Liberty Pointe Rehabilitation And Healthcare Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Doylestown, Pennsylvania.
- Location
- 252 Belmont Avenue, Doylestown, Pennsylvania 18901
- CMS Provider Number
- 395409
- Inspections on file
- 21
- Latest survey
- January 16, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Liberty Pointe Rehabilitation And Healthcare Ctr during CMS and state inspections, most recent first.
The facility failed to maintain the fire resistance rating of fire doors on the first floor due to the absence of a bottom latching device. This issue was initially observed and confirmed during an inspection in December and remained unresolved during a follow-up revisit in February.
The facility's building exceeds the maximum allowable story height for its Type V(III) protected wood frame construction, which is fully sprinklered. The building is three stories high, while the construction type permits only one story when sprinklered. This deficiency was confirmed during a document review and interview, and remains unresolved as of a follow-up visit.
The facility's dietary department was found to have several sanitation and food storage deficiencies. Observations included a large hole in the recycling area paneling, soiled convection ovens with grease and burnt debris, improper storage of a metal scoop in a flour bin, debris on the floor near the steamer and dry goods bins, a brown substance inside the ice machine, and cracked floor tiles near the utility hallway entrance.
The facility failed to maintain the fire resistance rating of fire doors, as observed when a fire door on the first floor lacked bottom latching. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility failed to maintain clear means of egress as required by NFPA 101 standards. The headroom clearance of Exit Stairway Five was below the required minimum, and obstructions were found in exit pathways on two floors, including storage and trash on landings. These deficiencies were confirmed during an exit interview with the facility's administration.
The facility did not maintain and inspect portable fire extinguishers as required, specifically missing monthly inspections for the extinguisher on the first floor next to a resident room. This was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility failed to ensure that corridor doors were properly latched, affecting fire safety and smoke containment. Observations revealed that doors on the first and second floors, including the Housekeeping Closet, Employee Storage Room, Nourishment Room, and Storage Room near resident room 106, failed to latch. These deficiencies were confirmed during an exit interview with the Administrator and Maintenance Director.
The facility did not maintain the smoke resistance of smoke barriers, as observed by an open penetration by a data wire in the smoke barrier on the third floor near a resident room. This was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility did not maintain the smoke resistance of smoke barrier doors on the third floor, as holes were found in the door frame. This issue was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility failed to maintain fire resistance in soiled linen and trash chutes, with doors on the third and second floors failing to close and latch. This was confirmed during an exit interview with the Administrator and Maintenance Director.
A resident with dementia and other health conditions did not have physician-ordered compression stockings applied as required. Observations over two days showed the resident without the Tubigrips, despite orders for daily application during morning care. Both an LPN and the DON confirmed the oversight.
Two residents experienced issues with the call bell system, as one resident's call bell did not activate the light outside her door, and another's produced no sound or light, requiring him to yell for help. Observations confirmed these deficiencies in the call bell system.
The facility was found to have a building classified as a three-story, Type V(III), protected wood frame construction, which is fully sprinklered. This classification exceeds the maximum allowable story height for this type of construction by one story, affecting the entire component of the facility.
A resident with dementia, difficulty walking, and osteoporosis experienced a fall, resulting in increased pain levels. Despite the facility's policy requiring notification of changes in clinical condition, the resident's physician was not informed of the increased pain following the fall.
A resident with dementia and osteoporosis was not properly assessed for pain medication effectiveness after a fall. Despite worsening pain, the resident was given acetaminophen without notifying the physician for additional pain management. The DON confirmed the lack of documentation on medication effectiveness.
The facility failed to monitor weight changes for two residents as per policy and physician orders. One resident with dementia and diabetes was not weighed weekly as required, and another with dementia and dysphagia lacked a documented weight schedule and weekly monitoring. The DON confirmed the absence of required documentation.
The facility failed to provide food that was palatable and at appetizing temperatures on three of five nursing units. Residents reported that the food was often cold and not palatable. A test tray audit confirmed that food temperatures were significantly below the required 130 degrees Fahrenheit, and further interviews indicated that this issue was consistent across both room service and dining room meals.
Fire Door Deficiency Due to Lack of Bottom Latching
Penalty
Summary
The facility failed to maintain the fire resistance rating of fire doors, specifically on the first floor, where the fire door did not have a bottom latching device. This deficiency was initially observed on December 12, 2024, during an inspection at 10:00 a.m. The absence of the bottom latching was confirmed during an exit interview with the Administrator and Maintenance Director at 10:30 a.m. on the same day. During a follow-up onsite revisit conducted on February 4, 2025, between 08:15 a.m. and 11:00 a.m., it was determined that the issue had not been resolved. The component separation fire door on the first floor still lacked a bottom latching device, as confirmed in an exit interview with the Administrator at 11:00 a.m.
Plan Of Correction
The first-floor fire door bottom latching has been repaired. Maintenance staff to be educated on the importance of maintaining fire resistance rating of fire doors. Maintenance to monitor monthly or until compliance is met. Findings will be brought to the QAPI committee.
Building Construction Type and Height Deficiency
Penalty
Summary
The facility was found to be non-compliant with building construction requirements as per NFPA 101 standards. During a document review and interview on December 12, 2024, it was revealed that the building is classified as a three-story, Type V(III), protected wood frame construction, which is fully sprinklered. However, this construction type is only permitted to have a maximum of one story when sprinklered, indicating that the facility exceeds the allowable story height by two stories. An onsite revisit conducted on February 4, 2025, confirmed that the issue of exceeding the maximum story height allowance had not been resolved. The Administrator acknowledged the deficiency and is in the process of obtaining a Fire Safety Evaluation System (FSES) to address the non-compliance. The deficiency affects the entire component of the building, as the construction type and story height do not meet the required standards.
Plan Of Correction
I am requesting the Department of Health do the FSES in this case. Facility is consulting Lenhardt Rodgers Architecture to assist with this citation. Facility will also be requesting a TLW.
Sanitation and Food Storage Deficiencies in Dietary Department
Penalty
Summary
The facility failed to maintain sanitary conditions and proper food storage in the dietary department. During an environmental tour, a large hole was observed in the paneling on the back wall of the recycling area. The convection ovens were found to be soiled, with the insides of the oven doors coated with grease and the bottom of the top oven covered with burnt debris and food crumbs. A large metal scoop was improperly stored inside a bin containing flour. Debris was present on the floor near the steamer and dry goods bins. Additionally, a brown substance was noted on parts of the lid and the left inside wall of the ice machine. There were also five cracked floor tiles near the entrance of the utility hallway within the dietary department.
Plan Of Correction
1) The hole in the back wall of the recycling area has been repaired. Convection ovens were cleaned & grease to top & bottom ovens removed & area cleaned. Metal scoop was removed from the flour bin. Debris was removed from wall near the steamer. Ice machine was cleaned. Cracked floor tiles near the entrance of the kitchen was repaired. 2) All residents have the potential to be affected by the failure to maintain sanitary conditions & storing food properly in the dietary department. 3) Dietary staff to be educated on importance of maintaining sanitary conditions & proper food storing in the dietary department. 4) Audits will be completed weekly x4 & then monthly x2 or until compliance is met to ensure that sanitary conditions & proper food storing in the dietary department is maintained. Findings will be brought to the QAPI committee.
Fire Door Deficiency Due to Lack of Bottom Latching
Penalty
Summary
The facility failed to maintain the fire resistance rating of fire doors, which is a requirement for ensuring safety in multiple occupancies. During an observation on December 12, 2024, at 10:00 a.m., it was noted that a fire door on the first floor lacked bottom latching. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director at 10:30 a.m. on the same day.
Plan Of Correction
The first-floor fire door bottom latching was repaired. Maintenance staff to be educated on the importance of maintaining fire resistance rating of fire doors. Maintenance to monitor monthly or until compliance is met. Findings will be brought to the QAPI committee.
Failure to Maintain Clear Means of Egress
Penalty
Summary
The facility failed to maintain the means of egress in compliance with NFPA 101 standards, as evidenced by two specific deficiencies. Firstly, during a document review, it was found that the headroom clearance of Exit Stairway Five leading to the attic was approximately 6'3", which is below the required minimum of 6'8". This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director. Secondly, observations revealed obstructions in the exit pathways on two different floors. On the second floor, storage was found on the lower landing of the exit stairwell by the RNAC Office. Additionally, trash was observed on the landing of the exit stairwell next to resident room 216, and storage was found on the lower landing of the exit stairwell near resident room 108 on the first floor. These obstructions were also confirmed during the exit interview with the facility's administration.
Plan Of Correction
I am requesting the Department of Health do the FSES in this case. Facility is consulting Lenhardt Rodgers Architecture to assist with this citation. The second-floor exit stairwell by the RNAC Office was cleaned from storage on the lower landing. Maintenance staff to be educated on the importance of maintaining means of egress. Maintenance to monitor monthly or until compliance is met. Findings will be brought to the QAPI committee. Trash was cleaned from landing on the second-floor exit stairwell next to room 216. Storage was removed from the exit stairwell lower landing near room 108. Maintenance staff to be educated on the importance of maintaining means of egress. Maintenance to monitor monthly or until compliance is met. Findings will be brought to the QAPI committee.
Failure to Inspect Portable Fire Extinguishers
Penalty
Summary
The facility failed to maintain and inspect portable fire extinguishers as required by NFPA 10, affecting one of three levels in the component. During an observation on December 12, 2024, at 9:52 a.m., it was noted that the portable fire extinguisher located on the first floor next to resident room 161 was missing its monthly inspections. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director on the same day at 10:30 a.m.
Plan Of Correction
Facility completed a monthly inspection for portable fire extinguisher next to resident room 161. Maintenance staff to be educated on how to maintain and inspect portable fire extinguishers. Maintenance to monitor monthly or until compliance is met. Findings will be brought to the QAPI committee.
Failure to Ensure Proper Latching of Corridor Doors
Penalty
Summary
The facility failed to ensure that corridor doors were properly latched, which is a requirement for maintaining fire safety and smoke containment. During an observation on December 12, 2024, it was noted that the Housekeeping Closet door on the second floor was binding on the floor and failed to latch. Similarly, the Employee Storage Room door on the first floor also failed to latch. These deficiencies were confirmed during an exit interview with the Administrator and Maintenance Director. Additionally, further observations on the same day revealed that the Nourishment Room door on the second floor and the Storage Room door near resident room 106 on the first floor also failed to latch. These findings indicate a pattern of non-compliance with the requirement for corridor doors to have positive latching hardware, as mandated by the NFPA 101 and CMS regulations. The failure to ensure proper latching of these doors affects the facility's ability to resist the passage of smoke, which is critical for the safety of residents and staff.
Plan Of Correction
The latch & door were repaired for the second floor Housekeeping Closet across from resident room 252. The latch was repaired for the employee storage room door on the first floor. Maintenance staff to be educated on ensuring corridor doors are latched. Maintenance to monitor monthly or until compliance is met. Findings will be brought to the QAPI committee. The second-floor nourishment door latch was repaired. The first-floor storage room door near resident room 106 latch was repaired. Maintenance staff to be educated on ensuring corridor doors are latched. Maintenance to monitor monthly or until compliance is met. Findings will be brought to the QAPI committee.
Smoke Barrier Deficiency Due to Open Penetration
Penalty
Summary
The facility failed to maintain the smoke resistance of smoke barriers, which is a requirement for ensuring safety in the event of a fire. During an observation on December 12, 2024, at 9:08 a.m., it was noted that there was an open penetration by a data wire in the smoke barrier located on the third floor near resident room 304. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director later that morning at 10:30 a.m.
Plan Of Correction
Open penetration by data wire in the smoke barrier by resident room 304 was repaired using an UL approved stop gap penetration system. Maintenance staff to be educated on maintaining the smoke resistance of smoke barriers. Maintenance to monitor monthly or until compliance is met. Findings will be brought to the QAPI committee.
Smoke Barrier Door Deficiency on Third Floor
Penalty
Summary
The facility failed to maintain the smoke resistance of smoke barrier doors on the third floor, as observed during a survey. Specifically, there were holes found in the door frame, which compromised the smoke resistance of the doors. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director.
Plan Of Correction
Holes in the door frame on the third floor were repaired. Maintenance to be educated on maintaining the smoke resistance of smoke barrier doors. Maintenance to monitor monthly or until compliance is met. Findings will be brought to the QAPI committee.
Fire Resistance Deficiency in Linen and Trash Chutes
Penalty
Summary
The facility failed to maintain the fire resistance of soiled linen and trash chutes, affecting two of four levels in the component. During an observation on December 12, 2024, it was noted that the door to the soiled linen chute on the third floor would not close and latch. Additionally, the trash chute door on the second floor also failed to latch. These deficiencies were confirmed during an exit interview with the Administrator and Maintenance Director on the same day.
Plan Of Correction
Latch was repaired for the third-floor door to the Soiled Linen chute. Latch was repaired for the trash chute door. Maintenance to be educated on maintaining the fire resistance of Soiled Linen and trash chutes. Maintenance to monitor monthly or until compliance is met. Findings will be brought to the QAPI committee.
Failure to Implement Physician's Orders for Compression Stockings
Penalty
Summary
The facility failed to implement physician's orders for a resident diagnosed with dementia, hypertension, and chronic obstructive pulmonary disease. The resident, who was dependent on staff for dressing, was ordered by a physician on November 10, 2024, to have compression stockings (Tubigrips) applied to both legs for swelling. However, observations on December 10 and 11, 2024, revealed that the resident was seated in her wheelchair without the Tubigrips in place. A licensed practical nurse confirmed that the Tubigrips were supposed to be applied during morning care. The Director of Nursing also stated that the staff was to apply the Tubigrips daily as per the physician's order.
Plan Of Correction
1. Tubigrips were immediately placed on resident 2. 2. Current residents with Compression stockings were reviewed to assure residents had application per the physician orders. 3. Education will be completed for licensed nursing staff by staff educator/designee on Importance of ensuring residents have physician prescribed measures in place. 4. Audits will be completed by DON/designee to assure residents with Compression stockings have it in place per physician orders. Audits will be done weekly x4 & then monthly x2 or until compliance is met. Findings will be brought to the QAPI committee.
Deficiency in Call Bell System for Two Residents
Penalty
Summary
The facility failed to provide a working call bell system for two residents, leading to a deficiency in resident safety and communication. During a resident group meeting, one resident reported that activating the call bell from her bed did not trigger the light outside her door. Another resident stated that his call bell did not produce any sound or light, forcing him to yell for assistance. Observations confirmed these issues, as the call bell for the first resident did not activate the light, and the second resident's call bell produced neither sound nor light when tested.
Plan Of Correction
1) The call bell system was immediately repaired for residents 4 & 142. 2) Audit was completed to assure residents have a working call bell available. 3) Staff will be educated on the importance of ensuring residents have access to a working call bell. 4) Audits will be completed weekly x4 & then monthly x2 or until compliance is met by randomly auditing 10 resident rooms, to ensure residents have access to working call bells. Findings will be brought to the QAPI committee.
Building Construction Type Exceeds Allowable Height
Penalty
Summary
The facility failed to maintain the building construction requirements as per NFPA 101 standards. During a document review and interview conducted on December 12, 2024, it was found that the building is classified as a three-story, Type V(III), protected wood frame construction, which is fully sprinklered. However, this classification exceeds the maximum allowable story height for this type of construction by one story. This deficiency affects the entire component of the facility, as confirmed during the exit interview with the Administrator and Maintenance Director.
Plan Of Correction
I am requesting the Department of Health do the FSES in this case. Facility is consulting Lenhardt Rodgers Architecture to assist with this citation. Facility will also be requesting a TLW.
Failure to Notify Physician of Resident's Increased Pain Post-Fall
Penalty
Summary
The facility failed to notify a resident's physician of a change in clinical condition, specifically an increase in pain following a fall. The facility's policy, last reviewed on November 1, 2023, requires staff to notify the physician and resident representative of any change in clinical condition. A review of the clinical records for a resident with dementia, difficulty walking, and osteoporosis revealed that the resident experienced a fall on May 13, 2024, and was found on her left side. Initially, the resident's pain was rated as a 3, but by the following morning, it had increased to a 6, with specific pain noted in the left hip. Despite this significant change in the resident's condition, there was no documentation indicating that the resident's physician was notified of the increased pain level.
Failure to Evaluate Pain Medication Effectiveness
Penalty
Summary
The facility failed to evaluate the effectiveness of pain medication for a resident, which is inconsistent with professional standards. The resident, who had diagnoses including dementia, difficulty walking, and osteoporosis, had a physician's order for acetaminophen to be administered as needed for mild pain. After a fall, the resident was given acetaminophen for pain rated at a 3, but there was no documentation of an assessment to determine if the medication was effective. The following morning, the resident's pain worsened to a 6, and the nurse administered the same medication without notifying the physician for additional pain management orders. The Director of Nursing confirmed that the nursing staff should have documented the effectiveness of the pain medication.
Failure to Monitor Resident Weight Changes
Penalty
Summary
The facility failed to accurately monitor weight changes for two residents, CL1 and 3, as per the facility's weight monitoring policy and physician orders. Resident CL1, who was admitted with diagnoses including dementia, diabetes, and adult failure to thrive, had a care plan that required weekly weight monitoring for four weeks. However, there was no documented evidence that weights were obtained on March 19 or 26, 2024, as ordered by the physician. Similarly, Resident 3, admitted with dementia and dysphagia, had a care plan that included monitoring weights per facility policy. A nutrition assessment recommended weekly weights for four weeks, followed by monthly monitoring. Despite this, there was no documented evidence of a weight schedule being developed upon admission or that weekly weights were obtained as recommended. The Director of Nursing confirmed the lack of documentation for weights as per physician orders, dietitian recommendations, or facility policy.
Failure to Provide Palatable and Appetizing Food
Penalty
Summary
The facility failed to provide food that was palatable and at appetizing temperatures on three of five nursing units. A review of the facility policy revealed that food should be palatable, attractive, and served at a safe and appetizing temperature. However, interviews with residents indicated that the food was often cold and not palatable. A test tray audit showed that the temperatures of the chicken, stuffing, and Brussels sprouts were significantly below the required 130 degrees Fahrenheit. Further interviews with residents confirmed that the issue of cold food was consistent, affecting both room service and dining room meals.
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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