Logan Square Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- 2 Franklin Town Blvd, Philadelphia, Pennsylvania 19103
- CMS Provider Number
- 395662
- Inspections on file
- 32
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at Logan Square Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
The facility did not maintain its fire alarm system properly, as evidenced by multiple trouble codes displayed on the fire alarm panel. This issue was confirmed by the Executive Director of Construction and Ancillary Services.
The facility failed to maintain its automatic sprinkler system, with missing tests and inspections, and improper installation issues. A 3-year full flow trip test and a 4th quarter 2024 inspection were not conducted. Data wires were strapped to a sprinkler pipe, and a sprinkler was missing its escutcheon. These issues were confirmed by the Executive Director of Construction and Ancillary Services.
The facility failed to maintain and inspect its HVAC systems, specifically the fire/smoke dampers, as they could not provide documentation of an inspection within the past four years. This deficiency was confirmed during an interview with the Executive Director of Construction and Ancillary Services.
The facility failed to maintain and inspect the emergency generator, affecting the entire facility. Documentation for monthly battery testing, an annual 90-minute load bank test, and an annual fuel quality test was missing. The Executive Director confirmed the absence of these records, indicating non-compliance with NFPA standards.
The facility failed to maintain accurate portable Life Safety Code Floor Plans, missing critical details such as smoke and fire barrier walls, horizontal exits, and rated rooms. This deficiency was confirmed during an interview with the Executive Director of Construction and Ancillary Services.
The facility did not maintain and inspect portable fire extinguishers as required by NFPA 10 standards. A document review revealed the absence of a certificate for the technician conducting annual inspections. This issue was confirmed during an interview with the Executive Director of Construction and Ancillary Services.
The facility failed to ensure corridor doors could resist smoke passage, as observed on the third floor near a resident room. The metal door frame had open penetrations, compromising safety standards. This was confirmed by the Executive Director of Construction and Ancillary Services.
The facility failed to maintain smoke barrier walls free of unsealed penetrations, compromising the required 1/2-hour fire resistance rating. Observations revealed penetrations around data wires and a sprinkler pipe in the basement near the upper garage elevator. This was confirmed by the Executive Director of Construction and Ancillary Services.
The facility failed to maintain the fire resistance rating of its trash chute system on the second floor. The trash chute door did not close and latch properly when tested, as confirmed by the Executive Director of Construction and Ancillary Services.
The facility failed to maintain electrical wiring protection in the main garage electrical room, where multiple panels were missing circuit breaker protective blanks. This was confirmed by the Executive Director of Construction and Ancillary Services.
The facility did not conduct required testing of non-hospital grade electrical receptacles at patient bed locations within the mandated 12-month intervals. The testing should have included visual inspection, polarity verification, and grounding blade retention force checks. This deficiency was confirmed during an interview with the Executive Director of Construction and Ancillary Services, who acknowledged the absence of necessary documentation.
An extension cord was improperly used to power a personal refrigerator in a resident's room, violating NFPA standards. The Executive Director confirmed the issue during an exit interview.
Logan Square Rehabilitation And Healthcare Center failed to review and update their Emergency Preparedness Plan annually, as required by federal regulations. This deficiency was identified during a survey, with no signatures confirming the plan's review or update. The issue was acknowledged by the Executive Director of Construction and Ancillary Services.
The facility failed to include required names and contact information in its Emergency Preparedness Plan. A document review revealed the absence of contact details for staff, service entities, patients' physicians, other facilities, and volunteers. The Executive Director confirmed the omission during an exit interview.
The facility's Emergency Preparedness Plan was found deficient as it lacked contact information for the State Licensing and Certification Agency and the Office of the State Long-Term Care Ombudsman. This was confirmed during a document review and an exit interview with the Executive Director of Construction and Ancillary Services.
The facility failed to maintain documentation of initial and annual Emergency Preparedness training for staff and volunteers, affecting the entire facility. A document review revealed the absence of records demonstrating staff knowledge of emergency procedures, confirmed by the Executive Director during an exit interview.
The facility failed to conduct the required two exercises to test the emergency preparedness plan, affecting the entire facility. A document review revealed that the facility did not perform the necessary exercises within the previous 12 months, and this was confirmed during an exit interview with the Executive Director of Construction and Ancillary Services, who acknowledged the lack of documentation.
The facility failed to label the date of opening on multi-use eye drops on two medication carts, as observed during a med pass. This oversight was confirmed by interviews with the responsible licensed nurses, violating the facility's policy on medication labeling.
Two residents experienced discomfort due to inadequate bed sizes in the facility. One resident, who is 6 feet 3 inches tall, had their feet pressing against the footboard, causing numbness and fear of falling due to the narrow bed width. Despite a maintenance request for a bed extender, the issue persisted. Another resident was observed with their foot on the footboard, indicating the bed was too short. Interviews confirmed the facility's failure to provide appropriate accommodations.
The facility failed to protect residents' privacy when a registered nurse was overheard relaying a resident's vital signs aloud in a room with multiple residents and staff, violating privacy protocols.
A facility failed to provide a written summary of the baseline care plan to a resident and their representative, which should have included initial goals, physician orders, therapy services, and social services. The resident, admitted with a progressive neurological condition, stroke, and Parkinson's disease, and their family were unaware if all medications were being administered. The Social Service Director confirmed that a baseline care plan meeting was not conducted, and a written summary was not provided.
A facility failed to ensure the administration of Warfarin for a resident with polycythemia vera and atrial fibrillation. The resident's medication was not administered on multiple occasions due to pharmacy delays, and there was no documentation of the pharmacy being contacted or the physician being informed, as required by facility policy.
A resident with severe cognitive impairment and a history of stroke was not provided with the prescribed adaptive eating utensils during a meal, despite a physician's order and facility policy requiring such equipment. The resident's family and a nurse aide confirmed the oversight.
The facility failed to ensure the Director of Nursing (DON) attended nine consecutive Quality Assurance Process Improvement (QAPI) meetings from February to October 2024. The absence was confirmed by regional staff, and documentation for July 2024 was missing, indicating a deficiency in meeting regulatory requirements for the QAPI committee.
The facility failed to offer influenza immunizations to two residents upon admission, despite their willingness to receive the vaccine. Both residents, who were cognitively intact, reported not being offered the vaccine, and their clinical records lacked documentation of the offer, administration, or refusal of the immunization.
The facility failed to provide a sanitary and comfortable environment for two residents. One resident's IV pole was found soiled with old tube feeding formula, while another resident had to endure a broken over-the-head light that could not be turned off, despite staff attempts to fix it. The latter resident, admitted with a progressive neurological condition, had been sleeping with the lights on since admission.
A facility failed to accurately assess a resident's catheter status. The resident, admitted with an indwelling catheter due to several medical conditions, was incorrectly documented in the MDS as not having a catheter. This error was confirmed by the DON.
A resident was mistakenly discharged due to an incorrect calculation of Medicare benefits, and the facility failed to provide the required Notice of Medicare Non-Coverage (CMS 10123), which would have informed the resident of their right to appeal the denial of Medicare services.
Fire Alarm System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its fire alarm system in proper operating condition, which affected the entire facility. During an observation on January 21, 2025, at 10:45 a.m., it was noted that the fire alarm panel displayed multiple trouble codes. This issue was confirmed during an exit interview with the Executive Director of Construction and Ancillary Services on the same day at 1:15 p.m.
Plan Of Correction
ED of construction to in-service the Maintenance staff of proper reading of the fire panel and report any trouble alarms immediately to their Supervisor. The Facility is working with the current Vendor (Johnson Controls) and an additional Vendor (Independence) to make repairs or replace the aged fire panel so trouble alarms stop randomly reporting. Due to the difficulty of parts or replacement of the fire panel, the Facility is requesting a 120-day time-limited waiver. The fire panel will be audited daily with a record of any current trouble signals recorded until repairs are completed. TLW request sent via email. Johnson Control letter sent to center and forwarded to DOH stating that they estimate that work can be completed 90 days from March 7th 2025 which June 5th 2025. If further extension is required center will update doh with further correspondence from Johnson Controls.
Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain its automatic sprinkler system, affecting the entire facility. During observations and document review on January 21, 2025, several deficiencies were identified. The facility did not conduct a 3-year full flow trip test of the dry automatic sprinkler system, and the 4th quarter 2024 sprinkler inspection was missing. Additionally, data wires were improperly strapped to the ceiling sprinkler pipe in the basement next to the upper garage elevator. Furthermore, a sprinkler in the 3rd floor Activities closet was missing its escutcheon. These deficiencies were confirmed during an exit interview with the Executive Director of Construction and Ancillary Services.
Plan Of Correction
ED of construction to Inservice supervisor of Plants Operations on policy and procedure ensuring sprinkler system maintained. All items A-D have been completed; 4th quarter report received after surveyor departed. Supervisor of Plants Operations or delegate to complete 3x per week x 4 weeks all items A-D to ensure compliance. Supervisor of Plant Operations or delegate to complete audits 3x per week x 4 weeks to compliance with policy and procedure. Audit findings will be submitted to QAPI committee monthly for review and recommendations as needed.
Failure to Inspect HVAC Fire/Smoke Dampers
Penalty
Summary
The facility failed to maintain and inspect its HVAC systems, specifically the fire/smoke dampers, affecting the entire facility. During a document review on January 21, 2025, it was found that the facility could not provide documentation of a fire/smoke dampers inspection performed within the past four years. This deficiency was confirmed during an exit interview with the Executive Director of Construction and Ancillary Services on the same day.
Plan Of Correction
ED of construction to Inservice supervisor of Plants Operations on policy and procedure on smoke dampers. Damper inspection was completed by facility on 11-06-2024. Supervisor of Plant Operations or delegate to complete audits 3x per week x 4 weeks to compliance with policy and procedure. Audit findings will be submitted to QAPI committee monthly for review and recommendations as needed.
Failure to Maintain and Inspect Emergency Generator
Penalty
Summary
The facility failed to maintain and inspect the emergency generator, which affects the entire facility. During a document review on January 21, 2025, it was found that the facility could not provide documentation for several critical tests and inspections. These included the monthly testing of battery electrolyte specific gravity or conductance testing, an annual 90-minute load bank test, and an annual fuel quality test. An exit interview with the Executive Director of Construction and Ancillary Services confirmed the absence of the required documentation. This lack of documentation indicates that the facility did not adhere to the necessary maintenance and testing protocols for the emergency generator as outlined by NFPA standards, potentially compromising the facility's ability to provide essential power in emergencies.
Plan Of Correction
- ED of construction to Inservice supervisor of Plant Operations on ensuring generator battery testing, fuel samples and 90 min load. - Fuel test, load bank and battery conductance testing. - Director of Plants Operations or delegate to complete audits 3x per week x 4 weeks to ensure generator battery testing and fuel quality sample and 90 min load test is completed. Audit findings will be submitted to the QAPI committee monthly for further review and recommendations as needed. - Further audit frequency will be determined based on the outcome of the previously completed audit findings.
Inaccurate Life Safety Code Floor Plans
Penalty
Summary
The facility was found to be deficient in maintaining accurate portable Life Safety Code Floor Plans. During a document review, it was observed that the floor plans did not include essential information such as smoke barrier walls, fire barrier walls, horizontal exits, and rated rooms like storage rooms, soiled utility rooms, and designated medical gas rooms. Additionally, required exits and shaft walls were not clearly noted on the plans. This deficiency was confirmed during an exit interview with the Executive Director of Construction and Ancillary Services.
Plan Of Correction
1) Facility obtained accurate floor plans. 2) ED of construction to Inservice on policy and procedure for ensuring the safe storage of floor plans. 3) Supervisor of Plant Operations or Delegate to complete audits 3x per week x 4 weeks to ensure plans are completed and available in accordance with policy and procedure.
Failure to Maintain and Inspect Portable Fire Extinguishers
Penalty
Summary
The facility failed to maintain and inspect portable fire extinguishers in accordance with NFPA 10 standards, affecting the entire facility. During a document review, it was discovered that the facility could not provide a certificate for the technician responsible for conducting the annual fire extinguisher inspections. This deficiency was confirmed during an exit interview with the Executive Director of Construction and Ancillary Services, who acknowledged the missing documentation.
Plan Of Correction
- ED of construction to Inservice supervisor of Plant Operations on policy and procedure for portable fire extinguishers. Document was received after surveyor exited. - Supervisor of Plant Operations or delegate to complete audits 3x per week x 4 weeks to ensure compliance. Audit findings will be submitted to QAPI committee monthly for further review.
Deficiency in Corridor Door Smoke Resistance
Penalty
Summary
The facility failed to ensure that doors protecting corridor openings could resist the passage of smoke, which is a requirement for safety in long-term care facilities. This deficiency was observed on the third floor, specifically at the double doors near resident room 310. The doors were found to have a metal door frame with open penetrations above the closer, which compromises their ability to prevent smoke from passing through. During an exit interview with the Executive Director of Construction and Ancillary Services, it was confirmed that the metal door frame had penetrations. This issue affects one of the twenty-four floors in the facility, indicating a lapse in maintaining the required safety standards for corridor doors, particularly in smoke compartments.
Plan Of Correction
ED of construction to Inservice supervisor of plants operations on policy and procedure regarding corridor doors. Door closures will be installed in the same open mounting holes at top of frame to ensure smoke doesn't pass. Supervisor of Plant Operations to conduct audits 3x per week x 4 weeks to ensure all corridor doors are smoke tight in accordance with policies and procedures. Supervisor of Plant Operations or delegate to complete audits 3x per week x 4 weeks to compliance with policy and procedure. Audit findings will be submitted to QAPI committee monthly for review and recommendations as needed.
Unsealed Penetrations in Smoke Barrier Walls
Penalty
Summary
The facility failed to maintain smoke barrier walls free of unsealed penetrations, which is a requirement for ensuring a 1/2-hour fire resistance rating. During an observation on January 21, 2025, at 10:55 a.m., it was noted that in the basement, next to the upper garage elevator, there were penetrations around data wires and a sprinkler pipe. This deficiency was confirmed during an exit interview with the Executive Director of Construction and Ancillary Services on the same day at 1:15 p.m.
Plan Of Correction
- ED of construction to Inservice supervisor of Plant Operations on policy and procedure for maintaining smoke barrier walls. - Penetration filled using 3M fire barrier sealant FD 150 + Red color and CP 25 WB+. - Supervisor of Plant Operations or delegate to complete audits 3x per week x 4 weeks to compliance with policy and procedure. - Audit findings will be submitted to QAPI committee monthly for review and recommendations as needed.
Trash Chute Door Fails to Close and Latch
Penalty
Summary
The facility failed to maintain the fire resistance rating of its trash chute system, specifically on the second floor. During an observation on January 21, 2025, at 12:20 p.m., it was noted that the trash chute door did not close and latch properly when tested. This deficiency was confirmed during an exit interview with the Executive Director of Construction and Ancillary Services at 1:15 p.m. on the same day.
Plan Of Correction
- ED of construction to Inservice supervisor of Plant Operations on policy and procedures for trash, laundry chutes. - Trash chute replaced. - Supervisor of Plant Operations or delegate to complete audits 3x per week x 4 weeks to ensure compliance of chute doors policy and procedure. - Supervisor of Plant Operations or delegate to complete audits 3x per week x 4 weeks to compliance with policy and procedure audit findings will be submitted to QAPI committee monthly for review and recommendations as needed.
Electrical Panel Deficiency in Main Garage
Penalty
Summary
The facility failed to maintain the protection of electrical wiring, specifically in the main garage electrical room. During an observation, it was noted that multiple electrical panels were missing a circuit breaker protective blank. This deficiency was confirmed during an exit interview with the Executive Director of Construction and Ancillary Services.
Plan Of Correction
- ED of construction to Inservice Supervisor of Plants Operations on policy and procedure for electrical panels. - Replaced open breakers with circuit breaker protective cover. - Supervisor of Plant Operations or delegate to complete audits of main electrical room 3x per week x 4 weeks to ensure compliance. - Supervisor of Plant Operations or delegate to complete audits 3x per week x 4 weeks to compliance with policy and procedure. - Audit findings will be submitted to QAPI committee monthly for review and recommendations as needed.
Failure to Test Electrical Receptacles at Patient Bed Locations
Penalty
Summary
The facility failed to ensure that electrical receptacles at patient bed locations were tested as required. During a document review, it was found that non-hospital grade receptacles were not tested at intervals not exceeding 12 months, as mandated. The testing should have included a visual inspection of physical integrity, verification of correct polarity of the hot and neutral connections, and ensuring the retention force of the grounding blade was not less than 4 oz. This deficiency was confirmed during an exit interview with the Executive Director of Construction and Ancillary Services, where it was acknowledged that the necessary documentation for these tests was missing.
Plan Of Correction
- ED of construction to Inservice supervisor or Plants Operation on policy and procedure for testing electrical receptacles. - Electrical receptacle test completed. - Supervisor of Plant Operations or delegate to complete audits 3x per week x 4 weeks to compliance with policy and procedure. Audit findings will be submitted to QAPI committee monthly for review and recommendations as needed.
Improper Use of Extension Cord in Resident Room
Penalty
Summary
The facility was found to be in violation of electrical safety standards as evidenced by the improper use of an extension cord in a resident's room. During an observation on January 21, 2025, at 12:45 p.m., it was noted that an extension cord was being used to power a personal refrigerator in a resident's room on the third floor. This use of an extension cord is not compliant with the National Fire Protection Association (NFPA) standards, which prohibit the use of extension cords as a substitute for fixed wiring. The Executive Director of Construction and Ancillary Services confirmed the presence of the extension cord during an exit interview on the same day at 1:15 p.m.
Plan Of Correction
- ED of construction to Inservice supervisor of Plant Operations on policy and procedure of power cords, extension cords and power strips. - Extension cord removed from room #331. - Director of Plants Operations or delegate to complete audits 3x per week x 4 weeks to ensure Power cords, extension cords and power strips audit is completed. Findings will be submitted to the QAPI committee monthly for further review and recommendations as needed. Further audit frequency will be determined based on the outcome of the previously completed audit findings.
Deficiency in Annual Review of Emergency Preparedness Plan
Penalty
Summary
Logan Square Rehabilitation And Healthcare Center was found to have a deficiency related to their Emergency Preparedness Plan during an Emergency Preparedness Survey conducted on January 21, 2025. The survey revealed that the facility failed to ensure that their Emergency Preparedness Plan policies and procedures were reviewed and updated at least annually, as required by 42 CFR 483.73(a). This deficiency affects the entire facility, as the plan is crucial for ensuring readiness in the event of an emergency. During the document review, it was noted that there were no signatures provided to confirm the annual review or update of the Emergency Preparedness Plan. This was acknowledged during an exit interview with the Executive Director of Construction and Ancillary Services, indicating a lapse in the facility's compliance with federal regulations. The lack of an updated emergency plan could potentially impact the facility's ability to respond effectively to emergencies, although the report does not specify any immediate consequences or risks.
Plan Of Correction
1) EPP reviewed and signed. 2) ED of construction to Inservice Plant Operations supervisor policy and procedure on how to review and update EPP annually. 3) Supervisor of Plant Operations or Delegate to complete audits 3x per week x 4 weeks to ensure compliance with policy and procedure audits to be submitted to quality assurance performance improvement committee monthly for further review. Further audit frequency will be determined based on the outcome of the previously completed audit findings.
Deficiency in Emergency Preparedness Plan
Penalty
Summary
The facility was found to be deficient in developing an Emergency Preparedness Plan that included the required names and contact information. During a document review on January 21, 2025, it was revealed that the facility's plan did not contain or reference the necessary contact information for staff, entities providing services under arrangement, patients' physicians, other facilities, and volunteers. This omission was identified as a failure to comply with the regulatory requirements for emergency preparedness communication plans. An exit interview with the Executive Director of Construction and Ancillary Services confirmed that while a contact information template was included in the Emergency Preparedness Plan, it lacked the specific names and contact information of facility-based individuals. This deficiency indicates that the facility did not meet the mandated standards for maintaining an up-to-date and comprehensive communication plan, which is essential for effective emergency preparedness.
Plan Of Correction
1) Updated communication plan and list completed by facility. 2) ED of construction to inservice supervisor of plant OPS on policy and procedure of keeping communications plan and list up to date. 3) ED of construction or delegate to complete audits 3x per week x 4 weeks to ensure communication plan and list are completed in accordance with policies and procedures. Audits findings will be submitted to QAPI committee monthly for further reviews and recommendations as needed. Further audits frequently will be determined based on the outcome of the survey.
Emergency Preparedness Plan Lacks Required Contact Information
Penalty
Summary
The facility failed to ensure that its Emergency Preparedness Plan included the necessary contact information for required emergency officials. During a document review conducted on January 21, 2025, it was discovered that the plan lacked contact information for the State Licensing and Certification Agency and the Office of the State Long-Term Care Ombudsman. This omission affects the entire facility, as these contacts are crucial for effective emergency preparedness and response. An exit interview with the Executive Director of Construction and Ancillary Services confirmed the deficiency. The interview, held on the same day as the document review, further verified that the facility had not developed an Emergency Preparedness Plan that included the required contact information for the specified emergency officials. This oversight indicates a failure to comply with the regulatory requirements for maintaining an updated and comprehensive emergency communication plan.
Plan Of Correction
1) Emergency list has been updated. 2) ED of construction to inservice supervisor of Plant Operations on policy and procedure on emergency contact information. 3) Supervisor of Plant Operations or delegate to complete audits 3x per week x 4 weeks to ensure document is completed in accordance with policy and procedure.
Deficiency in Emergency Preparedness Training Documentation
Penalty
Summary
The facility was found to be deficient in maintaining documentation of initial and annual Emergency Preparedness training for staff, individuals providing services, and volunteers. During a document review conducted on January 21, 2025, it was revealed that the facility failed to provide the required documentation demonstrating that staff members had received the necessary training in emergency procedures. This deficiency affected the entire facility, indicating a systemic issue in the training program. The surveyors noted that the facility did not have records to confirm that staff and service providers were knowledgeable about emergency procedures, as required by the regulations. The lack of documentation suggests that the facility did not conduct or properly record the training sessions, which are essential for ensuring that all personnel are prepared to respond effectively in emergency situations. An exit interview with the Executive Director of Construction and Ancillary Services confirmed the absence of annual records of employee training. This acknowledgment by the facility's leadership further substantiates the deficiency, highlighting a failure in the facility's compliance with emergency preparedness training requirements.
Plan Of Correction
1) EPP Inservice of staff to be completed. 2) ED of construction to Inservice supervisor of plant operations on EPP training program policy and procedure. 3) Supervisor of Plant Operations or delegate to complete audits 3x per week x 4 weeks to ensure compliance. Audit findings will be monthly for further review and recommendations as needed. Further audits frequency will be determined based on the outcome of the previously completed audit findings.
Failure to Conduct Required Emergency Preparedness Exercises
Penalty
Summary
The facility failed to conduct the required two exercises to test the emergency preparedness plan, which affected the entire facility. This deficiency was identified during a document review conducted on January 21, 2025, at 8:45 a.m. The review revealed that the facility did not perform the necessary exercises within the previous 12 months, as mandated by the regulations. The deficiency was confirmed during an exit interview with the Executive Director of Construction and Ancillary Services on the same day at 1:15 p.m. During this interview, it was acknowledged that the documentation supporting the completion of the required exercises was not available. This lack of documentation indicates that the facility did not adhere to the regulatory requirements for emergency preparedness testing. The absence of these exercises suggests a failure in maintaining compliance with the emergency preparedness standards set forth for long-term care facilities. The facility's inability to provide evidence of conducting these exercises highlights a significant oversight in their emergency preparedness protocols.
Plan Of Correction
1) Emergency prep exercise will be completed. 2) ED of construction to Inservice Supervisor of Plant Operations on policy and procedure for ensuring proper requirements are met. 3) Supervisor of Plant Operations or delegate to complete audits 3x per week x 4 weeks to compliance with policy and procedure. Audit findings will be submitted to QAPI committee monthly for review and recommendations as needed.
Failure to Label Ophthalmic Solutions
Penalty
Summary
The facility failed to properly label medications upon opening, specifically ophthalmic solutions, on two of the three medication carts observed on the third floor. During a medication pass on January 12, 2024, it was observed that seven boxes of multi-use eye drops on medication cart one and two boxes on medication cart two did not have the date of opening labeled on them. This was confirmed through interviews with the licensed nurses, Employee E5 and Employee E6, who were responsible for the medication carts at the time of the observation. The facility's policy titled "Medication Labeling and Storage" requires that multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a longer date for the open vial. The failure to label the date of opening on the multi-use eye drops is a deviation from this policy. The report does not mention any specific residents affected by this deficiency, nor does it provide details on any immediate consequences resulting from the oversight.
Plan Of Correction
1) Eye drops in both medication carts have been replaced and labeled correctly with date they were opened. 2) All Medication carts have been audited to ensure all eye drops have been dated upon opening. 3) Licensed nursing staff will be educated by Director of Nursing / designee on medication storage and labeling. 4) Director of Nursing / designee will conduct random audits of medication carts weekly x 3, then monthly x 2 or until compliance is met to ensure proper medication storage and labeling on medication carts. Variances will be addressed and reported to the QAA Committee.
Failure to Provide Adequate Bed Accommodations
Penalty
Summary
The facility failed to provide reasonable accommodation for the needs of two residents, R215 and R165, as required by regulations. Resident R215, who is 6 feet 3 inches tall and weighs 225 pounds, was admitted to the facility and immediately experienced discomfort due to the bed being too small. The resident's feet pressed against the footboard, causing numbness, and the narrow width of the bed left little room for repositioning, leading to fear of falling. Despite a maintenance request for a bed extender being placed shortly after admission, the resident continued to experience discomfort and fear due to the inadequate bed size. Interviews with the nursing supervisor and the nursing home administrator confirmed the issue and the ongoing efforts to obtain a bed extender. Similarly, Resident R165 was observed with their foot on the footboard and a pillow under the ankle, indicating the bed was too short. The resident reported being unable to raise the head of the bed without placing their foot on the footboard. An interview with the administrator confirmed the bed was too short for the resident and that a bed extender could be utilized. These observations and interviews highlight the facility's failure to provide appropriate accommodations for the residents' needs, as required by regulations.
Plan Of Correction
1) Resident 215 and Resident 165 were both provided appropriate bed size with appropriate length. 2) Current residents that are taller than 6ft have been audited by the Maintenance director/designee to ensure that the bed size is appropriate for resident. 3) The Maintenance Director will be educated by the Nursing Home Administrator / designee on appropriate bed size and extensions available for residents. 4) Random audits of new admission and beds that are appropriate in length are put in place to meet residents' needs. Audits will be conducted weekly x 3 weeks, then monthly x 2 or until compliance is sustained. Variances will be addressed and reported to the QAA committee.
Breach of Resident Privacy During Vital Sign Evaluation
Penalty
Summary
The facility failed to ensure the protection of residents' rights to privacy and confidentiality, as evidenced by observations and policy review. Specifically, the facility's policy titled "Confidentiality of Information and Personal Privacy" dated October 2017, mandates safeguarding the personal privacy and confidentiality of all resident personal and medical records. However, during an observation in the third-floor activity room, a registered nurse, identified as Employee E8, was overheard relaying a resident's vital signs aloud, compromising the resident's privacy. This incident involved two of the thirty residents reviewed, highlighting a breach in the facility's adherence to privacy protocols. The observation took place in a setting where eleven residents and two employees were present, further emphasizing the lack of discretion in handling sensitive medical information. The facility's failure to protect the resident's privacy in this instance is a direct violation of the residents' rights as outlined in the facility's policy and federal regulations.
Plan Of Correction
1) Employee E8 has been educated on the facility policy for Personal Privacy / confidentiality of records. 2) All residents have the potential to be affected. 3) Director of Nursing / designee will educate facility staff on the facility policy of resident personal privacy and confidentiality of records. 4) Random audits of common areas will be conducted daily x 7 days, weekly x 3 weeks then monthly x 2 or until compliance is met. Variances will be addressed and reported to the QAA committee.
Failure to Provide Baseline Care Plan Summary
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan to Resident R164 and their representative, which is a requirement under §483.21(a)(3). The baseline care plan should have included initial goals based on admission orders, physician orders, therapy services, and social services. Resident R164 was admitted with diagnoses including a progressive neurological condition, cerebrovascular accident (stroke), and Parkinson's disease. Despite these conditions, there was no documented evidence that the resident or their representative received the necessary written summary of the baseline care plan. Interviews with Resident R164 and their family revealed that they were unaware if all medications were being administered, indicating a lack of communication and documentation. The Social Service Director confirmed that a baseline care plan meeting was not conducted, and a written summary was not provided to the resident or their representative. This oversight was identified during a review of clinical records and interviews, highlighting a deficiency in meeting the regulatory requirements for baseline care planning.
Plan Of Correction
1) Resident R164 and their resident representative was provided with a written summary of the baseline care plan. 2) Current residents admitted in the past 30 days will be audited to ensure compliance with baseline care plans. Any variances will be addressed. 3) Administrator / designee will educate social services staff on baseline care plan policy. 4) Social Service Director / designee will conduct audits of new admissions to ensure compliance with baseline care plans policy. Audits will be completed weekly x 3, then monthly x 2 or until compliance is met. Variances will be addressed and reported to The QAA Committee.
Failure to Administer Anticoagulant Medication
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring and administering of medications for a resident, identified as Resident R34. The facility's policy on 'Unavailable Medication' requires nursing staff to contact the pharmacy, attempt to obtain the medication from the facility's automated dispensing system, notify the physician, report the expected delivery date, and obtain new orders if a medication is unavailable. However, for Resident R34, who was on anticoagulant therapy with Warfarin for blood clot prevention, these procedures were not followed. The resident's medication administration record showed that Warfarin doses were not administered on multiple occasions, with notes indicating the medication was 'awaiting pharmacy,' but there was no documented evidence that the pharmacy was contacted or that the physician was informed of the missed doses. Resident R34, who was cognitively intact and had diagnoses of polycythemia vera and atrial fibrillation, was at risk due to the missed doses of Warfarin, an anticoagulant medication. The facility's failure to ensure the availability and administration of this critical medication was confirmed through staff interviews, where a registered nurse attributed the missed medications to the pharmacy's untimely delivery. This deficiency highlights a breakdown in the facility's pharmaceutical services, as the necessary steps to address the unavailability of medication were not documented or executed, potentially compromising the resident's care.
Plan Of Correction
1) Resident 34 medication is now available from pharmacy. 2) Current residents ordered anticoagulants will be audited to ensure availability of medication from pharmacy. Variances to be addressed. 3) Director of Nursing / Designee will educate licensed nursing staff on facility medication availability policy and procedures. 4) Director of nursing / Designees will conduct audits weekly x 3, then monthly x 2 or until compliance is met to ensure compliance with med availability policy. Variances will be addressed and reported to The QAA Committee.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide adaptive eating equipment for a resident, identified as R83, who was observed during dining on the third-floor dining room. The facility's policy titled "Assistive Devices and Equipment" states that they maintain and supervise the use of assistive devices and equipment for residents, including specialized eating utensils. Recommendations for the use of such devices are based on comprehensive assessments and documented in the resident's care plan. However, during an observation of lunch, Resident R83, who had an order for buildup utensils, was given regular utensils instead. Resident R83 has a medical history that includes malnutrition, hemiplegia, aphasia, and stroke, and has been assessed with severe cognitive impairment. A physician's order dated January 4, 2024, specified the use of buildup utensils with meals. An interview with the resident's family confirmed that the resident was supposed to have special utensils but did not receive them. A nurse aide, identified as Employee E8, also confirmed that the resident was supposed to be given buildup utensils but did not receive them during the meal observed.
Plan Of Correction
1) Resident R83 was immediately provided with their assistive devices. 2) Current residents who are ordered assistive devices with meals have been audited to ensure assistive devices are available for use. 3) Dietary director / designee will educate dietary staff on ensuring assistive devices are provided to any resident indicated for such. 4) Dietary director / designee will complete random audits to ensure identified residents are provided with ordered assistive devices. Audits will be completed weekly x 3, monthly x 2, or until compliance is met. Variances will be addressed and reported to the QAA Committee.
Failure to Ensure DON Attendance at QAPI Meetings
Penalty
Summary
The facility failed to ensure that the Director of Nursing Services attended the quarterly Quality Assurance Process Improvement (QAPI) committee meetings for nine consecutive months, from February 2024 through October 2024. This was determined based on a review of the QAPI committee meeting attendees list, which consistently lacked the presence of the Director of Nursing. The absence of the Director of Nursing was confirmed by the facility's Regional Staff during a meeting on January 15, 2025. Additionally, there was no sign-in sheet or meeting minutes available for July 2024 to confirm the attendance of any required members at the QAPI meeting. The facility did not provide this documentation at the time of the survey, and a request for copies of the original QAPI sign-in sheet was not fulfilled. This lack of documentation and attendance by the Director of Nursing constitutes a deficiency in meeting the regulatory requirements for the facility's Quality Assessment and Assurance committee.
Plan Of Correction
1) QAPI meeting has been held with appropriate attendees signatures obtained. 2) Past 3 months QAPI will reviewed to determine appropriate staff members that were missing. The NHA / designee will review the past three months of QAPI meeting minutes with the Director of Nursing. 3) NHA and Director of nursing will be educated by the Regional Clinical Consultant / Designee on Facility QAPI policy and ensuring appropriate staff members present. 4) Monthly QAPI will be audited for three months for appropriate staff member attendance. Variances will be addressed and reported to the QAA Committee.
Failure to Offer Influenza Immunizations to Residents
Penalty
Summary
The facility failed to ensure that each resident was offered an influenza immunization, as required by regulations. Specifically, two residents, identified as R34 and R315, were not offered the influenza vaccine upon admission, despite being cognitively intact and willing to receive the immunization. Resident R34, admitted on December 17, 2024, confirmed during an interview that they were not offered the vaccine but expressed willingness to accept it if suggested by a physician. A review of Resident R34's clinical records showed no documentation of the offer or administration of the influenza vaccine, nor any record of refusal or medical contraindication. Similarly, Resident R315, admitted on December 11, 2024, reported not being offered the influenza vaccine upon admission and expressed a desire to receive it before discharge. The review of Resident R315's clinical records also revealed a lack of documentation regarding the offer or administration of the influenza vaccine, as well as any refusal or medical contraindication. These findings indicate a failure by the facility to comply with the regulatory requirement to offer influenza immunizations to residents, as evidenced by the absence of necessary documentation and resident interviews.
Plan Of Correction
1) Resident R34 and Resident R315 were both offered the influenza vaccine. 2) Residents admitted during the last 30 days will be audited to ensure influenza vaccine has been offered. Variances will be addressed. 3) Director of nursing / designee will educate admissions nurse, assistant director of nursing, infection preventionist, clinical nurse leads and supervisors to ensure all new residents' vaccine history is reviewed for influenza vaccine administration and offered influenza vaccine on admission if appropriate. 4) Audits will be conducted weekly x 3, then monthly x 2 on new admissions to ensure influenza vaccines are offered if appropriate, until compliance is met. Variances will be addressed, and reported to the QAA Committee.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary and comfortable environment for two residents. For Resident R220, an observation on January 15, 2024, revealed that the IV pole used for administering an antibiotic intravenously was soiled at its base with what appeared to be old tube feeding formula. This observation was made in the presence of the Director of Nursing, indicating a lapse in maintaining cleanliness of medical equipment. Resident R164 experienced discomfort due to a malfunctioning over-the-head light that could not be turned off. The resident, who was admitted on January 2, 2025, with a progressive neurological condition, cerebrovascular accident, and Parkinson's disease, reported that the light had been broken since admission. Despite attempts by facility staff to fix the light, it remained inoperable, forcing the resident to sleep with the lights on. The administrator confirmed the issue with the light on January 12, 2025.
Plan Of Correction
1) Overhead light for resident R164 was fixed. IV pole for Resident R220 was cleaned. 2) Facility wide audit of current residents who are ordered IV medication were checked for cleanliness; variances were addressed. A facility wide audit was also completed of all resident rooms to ensure that all overhead lights had strings that were appropriate in length to meet the needs of the residents. Variances were addressed. 3) Maintenance director/designee will educate maintenance department staff members on ensuring broken overhead lights are fixed timely. Housekeeping director/designee will educate housekeeping department staff members on ensuring proper cleanliness of IV poles. 4) Random room audits will be conducted weekly x 3, then monthly x 2 or until compliance is met to ensure cleanliness of IV poles and that overhead lights are in proper working order. Variances will be addressed and reported to the QAA committee.
Inaccurate Resident Assessment of Catheter Status
Penalty
Summary
The facility failed to ensure the accuracy of a resident's assessment, specifically regarding the resident's catheter status. A clinical record review revealed that a resident was admitted to the facility with an indwelling catheter due to conditions including metabolic encephalopathy, acute kidney failure, and acute pyelonephritis. Despite the presence of the catheter, the resident's Minimum Data Set (MDS) assessment, dated December 10, 2024, inaccurately indicated that the resident did not have a catheter. This discrepancy was confirmed during an interview with the Director of Nursing on January 15, 2024.
Failure to Provide Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide the required advanced notice, through a Notice of Medicare Non-Coverage (CMS 10123), regarding the termination of Medicare services for one of the residents. Resident R1 was admitted on February 7, 2024, for short-term rehabilitation with Medicare skilled A services. The resident was discharged on March 15, 2024, and readmitted from the local hospital on March 19, 2024, with Medicare Part A benefits. However, the facility mistakenly discharged Resident R1 on the belief that Medicare benefits were exhausted without issuing the required NOMNC form, which would have informed the resident of their right to appeal the denial of Medicare services. An interview with the Social Worker Director revealed that Resident R1 was discharged because the Medicare service benefits were thought to be exhausted. Further interviews with the Administrator and Business Director confirmed that the facility's system incorrectly calculated the remaining Medicare benefit days, leading to the erroneous discharge. The facility acknowledged that Resident R1 should not have been discharged and that the NOMNC form should have been issued if the discharge was appropriate.
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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