours of education yearly is completed and that any weaknesses identified in yearly evaluation are addressed and report findings to the QAPI committee meeting monthly.
Failure to Notify Ombudsman of Emergency Transfers
Penalty
Summary
Horsham Center for Jewish Life was found to be non-compliant with specific requirements of 42 CFR Part 483, Subpart B, and the 28 PA Code during a series of surveys, including a Medicare/Medicaid Recertification survey and a State Licensure survey. The deficiency was identified in the facility's failure to notify the Office of the State Long-Term Care Ombudsman about facility-initiated emergency transfers to the hospital for two residents. This oversight was discovered through a review of facility documentation, clinical records, and staff interviews. The first resident, identified as R67, experienced an unwitnessed fall and was transferred to a local hospital for evaluation. Additionally, this resident had previously been admitted to the hospital for symptoms of nausea and dizziness, with a note indicating observation for syncope. The second resident, R237, had multiple incidents leading to hospital transfers, including pulling out a hypodermoclysis and a PEG tube. Despite these transfers, the facility failed to notify the Ombudsman as required. The Assistant Administrator, identified as Employee E15, confirmed on February 6, 2025, that the Ombudsman was not informed of these emergency transfers. This lack of notification is a violation of the specified regulations, which require that the Ombudsman be made aware of such transfers to ensure proper oversight and advocacy for the residents involved.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance. Ombudsman was made aware of R67 and R237 facility initiated emergency transfers to the hospital. Audit was completed of facility initiated emergency transfers to the hospital in the past 30 days to ensure Ombudsman notification. Administrator/designee re-educated Social Services staff on notification of ombudsman of facility initiated emergency transfers to the hospital. Social Services director/designee will audit facility initiated emergency transfers to the hospital monthly x3 to ensure that Ombudsman notification is completed and report findings to OAPI committee monthly.
Failure to Document Resident's Property Disposition After Death
Penalty
Summary
The facility failed to protect the personal and property rights of a resident upon their death. A review of the closed clinical record for a resident who expired at the facility revealed a lack of documentation regarding the final disposition of the resident's personal property. This deficiency was confirmed during an interview with the Nursing Home Administrator and the Director of Nursing, who acknowledged that the facility did not document the disposition of the resident's personal property after their death.
Plan Of Correction
Resident 306 passed away on 1/25/25 (survey 2/4/25). Belongings were returned. The facility cannot retroactively correct alleged deficient practice. Staff development/designee re-educated licensed staff on documenting notification to resident/family on retrieving belongings. Director of customer engagement/designee will audit personal property documentation for notification weekly x4, then monthly x2, and report findings to QAPI committee monthly.
Housekeeping Staff Found Sleeping on Duty in Resident Area
Penalty
Summary
The facility failed to ensure that housekeeping staff was fulfilling their work duties on Unit D2. During an observation, Employee E17, a housekeeping staff member, was found laying across the arm of a couch in the common area near rooms 210-218. She was wearing earbuds and appeared to be sleeping, showing no reaction to the presence of the surveyor. This incident occurred in full view of residents and visitors, which was confirmed by an interview with Unit Manager Employee E18, who stated that Employee E17 should not be sleeping while on duty, especially in resident areas. The Nursing Home Administrator, Employee E1, was informed of the situation and acknowledged that this behavior constituted a lack of professionalism on the part of Employee E17. It was also noted that such conduct did not promote the dignity of the residents.
Plan Of Correction
Employee E17 was interviewed and progressive discipline per facility guidelines. The facility cannot retroactively correct this alleged deficient practice. Director of Environmental services/designee educated housekeeping staff on appropriate break areas to maintain resident dignity in resident care areas. Director of Environmental services/designee will complete random audits weekly x4 then monthly x2 to ensure housekeeper breaks are conducted in designated break areas.
Staffing Deficiency in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides during the day shift on two specific dates. On September 1, 2024, the facility had a census of 300 residents, necessitating 30 nurse aides, but only 26.90 nurse aides were available. Similarly, on February 1, 2025, with a census of 309 residents, 30.90 nurse aides were required, yet only 29.83 were present. In both instances, there were no additional higher-level staff available to compensate for the shortfall, leading to a deficiency in meeting the mandated staffing requirements.
Plan Of Correction
Facility is staffing to maintain the required staffing ratios related to C.N.A's on all shifts. Staffing will be reviewed by facility administrator/designee prior to each shift to ensure required ratios are met. Interim steps include nursing on-call is in place, bi-weekly orientation schedule for new hires, OT and bonuses are offered. Random audits of daily staffing will be reviewed by Administrator/designee weekly X4 weeks to ensure required staffing ratios are met. Findings will be reviewed at QAPI monthly X2.
Failure to Provide Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure a resident's environment was free of accident hazards and did not provide adequate supervision for a resident with a documented history of suicidal ideation. This resulted in the resident obtaining a disposable razor and cutting their wrist, creating an Immediate Jeopardy situation. The resident, who had diagnoses of bipolar disorder, major depressive disorder, and generalized anxiety disorder, expressed suicidal thoughts and was placed on 1:1 supervision. However, the supervision was not consistently maintained, and the resident was able to access hazardous materials. The facility's policies on safety and supervision were not effectively implemented. Staff failed to thoroughly search the resident's room for potentially dangerous objects, and the resident was left unsupervised in the bathroom, where they found the razor. Interviews with staff revealed that the room was not adequately checked for hazardous items, and the 1:1 supervision was not maintained at all times, particularly when the resident was in the bathroom. The resident's care plan included interventions for suicidal ideation, such as removing harmful objects and providing 1:1 supervision. However, these interventions were not fully executed, leading to the resident's self-harm incident. The staff's inaction and failure to adhere to the facility's policies and procedures contributed to the deficiency, placing the resident at risk for serious injury.
Removal Plan
- Resident's room was searched for all potentially dangerous objects and were removed.
- Documentation revealed 1:1 supervision continued and remains in place.
- Review of residents with SI was conducted, no other residents were being observed for SI.
- The facility reviewed and implemented policies to ensure that the residents with suicidal ideation/behaviors that can lead to self-harm, do not have access to potentially dangerous objects such as sharp objects, medications, hazardous chemicals and staff provide appropriate 1:1 supervision when indicated.
- Education was started for staff responsible for overseeing room searches on the policy of ensuring no sharp objects, medications, hazardous chemicals are accessible to the resident, achieving >77% and continued with the facility completing >90%.
- Education will continue for any staff not educated, upon their return, prior to their 1:1 shift, until reaching 100%.
- Education was provided to staff providing 1:1 on ensuring that residents with SI are always within arm's length as per the supervision policy, achieving >77% and continued with the facility completing >90% and will continue upon their return for any staff not educated prior to their 1:1 shift until reaching 100%.
- Audit completed and continues every shift for the resident on 1:1 for SI to ensure safe environment.
- QAPI meeting was conducted with the IDT and will continue to be reviewed with the committee to determine if further action is needed.
- The action plan was reviewed, observations were made of all nursing units and resident rooms. Interviews were conducted with staff to confirm that the in-service education was completed. Observation was completed to ensure consistent 1:1 observation was provided.
- Review of facility documentation revealed that the corrective plan was immediately developed and initiated. Audits were initiated to ensure that no sharp objects, medications, hazardous chemicals are accessible to the residents with suicidal ideation and residents with SI are always within arm's length as per the supervision policy. The facility reviewed and updated their policy related to 1:1 supervision. Additionally, the facility educated all staff to the updated facility policy.
Failure to Ensure Resident Safety Leads to Immediate Jeopardy
Penalty
Summary
The deficiency involves the failure of the Nursing Home Administrator (NHA) and the Director of Nursing (DON) to effectively manage the facility, resulting in an environment that was not free of accident hazards. This failure allowed a resident with a history of suicidal ideation to access hazardous materials, specifically a disposable razor, which the resident used to cut their wrist. The incident placed the resident at risk for serious injury and resulted in an Immediate Jeopardy situation. The resident involved was admitted to the facility with diagnoses of bipolar disorder with psychotic episodes, major depressive disorder, and generalized anxiety disorder. The resident's clinical records indicated a history of suicidal ideation, and the care plan included interventions such as assessing for suicidal ideations and removing potentially harmful objects from the resident's environment. Despite these measures, the resident was able to obtain a razor and harm themselves, highlighting a lapse in the facility's supervision and safety protocols. Interviews with staff revealed that there were significant oversights in the supervision and room searches conducted for the resident. A nurse aide assigned to 1:1 supervision did not conduct a thorough room sweep at the start of their shift, and hazardous items such as razors, a screwdriver, and scissors were found in the resident's room after the incident. Additionally, the nurse who initially searched the room did not thoroughly check all areas, leaving potentially dangerous items accessible to the resident. These lapses in protocol contributed to the resident's ability to harm themselves, underscoring the facility's failure to ensure a safe environment.
Plan Of Correction
NHA and DON have been re-educated on their job descriptions by the Regional Support Team. NHA and DON will have their job description reviewed with them on an annual basis. The Regional Director of Operations/Designee will oversee the ADMIN and Director of Nursing to monitor job performance. The RDO/Designee will meet with the ADMIN and DON weekly x4 weeks to ensure ongoing compliance.
Failure to Supervise Resident with Suicidal Ideation
Penalty
Summary
The facility failed to provide adequate supervision to a resident who expressed suicidal ideation, resulting in an immediate jeopardy situation. The resident, who had a history of anxiety and depression, verbally expressed to nursing staff on multiple occasions that she wanted to kill herself. Despite these clear indications of distress, the facility did not implement sufficient monitoring or interventions to ensure the resident's safety. The resident subsequently ingested a large quantity of acetaminophen, leading to an intentional overdose. The resident's medical history included hypertension, chronic kidney disease, cerebral infarction, muscle weakness, anxiety, and depression. She was assessed as cognitively intact with a BIMS score of 15. Despite her mental health challenges, the facility's response to her expressed suicidal thoughts was inadequate. The nursing staff, including a licensed nurse and a nurse aide, were informed of the resident's intentions, but the nursing supervisor failed to take appropriate action. The resident was not placed on a 1:1 supervision, and the staff did not effectively communicate or escalate the situation to ensure her safety. The lack of immediate and appropriate response from the nursing supervisor and other staff members contributed to the resident's ability to access and ingest a significant amount of Tylenol. The resident's condition was not adequately monitored, and the facility did not have measures in place to prevent such an incident. This oversight resulted in the resident being transferred to the hospital with elevated acetaminophen levels, where she received treatment for the overdose.
Failure to Notify Physician of Resident's Self-Harm Threats and Tylenol Ingestion
Penalty
Summary
The facility failed to notify the physician regarding a resident's verbal threats of self-harm and reported ingestion of Tylenol. The resident, who had a medical history of hypertension, chronic kidney disease, cerebral infarction, muscle weakness, anxiety, and depression, expressed suicidal ideations to multiple staff members. Despite these serious threats, there was no evidence that the physician was informed during the 3:00 p.m. to 11:00 p.m. shift. Licensed nurse, Employee E3, documented that the resident expressed a desire to kill herself and later reported ingesting 25-30 milligrams of Tylenol. Employee E3 notified the nursing supervisor, Employee E5, but did not receive an immediate response. The Unit Manager, Employee E7, was also contacted but did not provide clear guidance. The nursing supervisor eventually assessed the resident but did not take further action to notify the physician or implement specific care instructions. The investigation revealed that the nursing staff did not follow the facility's policy for notifying the physician of significant changes in a resident's mental condition. The lack of communication with the physician meant that no specific orders or instructions were implemented to ensure the resident's safety and appropriate care. This deficiency was confirmed during interviews with the Director of Nursing and the Nursing Home Administrator.
Failure to Address Passive Suicidal Ideation in Care Plan
Penalty
Summary
The facility failed to ensure a comprehensive person-centered care plan for a resident with a history of passive suicidal ideation. The resident, who was cognitively intact with a BIMS score of 15, had a history of expressing thoughts of being better off dead to the facility's psychologist and unit manager. Despite these expressions, the resident's care plan did not include any goals or interventions to address these passive suicidal ideations, which were documented on multiple occasions by the psychologist. The resident had several medical diagnoses, including hypertension, chronic kidney disease, cerebral infarction, muscle weakness, anxiety, and depression. The facility's policy required ongoing assessments and revisions of care plans as the resident's conditions changed. However, there was no evidence in the clinical record that a person-centered plan of care was developed to address the resident's passive suicidal ideation, as discussed during an interview with the Director of Nursing and Nursing Home Administrator.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to ensure timely administration of medications for a resident, identified as Resident R2, which was determined through staff interviews, facility policy review, and clinical record examination. The facility's policy on administering medications, revised in April 2019, mandates that medications be administered within one hour of their prescribed time unless specified otherwise. However, the Medication Administration Audit Report for July 2024 revealed multiple instances where Resident R2's medications were administered late. Specifically, the resident's Selegiline, Carbidopa-Levodopa, and Amantadine HCI were not given at the prescribed times on several occasions. Resident R2 was admitted for rehabilitation services with diagnoses including aftercare for knee replacement surgery, cataracts, dysphagia, and Parkinson's disease. The resident's physician orders specified precise times for medication administration, which were not adhered to. For example, Selegiline was ordered for 8:00 a.m. and 8:00 p.m. but was administered late on multiple days. Similarly, Carbidopa-Levodopa and Amantadine HCI were also administered late on several occasions. This deficiency was discussed with the Director of Nursing and the Nursing Home Administrator, highlighting a failure to comply with the facility's medication administration policy.
Failure to Manage Resident's Suicidal Crisis
Penalty
Summary
The Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility in response to a suicide attempt by a resident, identified as Resident R1. The resident had a history of hypertension, chronic kidney disease, cerebral infarction, muscle weakness, anxiety, and depression. On August 3, 2022, during a routine check, Resident R1 expressed suicidal ideations to Licensed Nurse, Employee E3, stating intentions to kill herself. Despite notifying the nursing supervisor, Employee E5, the supervisor did not respond promptly to assess the resident. The situation escalated when the resident's assigned nurse aide, Employee E6, reported that the resident claimed to have ingested 25 Tylenol pills. Employee E3 attempted to alert the nursing supervisor again, but there was no immediate response. The Unit Manager, Employee E7, was informed and advised Employee E3 to physically locate the supervisor. Eventually, the supervisor arrived and took vital signs, but the resident was not placed on a 1:1 observation, raising concerns about the adequacy of the response to the resident's suicidal ideations. Later, during the night shift, Licensed Nurse, Employee E4 was informed of the situation and questioned why the resident was not on a 1:1 observation. The resident called 911, reporting the overdose, and was subsequently transported to the hospital. The nursing supervisor for the night shift, Employee E8, was not informed of the resident's suicidal ideations at the start of her shift. The deficiencies in communication and response to the resident's mental health crisis contributed to an Immediate Jeopardy situation, highlighting failures in the management and oversight by the NHA and DON.
Failure to Document Resident's Mental Health Concerns
Penalty
Summary
The facility failed to ensure complete and accurate documentation related to a resident's mental health status. The resident, who had a history of hypertension, chronic kidney disease, cerebral infarction, muscle weakness, anxiety, and depression, was assessed with a BIMS score indicating cognitive intactness. However, a psychologist's note revealed that the resident had left several voicemails for the unit manager expressing thoughts of being better off dead, although denying self-harm or suicide ideation. Despite this, there was no documentation from the unit manager regarding the receipt of these voicemails, the specific content of the voicemails, or any actions taken in response. During an interview, the unit manager admitted to not remembering when the incident occurred, failing to document the voicemails, and not recalling the exact content of the resident's messages. The only action taken was notifying the psychologist to address the resident's mental health concerns. This lack of documentation and follow-up by the unit manager constitutes a deficiency in maintaining accurate medical records and safeguarding resident-identifiable information, as required by professional standards.
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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