Laureldale Skilled Nursing And Rehabilitation Cent
Inspection history, citations, penalties and survey trends for this long-term care facility in Laureldale, Pennsylvania.
- Location
- 2125 Elizabeth Avenue, Laureldale, Pennsylvania 19605
- CMS Provider Number
- 395477
- Inspections on file
- 27
- Latest survey
- July 28, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Laureldale Skilled Nursing And Rehabilitation Cent during CMS and state inspections, most recent first.
A deficiency was identified when an exit sign near a resident room in one smoke compartment was found to be unilluminated, as confirmed by the Director of Maintenance.
A corridor door leading to the Patio Lounge failed to positively latch within the door frame, as observed and confirmed by the Director of Maintenance. This deficiency affected one of twelve smoke compartments and did not meet NFPA 101 and CMS requirements for corridor door latching.
An unprotected penetration was found in a smoke barrier wall above double doors near the ADON/Medical Records Office, where blue and red wires passed through without proper protection. This issue, confirmed by the Director of Maintenance, affected two of twelve smoke compartments.
An electrical junction box above the Zone 8 suspended ceiling, near the smoke barrier doors by the Unit Scheduler's Office, was found without a cover plate, leaving electrical wiring exposed. The Director of Maintenance confirmed the issue during the inspection.
A surge suppressor was used to supply power to a toaster, coffee machine, and microwave in a medical records room, contrary to NFPA requirements. The Director of Maintenance confirmed the improper use of the surge suppressor for these high-draw appliances.
A survey found that the facility is a three-story, Type II (000) unprotected noncombustible building with a basement, which exceeds the maximum allowable story height for this construction type. The Director of Maintenance confirmed that the building's construction type and height are not permitted under current regulations.
The facility did not provide documentation confirming that quarterly inspections of the automatic sprinkler system were completed over the past year. This was confirmed by the Director of Maintenance, and the deficiency impacted the entire sprinkler system component.
Surveyors observed multiple environmental deficiencies across two nursing units, including missing roof shingles, peeling ceiling tiles and wallpaper, damaged walls, stained ceiling tiles, and a crushed dryer vent hose. These issues reflect a failure to maintain a safe, clean, and comfortable environment for residents.
Four residents with significant medical conditions requiring ADL assistance were repeatedly observed with long, dirty fingernails and, in some cases, unshaven, despite care plans specifying the need for grooming and bathing support. Staff did not provide necessary grooming services, and the administrator confirmed these tasks should have been completed during bathing and as needed.
Staff did not follow physician orders for two residents regarding medication administration. One resident received a blood pressure medication despite a low heart rate, and another did not receive an as-needed antihypertensive when their blood pressure was elevated. These failures were confirmed by the Administrator.
A resident with dementia and ventricular tachycardia, who was dependent on staff for care, was found with multiple unexplained bruises by a nurse aide and an LPN. Despite facility policy requiring immediate reporting of such incidents, the Administrator was not notified until nearly two days later, and an investigation was delayed accordingly.
A cognitively impaired female resident, dependent on staff for mobility, was not protected from sexual abuse by another resident with a known history of sexually inappropriate behavior. Despite repeated incidents, including wandering into female residents' rooms, exposing himself, and ultimately groping a peer, the facility did not update the care plan or increase supervision to prevent further abuse.
A resident with a history of falls and requiring maximum assistance for toileting fell and sustained a head injury due to neglect. Despite the care plan's requirement for two staff members to assist, only one nurse aide was present, leading to the resident's fall and subsequent death. The facility's investigation confirmed the aide's awareness of the need for two-person assistance.
A resident with a history of falls and requiring maximum assistance for toileting fell and suffered a head injury when only one nurse aide assisted during a transfer. Despite the care plan requiring two staff members for assistance, this protocol was not followed, resulting in the resident's fall and subsequent death.
A resident with multiple health conditions fell after using the toilet, and the facility failed to notify the responsible party immediately, delaying notification until the next day. This was against the facility's protocol, as confirmed by the DON.
The facility failed to maintain sanitary conditions in the kitchen. Observations revealed three dusty pipes on the floor near the ice machine, two dirty bowls behind it, and water draining onto the floor, creating standing water. Additionally, a vent in the dish room had peeling paint.
The facility failed to follow physician's orders for two residents, leading to improper medication administration. A resident with a history of stroke and high blood pressure received metoprolol without checking required blood pressure and heart rate parameters. Another resident with sepsis and heart failure was given furosemide without confirming blood pressure was above the prescribed threshold. The DON confirmed the oversight.
The facility failed to provide restorative nursing services for three residents, leading to a lack of documented evidence for required passive range of motion exercises. A resident with dementia and hemiplegia, another with dementia and knee pain, and a third with COPD and anxiety were all at risk for loss of range of motion. Despite care plans indicating the need for exercises, there was no documentation to confirm their completion, as confirmed by the DON.
The facility failed to provide adequate supervision and prevent accident hazards on two nursing units. A resident with cognitive impairment was fed by another resident without staff intervention, and a treatment cart with medications was left unlocked near unsupervised, cognitively impaired residents. Additionally, the facility did not properly investigate a fall involving a resident with dementia, implementing an inappropriate intervention and failing to document bed positioning as required.
The facility did not accommodate the meal preferences of two residents, leading to deficiencies. A resident with diabetes and GERD was served a meal with gravy, contrary to her preference. Another resident with dementia and malnutrition received broccoli instead of the specified carrots. These actions did not align with their care plans.
The facility failed to provide written notification to the representatives of nine residents who were transferred to the hospital due to changes in their conditions. The Director of Nursing confirmed that the required documentation was not provided.
The facility failed to develop a comprehensive care plan for a resident with diabetes and an altered mental state. The resident was identified as being at risk for impaired nutrition, but no interventions were included in the care plan. This was confirmed by the Nursing Home Administrator.
The facility failed to timely assess the nutritional status of two residents, leading to significant weight loss without appropriate intervention. One resident lost 12.5% of their weight, and another lost 10.13%, with no evidence of assessment or notification to the physician and responsible party.
Failure to Maintain Illuminated Exit Signage
Penalty
Summary
The facility failed to maintain the required illumination of exit signage in accordance with NFPA 101 standards. During an observation, it was found that the exit sign located in Zone 11, near Resident Room 319, was not illuminated. This deficiency was confirmed through an interview with the Director of Maintenance, who acknowledged that the exit sign was not functioning as required. The issue affected one of twelve smoke compartments within the component.
Plan Of Correction
The light bulb for the Exit Signage in Zone 11 by Resident room 319 has been replaced. Maintenance staff will be educated on ensuring all exit signage is illuminated moving forward. Maintenance Director/Designee to perform random quarterly audits on exit signage to ensure all exit signage is illuminated. Results of audits will be forwarded to the QAPI Committee.
Failure to Maintain Positive Latching of Corridor Door
Penalty
Summary
The facility failed to maintain the positive latching of a corridor door, specifically the Zone 8 door to the Patio Lounge. During an observation, it was found that this door did not positively latch within the door frame as required by NFPA 101 and CMS regulations. The deficiency was identified during a survey, and the issue was confirmed through an interview with the Director of Maintenance, who acknowledged that the corridor door failed to latch properly. This deficiency affected one of twelve smoke compartments within the facility. The report does not mention any specific residents or patients involved, nor does it provide details about their medical history or condition at the time of the deficiency. The focus of the finding is solely on the failure of the door to meet the required positive latching standard, as observed and confirmed by facility staff.
Plan Of Correction
The Zone 8 patio lounge door has been adjusted to latch positively. Maintenance staff will be educated on ensuring all doors latch positively moving forward. Maintenance Director/Designee to perform an audit on doors latching positively weekly for 4 weeks and monthly for 2 months to ensure doors in the facility are latching properly. Results of audits will be forwarded to the QAPI Committee. The Zone 8 patio lounge door has been adjusted to latch positively. Maintenance staff will be educated on ensuring all doors latch positively moving forward. Maintenance Director/Designee to perform an audit on doors latching positively weekly for 4 weeks and monthly for 2 months to ensure doors in the facility are latching properly. Results of audits will be forwarded to the QAPI Committee.
Unprotected Penetration in Smoke Barrier Wall
Penalty
Summary
The facility failed to maintain the smoke resistance of smoke barrier walls as required by NFPA 101. During an observation, an unprotected penetration was found in the Zone 11 smoke barrier wall, located above the double doors near the ADON/Medical Records Office, where blue and red wires passed through the wall without proper protection. This deficiency was confirmed during an interview with the Director of Maintenance, who acknowledged the unprotected penetration. The issue affected two of twelve smoke compartments within the component. No information about residents, their medical history, or their condition at the time of the deficiency is provided in the report.
Plan Of Correction
The smoke barrier wall was repaired using an approved through-penetration fire stop system. The facility will maintain the rating of the smoke barrier walls moving forward. Maintenance staff will be educated on ensuring penetrations are protected and maintaining the rating within smoke barrier walls. Maintenance Director/Designee to perform random quarterly audits for 1 year on smoke barrier walls. Results of audits will be forwarded to the QAPI Committee.
Exposed Electrical Wiring Due to Missing Junction Box Cover
Penalty
Summary
During an inspection, it was observed that an electrical junction box located above the Zone 8 suspended ceiling, near the smoke barrier doors by the Unit Scheduler's Office, was missing a cover plate. This resulted in exposed electrical wiring. The Director of Maintenance confirmed the presence of the exposed wiring at the time of the observation. No information regarding residents or their medical conditions was provided in relation to this deficiency.
Plan Of Correction
The electrical junction box cover plate was replaced above the suspended ceiling in Zone 8. Maintenance staff will be educated on ensuring cover plates are in place for junction boxes moving forward. The Maintenance Director/Designee will perform an audit on junction box cover plates when work is completed above the ceiling to ensure the junction boxes have a cover plate in place. Results of audits will be forwarded to the QAPI Committee.
Improper Use of Surge Suppressor for High-Draw Appliances
Penalty
Summary
A deficiency was identified when, during an observation, a surge suppressor was found supplying electrical power to a toaster, coffee machine, and microwave in the Zone 11 Medical Records Room. The use of a surge suppressor for these high-draw appliances does not comply with NFPA 101 and related standards, which restrict the use of power strips and surge suppressors for such equipment. The Director of Maintenance confirmed during an interview that these appliances were indeed plugged into the surge suppressor, indicating a failure to monitor and ensure proper use of electrical equipment within the facility. No information regarding residents or their medical conditions was provided in relation to this deficiency.
Plan Of Correction
The surge suppressor containing the toaster, coffee machine, and microwave has been removed from the Medical Records Office. Staff will be educated on the forbidden use of surge suppressors/mini appliances moving forward. Maintenance Director/Designee to perform a quarterly random audit for 1 year to determine if surge protectors are in use within the facility. Results of audits will be forwarded to the QAPI Committee.
Noncompliance with Building Construction Type and Height Requirements
Penalty
Summary
The facility failed to maintain compliance with building construction requirements as specified by NFPA 101. During an observation, it was found that the building is a three-story, Type II (000) unprotected noncombustible structure with a basement, which exceeds the maximum allowable story height for this construction type. The deficiency was confirmed through an interview with the Director of Maintenance, who acknowledged that the construction type and height do not meet the permitted standards. No information about specific residents or their conditions was provided in the report. The deficiency centers on the facility's noncompliance with the required building construction type and height limitations, as the structure's number of stories surpasses what is allowed for its construction classification.
Failure to Maintain Documentation of Quarterly Sprinkler System Inspections
Penalty
Summary
The facility failed to provide documentation verifying that quarterly inspections of the automatic sprinkler system were conducted over the previous twelve months. During a document review, it was found that there was no documentation available to confirm that the sprinkler system was inspected between January 23, 2025, and July 3, 2025. This was confirmed in an interview with the Director of Maintenance, who acknowledged the absence of inspection records for the specified period. The deficiency affected the entire sprinkler system component, as required records of inspection and maintenance were not available for review.
Plan Of Correction
Quarterly sprinkler inspections were conducted at Laureldale Skilled Nursing and Rehabilitation Center throughout the previous 12 months. Maintenance staff will be educated on ensuring all sprinkler inspection documentation is maintained moving forward. Maintenance Director/Designee to perform quarterly audits on sprinkler inspection documentation for 1 year to ensure compliance. Results of audits will be forwarded to the QAPI Committee.
Environmental Deficiencies Compromise Resident Comfort and Safety
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment on two of its three nursing units, specifically the second and third floors. Observations conducted over a seven-hour period revealed multiple environmental deficiencies, including missing roof shingles over the Heritage Wing, peeling ceiling tiles and wallpaper in several resident rooms and bathrooms, damaged walls in both resident rooms and common areas, and stained ceiling tiles. Additional issues included a badly crushed vent hose for a resident dryer and discolored areas below molding trim. These findings were directly observed and documented by surveyors, indicating a lack of adequate facility maintenance and oversight in ensuring a homelike and safe environment for residents.
Failure to Provide Adequate Grooming and Hygiene Assistance
Penalty
Summary
The facility failed to provide adequate grooming and hygiene services for four residents who required assistance with activities of daily living (ADLs), specifically grooming and bathing. Clinical record reviews indicated that these residents had significant medical conditions such as paraplegia, congestive heart failure, dementia, polyneuropathy, muscle wasting, diabetes with neuropathy, and hemiplegia due to stroke, all of which necessitated staff support for personal care. Despite care plans outlining the need for assistance, observations on multiple dates revealed that these residents consistently had long and dirty fingernails, and in some cases, were unshaven. Residents who were able to communicate confirmed their need for nail trimming and shaving, while non-verbal residents indicated agreement through gestures. Staff interviews and documentation confirmed that grooming tasks, such as nail trimming and shaving, were not performed as required. The administrator acknowledged that these services should have been provided during bathing and as needed. The repeated observations over several days demonstrated a pattern of inaction in maintaining residents' grooming and hygiene, directly contradicting the care plans and residents' expressed or indicated needs.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
Facility staff failed to follow physician orders for two residents. One resident with Alzheimer's disease and hypertension had a physician's order for Bisoprolol Fumarate to be administered three times daily, with instructions to hold the medication if the systolic blood pressure was below 90 mm/Hg or if the heart rate was less than 60 beats per minute. Despite these parameters, the medication was administered multiple times over several months when the resident's heart rate was below 60. Another resident with epilepsy, dementia, and hypertension had a physician's order for Hydralazine to be given every 8 hours as needed if the systolic blood pressure exceeded 140 mm/Hg. Staff failed to administer the medication on several occasions when the resident's blood pressure was above this threshold. These findings were confirmed by the Administrator during an interview.
Failure to Immediately Report Injury of Unknown Origin
Penalty
Summary
The facility failed to immediately report an allegation of abuse or injury of unknown origin to the Administrator or Abuse Prevention Coordinator as required by facility policy. According to the policy, all incidents and allegations of abuse, including injuries of unknown origin, must be reported immediately to the administrator or designee. In this case, a nurse aide observed multiple bruises on a resident's left arm, breast, and axilla during the evening shift, and an LPN documented the injuries as being of unknown cause or onset. Facility documentation indicated that the injury was identified by the LPN, but there was no evidence that the Administrator was notified within two hours as required. The resident involved had diagnoses including dementia and ventricular tachycardia, was cognitively impaired, and required staff assistance for personal hygiene and transfers. Despite the identification and documentation of the injuries, the Administrator was not notified until nearly two days later, and an investigation was not initiated until that time. Interviews with the Administrator confirmed that staff did not follow the facility's policy for immediate notification regarding the injury of unknown origin.
Failure to Protect Resident from Sexual Abuse by Peer
Penalty
Summary
The facility failed to protect a cognitively impaired female resident, who had dementia and depression and was dependent on staff for mobility, from sexual abuse by another resident with a history of sexually inappropriate behavior. The male resident, who also had dementia and was able to move about the facility independently, had previously exhibited sexually inappropriate behaviors, including being moved to a different room due to such incidents and being monitored by a psychiatrist for these concerns. Despite multiple documented instances of the resident wandering into female residents' rooms without consent, becoming aggressive when discovered, and exposing himself to others, there was no evidence that the facility took action to address or prevent further incidents. The male resident's sexually inappropriate behavior was not included in his care plan, and supervision was not increased, even after repeated incidents. The situation culminated in an incident where the male resident was found groping the female resident while unsupervised in her room. Facility documentation and staff interviews confirmed that no interventions were implemented to protect residents from further abuse, despite a clear pattern of behavior and ongoing risk.
Neglect Leads to Resident's Fall and Head Injury
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in actual harm. The resident, who had a history of falls and required maximum assistance for toileting, was diagnosed with muscle wasting, hypertension, transient ischemic attacks, atherosclerotic cardiovascular disease, and chronic respiratory failure. The care plan specified that two staff members were needed to assist the resident with transfers. Despite this, on the day of the incident, only one nurse aide assisted the resident, leading to a fall in the bathroom where the resident struck his head. The incident occurred when the resident's knees buckled while being assisted off the toilet, causing him to fall and sustain a head injury, including a hematoma and bleeding. The resident was dazed and had difficulty breathing following the fall. Although the resident refused hospital transport, he stopped breathing shortly after, and staff were unable to revive him. The facility's investigation confirmed that the nurse aide was aware of the requirement for two staff members but failed to comply, contributing to the resident's fall and subsequent injury.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision and interventions to prevent accidents related to falls for a resident, resulting in actual harm. The resident had a history of falls and required maximum assistance for toileting, as indicated in the care plan. The care plan specified that two staff members were needed to assist the resident with walking and transferring. However, on the day of the incident, only one nurse aide was assisting the resident during a transfer from the toilet, leading to the resident's fall. The resident, who had multiple diagnoses including muscle wasting, hypertension, and chronic respiratory failure, fell and struck his head, resulting in a hematoma and bleeding. Despite being monitored by staff, the resident refused hospital transport and later stopped breathing, with staff unable to revive him. The Director of Nursing confirmed that two staff members should have been assisting the resident at the time of the fall.
Failure to Notify Responsible Party of Resident's Fall
Penalty
Summary
The facility failed to notify the responsible party of a change in condition and a fall for one of the sampled residents. The resident, who had diagnoses including muscle wasting, hypertension, history of transient ischemic attacks, atherosclerotic cardiovascular disease, and chronic respiratory failure, experienced a fall on August 6, 2024, at 3:15 p.m. after using the toilet. Despite the facility's protocol to notify the responsible party immediately after a fall, the notification was delayed until the following day at 3:30 p.m. This deficiency was confirmed during an interview with the Director of Nursing on August 16, 2024.
Sanitary Conditions Not Maintained in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during an environmental tour. Three pipes covered in dust were found lying on the floor near the ice machine. Additionally, two dirty bowls were located behind the ice machine, and water was observed draining from the ice machine onto the floor, creating areas of standing water. In the dish room, a vent was noted to have various areas of peeling paint.
Failure to Implement Physician's Orders for Medication Administration
Penalty
Summary
The facility failed to implement physician's orders for two residents, leading to a deficiency in care. Resident 135, with a history of stroke and high blood pressure, was prescribed metoprolol tartrate to be administered twice daily, with specific parameters to hold the medication if the systolic blood pressure was below 110 mmHg or the heart rate was less than 50 beats per minute. However, the medication was administered over 43 times in June 2024 without checking these parameters. Similarly, Resident 151, diagnosed with sepsis, kidney failure, and heart failure, was ordered to receive furosemide on specific days, with instructions to hold the medication if blood pressure was below 90/60 mmHg. The medication was given ten times in June 2024 without confirming the blood pressure was above the set parameter. The Director of Nursing confirmed that the parameters were not checked prior to administering the medications for both residents.
Failure to Provide Restorative Nursing Services
Penalty
Summary
The facility failed to provide restorative nursing services to prevent a reduction in range of motion and/or to improve or maintain mobility for three residents. Resident 4, diagnosed with dementia, congestive heart failure, and hemiplegia, was identified as being at risk for loss of range of motion. Her care plan required staff to perform passive range of motion exercises on her legs during morning and evening care. However, there was no documented evidence that these exercises were being completed. Similarly, Resident 31, who had dementia and knee pain, required passive range of motion exercises for his legs, but again, there was no documentation to confirm these were performed. Resident 83, with chronic obstructive pulmonary disease and anxiety, was supposed to receive passive range of motion exercises for her right arm, but she reported that staff did not complete these exercises. The Director of Nursing confirmed the lack of documentation for the completion of these restorative nursing programs.
Inadequate Supervision and Fall Prevention
Penalty
Summary
The facility failed to provide adequate supervision and prevent accident hazards on two of its nursing units. On the Second Floor Unit, Resident 9, who had cognitive impairment and required a mechanically altered texture diet, was observed being fed by another resident without staff intervention. This lack of supervision posed a risk to Resident 9, who had a self-care deficit and required meal support as per her care plan. On the Third Floor Unit, a treatment cart containing various medications was found unlocked and accessible to cognitively impaired residents, including Residents 56 and 88, who were observed moving around the unit unsupervised. Additionally, the facility failed to thoroughly investigate a fall involving Resident 56, who had dementia and was at risk for falls. After a fall, the intervention added was inappropriate, as it involved a toileting program despite the resident having an indwelling urinary catheter. Furthermore, there was no documentation confirming that the resident's bed was in a low position during a subsequent fall, as required by the care plan.
Failure to Accommodate Resident Meal Preferences
Penalty
Summary
The facility failed to accommodate the meal preferences of two residents, leading to deficiencies in their care. Resident 21, who has diabetes, gastro-esophageal reflux disease (GERD), and intestinal issues, was observed with a meal that included gravy, despite her meal ticket specifying no gravy due to her dislike for it. This occurred while she was alert and oriented, as noted in her care plan. Additionally, Resident 130, who suffers from dementia, underweight, and malnutrition, was served broccoli instead of the carrots specified on her meal ticket. Her care plan highlighted a potential nutritional problem due to poor appetite, yet the meal provided did not align with her documented preferences.
Failure to Notify Residents' Representatives of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to the residents' representatives regarding the transfer of nine residents to the hospital. These residents were transferred due to changes in their conditions, but there was no evidence that their responsible parties were informed in writing about the transfers and the reasons for these moves. This deficiency was identified through clinical record reviews and confirmed by the Director of Nursing during an interview. The residents involved in this deficiency were transferred to the hospital on various dates between March and June 2024. Despite the requirement to notify the residents' representatives in writing, the facility did not provide such documentation for any of the nine residents. This lack of communication was acknowledged by the Director of Nursing, who confirmed that the necessary written information was not provided to the residents' representatives.
Failure to Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan to meet the needs of a resident identified in the comprehensive assessment. Clinical record review revealed that the resident was admitted with diagnoses including diabetes and an altered mental state. The Minimum Data Set Care Area Assessment summary noted that the resident was at risk for impaired nutrition and that this should be addressed in the care plan. However, there was no evidence that interventions to address the resident's nutritional needs were included in the current care plan. This deficiency was confirmed by the Nursing Home Administrator during an interview.
Failure to Timely Assess Nutritional Status
Penalty
Summary
The facility failed to timely assess the nutritional status of two residents, leading to significant weight loss without appropriate intervention. Resident 1, who had diagnoses including diabetes and altered mental state, was admitted to the facility and weighed 147 pounds on January 12, 2024. However, no further weights were recorded until March 5, 2024, when the resident weighed 128.65 pounds, indicating a significant 12.5 percent weight loss. During this period, the resident was documented to be eating only about 25 percent of his meals from February 27 to March 8, 2024. There was no evidence that the facility assessed or addressed this significant weight loss or notified the physician and responsible party of the resident's change in condition. Similarly, Resident 6, who had diagnoses including spastic paraplegia and anemia, weighed 122.4 pounds on January 5, 2024. The next recorded weight was on March 8, 2024, showing a weight of 110 pounds, a significant 10.13 percent weight loss. Again, there was no evidence that the facility assessed or addressed this significant weight loss or notified the physician and responsible party. The Nursing Home Administrator confirmed that there was no documented evidence that staff obtained weights according to the facility policy or that they immediately notified the physician and responsible party of the significant weight losses.
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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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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