Ivy Park Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Pittsburgh, Pennsylvania.
- Location
- 5609 Fifth Avenue, Pittsburgh, Pennsylvania 15232
- CMS Provider Number
- 395251
- Inspections on file
- 37
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 10 (1 serious)
Citation history
Health deficiencies cited at Ivy Park Post Acute during CMS and state inspections, most recent first.
A resident with multiple serious diagnoses, including PE, B-cell lymphoma, DM, HTN, kidney disease, and cancer, experienced an acute neurological change consistent with stroke and was transferred to the hospital with an acute care transfer/change of condition form. After the resident’s next of kin submitted a written request for the complete medical record, the facility mailed a large packet of documents; however, the family later reported that parts of the record were missing. Medical records staff stated they believed the entire record, including nurse notes, had been sent, but there was no evidence that all components of the record were provided. Surveyors determined the facility failed to provide a complete copy of the resident’s record upon the initial request, citing violations of state regulations on licensee responsibility and management.
Unsafe Indoor Temperatures: The facility failed to maintain comfortable air temperatures in resident areas, with multiple rooms and dining areas measuring above the acceptable range and residents describing the environment as hot. A resident was seen fanning herself with paper, other residents relied on personal or family-provided fans, and staff said there were not many fans available. The NHA stated the cooling system had been affected by a power surge and later confirmed the facility did not keep temperatures within the required range for several days.
A resident was seen by the contracted dental provider at bedside, and the provider recommended clinic follow-up for ultrasonic scaling with deposit remaining. The resident had diagnoses including HTN, vitamin D deficiency, and muscle weakness, and a resident representative later reported that the resident’s gums were very bloody. The DON confirmed that no dental clinic appointment had been made for the recommended follow-up.
The facility failed to follow its resident fund management policy requiring closure of discharged residents’ trust accounts and release of funds within 30 days. Two residents, one transferred for psychiatric evaluation and another who died with physician authorization to release the body, both had ongoing open trust accounts with balances documented on a later fund trial balance. Review of their clinical records showed no evidence that their monies were provided within 30 days of discharge, and the Business Office Manager confirmed that the accounts were not closed or funds conveyed as required.
A resident with chronic kidney disease, adult failure to thrive, and HTN had an active physician order for full code and no advance directives limiting resuscitation, yet the care plan did not address full code status. One morning, an LPN found the resident unresponsive, with eyes open and skin pale and cool, and notified an RN supervisor and the MD but did not start CPR, believing there were signs of irreversible death. Later, an RN assessed the resident as pulseless, apneic, pale, cool, and mottled, judged these as signs of irreversible death, and also did not initiate CPR. Review of the clinical record confirmed that no CPR was provided despite the full code order, while interviews with other LPNs and RNs showed they understood that CPR should be started for full code residents found pulseless, leading surveyors to cite a failure to provide consistent CPR in accordance with orders and guidelines.
Facility leadership, including the NHA and DON, failed to ensure that staff consistently initiated CPR for an unresponsive resident, despite job descriptions requiring them to direct day-to-day operations and oversee resident care in accordance with federal and state regulations. Review of job descriptions, clinical records, and staff interviews showed that CPR was not initiated when the resident became unresponsive, and surveyors determined that the NHA and DON did not fulfill their essential duties to ensure compliance with applicable guidelines, resulting in an Immediate Jeopardy situation for one of the facility’s residents.
Surveyors found that 3rd floor shower rooms had visible buildup of red grime and black debris where the walls met the floors, and the DON confirmed these areas were not clean or sanitary, contrary to facility policy. On the 4th floor, an air temperature log completed by the DOM showed multiple resident rooms and the dining room with temperatures between 83°F and 88°F, above the facility’s stated comfort range of 71°F to 81°F. The NHA acknowledged that the environment on the 3rd floor was not clean and that air temperatures on the 4th floor were not maintained at comfortable levels.
A resident with complex neurological diagnoses refused ordered bloodwork, and staff did not notify the physician of this change in condition. The DON confirmed that the required notification was not made.
Surveyors observed that food items such as bread, bagels, deli ham, salads, and sandwiches were stored in the kitchen coolers without proper labels or dates, contrary to facility policy. The Dietary Manager confirmed that these practices failed to maintain sanitary conditions and created the potential for cross contamination.
The facility did not ensure that necessary resident information was communicated to receiving health care providers during transfers for two residents, and failed to provide written notification of the bed-hold policy to a resident or their representative during a hospital transfer. Additionally, a physician discharge order was not obtained for a resident discharged home. These deficiencies were confirmed through record review and staff interviews.
Surveyors found that the facility did not include specific, individualized interventions in the care plans for three residents, including missing care plan details for a wound vac, a trapeze bar used for mobility, and a wander guard device for elopement risk. Staff and the DON confirmed these omissions after review of clinical records, observations, and interviews.
The facility did not consistently follow physician orders for blood glucose monitoring and insulin administration, failed to document physician notifications and interventions for abnormal blood glucose levels, and did not provide required lab monitoring for a resident on Lithium. Additionally, the process for scheduling and communicating physician appointments was inconsistent, leading to missed and delayed follow-ups.
The facility did not consistently identify or reassess residents with cognitive impairment and exit-seeking behaviors for elopement risk, nor did it ensure care plans and physician orders addressed these risks. For example, a resident with dementia and moderate cognitive impairment was not reassessed despite ongoing exit-seeking behavior, another resident with a high elopement risk score had no further assessments, and a third resident was observed without a required wanderguard device. Staff and leadership confirmed these lapses in assessment and intervention.
The facility did not consistently maintain required dialysis communication forms for two residents with renal conditions, resulting in missing or incomplete documentation over several months. Additionally, current contracts with dialysis vendors were not in place for two residents, as confirmed by the administrator and DON. These deficiencies were identified through record review and staff interviews.
The facility did not complete required annual performance evaluations for three nurse aides, with some evaluations missing for multiple years and one aide lacking any evaluation since hire. This was confirmed by personnel file review and staff interview.
Two outside dumpsters were found with lids left open and liquid collecting in the disposal area, in violation of facility policy requiring proper containment and disposal of garbage to minimize infection risks and deter pests.
Three nurse aides did not receive the required 12 hours of annual in-service education, as confirmed by a review of training records and facility policy. The facility could not provide documentation to show that these staff members completed the mandated training, and this was acknowledged by Human Resources.
Seven residents were found to have beds with stained, dirty, or damaged linens, including fitted sheets with holes, thin and see-through sheets, and dirty blankets. These issues were confirmed by an LPN and the Nursing Home Administrator, indicating a failure to provide a clean and comfortable environment as required by facility policy.
A resident with multiple medical conditions, including a pressure ulcer, did not receive care in a manner that maintained dignity when an RN wrote on a dressing after it was applied to the resident's heel, contrary to facility policy.
A resident with heart failure, high blood pressure, and coronary artery disease, who was dependent on staff for personal hygiene, was repeatedly observed with significant facial hair and debris under fingernails. Staff and nursing leadership confirmed that required ADL assistance was not provided, contrary to facility policy.
The facility did not provide an ongoing program of activities to meet the interests and support the physical, mental, and psychosocial well-being of residents on one floor. Observations showed that an activity aide failed to interact with or engage residents during scheduled activities, and this was confirmed by staff interviews.
The facility did not accurately assess or document pressure ulcers for two residents, including one with a right foot amputation site and another with a coccyx ulcer, as required by policy and physician orders. Clinical records lacked necessary wound measurements over an extended period, and this deficiency was confirmed by nursing leadership.
A resident with PTSD did not have specific trauma triggers identified or addressed in their care plan, despite facility policy requiring individualized trauma-informed care. The Social Services Director confirmed that the facility failed to identify and mitigate triggers that could cause re-traumatization.
Surveyors found that two medication carts contained opened medications that were either undated or past their use-by date, including ipratropium nebulizer medication, an Ellipta inhaler, and Ketotifen Fumarate eye drops. LPNs and the DON confirmed that these medications were not stored or labeled according to policy.
A resident with dysphagia and physician orders for nectar thick liquids and no straw was given a thin liquid with a straw, contrary to their care plan and dietary orders. Staff confirmed the error occurred because the nursing assistant did not check the resident's prescribed diet before providing the drink, and facility leadership acknowledged the failure to meet the resident's dietary needs.
Two residents with severe cognitive impairment, as evidenced by low BIMS scores and dementia diagnoses, were allowed to sign binding arbitration agreements without confirmation of their capacity to understand the terms. The facility administrator confirmed this failure to ensure resident understanding.
A RN failed to follow infection control protocols during a wound dressing change for a resident with multiple diagnoses requiring pressure ulcer care. The RN did not clean the supply surface, failed to use a barrier under the resident's foot, used unclean scissors, and placed soiled dressings on the floor, resulting in a failure to prevent cross contamination.
The facility did not assign a qualified individual to oversee infection prevention and control activities while the Infection Preventionist was on leave, as confirmed by the DON and absence of meeting documentation.
Two residents with diabetes, high blood pressure, and dementia did not receive routine podiatry care as required by facility policy. Observations by nursing staff revealed both had thick, elongated, and curved toenails, and the DON confirmed that podiatry services had not been provided since admission.
The facility failed to provide timely access to personal funds for three residents, leading to grievances and frustration. One resident waited 13 days for Social Security funds, another did not receive a personal allowance despite having a sufficient balance, and a third experienced delays due to a transition in account management. The Nursing Home Administrator acknowledged the issue.
A resident with quadriplegia and Multiple Sclerosis, requiring two-person assistance for bed mobility, fell from bed when a nurse aide provided care alone and left the resident unattended. The resident experienced spasms and fell, but no injuries were noted. The facility failed to follow the care plan, resulting in neglect.
A resident with quadriplegia and Multiple Sclerosis, requiring two-person assistance for bed mobility, fell from bed when left unattended by a nurse aide who was providing incontinence care alone. The resident experienced spasms and fell, highlighting a failure in supervision and adherence to care plans.
A resident with MS and quadriplegia experienced a delay in receiving emergency care due to the facility's failure to ensure timely physician services. Despite the resident's repeated requests for emergency care, staff did not act promptly, and the resident was eventually admitted to the ICU with sepsis. The delay was partly due to confusion about procedures when a physician could not be reached.
A resident with aphasia, depression, and cerebral infarction had Flexeril ordered without proper authorization by an LPN, who did not consult the physician or NP. The RN noticed the unauthorized order and confirmed the LPN's actions. The NP and physician were not contacted for the reorder, and the facility failed to notify the family. Management acknowledged the failure to follow procedures.
A facility failed to dispose of discontinued medication for a resident in a timely manner, as required by their policy. The resident, with conditions including aphasia and cerebral infarction, had a prescription for Flexeril that was discontinued, yet the medication was still found in the medication room. The DON confirmed the medication should have been returned or destroyed.
A resident with a history of aphasia, depression, and cerebral infarction was improperly administered Flexeril after an LPN ordered it without consulting a physician or NP. The medication had been previously discontinued, and the error was discovered by an RN. The facility's management confirmed the failure to follow proper procedures for obtaining medication orders.
A facility failed to ensure a safe and orderly discharge for a resident with Conversion Disorder and Shortness of Breath. The discharge plan included returning to North Carolina with home care arrangements, but the facility lacked the resident's home address, personal provider's name, and contact information. Despite confirming a bus ticket and medication delivery, the facility could not verify the resident's destination or care arrangements, as confirmed by the Nursing Home Administrator and DON.
The facility failed to properly label and date food products, monitor food temperatures, and maintain kitchen cleanliness, leading to potential foodborne illness risks. Observations revealed improperly stored kitchenware, unlabeled and expired food items, and inconsistent temperature monitoring, confirmed by dietary staff.
The facility failed to maintain an adequate linen supply on two units, leading to residents being cleaned with paper towels and new admissions waiting for linens. Observations and interviews with residents and staff confirmed the shortage, with linen rooms often found barren or insufficiently stocked. The Nursing Home Administrator acknowledged the issue, which affected the second and third floors.
The facility failed to communicate necessary resident information during transfers for four residents, as required by policy. The residents, who had various medical conditions, were transferred to a hospital and returned without documented evidence of communicated care plan goals, advanced directives, or specific care instructions. The Nursing Home Administrator confirmed this deficiency.
The facility failed to notify the LTC Ombudsman of hospital transfers for four residents, as required by policy. The residents, with various medical conditions, were transferred without documented notification to the Ombudsman. The Director of Social Services was unaware of this requirement, confirmed by the Nursing Home Administrator.
The facility failed to notify residents or their representatives about the bed-hold policy during hospital transfers, as required by their policy. This deficiency was identified for four residents with various medical conditions, who were transferred to hospitals without receiving the necessary information. Staff interviews revealed that the policy was only communicated to private pay residents, which was confirmed by the Nursing Home Administrator.
The facility did not develop baseline care plans within 48 hours for 17 new residents admitted in the past 30 days, as required by their policy. The policy mandates a person-centered care plan to be created within 48 hours of admission, but a review showed no such plans were documented. The Nursing Home Administrator confirmed the oversight, acknowledging the failure to initiate these plans.
The facility failed to maintain consistent and complete communication with the dialysis center for three residents requiring dialysis services. Facility policy required licensed nurses to complete a Hemodialysis Communication Record before and after each dialysis session. However, records for a resident were incomplete for several dialysis days, and interviews with staff confirmed the lack of completed forms. This deficiency was identified through a review of clinical records, facility policy, and staff interviews.
The facility failed to store drugs and biologicals safely and orderly in two medication rooms. On the third floor, an opened and undated tuberculin solution was found, along with slime and sticky substances in the refrigerator. On the fourth floor, expired supplies were discovered, including glucose control solutions and a viral transport swab kit. These issues were confirmed by an RN and an LPN, respectively.
The facility failed to coordinate hospice services for two residents, as required by policy. Both residents, with diagnoses including dementia and cerebral atherosclerosis, were admitted to hospice care, but the facility lacked hospice communication binders and did not include hospice coordination in the care plans. This was confirmed by staff and violated state regulations.
The facility did not conduct Quality Assessment and Assurance (QAA) meetings quarterly with all required members for three consecutive quarters. The policy requires the QAA committee to include the Administrator, DON, Medical Director, Infection Preventionist, consultant pharmacist, patient/family representatives, and three additional staff. The facility could not provide attendance records for the specified periods, and the NHA confirmed the failure to hold these meetings.
The facility failed to prevent cross-contamination during medication administration for two residents, as an LPN handled medications without gloves. Additionally, Enhanced Barrier Precautions were not implemented for residents with medical devices, as confirmed by the Infection Preventionist, who was unaware of the updated guidelines.
The facility failed to offer influenza and pneumococcal vaccinations to four residents, as required by their policies. Residents with various diagnoses, including seizure disorder, high blood pressure, depression, Alzheimer's, and anxiety, were not provided these vaccinations or related education. The lack of documentation and offering of vaccines was confirmed by the Infection Preventionist.
The facility failed to maintain an effective training program for its staff, as three personnel records lacked documentation of required annual in-service training. A nurse aide hired in 2005 was missing training in several areas, including effective communication and resident rights. Another aide hired in 2018 lacked training in resident rights and compliance, while a third aide hired in 2003 was missing training in communication and QAPI. This was confirmed by a scheduler.
Incomplete Release of Resident Medical Record to Family
Penalty
Summary
The deficiency involves the facility’s failure to provide a complete copy of a resident’s medical record upon request by the resident’s next of kin. Facility policy on release of information, last reviewed on 1/9/26, stated that all information in a resident’s medical record is confidential and may only be released with written consent from the resident or legal representative. Closed Resident Record CR1 had multiple serious diagnoses, including pulmonary embolism, B-cell lymphoma, diabetes, hypertension, kidney disease, and cancer. On 1/9/26, a nurse practitioner documented that the resident exhibited signs consistent with a stroke, including a flaccid left upper extremity and slow speech, and ordered transfer to the emergency department for a higher level of care. A nurse’s note the same day documented the resident’s transfer to the hospital via stretcher, with an acute care transfer/change of condition form sent and the family notified. On 1/14/26, the facility received a signed request from the family for the resident’s medical record. Facility documentation showed that on 2/28/26 the family received a mailed four‑pound shipment of documents. However, by 3/5/26, the family reported concern that not all of the medical record had been released. In internal communications, administration indicated that Medical Records Personnel E1 believed the entire record had been sent. During an interview, E1 stated she had not received any additional records requests, believed she had given the family everything she had, and thought the nurse notes were included with the other records, but there was no evidence that the nurse notes were actually sent. Surveyors informed the Nursing Home Administrator and DON that the facility failed to provide a complete copy of the closed resident’s record upon the family’s initial request, in violation of 28 Pa Code 201.14(a) and 201.18(b)(2).
Unsafe Indoor Temperatures
Penalty
Summary
The facility failed to ensure comfortable air temperature levels between 71 and 81 degrees Fahrenheit were maintained in resident areas for three of seven days. The facility policy dated 1/9/26 stated that the facility would provide a safe, clean, comfortable, and homelike environment and maximize characteristics that include comfortable and safe temperatures. Resident representative concerns dated 4/13/26 stated that the nursing home did not have a functioning air conditioning unit and that temperatures were unsafe for residents, with one concern noting that a window had been cracked but it was still very hot inside. During an interview on 4/15/26, the Nursing Home Administrator stated the facility was in the process of completing a $1.3 million heating and cooling system installation and expected work to begin at the end of May or beginning of June. A tour with maintenance staff on 4/15/26 found multiple areas above the acceptable range, including the 2nd, 3rd, and 4th floor dining rooms and resident rooms with temperatures ranging from 80.6 to 91.0 degrees Fahrenheit. Residents and staff described the environment as hot, with one resident fanning herself with paper, another using a fan provided by a roommate's family, and another using a personal fan. Maintenance staff stated there were not many fans available and they were placed at nurse stations and in hallways. An HVAC vendor later stated a power surge had shut off the cooling system and that he was able to fix it so the system would work again. The NHA confirmed the facility failed to maintain comfortable air temperatures for three of seven days.
Failure to Arrange Follow-Up Dental Care
Penalty
Summary
The facility failed to ensure that a dental appointment was scheduled for Resident R1 after the contracted dental provider documented on 10/9/25 that the resident was treated at bedside and recommended that the resident be brought to the clinic for ultrasonic scaling, with deposit remaining. The resident’s record showed diagnoses of high blood pressure, vitamin D deficiency, and muscle weakness, and a resident representative concern dated 4/13/26 stated that Resident R1’s gums were so bloody. During an interview on 4/15/26, the DON stated that no appointment had been made to take Resident R1 to the Dental Clinic for follow-up as suggested at the prior dental visit, confirming that the facility failed to obtain the dental services required.
Failure to Timely Convey Resident Trust Funds After Discharge or Death
Penalty
Summary
The deficiency involves the facility’s failure to convey resident funds and close resident trust accounts within 30 days of discharge, as required by its own resident fund management policy and applicable regulations. The facility policy, last reviewed on 5/20/25, stated that discharged resident accounts are to be closed following reconciliation and that funds are to be released after completion of an audit and reconciliation. Review of the resident fund trial balance dated 3/18/26 showed that two discharged residents still had open accounts with balances: one with $384.68 and another with $7,430.63. The clinical records for these residents did not contain documentation that their monies were provided within 30 days after discharge. The first closed record (CR1) was for a resident with diabetes, schizophrenia, and hypertension, whose progress note on 1/4/26 documented acute psychiatric distress, including refusal of medications and repeated verbalizations to be killed, leading to a 302 involuntary commitment and transfer from the facility with EMT and police escort. The second closed record (CR2) was for a resident with diabetes, hypertension, and Alzheimer’s dementia, whose progress note on 1/25/26 documented that she was found without pulse or respirations, the physician was notified, and an order was given to release the body to the funeral home, with a nephew notified. Despite these discharges—one due to transfer for psychiatric evaluation and one due to death—there was no indication in either clinical record that their funds were conveyed within 30 days, and the Business Office Manager confirmed that the facility failed to close these accounts and release the funds as required.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to initiate CPR for a resident who was a documented full code. The resident, identified as CR1, had diagnoses including chronic kidney disease, adult failure to thrive, and hypertension, and had a physician’s order indicating full code status current through the time of the incident. The resident’s advance directive form showed no advance directives, no living will, and no Power of Attorney, and there was no documentation that the resident had opted out of resuscitative efforts. The resident’s care plan, although current, did not include goals, plans, or interventions related to the resident’s full code status. On the morning of the incident, an LPN (E3) documented that at approximately 7:45 a.m. the resident was found lying in bed on her right side, not responding to her name, with eyes open and skin pale and cool. The call bell was within reach, and the RN supervisor and physician were notified of a change in condition. In a written statement, the LPN reported that CPR was not started because the nurse believed the resident showed signs of irreversible death. There is no indication in the clinical record that the resident’s code status was unclear or that any conclusive signs of irreversible death, such as rigor mortis or other criteria described in the facility’s CPR policy and AHA guidelines, were present or documented at that time. An RN (E4) later documented, in a late entry, that she was informed that the resident ceased to breathe at 7:56 a.m. and that the physician was notified and the resident pronounced deceased. In her statement, the RN reported that when she assessed the resident after being alerted by the LPN that there was no pulse, the resident’s eyes were open, the resident was pale and cool, and there was mottling of the extremities. The RN described these findings, along with the absence of pulse and respirations, as “obvious signs of death” and concluded that the resident had signs of irreversible death and that CPR would not have helped. The clinical record review confirmed that CPR was not administered despite the existing full code order, and staff interviews with other LPNs and RNs indicated that their understanding of procedure was to check code status and initiate CPR for full code residents found pulseless or without respirations. Surveyors determined that the facility failed to ensure consistent care by not initiating CPR for this unresponsive, pulseless full code resident, resulting in an immediate jeopardy situation.
Removal Plan
- Resident R1 no longer resides in facility.
- All professional nursing staff (LPN/RN) will be re-educated on the CPR procedure.
- Agency staff will be educated on the CPR procedure prior to the start of their next shift.
- All professional nursing staff (LPN/RN) will be re-educated on the definition of irreversible death and that it must be documented in the clinical record.
- Agency staff will be educated on the definition of irreversible death and documentation requirements prior to the start of their next shift.
- Whole-house audit will be conducted by the DON/designee to ensure that every resident has a completed POLST order form, the code status order in EHR, and the care plan updated accordingly.
- Policies related to CPR have been reviewed by NHA and DON and updated to include signs of irreversible death.
- Facility will review the incident in QAPI (Quality Assurance/Process Improvement) meeting.
- New admissions will be audited by DON/designee to ensure that the POLST is located in the resident chart and the DNR or Full Code status is in EHR.
- Findings of audits will be submitted through the facility QAPI program.
- All new hires will be educated on CPR procedures and signs of irreversible death.
Failure of Facility Leadership to Ensure CPR Initiation for Unresponsive Resident
Penalty
Summary
The deficiency involves the failure of the Nursing Home Administrator (NHA) and the Director of Nursing (DON) to effectively manage the facility so that consistent care was provided to initiate cardiopulmonary resuscitation (CPR) for an unresponsive resident (Resident R1). The NHA’s job description dated 2/2024 required directing the day-to-day functions of the facility in accordance with federal, state, and local regulations to assure the highest degree of quality care at all times, and the DON’s job description dated 2/2024 required overseeing and supervising the care of all residents and providing direct resident care. Based on review of job descriptions, clinical records, and staff interviews, surveyors determined that the facility failed to ensure that CPR was initiated for Resident R1 when the resident was unresponsive, and this failure was attributed to the NHA and DON not fulfilling their essential job duties to ensure that applicable federal and state guidelines and regulations were followed. During an interview, the NHA and DON were informed that their failure to effectively manage the facility and ensure consistent initiation of CPR for the unresponsive resident resulted in an Immediate Jeopardy situation for one of 131 residents, in violation of 28 Pa. Code 201.14(a), 201.18(b)(1)(3)(e)(1), and 211.12(d)(1)(2)(3)(5).
Unclean Shower Areas and Excessive Temperatures on Upper Floors
Penalty
Summary
Surveyors identified that the facility failed to maintain a clean, safe, comfortable, and homelike environment on the 3rd floor. During an observation conducted with the DON, both the low hallway and high hallway shower rooms on the 3rd floor were found to have a buildup of red grime and black debris where the wall meets the floor, indicating the shower areas were not clean and sanitary. The DON confirmed during interview that these 3rd floor shower areas failed to be clean and sanitary, which did not comply with the facility’s Safe and Homelike Environment policy requiring a clean, sanitary, and orderly environment. The facility also failed to ensure comfortable air temperature levels on the 4th floor. Review of an air temperature log completed by the DOM showed that multiple resident rooms and the dining room on the 4th floor had temperatures ranging from 83.0°F to 88.0°F, exceeding the facility’s policy range of 71°F to 81°F for comfortable and safe temperatures. The DOM confirmed that comfortable air temperature levels were not maintained for 11 resident rooms and the dining room on the 4th floor. The NHA later confirmed that the facility failed to provide a clean, safe, comfortable, and homelike environment on the 3rd floor and failed to ensure comfortable air temperature levels on the 4th floor as required.
Failure to Notify Physician of Resident's Refusal of Lab Work
Penalty
Summary
The facility failed to notify the physician of a change in condition for one resident who refused ordered bloodwork. The resident, admitted with diagnoses including seizures, moyamoya disease, and cerebral infarction, had a physician order for valproic acid and laboratory tests. Documentation showed that the resident refused the required bloodwork, but there was no evidence in the clinical progress notes that the physician was informed of this refusal. The Director of Nursing confirmed during an interview that staff did not notify the physician about the resident's refusal of lab work.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to properly store food products in both the walk-in and reach-in coolers in the main kitchen, as observed during a survey. Specifically, multiple food items including cinnamon bread, bagels, deli ham, salads, and sandwiches were found without required labels or dates. The facility's policy on food receiving and storage requires that foods be received and stored in compliance with safe food handling practices, but these procedures were not followed. The Dietary Manager confirmed that these lapses in food storage and labeling created unsanitary conditions and the potential for cross contamination in the kitchen. No information about specific residents or their medical conditions was provided in the report.
Failure to Communicate Resident Information and Provide Bed-Hold Notification During Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider during facility-initiated transfers for two residents. Specifically, the clinical records for these residents did not contain documentation that care plan goals and all information necessary to meet the residents' specific needs were provided to the receiving facility at the time of transfer. Additionally, for one resident who was transferred to the hospital and later returned, there was no documented evidence that the resident or their representative was provided with written information about the facility's bed-hold policy at the time of transfer. Furthermore, the facility failed to obtain a physician discharge order for one resident who was discharged home. These deficiencies were confirmed through review of facility policy, clinical records, and staff interviews, which indicated that required notifications and documentation were not completed as per regulatory requirements. The residents involved had significant medical histories, including dementia, major depressive disorder, urinary tract infection, high blood pressure, anemia, and renal insufficiency.
Failure to Develop Comprehensive, Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans for three of five residents reviewed, as required by policy. For one resident with coronary artery disease, hypertension, and acute osteomyelitis of the right foot, the care plan did not include interventions for the use of a wound vac, despite physician orders and direct observation confirming its use. Another resident with anemia, diabetes, and a right leg above-the-knee amputation had a trapeze bar above the bed for mobility, but the care plan did not address interventions related to the trapeze, even though staff confirmed its use for transfers. A third resident with high blood pressure, diabetes, and dementia had physician orders for a wander guard device due to poor safety awareness, but the care plan lacked interventions and goals for elopement risk management. Staff interviews, clinical record reviews, and direct observations confirmed these omissions. The Director of Nursing and other staff acknowledged that the care plans did not include the necessary individualized interventions and goals to address these residents' specific care needs.
Failure to Follow Physician Orders and Ensure Monitoring for Diabetic and Medically Complex Residents
Penalty
Summary
The facility failed to follow physician orders and provide appropriate monitoring and documentation for residents with diabetes and other medical conditions. For one resident, blood glucose levels were not obtained for an extended period despite physician orders, and the order itself lacked parameters for when to notify the physician. Additionally, several residents had physician orders for blood glucose monitoring and insulin administration that either lacked clear notification parameters or were not followed when abnormal blood glucose readings occurred. In multiple cases, there was no documentation that the physician was notified of blood glucose results outside of the ordered parameters, and interventions for hypoglycemia were not documented. The review also found that for one resident prescribed Lithium, there were no physician orders for the required therapeutic lab monitoring, and the resident did not receive routine lab work to monitor Lithium levels. This omission was confirmed by the Director of Nursing. Furthermore, the facility failed to ensure timely follow-up physician appointments for another resident. The process for scheduling appointments and transportation was inconsistent, with staff interviews revealing a lack of communication and a standardized process, resulting in missed appointments and delays in rescheduling. These deficiencies were identified through a review of facility policies, clinical records, and staff interviews. The issues included failures in following physician orders, lack of documentation for critical interventions, absence of required monitoring, and inadequate processes for scheduling and communication regarding resident care. The findings were confirmed by interviews with the Director of Nursing and other staff members, who acknowledged the lapses in care and documentation.
Failure to Identify and Address Elopement Risk in Residents with Cognitive Impairment
Penalty
Summary
The facility failed to identify and address elopement risks for several residents as required by policy. Specifically, residents with cognitive impairments and behaviors such as exit-seeking and wandering were not consistently assessed for elopement risk upon admission, quarterly, or when there were significant changes in condition. For one resident with dementia and a BIMS score indicating moderate impairment, only one elopement risk screen was found in the record, and it was not updated despite ongoing behaviors such as fixating on going home and independently moving about the unit in a wheelchair. Staff interviews confirmed that these behaviors were not recognized as triggers for reassessment, and the required quarterly elopement risk screens were not completed. Another resident, also with dementia and a high elopement risk score on admission, did not have further elopement assessments completed as required. A third resident with dementia and a physician order for a wanderguard was observed without the device, and staff were unable to account for its absence. The Director of Nursing confirmed that the facility did not timely identify residents with behaviors triggering elopement risk, failed to assess them on an ongoing basis, and did not provide appropriate care plans or physician orders for interventions related to exit-seeking behaviors.
Failure to Maintain Dialysis Communication and Vendor Contracts
Penalty
Summary
The facility failed to ensure consistent communication and documentation regarding dialysis care for two of three residents requiring such services. Specifically, for one resident with diagnoses including high blood pressure, anemia, and renal insufficiency, dialysis communication forms were either missing or incomplete for several months, as confirmed by staff review. Another resident with high blood pressure, diabetes, and end-stage renal disease also had incomplete or missing dialysis communication forms, with staff acknowledging that the documentation process had only recently been initiated. These lapses were identified through review of clinical records and staff interviews, which confirmed the absence and incompleteness of required documentation. Additionally, the facility did not maintain current dialysis contracts with the dialysis vendors for two residents as required by facility policy. Review of facility-provided dialysis agreements revealed that contracts were missing for these residents, a fact confirmed by the Nursing Home Administrator. The lack of proper agreements and incomplete communication forms were in violation of facility policy and state regulations regarding clinical records and nursing services.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance evaluations for three of five nurse aides, as required by regulation. Personnel file reviews showed that one nurse aide had not received a performance evaluation since 2019, another since 2021, and a third had no performance evaluation on file since their hire date. During an interview, the Human Resources employee confirmed that up-to-date performance appraisals were not completed for these nurse aides. This deficiency was identified through review of personnel records and staff interviews.
Improper Containment and Disposal of Garbage in Dumpsters
Penalty
Summary
The facility failed to properly contain and dispose of garbage in two of three outside dumpsters, as observed during a review of the outdoor trash receptacles. The lids or covers on dumpster one and two were not closed, and liquid from the dumpster area was found collecting in the disposal area. These conditions were confirmed by the Dietary Manager during the observation. The facility's policy requires the dumpster area to be clean, safe, and compliant with infection control and sanitation regulations, but these standards were not met in this instance.
Failure to Provide Required Annual In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that three out of five sampled nurse aides received the required minimum of 12 hours of in-service education within the past year. Review of facility policy indicated that all staff must participate in both initial orientation and annual in-service training. However, examination of nurse aide training records showed that the identified nurse aides did not meet the annual in-service training requirement. The facility was unable to provide documentation confirming that these nurse aides had completed the mandated training hours. This was confirmed during an interview with a Human Resources employee, who acknowledged the lack of evidence for the required in-service education.
Failure to Maintain Homelike Environment Due to Unsanitary and Damaged Linens
Penalty
Summary
The facility failed to maintain a homelike environment for seven of eight residents, as evidenced by observations during a unit tour. Specific deficiencies included beds with stained fitted sheets and pillowcases, holes in fitted sheets, thin and stretched see-through fitted sheets, and dirty, stained blankets. These conditions were confirmed by both an LPN and the Nursing Home Administrator. Facility policies on linen management and maintaining a homelike environment were reviewed, indicating expectations for cleanliness and comfort that were not met for the affected residents. No information was provided regarding the medical history or condition of the residents at the time of the deficiency.
Failure to Maintain Resident Dignity During Wound Care
Penalty
Summary
A deficiency was identified when a registered nurse (RN) failed to maintain a resident's dignity during wound care. Specifically, the RN wrote on the dressing after it had already been placed on the resident's right heel. This action was observed during a wound care procedure and was later confirmed by the RN in an interview. The facility's policy on dignity requires that each resident be cared for in a manner that promotes their sense of well-being and self-worth. The resident involved had a medical history including high blood pressure, diabetes, and dementia, and was admitted with a pressure ulcer on the right heel. Physician orders specified a detailed wound care regimen for the pressure ulcer, but the deficiency occurred when the RN wrote on the dressing post-application, which did not align with the facility's dignity policy. This incident was cited as a failure to provide care in a manner that maintains resident dignity.
Failure to Provide ADL Assistance for Dependent Resident
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident who was unable to perform these tasks independently. According to the facility's policy, residents who cannot carry out ADLs on their own are to receive services to maintain good nutrition, grooming, and personal and oral hygiene. Review of the resident's clinical record indicated diagnoses of high blood pressure, heart failure, and coronary artery disease, and the Minimum Data Set assessment documented that the resident was dependent for personal hygiene needs. Multiple observations over three consecutive days revealed that the resident remained in bed with a large amount of facial hair on the upper lip and chin, and black debris under the fingernails of both hands. These findings were confirmed by both a nurse aide and the Assistant Director of Nursing during separate interviews and observations. The Director of Nursing also confirmed that the facility did not provide the required ADL assistance for this resident.
Failure to Provide Ongoing Resident Activity Program
Penalty
Summary
The facility failed to provide an ongoing program of activities to meet the interests and support the physical, mental, and psychosocial well-being of each resident on the fourth floor. Review of the activity calendar showed scheduled activities, including 'Moovin and Groovin' and 'Connect Four.' However, during observations, the activity aide was present but did not engage with the residents. For example, during the 'Moovin and Groovin' activity, the aide sat at a table, played music, and did not interact with the group, instead eating a lollipop and resting her head on her hand. Similarly, during the 'Connect Four' activity, the aide sat at a table with the game present but did not encourage or facilitate resident participation. Interviews with the activity aide and the Activity Director confirmed that the aide did not interact with residents or attempt to involve them in the scheduled activities. The Activity Director acknowledged that the aide should have been engaging residents, such as encouraging movement or participation, but this did not occur. As a result, the facility did not meet the requirement to provide an ongoing program of activities tailored to the needs and interests of residents on the fourth floor.
Failure to Accurately Assess and Document Pressure Ulcers
Penalty
Summary
The facility failed to accurately assess and document pressure ulcers for two residents, as required by facility policy and nationally accepted guidelines. For one resident with a history of coronary artery disease, hypertension, and acute osteomyelitis of the right foot and ankle, there were no documented wound measurements for the right foot amputation site from late May through late June, despite physician orders for wound vac application and care. The Director of Nursing confirmed the absence of weekly wound measurements for this site. Another resident, admitted with diagnoses including surgical aftercare of the digestive system, peritonitis, and alcoholic cirrhosis of the liver, had a pressure ulcer on the coccyx. The clinical admission assessment and subsequent clinical records from late April through late June showed no documented measurements of the pressure ulcer, despite physician orders for daily wound care. The Assistant Director of Nursing confirmed that the facility did not accurately assess pressure ulcers for these two residents as required.
Failure to Identify and Address PTSD Triggers in Trauma-Informed Care
Penalty
Summary
The facility failed to provide trauma-informed care to a resident with a diagnosis of post-traumatic stress disorder (PTSD). The facility's policy on trauma-informed and culturally competent care requires staff to develop individualized care plans that address past trauma, identify triggers, and minimize exposure to those triggers in collaboration with the resident and family. However, review of the resident's care plan showed that while it acknowledged the risk for decreased psychosocial well-being and adjustment issues related to a history of assault with a weapon, it did not identify specific PTSD triggers or outline strategies to avoid them. Further review of the resident's clinical record confirmed the diagnosis of PTSD, along with anemia and a hip fracture. During an interview, the Social Services Director acknowledged that the facility did not identify or address the resident's PTSD triggers, which is necessary to eliminate or mitigate potential re-traumatization. This deficiency was cited under the relevant state codes for responsibility of the licensee and management.
Failure to Properly Store and Label Medications in Medication Carts
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications in two of three medication carts, as required by facility policy and professional standards. During an observation of the Second floor Low Cart, surveyors found three opened packages of ipratropium nebulizer medication and one Ellipta inhaler that were not dated as required. An LPN confirmed that these medications were opened and lacked the necessary dates. On a separate observation of the Third floor Low Cart, a vial of Ketotifen Fumarate eye drops was found opened and dated January 28, 2025, which was past its use-by date. Another LPN confirmed that this eye medication was opened and expired. The DON acknowledged that the facility did not properly and securely store medications in these two medication carts, in violation of facility policy and state regulations.
Failure to Provide Prescribed Thickened Liquids to Resident with Dysphagia
Penalty
Summary
A deficiency occurred when a resident with a physician-ordered diet of nectar thick liquids and no straws, due to diagnoses including dysphagia, was provided with a clear thin liquid and a straw. The resident's care plan, physician's orders, and Kardex all specified the need for nectar thick liquids and no straw, in accordance with the resident's medical needs and facility policy on therapeutic diets. During an observation, the resident was found in bed with a Styrofoam cup containing thin liquid and a straw within reach. Staff interviews confirmed that the resident should not have received this type of drink and that the nursing assistant responsible did not check the resident's ordered diet before providing the drink. The Director of Nursing acknowledged that the facility failed to provide drinks in the form required to meet the resident's individual needs.
Failure to Ensure Resident Capacity for Binding Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents had the capacity to understand the terms of a binding arbitration agreement prior to signing. Specifically, two residents were identified as having signed such agreements despite documented severe cognitive impairment. For one resident, the clinical record showed a diagnosis of dementia and a Brief Interview for Mental Status (BIMS) score of six, indicating severe impairment, at the time the agreement was signed. For the second resident, the record also showed a diagnosis of dementia and a BIMS score of three, again indicating severe impairment, at the time of signing. These findings were confirmed through review of facility documents, resident clinical records, and staff interviews. The Nursing Home Administrator acknowledged that the facility did not ensure these residents had the capacity to understand the binding arbitration agreements they signed. The deficiency was cited under 28 Pa. Code: 201.18(e)(1) Management.
Failure to Prevent Cross Contamination During Wound Dressing Change
Penalty
Summary
A deficiency was identified when a Registered Nurse (RN) failed to follow infection prevention and control protocols during a wound dressing change for a resident with diagnoses including high blood pressure, diabetes, and dementia, who required pressure ulcer care. The RN did not clean the surface used to hold wound care supplies before or after the dressing change, did not place a barrier under the resident's foot, and used scissors taken from a pocket without cleaning them prior to use. Additionally, after removing the soiled dressing, the RN placed the dirty dressing and empty packaging on the floor. These actions were observed during a dressing change and later confirmed by the RN in an interview. The facility's policy on wound care was not followed, resulting in a failure to prevent cross contamination during the procedure. The deficiency was cited under the relevant Pennsylvania Codes for resident care policies and nursing services.
Failure to Designate Qualified Infection Preventionist During Staff Absence
Penalty
Summary
The facility failed to designate a qualified individual onsite to be responsible for implementing infection prevention and control programs and activities during a specified period. Review of the Infection Control Committee meeting records for the third quarter revealed that the facility did not provide signatures of attendees for the July, August, and September meetings. During staff interviews, the DON stated that the Infection Preventionist was on leave of absence during these months and was unable to provide documentation of a qualified replacement fulfilling the Infection Preventionist role. The DON confirmed that no qualified individual was designated to oversee infection prevention and control during this time frame.
Failure to Provide Routine Podiatry Care
Penalty
Summary
The facility failed to provide appropriate foot care to two residents, both of whom had significant medical histories including diabetes, high blood pressure, and dementia. According to the facility's Podiatry Services Policy, podiatry services should be provided routinely every six to eight weeks, coordinated by nursing staff. However, review of clinical records and staff interviews confirmed that neither resident had received podiatry care since admission. Observations revealed that both residents had thick, elongated, and curved toenails, with lengths extending up to one inch beyond the ends of their toes. One resident was observed in bed with exposed feet, and a nurse confirmed the condition of the toenails. The other resident, who also had a physician order for a podiatry consult and ongoing wound care for a pressure injury, was observed during a dressing change with similarly neglected toenails. The Director of Nursing confirmed the lack of podiatry care for both residents, indicating a failure to follow facility policy and provide necessary foot care services.
Delayed Access to Resident Funds
Penalty
Summary
The facility failed to provide timely access to personal funds for three residents, as evidenced by grievances and interviews. Resident R2 expressed dissatisfaction with the delay in receiving his Social Security funds, which took 13 days to be resolved. Similarly, Resident R4's family raised concerns about the resident not receiving his personal allowance for December, despite having a sufficient account balance. The Business Office Manager noted that the delay was due to the check arriving late and the bank's opening schedule, which led to frustration and erratic behavior from the resident and family. Resident R1 also experienced issues accessing her funds, as she had been waiting since the beginning of December for her check to be processed. The Business Office Manager confirmed that the check had just arrived, and the delay was attributed to the transition of account management from the previous owner. The Nursing Home Administrator acknowledged the facility's failure to provide timely access to personal funds for these residents, which is a violation of their rights under the applicable state codes.
Neglect Due to Inadequate Assistance Leads to Resident Fall
Penalty
Summary
The facility failed to ensure that a resident was free from neglect by not providing the required two-person assistance for bed mobility, resulting in a fall. The resident, who had diagnoses of high blood pressure, quadriplegia, and Multiple Sclerosis, was assessed as needing two-person assistance for bed mobility. Despite this requirement being documented in the resident's care plan and Kardex, a nurse aide provided incontinence care alone and left the resident unattended on their side to obtain new briefs. During this time, the resident experienced spasms and fell from the bed. The incident was reported by the nurse aide, who heard the resident yell about falling and having spasms before hearing a crash. Upon assessment by a registered nurse, the resident was found on the floor without physical injuries and was assisted back to bed using a hoyer lift. The Nursing Home Administrator confirmed that the facility did not adhere to the care plan requiring two-person assistance, which led to the resident's fall.
Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision for a resident with significant mobility needs, resulting in an avoidable fall. The resident, who was diagnosed with high blood pressure, quadriplegia, and Multiple Sclerosis, required assistance from two staff members for bed mobility. However, during an incident, a nurse aide provided incontinence care alone and left the resident unattended on their side to obtain new briefs. During this time, the resident experienced spasms and fell from the bed onto the floor. The incident was documented in progress notes and verbal statements, confirming that the resident was left without the required assistance, leading to the fall. The Nursing Home Administrator acknowledged that the facility did not adhere to the care plan, which specified the need for two-person assistance for bed mobility. This oversight resulted in a failure to provide adequate supervision, as required by the facility's policies and state regulations.
Failure to Provide Timely Physician Services
Penalty
Summary
The facility failed to provide consistent and timely physician services for a resident with a history of high blood pressure, quadriplegia, and Multiple Sclerosis (MS). The resident expressed feeling unwell and requested emergency care on two consecutive days, but the staff did not act promptly. On the first day, the resident's request to go to the emergency room was ignored by aides and nurses. The following day, the resident's representative intervened, and it was revealed that the resident had not been sent to the hospital because the attending physician did not respond to the nurse's call. The resident was eventually sent to the emergency room after a physician assistant evaluated him and noted his symptoms, which included weakness, tiredness, and pain. The resident was admitted to the ICU with sepsis, indicating a delay in receiving necessary emergency treatment. Interviews with staff revealed that there was confusion about the procedure to follow when a physician could not be reached, contributing to the delay in care. The Nursing Home Administrator confirmed the facility's failure to ensure timely physician services for the resident.
Unauthorized Medication Order and Communication Failure
Penalty
Summary
The facility failed to ensure that physician orders were properly obtained, identify pain or spasms to warrant medication, and notify the family for one resident. The review of the clinical record indicated that the resident was admitted with diagnoses including aphasia, depression, and cerebral infarction. The resident had a physician order for Flexeril, a muscle relaxant, which was discontinued and then reordered without proper authorization. The LPN involved ordered the medication without consulting the physician or nurse practitioner, which was against the facility's policy and the scope of practice for an LPN. Interviews with staff revealed that the RN was aware of the discontinuation of Flexeril and questioned the LPN about the unauthorized reorder. The LPN admitted to ordering the medication without contacting the physician. The nurse practitioner and physician confirmed that they were not contacted for the reorder. The facility's management acknowledged the failure to follow proper procedures, which resulted in the deficiency. The report highlights the lack of adherence to policies regarding medication orders and communication with family members.
Failure to Timely Dispose of Discontinued Medication
Penalty
Summary
The facility failed to dispose and reconcile discontinued medication in a timely manner for a resident, identified as Resident R1. According to the facility's policy on the disposal of medication waste, medications that are discontinued, expired, or contaminated should be disposed of in accordance with federal, state, and local regulations. Resident R1 was admitted to the facility with diagnoses including aphasia, depression, and cerebral infarction. The resident had a physician's order for Flexeril, a muscle relaxant, which was discontinued on a specified date. However, during an observation, it was found that a blister pack of Flexeril was still being stored in the medication room. Interviews with the Director of Nursing (DON) confirmed that the Flexeril should have been sent back to the pharmacy or destroyed when the order to discontinue the medication was obtained. The DON acknowledged that the facility did not dispose of and reconcile the discontinued medication in a timely manner for Resident R1. This oversight was identified during a review of the clinical record and through staff interviews, highlighting a lapse in adhering to the facility's medication disposal policy.
Improper Medication Order Without Physician Authorization
Penalty
Summary
The facility failed to ensure that medication orders were properly obtained by a Physician, Physician Assistant, or Nurse Practitioner (NP) for a resident. The issue arose when an LPN ordered Flexeril, a muscle relaxant, for a resident without consulting a physician or NP, despite the medication having been previously discontinued. The LPN believed the resident needed the medication and signed off on the order without proper authorization. This action was discovered by an RN who noticed the discrepancy upon reviewing the resident's chart. The resident involved had a history of aphasia, depression, and cerebral infarction. The medication order was initially discontinued by an NP, and neither the NP nor the physician was contacted to reorder it. Interviews with the NP and physician confirmed that they were not consulted regarding the reordering of Flexeril. The facility's management acknowledged the failure to adhere to proper procedures for obtaining medication orders, as required by state regulations.
Failure to Ensure Safe and Orderly Discharge
Penalty
Summary
The facility failed to implement a safe and orderly discharge for one resident, identified as CR R2, who was admitted on 9/6/24 and diagnosed with Conversion Disorder and Shortness of Breath. The discharge planning indicated that the resident was to return to North Carolina, with arrangements for home care and a personal provider. However, the facility did not have the resident's home address, personal provider's name, or contact information for the resident or physician. On 9/26/24, progress notes indicated that the resident was set to discharge with a bus ticket confirmed and medication delivered, but the facility could not confirm the resident's destination or care arrangements. Interviews with the Nursing Home Administrator and Director of Nursing on 10/8/24 confirmed the failure to ensure a safe discharge, as required by Pa. Code 201.25 and 201.29 (f)(g).
Deficiencies in Food Handling and Sanitation Practices
Penalty
Summary
The facility failed to adhere to its food handling policy, resulting in several deficiencies related to food storage, labeling, and sanitation in the Main Kitchen. Observations revealed that mixing bowls and pots were not stored inverted, a black cart had a white substance on it, and the kitchen floor was littered with debris. Additionally, a drawer containing prep tools had a visible brown/rusty substance. These conditions were confirmed by Dietary Employee E12, indicating a failure to properly store kitchenware and maintain cleanliness. Further observations in the walk-in cooler and dry goods storage area highlighted issues with food labeling and expiration monitoring. Items such as ham, tomato soup, and chicken noodle soup were either past their use-by dates or lacked proper labeling. Similarly, fruit cups, cottage cheese, and creamer in the small cooler were not labeled with prepared or use-by dates. The dry goods storage area contained bins with dust-like substances and items without proper labeling or expiration dates. Additionally, the facility failed to consistently monitor food temperatures, as evidenced by Dietary Employee E12's inability to produce temperature records for breakfast items. These deficiencies were confirmed by Food Service Director Employee E10, who acknowledged inconsistent temperature monitoring practices.
Inadequate Linen Supply on Two Units
Penalty
Summary
The facility failed to maintain an ample linen supply for staff's immediate use on two of three units, specifically the second and third floors. This deficiency was identified through a review of the facility's Accommodation of Needs policy, observations, and interviews with residents and staff. The policy mandates a safe, clean, and comfortable environment, including the provision of clean bed and bath linens. However, residents reported a lack of washcloths and towels, with one resident stating that paper towels were used for personal care due to the shortage. Staff interviews corroborated these claims, with registered nurses and nurse aides acknowledging the frequent shortage of linens, which sometimes required them to search other floors or use alternative materials for resident care. Observations confirmed the deficiency, revealing barren linen supplies in the second-floor linen room and insufficient supplies on the third floor. During a Resident Council meeting, multiple residents expressed concerns about the inadequate supply of towels and washcloths, noting that the facility no longer provided wipes and relied on wash towels for various care needs. Staff interviews further highlighted the issue, with reports of new admissions waiting for linens and residents being cleaned with paper towels due to the shortage. The Nursing Home Administrator confirmed the facility's failure to maintain an adequate linen supply on the affected units.
Failure to Communicate Resident Information During Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider during facility-initiated transfers for four out of five residents sampled. The deficiency was identified through a review of facility policy, clinical records, and staff interviews. The facility's policy on Discharge and Transfer, dated 5/7/24, requires that specific information be communicated when a resident is transferred. However, for Residents R29, R39, R75, and R82, there was no documented evidence that the facility had communicated essential information such as care plan goals, advanced directive information, specific instructions for ongoing care, and resident representative information to the receiving health care provider. Each of the residents involved had been transferred to a hospital and later returned to the facility. Resident R29 had diagnoses including high blood pressure, muscle weakness, and acute cholecystitis. Resident R39 had high blood pressure, coronary artery disease, and osteoarthritis. Resident R75 had high blood pressure, atrial fibrillation, and thyroid disease. Resident R82 had high blood pressure, coronary artery disease, and cerebral infarction. Despite these medical conditions, the facility did not provide the necessary information to ensure continuity of care at the receiving facility. The Nursing Home Administrator confirmed the failure to communicate the required information during an interview.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide timely notification to the Office of the Long-Term Care Ombudsman Division regarding the transfer of four residents to the hospital. The facility's policy on Discharge and Transfer, dated 5/7/24, requires that copies of notices for emergency transfers be sent to the Ombudsman, either when practicable or as per state requirements. However, the clinical records for Residents R29, R39, R75, and R82 did not contain documented evidence of such notifications being sent for their respective hospitalizations. Resident R29, diagnosed with high blood pressure, muscle weakness, and acute cholecystitis, was transferred to the hospital on 5/9/24. Resident R39, with high blood pressure, coronary artery disease, and osteoarthritis, was transferred on 10/23/23. Resident R75, suffering from high blood pressure, atrial fibrillation, and thyroid disease, was transferred on 5/7/24. Lastly, Resident R82, diagnosed with high blood pressure, coronary artery disease, and cerebral infarction, was transferred on 11/27/23. The Director of Social Services admitted to being unaware of the requirement to include transfers and bed holds in the Ombudsman notification list, which was confirmed by the Nursing Home Administrator.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify residents or their representatives about the bed-hold policy during hospital transfers, as required by their own policy and regulatory standards. This deficiency was identified through a review of facility policy, clinical records, and staff interviews. The facility's policy, dated 5/7/24, mandates that a Bed Hold Notice of Policy & Authorization form be provided to residents or their representatives. However, for four out of five residents who were transferred to the hospital, there was no documented evidence that this information was provided. Specifically, residents with various medical conditions, including high blood pressure, coronary artery disease, and other ailments, were transferred to hospitals without receiving the necessary bed-hold policy information. Interviews with facility staff revealed a misunderstanding or misapplication of the policy. Admission Employee E19 stated that they only contacted families about the bed-hold policy if the residents were private pay, to determine if they wanted to continue paying for the bed during the hospital stay. This practice was confirmed by the Nursing Home Administrator, who acknowledged the failure to notify residents or their representatives as required. The deficiency was noted under 28 Pa. Code: 201.29(b)(d)(j) concerning resident rights.
Failure to Implement Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for 17 new residents in the past 30 days. The facility's policy, last reviewed on May 7, 2024, mandates the creation of a person-centered care plan within 48 hours of admission or readmission. This care plan should include the necessary instructions to provide effective and person-centered care that meets professional standards. However, a review of the facility's records revealed that no baseline care plans were documented for any of the new admissions during this period. The Nursing Home Administrator confirmed during an interview that the baseline care plans were not being completed as required, acknowledging the facility's failure to initiate these plans for all 17 new admissions.
Inadequate Dialysis Communication in LTC Facility
Penalty
Summary
The facility failed to provide consistent and complete communication with the dialysis center for three residents requiring dialysis services. The facility's policy required licensed nurses to complete a Hemodialysis Communication Record before and after each dialysis session, ensuring communication with the dialysis center. However, for Resident R1, the facility did not complete the required forms for four out of sixteen dialysis days. Similarly, Resident R27's records showed incomplete forms for ten out of sixteen days, and Resident R41's records were missing forms for thirteen out of twenty-two days, with incomplete documentation for eight additional days. Interviews with facility staff, including registered nurses and the Nursing Home Administrator, confirmed the lack of completed dialysis communication forms. The facility's failure to adhere to its policy resulted in inadequate documentation and communication with the dialysis center, as evidenced by the missing and incomplete forms for the residents. This deficiency was identified through a review of clinical records, facility policy, and staff interviews, highlighting a significant lapse in the facility's dialysis care communication process.
Deficiencies in Medication Storage and Labeling
Penalty
Summary
The facility failed to store drugs and biologicals in a safe, secure, and orderly manner in two of its medication rooms, leading to deficiencies in compliance with health regulations. On the third floor, a vial of tuberculin solution was found opened and undated in the medication room refrigerator. Additionally, the refrigerator was observed to have a brown slime on the bottom drawer and a pink sticky substance in the door seal, while the freezer contained a pink sticky substance and a blue frozen water bottle. These observations were confirmed by a Registered Nurse (RN) during an interview. On the fourth floor, several expired supplies were found in the medication room, including five glucose control solutions, a 0.9% normal saline solution, and a universal viral transport swab kit. These expired items were confirmed by a Licensed Practical Nurse (LPN) during an interview. The facility's policies on medication administration and storage were reviewed, indicating that medications should be dated when opened and stored properly to maintain their integrity, but these policies were not adhered to in the observed instances.
Failure to Coordinate Hospice Services for Residents
Penalty
Summary
The facility failed to ensure the coordination of hospice services with facility services to meet the needs of two residents, identified as R31 and R97, for end-of-life care. The facility's policy required a written plan of care that included the hospice plan and a description of services to maintain the resident's wellbeing. However, the facility did not have a hospice communication binder for either resident, which was confirmed by a Registered Nurse (RN) and the Nursing Home Administrator. Resident R31, who had diagnoses including dementia and cerebral atherosclerosis, was admitted to hospice care, but the facility lacked the necessary documentation to coordinate hospice services. Similarly, Resident R97, with diagnoses of dementia and weakness, was also admitted to hospice care, but the facility failed to include hospice coordination in the resident's comprehensive care plan. The care plan did not provide contact information for the hospice agency or instructions on accessing the hospice's 24-hour on-call system. The Director of Nursing confirmed the facility's failure to coordinate hospice services for Resident R97, which was a violation of the facility's policy and state regulations.
Failure to Conduct Quarterly QAA Meetings
Penalty
Summary
The facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all required committee members for three consecutive quarters. The facility's policy, dated May 7, 2024, mandates that the QAA committee, which operates under the authority of the Administrator and the Governing Body, includes the Administrator, Director of Nursing, Medical Director, Infection Preventionist, consultant pharmacist, patient and/or family representatives, and three additional staff representatives. Despite this requirement, the facility was unable to provide any sign-in sheets or attendance records for the periods of October 2023 through December 2023, January 2024 through March 2024, and April 2024 through June 2024. During an interview on July 26, 2024, the Nursing Home Administrator confirmed the absence of these records and acknowledged the failure to hold the required QAA meetings. This deficiency was identified under the regulation 28 Pa Code: 201.18(e)(1)(2)(3)(4) Management.
Failure to Prevent Cross-Contamination and Implement EBP
Penalty
Summary
The facility failed to prevent cross-contamination during a medication pass for two residents. During observations, an LPN was seen removing medication from its package into their hand and placing it into a medication cup without wearing gloves for two residents. This action was confirmed by the LPN during interviews, and the Director of Nursing acknowledged the failure to prevent cross-contamination during the medication pass. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for residents with tube feedings, indwelling urinary catheters, and indwelling dialysis catheters. The Infection Preventionist admitted to not being aware of all items included in EBP and confirmed the oversight. This lack of implementation was noted for several residents with specific medical devices, indicating a failure to adhere to the facility's policy and CDC guidelines.
Failure to Offer Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that influenza and pneumococcal immunizations were offered to four out of five residents, as required by their policies. The facility's policy IC600, dated 5/7/24, mandates that influenza immunization history be obtained and documented upon admission. Similarly, policy OC601 requires that the pneumococcal vaccination history be obtained and documented, and the opportunity to receive the vaccine be provided to all residents. However, upon review, it was found that Residents R53, R94, R106, and R112 were not offered these vaccinations, and there was no documentation in their clinical records indicating that the vaccinations or related education were provided. Resident R53, with diagnoses of seizure disorder and high blood pressure, was not offered the influenza or pneumonia vaccines, and no reason was documented. Resident R94, diagnosed with depression and high blood pressure, was not offered the influenza vaccine, with no documentation of education provided. Resident R106, with Alzheimer's disease, depression, and anxiety, was not offered the pneumonia vaccine, and there was no documentation of education. Resident R112, also with depression and high blood pressure, was not offered the influenza vaccine and was not administered the pneumonia vaccine, with no reason documented. The Infection Preventionist confirmed these deficiencies during an interview.
Deficiency in Staff Training Program
Penalty
Summary
The facility failed to implement and maintain an effective training program for its staff, as evidenced by the review of personnel records and staff interviews. Specifically, three out of five personnel records reviewed did not include documentation of required annual in-service training. Nurse Aide Employee E25, hired on 4/13/05, lacked training in effective communication, resident rights, abuse, QAPI, infection control, compliance and ethics, and behavioral health. Nurse Aide Employee E26, hired on 12/31/18, did not have training in resident rights, abuse, and compliance and ethics. Nurse Aide Employee E27, hired on 3/31/03, was missing training in effective communication and QAPI. This deficiency was confirmed during an interview with Scheduler Employee E18.
Latest citations in Pennsylvania
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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