Juniper Village At Bucks County Rehab And Skd Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Bensalem, Pennsylvania.
- Location
- 3200 Bensalem Boulevard, Bensalem, Pennsylvania 19020
- CMS Provider Number
- 395864
- Inspections on file
- 18
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Juniper Village At Bucks County Rehab And Skd Care during CMS and state inspections, most recent first.
A resident with dementia, GERD, and other comorbidities, identified as at risk for malnutrition, experienced a 7.4% weight loss over a short period despite a care plan calling for small frequent meals, intake monitoring, and nutritional supplements. Nursing notes documented poor appetite and the need for encouragement to eat, but although a dietitian consult was ordered, there was no documented RD evaluation of the resident’s nutritional status or weight loss, and orders for supplements and weekly weights were delayed. The RD, on limited hours, could not recall when she was notified of the resident’s poor intake or weight loss and could not confirm that timely interventions were implemented, demonstrating a failure to follow the facility’s own unintended weight loss policy for assessment and monitoring.
The facility did not provide the required RN coverage on two separate shifts, resulting in no RN hours being recorded when a minimum of 8.0 hours was required for each shift.
A resident who was cognitively intact signed a binding arbitration agreement at admission without being informed of the right to rescind the agreement within 30 days or that the agreement does not prevent communication with regulatory officials. Both the social worker and administrator confirmed they did not provide this information during the review process, and the resident was unaware of these rights.
A resident experienced a significant weight loss following a hospital stay and return to the facility. Although the dietician was eventually notified and offered nutritional supplements, the care plan was not updated to address the resident's recent weight loss or interventions, as required by facility policy and regulations.
The facility did not ensure ongoing water testing and compliance with its water management plan for Legionella prevention, as the last water test was completed over a year prior to the survey. Staff confirmed that required procedures and documentation were not maintained, resulting in a failure to adhere to CDC and CMS guidelines for waterborne pathogen control.
A facility failed to document a resident's advanced directives in their electronic medical record. Despite having a signed POLST form indicating DNR status and specific medical treatment preferences, these directives were not reflected in the resident's records. Staff interviews confirmed the oversight, highlighting a lapse in adhering to the facility's policy on maintaining accurate records.
The facility failed to notify the State Long Term Care Ombudsman of facility-initiated discharges for three residents. Despite informing responsible parties of hospital transfers, there was no documented evidence of Ombudsman notification. The Facility Administrator confirmed the lack of a process for notifying the Ombudsman of such discharges.
The facility failed to develop baseline care plans within 48 hours of admission for four residents, as required. A resident with multiple diagnoses, including reduced mobility, had no baseline care plan, and an error in the admission MDS regarding dental status was noted. Another resident with chronic venous hypertension and ulcers lacked a care plan for skin integrity. Two other residents had care plans without necessary interventions. Interviews confirmed the absence of timely baseline care plans.
The facility failed to create and implement individualized care plans for two residents, leading to deficiencies in addressing their specific needs. One resident, who was edentulous, had no care plan for dental issues, while another resident with chronic ulcers had care plans lacking specific interventions. This indicates a failure to provide comprehensive care as required by regulations.
The facility failed to timely address pharmacy recommendations for three residents, leading to deficiencies in medication management. A resident with Major Depressive Disorder experienced a 33-day delay in addressing a recommended dose reduction. Another resident's medication evaluation and adjustment were delayed, and a third resident's medication record had irregularities that were not reviewed by a physician. These issues were confirmed by the DON.
The facility failed to implement an effective infection control program, lacking systems to track infections and review antibiotic use as per their policy. An interview with a staff member confirmed the absence of these critical components, indicating non-compliance with established procedures.
Failure to Adequately Assess and Monitor Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to accurately assess and monitor significant weight loss for a resident, contrary to its own Unintended Weight Loss policy. That policy requires close monitoring of weights, timely assessment by an interdisciplinary team, and implementation of interventions when weight loss occurs, with the Director of Wellness and Dietary Manager overseeing related processes. Compliance under the policy is defined as proper assessment, care planning, intervention, and ongoing evaluation, even when weight loss cannot be prevented. The resident involved was admitted with diagnoses including GERD, arthritis, dementia, traumatic brain injury, and anxiety, and had a BIMS score of 4 indicating severely impaired cognition. On admission assessment, the resident could use utensils, bring food and liquids to the mouth, and swallow safely, but required supervision with eating. A Mini nutrition note dated in February documented a weight of 94 pounds, no decrease in food intake over the prior three months, no weight loss, and a nutrition score of nine indicating risk of malnutrition. The care plan initiated in February 2026 identified gastrointestinal alteration, nutritional risk factors, and significant weight loss, and included interventions such as small frequent meals, monitoring intake, providing supplements, documenting intake each meal, and reporting signs and symptoms of malnutrition and weight loss to the physician as needed. Despite these identified risks and care plan interventions, the clinical record showed the resident experienced a 7.4% weight loss between early February and early March, with weights declining from 97 pounds to as low as 86 pounds. Nursing notes documented that the resident needed encouragement to eat and had poor appetite on multiple days in February. A dietitian consult was ordered on February 25, but March physician orders for a nutritional supplement and weekly weights were not obtained until early and mid-March. Nutritional progress notes lacked documented evidence that the RD evaluated the resident’s nutritional status and significant weight loss. In a phone interview, the RD, who is present about 10 hours per week, could not recall when she was first notified of the resident’s poor appetite or weight loss and could not confirm whether timely interventions were implemented, indicating a breakdown in the assessment and monitoring process required by facility policy.
Failure to Meet Minimum RN Staffing Requirements
Penalty
Summary
The facility failed to comply with Pennsylvania state regulations requiring a minimum of one registered nurse (RN) per 250 residents on all shifts. A review of the facility's nursing staff ratio for the week of July 29, 2025, through August 5, 2025, showed that on two separate shifts, the required RN coverage was not met. Specifically, there was no RN coverage for the entire night shift on July 31, 2025, and no RN coverage for the entire evening shift on August 2, 2025, despite a minimum of 8.0 hours being required for each shift. These findings were discussed with the facility's administrator.
Plan Of Correction
No negative outcomes occurred due to this deficient practice. DON/designee will review and approve all schedules to ensure one RN is scheduled for each shift. DON/designee will audit staffing daily for 4 weeks, then weekly for 2 months, reporting results to the QA Committee. Noncompliance will be corrected immediately.
Failure to Inform Resident of Arbitration Agreement Rights
Penalty
Summary
The facility failed to ensure that a resident was properly informed about the terms and rights associated with signing a binding arbitration agreement upon admission. Although the resident was cognitively intact, as indicated by a BIMS score of 15 on the admission MDS, the review of the signed arbitration agreement revealed that it lacked documentation of who reviewed the agreement with the resident. Interviews with the social worker and the nursing home administrator confirmed that neither informed the resident of their right to rescind the agreement within 30 days of signing, nor did they explain that the agreement does not prevent communication with federal, state, or local officials, including surveyors and ombudsmen. Further interviews with the resident and their spouse revealed that the resident was unaware of the right to rescind the agreement or the ability to communicate with regulatory officials despite having signed the document. Both the social worker and the administrator admitted to omitting these critical explanations during their review of the arbitration agreement with residents. The deficiency was confirmed by the administrator, who acknowledged that residents were not informed of these rights in a language they could understand, as required.
Failure to Update Care Plan for Significant Weight Loss
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive care plan to address a significant weight loss in a resident. The facility's policy requires that residents experiencing unintended weight loss be assessed by the interdisciplinary team, with interventions implemented and documented in the care plan, including measurable objectives and time frames. However, review of the clinical record for a resident who was admitted after a hospital stay, subsequently discharged back to the hospital for gastrointestinal bleeding, and then readmitted, revealed a significant weight loss of 18.8 pounds over eleven days. The resident's weight dropped from 143.8 pounds to 125.0 pounds during this period. Despite this significant weight loss, the registered dietician was only made aware of the issue several days later and, although supplemental shakes were offered and refused by the resident, the care plan was not updated to reflect the new interventions or the resident's current nutritional status. The dietician confirmed that the protocol would involve communication with nursing staff and the physician, followed by an update to the care plan, but this was not completed. The failure to update the care plan and document appropriate interventions constituted noncompliance with facility policy and regulatory requirements.
Failure to Implement and Maintain Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to develop and implement an effective water management program for the prevention, detection, and control of waterborne contaminants, specifically Legionella. According to the report, the facility's water management plan, which is contracted to an outside company, outlines procedures such as routine control measures, inspection of plumbing and hot water systems, quarterly cleaning of aerators, and regular water testing. However, documentation and staff interviews confirmed that the facility did not ensure ongoing water testing and compliance with its own water management plan, as the last recorded water test was completed on February 18, 2023. This deficiency was identified through observation, policy review, and staff interviews, which revealed that the facility did not adhere to CDC and CMS guidelines requiring regular risk assessments, implementation of water management programs, and documentation of testing and corrective actions. The Environmental Director and Nursing Home Administrator confirmed the lapse in water testing and compliance, indicating a failure to follow established protocols for minimizing the risk of Legionella and other waterborne pathogens in the facility's water system.
Failure to Document Advanced Directives in Resident's Record
Penalty
Summary
The facility failed to ensure that advanced directives were accurately reflected in the records of a resident, identified as Resident R70. Upon review of the clinical records and interviews with staff, it was found that Resident R70's electronic medical record did not include their DNR status or any advanced directives. This omission was despite the resident having a completed and signed POLST form indicating their preferences for medical interventions, including a DNR order, limited additional interventions, and no artificial hydration or nutrition by tube. The POLST form was signed by both the physician and Resident R70. Interviews with facility staff, including Employee E4 and the Facility Administrator, confirmed the absence of the advanced directives in the electronic medical record. Employee E4 acknowledged that Resident R70 had signed a POLST form and expressed specific medical treatment preferences, yet these were not documented in the electronic system. The Facility Administrator also confirmed the lack of documentation for Resident R70's advanced directives in the electronic medical record, indicating a failure to adhere to the facility's policy on maintaining accurate records of residents' advanced directives.
Failure to Notify Ombudsman of Facility-Initiated Discharges
Penalty
Summary
The facility failed to notify the State Long Term Care Ombudsman of facility-initiated emergency transfers and discharges for three residents. Resident R73 was discharged to the hospital on July 26, 2024, but there was no documented evidence that the Ombudsman was informed of this discharge. Similarly, Resident R74 was transferred to the hospital on two occasions, May 19, 2024, and June 23, 2024, without notification to the Ombudsman. Resident R75 was also discharged to the hospital on July 25, 2024, with no evidence of Ombudsman notification. Interviews with the Facility Administrator, Employee E1, confirmed that the facility lacked a process for providing the Ombudsman with copies of discharge notices. Employee E1 acknowledged that the Ombudsman was not notified of the discharges for Residents R73, R74, and R75. This oversight was identified during a review of clinical records and facility documents, which revealed the absence of documented notifications to the Ombudsman for these facility-initiated discharges.
Failure to Develop Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for four residents, as required by regulations. The facility's policy on care planning did not address the creation of a baseline care plan. Resident R14 was admitted with multiple diagnoses, including reduced mobility and cognitive communication deficit, but no baseline care plan was established. Additionally, an error was found in the admission MDS regarding the resident's dental status, which was not corrected. Observations revealed that Resident R14 was edentulous and not wearing dentures, which he reportedly did not like wearing. Resident R70 was admitted with chronic venous hypertension and multiple non-pressure ulcers, yet no baseline care plan for skin integrity or wound care was in place. Resident R9, admitted with sepsis and other conditions, had a care plan that lacked necessary interventions. Similarly, Resident R120, admitted with a thoracic spine fracture and bipolar disorder, had a care plan without interventions. Interviews confirmed that baseline care plans were not completed within the required timeframe for Residents R9 and R120.
Failure to Implement Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement individualized comprehensive care plans for two residents, leading to deficiencies in addressing their specific needs. Resident R14, who was admitted with conditions including reduced mobility and cognitive communication deficit, was observed to be edentulous and not wearing dentures during a meal. Despite having dentures, the resident expressed a preference not to wear them. However, there was no care plan in place to address the resident's dental issues, indicating a lack of individualized planning for this aspect of care. Similarly, Resident R70, admitted with multiple chronic ulcers and other health issues, had a care plan for venous stasis ulcers that lacked specific interventions. Additionally, care plans for falls, impaired vision, and potential pressure ulcers were also missing interventions. This lack of detailed planning and intervention documentation highlights the facility's failure to provide comprehensive care plans tailored to the residents' needs, as required by their own policies and federal and state regulations.
Delayed Response to Pharmacy Recommendations
Penalty
Summary
The facility failed to act on pharmacy recommendations in a timely manner for three residents, leading to deficiencies in medication management. Resident R10, who was admitted with Major Depressive Disorder, had a pharmacy recommendation for a gradual dose reduction of Mirtazapine and Citalopram on August 15, 2024. However, the attending physician did not address this recommendation until September 17, 2024, resulting in a 33-day delay. This delay was confirmed by the Director of Nursing (DON) during an interview. For Resident R14, the pharmacy recommended evaluating the necessity of atorvastatin, monitoring symptoms, and adjusting the Eliquis dose. Despite the DON signing off on the pharmacy review, the physician reviewed the recommendations late. Additionally, Resident R70's pharmacy consultation report noted irregularities in the medication administration record, including incomplete directions and missing strength for ascorbic acid. The report lacked the physician's signature, indicating that the recommendations were not reviewed. These issues were confirmed by the DON, highlighting a pattern of delayed response to pharmacy recommendations.
Failure in Infection Control and Antibiotic Stewardship
Penalty
Summary
The facility failed to establish an effective infection control program related to infection surveillance and periodic review of antibiotic use. The facility's policy on antibiotic stewardship outlines the need for a program to promote appropriate antibiotic use and optimize infection treatment while reducing adverse events. However, the facility did not have documented evidence of tracking infections or conducting periodic reviews of antibiotic use, as required by their policy. This lack of documentation indicates a failure to adhere to the established procedures for monitoring antibiotic usage patterns, reviewing antibiograms, and tracking multi-drug resistant organisms. An interview with Employee E2 confirmed that the facility lacked a system to track infections and antibiotic use, and there was no periodic review of antibiotic use in place. This deficiency was identified through observations, policy reviews, and staff interviews, highlighting a significant gap in the facility's infection control and antibiotic stewardship efforts. The absence of these critical components in the infection control program suggests non-compliance with the facility's own policies and state regulations.
Latest citations in Pennsylvania
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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