Laurel Ridge Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Uniontown, Pennsylvania.
- Location
- 75 Hickle Street, Uniontown, Pennsylvania 15401
- CMS Provider Number
- 395243
- Inspections on file
- 21
- Latest survey
- August 20, 2025
- Citations (last 12 mo.)
- 1 (1 serious)
Citation history
Health deficiencies cited at Laurel Ridge Center during CMS and state inspections, most recent first.
A resident with a history of stroke, hypertension, and mobility issues, identified as a risk for elopement, left the facility unsupervised and was missing for nearly a day before being found by police. Staff failed to provide adequate supervision, relied on assumptions about the resident's location, and did not conduct regular checks, resulting in delayed recognition of the resident's absence.
Six residents were affected by environmental deficiencies, including a dusty fan blowing toward a resident's bed and repeated loud slamming of a kitchen door that startled both residents and staff. Despite complaints to the NHA, the issues persisted, impacting comfort and the homelike atmosphere.
Comprehensive MDS assessments were not completed within the mandated 14-day period for four residents. Both the DON and the administrator confirmed that these assessments were completed late, in violation of regulatory requirements.
A resident with diabetes and heart failure experienced multiple episodes of critically high blood glucose levels, as documented in the clinical record. Despite facility policy and physician orders requiring notification for blood sugar readings above 500 mg/dL, there was no documentation that the provider was notified. This deficiency was confirmed by the DON and the Nursing Home Administrator.
Two residents received potassium chloride at times inconsistent with physician orders, with repeated late or early administrations documented over several days. An LPN was observed administering the medication outside the prescribed time and was unable to document it properly in the electronic record. The DON and Nursing Home Administrator confirmed the failure to prevent significant medication errors.
The facility did not provide written notice of its bed-hold policy to residents or their representatives during multiple hospital transfers, as required by facility policy. Several residents with complex medical conditions were transferred for acute health issues, but clinical records lacked documentation of the required notification. This deficiency was confirmed by both record review and staff interviews.
Three staff members, including a nurse aide, an LPN, and a dietary employee, did not receive required annual training on the facility's QAPI program, as confirmed by document review and interviews with the administrator and DON.
A resident with Parkinson's and severe cognitive impairment was restrained with a gait belt without a physician's order, violating facility policy. The resident had a history of falls and difficulty maintaining safe positioning due to rigidity. Despite discussions with the resident's family and attempts to find suitable positioning devices, the unauthorized use of the gait belt led to a deficiency finding.
A resident with severe cognitive impairment was improperly restrained with a gait belt tied to a wheelchair by an RN, contrary to facility policy. Several staff members witnessed the incident but failed to report it to supervisors or authorities, violating state law and facility procedures. The facility's management confirmed the failure to implement necessary reporting policies.
The facility failed to notify physicians and assess residents for abnormal glucose levels, affecting three residents with diabetes. Despite care plans requiring monitoring and reporting of hypo-/hyperglycemia symptoms, residents experienced abnormal CBG levels without proper assessment or physician notification. Interviews with LPNs and the DON revealed inconsistencies in following protocols for managing abnormal glucose levels.
A resident with multiple health issues was neglected when two nurse aides transferred them from a wheelchair to a bed without using the required lift, resulting in severe pain and injury. The aides admitted to the manual transfer due to the absence of a lift pad, contrary to the facility's policy on preventing neglect.
Elopement Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction, high blood pressure, and difficulty walking eloped from the facility without staff knowledge or supervision. The resident was assessed as cognitively intact with a BIMS score of 15 and had a care plan in place identifying a risk for wandering or elopement. Despite this, staff did not provide adequate supervision, and the resident was able to leave the facility undetected for approximately 22 hours before being located by police. Multiple staff members observed the resident throughout the evening, noting that he was frequently walking in the hallways and was last seen between 8:00 and 9:00 p.m. Staff relied on assumptions about the resident's whereabouts, with some believing he was in the dining room or elsewhere in the building, and did not verify his location during rounds. The facility's practice was to conduct two-hour checks only on incontinent residents, and staff admitted to bypassing the resident's room during rounds due to his usual activity of walking around the facility. The facility was unaware of how or when the resident exited the building, and it was noted that door codes may have been accessible to residents. The lack of consistent supervision and failure to account for the resident's whereabouts resulted in a delay in recognizing his absence. The deficiency was confirmed by the facility's administration, who acknowledged that staff should have realized the resident was missing sooner.
Failure to Maintain Safe, Clean, and Comfortable Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for six of seventeen residents on one of three nursing units and in the main dining room. Observations revealed that a large box fan in a resident's room was covered in dust while actively blowing air toward the resident's bed, indicating a lack of cleanliness and attention to environmental safety. Additionally, during a group interview, multiple residents reported that kitchen staff routinely slammed the kitchen door during meal times and activities, causing discomfort and startle responses among residents. One resident stated that this concern had been reported to the Nursing Home Administrator weeks prior, but the issue persisted. Further observations confirmed that the kitchen entry/exit hallway door repeatedly slammed shut due to its automatic mechanism and the vacuum effect created when the dining room door was kept closed, as instructed by maintenance staff. Staff members working near the door were observed to flinch at the loud noise, and interviews confirmed that both staff and residents were affected by the repeated slamming. The Nursing Home Administrator acknowledged the facility's failure to maintain a safe, clean, and comfortable environment as required by policy and state regulations.
Failure to Complete MDS Assessments Within Required Time Frame
Penalty
Summary
The facility failed to complete comprehensive Minimum Data Set (MDS) assessments within the required time frame for four of eight residents reviewed. According to the Resident Assessment Instrument (RAI) User's Manual, an admission MDS assessment must be completed no later than 14 days following admission. Documentation showed that the MDS assessments for these residents were completed after the required 14-day period. This was confirmed by both the Director of Nursing and the Nursing Home Administrator during interviews, who acknowledged that the assessments were not completed on time as required by regulation.
Failure to Notify Physician of Critically High Blood Glucose Levels
Penalty
Summary
The facility failed to notify physicians of significantly elevated capillary blood glucose (CBG) levels for a resident with diabetes and heart failure. According to facility policy, licensed nurses are required to report abnormal laboratory values, including changes in blood glucose, to the physician or advanced practice provider. The resident's care plan specifically directed staff to monitor for signs and symptoms of hyperglycemia or hypoglycemia and to report abnormal findings to the physician. A physician order was in place instructing staff to call the physician if the resident's blood sugar exceeded 500 mg/dL. Despite these directives, the clinical record showed multiple instances where the resident's blood sugar readings were at or above 500 mg/dL, with no documentation that the provider was notified. This was confirmed by the DON and the Nursing Home Administrator during interviews. The failure to notify the physician of these abnormal blood glucose levels constituted a violation of facility policy and state regulations regarding resident care and physician notification.
Failure to Prevent Significant Medication Errors in Scheduled Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the administration of potassium chloride at incorrect times for two residents. For one resident with diagnoses of atrial fibrillation and chronic kidney disease, physician orders specified potassium chloride to be administered at 10:00 a.m. and 10:00 p.m., and furosemide at 8:00 a.m. However, observations and medication audit reports revealed that potassium chloride was administered outside the prescribed times on multiple occasions, including one instance where the medication was given at 8:44 a.m. instead of the scheduled time, and the administration could not be properly documented in the electronic medical record due to timing restrictions. Additional audit findings showed repeated late administrations over several days. Another resident with dementia and a thyroid disorder also had orders for potassium chloride at 10:00 a.m. and furosemide at 8:00 a.m. Medication audit reports indicated that these medications were frequently administered and documented at times inconsistent with the physician's orders, with doses given significantly earlier or later than scheduled. Interviews with the DON and Nursing Home Administrator confirmed that the facility did not ensure residents were free from significant medication errors, as required by facility policy and state regulations.
Failure to Provide Written Bed-Hold Policy Notification at Time of Hospital Transfer
Penalty
Summary
The facility failed to provide written notice of its bed-hold policy to residents or their representatives at the time of transfer to the hospital for five out of nine residents reviewed. According to the facility's own policy, written notification of the bed-hold policy is required for all residents at the time of transfer, regardless of payer source. Clinical record reviews for multiple residents revealed no documentation that this notification was given during several hospital transfers. These residents had various medical conditions, including cerebral palsy, paraplegia, seizure disorder, coronary artery disease, history of stroke, chronic kidney disease, diabetes, heart failure, and psychotic disorder. Transfers occurred for reasons such as high fever, hypertensive crisis, low oxygen levels, erratic behavior, hallucinations, low blood sugar, pain, and other acute symptoms. Staff interviews with the Nursing Home Administrator and the DON confirmed that the facility did not ensure written notice of the bed-hold policy was provided at the time of transfer for the affected residents. The deficiency was identified through policy review, clinical record review, and staff interviews, with no evidence found in the records that the required notifications were given during any of the documented transfers for these residents.
Failure to Provide Mandatory QAPI Training to All Staff
Penalty
Summary
The facility failed to provide mandatory training on its Quality Assurance and Performance Improvement (QAPI) program to three of eight reviewed staff members, as required by its Facility Assessment and state regulations. Specifically, a nurse aide, an LPN, and a dietary employee did not have documented QAPI in-service education within the required annual period based on their hire dates. This deficiency was identified through a review of facility documents, personnel in-service training records, and was confirmed during interviews with the Nursing Home Administrator and the Director of Nursing.
Unauthorized Use of Physical Restraint on Resident
Penalty
Summary
The facility failed to ensure that a resident was free from the use of a physical restraint without a physician's order. The incident involved a resident with Parkinson's disease, a leg/hip fracture, and a BIMS score of 5, indicating severe cognitive impairment. The resident had a history of repeated falls and was being managed for behavior to ensure safety. On a particular weekend, a gait belt was applied to the resident's torso, effectively restraining them without a physician's order. This action was contrary to the facility's policy, which requires documentation of the medical symptom being treated and an order for the use of any restraint. The incident was reported after a concern was raised about the use of the gait belt as a restraint. The resident had previously fallen multiple times and was experiencing rigidity due to Parkinson's disease, making it difficult to keep them safely positioned. Despite attempts to find a suitable positioning device, the resident continued to slide out of chairs. The RN involved in the incident noted the lack of sufficient staff for one-on-one monitoring and discussed the situation with the resident's son, who agreed to the use of a lap buddy. However, the use of the gait belt as a restraint was not authorized, leading to the deficiency finding.
Failure to Report and Address Improper Use of Restraints
Penalty
Summary
The facility failed to implement its policies and procedures for reporting suspected abuse, neglect, or misuse of restraints, as evidenced by an incident involving a resident with cognitive impairment and a history of falls. The resident, who had a BIMS score of 5 indicating severe cognitive impairment, was found to have been improperly restrained with a gait belt tied around their torso to a wheelchair. This restraint was applied by an RN to prevent the resident from sliding out of the chair, which is against the facility's policy prohibiting the use of restraints not required to treat medical symptoms. Multiple staff members, including nurse aides and an LPN, were aware of the improper use of the gait belt but failed to report the incident to their supervisors or the appropriate authorities as mandated by the facility's abuse prohibition policy and state law. Witness statements revealed that some staff members observed the resident tied to the chair and either did not report it or reported it to peers who did not take further action. This lack of reporting and failure to follow established procedures contributed to the deficiency. The facility's management, including the Nursing Home Administrator and the Director of Nursing, confirmed the failure to implement the necessary policies and procedures for reporting suspected abuse. This deficiency was identified during a review of the facility's documents, clinical records, and staff interviews, highlighting a significant lapse in the facility's responsibility to protect residents from abuse and ensure staff compliance with reporting requirements.
Failure to Notify Physicians and Assess Residents for Abnormal Glucose Levels
Penalty
Summary
The facility failed to notify physicians of abnormal capillary blood glucose (CBG) levels and did not assess residents for hyperglycemia and hypoglycemia, affecting three residents. Resident R5, diagnosed with diabetes, high blood pressure, and anxiety, had several instances of low CBG levels recorded, but there was no assessment for hypoglycemia, monitoring for treatment effectiveness, or physician notification. The care plan required monitoring and reporting of hypo-/hyperglycemia symptoms, which was not followed. Resident R30, with diabetes and end-stage renal disease, experienced both high and low CBG levels. Despite the care plan's directives to monitor and report abnormal glucose levels, the resident was not assessed for hyperglycemia, and the physician was not informed of the abnormal results. Similarly, Resident R37, with diabetes and chronic obstructive pulmonary disease, had multiple instances of abnormal CBG levels without proper assessment or physician notification, contrary to the care plan and physician orders. Interviews with LPNs and the Director of Nursing (DON) revealed inconsistencies in following facility protocols for managing abnormal glucose levels. The DON confirmed the facility's failure to provide timely communication to physicians and to recognize and document diabetes-related complications. The facility did not adhere to its policies for monitoring and documenting diabetic residents' conditions, including vital signs, meal consumption, and blood glucose results.
Neglect Due to Improper Transfer Procedure
Penalty
Summary
The facility failed to protect a resident from neglect by not following physician's orders during a transfer from a wheelchair to a bed. The resident, who had diagnoses including kidney disease, bladder dysfunction, adult failure to thrive, chronic pain, and a sacral pressure ulcer, was supposed to be transferred using a total lift with the assistance of two staff members. However, on one occasion, two nurse aides transferred the resident without using the lift, resulting in the resident experiencing severe pain in the right lower extremity, bruising, and internal rotation of the right leg. The incident was reported by the resident to a registered nurse, who assessed the resident's pain as a ten out of ten. The resident's roommate confirmed overhearing staff discussions about the transfer without the lift. The nurse aides involved admitted to lifting the resident manually due to the absence of a lift pad under the resident, which they attributed to the previous shift's actions. The facility's policy on abuse prohibition, which includes neglect, was not adhered to, as the staff failed to provide necessary services to avoid physical harm to the resident.
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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