Luther Woods Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hatboro, Pennsylvania.
- Location
- 313 County Line Road, Hatboro, Pennsylvania 19040
- CMS Provider Number
- 395370
- Inspections on file
- 19
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Luther Woods Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A facility failed to promptly investigate a suspected diversion of narcotic medication after a resident with chronic pain syndrome was found to have discrepancies in their oxycodone administration records. The issue was reported to the DON, but no investigation was initiated until a second, similar allegation arose involving the same nurse.
A resident with Alzheimer's Disease and moderate cognitive impairment, identified as at risk for elopement, was able to exit the facility when the receptionist released the front door lock for visitors. The resident was found outside in the parking lot by staff, and the wander guard alarmed only upon re-entry. This incident demonstrates a failure to provide adequate supervision and prevent elopement.
The facility failed to maintain accurate records and reconciliation of controlled substances for two residents, resulting in medication discrepancies and diversion by an LPN. In both cases, oxycodone was signed out and administered without proper documentation or resident request, and required dual signatures for narcotic counts were missing across multiple shifts.
A resident with Alzheimer's Disease and moderate cognitive impairment was incorrectly documented as having no dementia or cognitive impairment on the Elopement Evaluation Assessment tool, despite their care plan identifying elopement risk and the use of a wander prevention band. An LPN confirmed the documentation error.
The facility failed to maintain and inspect its emergency generator, lacking documentation for an annual fuel quality test and a 3-year load test. The generator was also in alarm for 'over-cranking.' A revisit confirmed the missing documentation for the fuel quality test.
The facility failed to obtain required occupancy inspection approval for its emergency power generator and did not update policies per the 2016 Act 48. Additionally, it lacked a carbon monoxide alarm evacuation policy and accurate portable floor plans, as confirmed during interviews and document reviews.
The facility failed to maintain and inspect the kitchen hood suppression system, affecting the entire facility. The required semi-annual testing was not conducted within six months, and monthly quick checks were not performed throughout the survey year. This was confirmed by the facility's administrative staff during an exit interview.
The facility failed to maintain its fire alarm system components, affecting the entire facility. A document review revealed two deficiencies: the inability to use the Xaap device for inspection due to lack of reception in the basement, and a repeat functional failure of a pull station on the first floor. Additionally, there was a high priority recommendation to update smoke detectors for better sensitivity testing. These issues were confirmed during an exit interview with facility leadership.
The facility failed to maintain and inspect its emergency generator, lacking documentation for an annual fuel quality test and a 3-year load test. Additionally, the newly installed generator was in alarm for 'over-cranking,' indicating potential malfunction. These issues were confirmed during an exit interview with facility leadership.
The facility did not obtain necessary approvals for emergency power generator replacements and failed to update policies per the 2016 Act 48 - Care Facility Carbon Monoxide Alarms Standards Act. Additionally, it lacked accurate floor plans for the Life Safety Code Survey, as confirmed by administrative staff.
The facility failed to maintain self-closing doors on both levels, with several doors found propped open or not functioning correctly. Issues included doors propped open with wedges, chairs, and door stops, as well as a door that did not latch and another with a large gap when latched. These deficiencies were confirmed during an exit interview with the Facility Administrator and other staff.
The facility was found to have a deficiency in maintaining emergency lighting, as the emergency spot lighting in the loading dock/maintenance shop was damaged and detached from its housing. This was confirmed during an exit interview with the facility's administration and maintenance staff.
The facility did not maintain proper hazardous area enclosures, with laundry room doors propped open and lacking door closers, and maintenance area doors also propped open, compromising fire safety standards.
The facility did not properly maintain and inspect its sprinkler systems, impacting the entire facility. Damage was observed in the C wing supply closet to the ceiling grid and sprinkler escutcheon around the sprinkler head. This issue was confirmed during an exit interview with the facility's administration and maintenance staff.
The facility failed to maintain smoke barrier walls free of unsealed penetrations, as required by NFPA 101 standards. Observations revealed unsealed penetrations above smoke barrier doors next to a room due to a newly run data line, compromising the smoke barrier's integrity. This was confirmed during an exit interview with the facility's administration and maintenance staff.
The facility was found to be non-compliant with NFPA 70, National Electric Code, due to a non-GFCI outlet located within 6 feet of a sink in the women's room/locker room. This deficiency was confirmed during an exit interview with the Administrator, Administrator in training, and the Director of Maintenance.
The facility did not conduct fire drills once per shift per quarter, impacting the entire facility. A document review revealed the absence of accurate documentation for fire drills from July to November 2024. An exit interview confirmed the reuse of documentation for these months.
The facility did not maintain its electrical system as required by NFPA standards. An observation revealed an electrical panel in the basement's electrical room without a cover. This deficiency was confirmed during an exit interview with the facility's administration and maintenance staff.
The facility was cited for improper use of electrical equipment, including extension cords powering Christmas trees, a refrigerator plugged into a power strip in the laundry room, and a heat/blower hand dryer using an outlet multiplier. These issues were confirmed during an exit interview with facility leadership.
The facility failed to maintain proper storage of oxygen and gas cylinders, with freestanding cylinders found in multiple locations, including the C wing oxygen room and the Activities Room. Additionally, a door was propped open using a full oxygen cylinder storage rack, indicating non-compliance with NFPA 101 standards. This was confirmed during an exit interview with facility administrators.
The facility failed to develop and document an Emergency Preparedness Plan addressing its role under a waiver declared by the Secretary, as required by section 1135 of the Act. This deficiency was confirmed during a document review and exit interview, affecting the entire facility's ability to provide care at alternate sites during emergencies.
The facility was found non-compliant with NFPA 101 standards as one of its smoke compartments exceeded the maximum size of 22,500 square feet and the travel distance limit of 200 feet. This was confirmed during an exit interview with the Administrator and Maintenance Director.
A facility failed to obtain a physician's order for a resident's oxygen therapy. The resident was observed using a nasal cannula connected to an oxygen concentrator at 4 liters per minute, which she had been on since a recent hospitalization. The DON confirmed the absence of a physician's order, despite the resident's discharge summary indicating continuous oxygen use.
The facility failed to properly store controlled drugs in the B wing medication room. The door lock code was written on the door jamb, and the medication refrigerator was unlocked, containing an unsecured bottle of Lorazepam. These issues were confirmed by the unit manager during an observation.
The facility did not meet the required nurse aide-to-resident ratios on several occasions, failing to provide the mandated number of nurse aides during day, evening, and night shifts. This deficiency was confirmed through a review of staffing data and an interview with the Scheduler.
In 2024, the facility failed to meet the required LPN staffing ratios during various shifts over several weeks. On multiple occasions, the number of LPNs provided was below the mandated levels, such as on July 4, when only 40.50 LPNs were available during the day shift, while 41.92 were required. These deficiencies were confirmed through a review of staff schedules and punch reports.
The facility failed to provide the required minimum of 3.20 hours of direct nursing care per resident per day on multiple occasions. A review of nursing schedules and punch reports revealed that on several days, the care hours ranged from 2.70 to 3.14, falling short of the mandated requirement. This deficiency was confirmed through staff interviews and documentation review.
The facility failed to maintain a safe, clean, and homelike environment in B and C Units. Observations revealed exposed bedpans, missing tiles, and dirty linen in B Unit, along with an exposed electrical heater in the hallway. In C Wing, shower rooms were cluttered and used for storage, making them non-functional. A resident reported unfinished repairs in their bathroom.
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with specific communication needs. Despite the resident's preference for using paper and pen to communicate, the care plan did not reflect this, leading to frustration and ineffective communication. This deficiency was confirmed through staff interviews and a review of the facility's policy and clinical records.
The facility failed to monitor and address significant weight loss for two residents. One resident experienced a weight drop from 190.2 pounds to 141.0 pounds over several months, while another resident's weight dropped from 170.4 pounds to 143 pounds. Despite documented weight loss, timely interventions were not implemented, and the Registered Dietitian could not explain the lack of timely assessment and intervention.
The facility failed to provide pharmaceutical services to meet the needs of a resident, specifically in acquiring, receiving, and administering Pregabalin. The resident missed multiple doses due to the medication being unavailable, and there was no documented evidence that the physician was informed or that backup pharmacy procedures were activated. The Director of Nursing confirmed the nursing staff did not follow the facility's policy and procedure.
The facility failed to ensure that residents and their representatives understood the terms of binding arbitration agreements. Four residents signed the agreements without proper explanation in a language they could understand. The agreements were missing key elements, and the Admission Director confirmed that they were read to residents without ensuring comprehension.
Failure to Investigate Suspected Narcotic Diversion
Penalty
Summary
The facility failed to conduct a complete and thorough investigation into an allegation of missing potential narcotic medication for one resident. According to the facility's policy, all discrepancies, suspected loss, or diversion of medications must be immediately investigated and reported. A review of clinical records showed that a resident with chronic pain syndrome had an order for oxycodone as needed for migraines. The Medication Administration Record (MAR) and controlled substance inventory sheets revealed that a single licensed nurse was signing out and administering the medication, with discrepancies noted on specific dates. The resident later stated they had not requested the medication, prompting suspicion of possible diversion. The unit manager identified inconsistencies between the narcotic book and the MAR and reported the issue to the DON when the medication was discontinued. Despite the suspicion of medication diversion, the DON confirmed that no investigation was initiated at the time the concern was reported, as the administrator was out of the office and the nurse in question was not scheduled to return for several days. An investigation was only started after a subsequent, similar allegation involving another resident. The failure to promptly investigate the initial suspicion of narcotic diversion constituted a violation of facility policy and state regulations.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent an elopement incident involving a resident with Alzheimer's Disease and moderate cognitive impairment. Upon admission, the resident was assessed for elopement risk and scored as low risk, but the care plan identified the resident as being at risk for elopement due to dementia and included a wander prevention band. Despite these measures, the resident was able to exit the building when the receptionist released the front door lock, allowing multiple visitors and the resident to leave the premises. The incident report and staff witness statements confirm that the resident left the building and was later found in the parking lot near the road by a nurse aide. The wander guard alarmed only when the resident re-entered the building. The event was confirmed by the DON, who provided the timeline of the resident's exit and subsequent recovery. The deficiency was cited under regulations related to the responsibility of the licensee, resident care policies, and nursing services.
Failure to Maintain Accurate Controlled Substance Records and Reconciliation
Penalty
Summary
The facility failed to ensure that drug records were properly maintained and that an accurate account of all controlled substances was kept for two residents. Facility policy required special handling, storage, disposal, and recordkeeping for controlled substances in accordance with federal and state regulations. However, discrepancies were identified in the narcotic count sheets and Medication Administration Records (MARs) for two residents who had orders for PRN oxycodone. In both cases, the controlled substance inventory did not match the documented administration, and doses were signed out without corresponding physician orders or resident requests. For one resident with chronic pain syndrome, the MAR indicated that oxycodone was administered multiple times by a single nurse, despite the resident stating he had not requested or taken the medication for nearly two months. The medication was discontinued by the physician after this was discovered. For another resident with chronic migraines, the controlled substance count decreased by two tablets during a night shift, but only one dose was documented as given. The resident confirmed she had not requested the medication during that time. In both cases, the nurse responsible admitted to diverting the narcotics for personal use. Additionally, the facility failed to maintain proper dual signatures for narcotic counts during shift changes, as required by policy. Multiple interviews with nursing staff confirmed that several shifts lacked the required signatures in the controlled substance inventory count books across different wings of the facility. This lack of proper documentation and reconciliation of controlled substances contributed to the inability to promptly detect and prevent the diversion of medications.
Inaccurate Documentation of Elopement Risk Assessment
Penalty
Summary
The facility failed to ensure complete and accurate documentation for a resident assessed for elopement risk. Upon admission, the resident, who had a diagnosis of Alzheimer's Disease and a BIMS score indicating moderate cognitive impairment, was required to be evaluated for elopement risk using the facility's Elopement Risk Tool Assessment. The resident's care plan identified them as being at risk for elopement due to dementia and noted the use of a wander prevention band. However, the Elopement Evaluation Assessment tool incorrectly indicated that the resident had no diagnosis of dementia or cognitive impairment. This discrepancy was confirmed during an interview with an LPN, who acknowledged that the resident did have a standing diagnosis of Alzheimer's dementia and that the assessment tool was coded incorrectly.
Emergency Generator Maintenance and Inspection Deficiency
Penalty
Summary
The facility failed to maintain and inspect its emergency generator, which affected the entire facility. During a document review on December 18, 2024, it was found that the facility could not provide documentation for an annual fuel quality test and a 3-year, 4-hour load test. Additionally, an observation on the same day revealed that the newly installed generator was in alarm for 'over-cranking.' These findings were confirmed during an exit interview with the Administrator, Administrator in training, and the Director of Maintenance. A follow-up onsite revisit conducted on February 11, 2025, confirmed that the facility still could not provide documentation for the annual fuel quality test. This was verified during an exit interview with the Maintenance Director. All other deficiencies listed under this tag were corrected, but the lack of documentation for the annual fuel quality test remained unresolved.
Plan Of Correction
The annual fuel test is scheduled to be completed on 2/26/25. Results take up to 2 weeks to receive, so they will be available to us by 3/12/25. Maintenance will keep the date and the results logged in our Generator Binder and will ensure the fuel quality test is completed in February every year ongoing.
Deficiencies in Emergency Power Generator Approval and Policy Updates
Penalty
Summary
The facility failed to obtain the required Pennsylvania Department of Health Final Occupancy Inspection approval for the replacement of the facility's emergency power generator and other essential electrical system components. This deficiency was identified during an observation, interview, and documentation review conducted on December 18, 2024. The facility did not notify the Norristown Department of Safety Inspection in writing about the approved PA DOH Stamped Drawing Index of H-22-0230, indicating when construction started and was completed. This lack of notification was confirmed during an exit interview with the Administrator, Administrator in training, and Maintenance Director. Additionally, the facility did not update its policies in accordance with the 2016 Act 48 - Care Facility Carbon Monoxide Alarms Standards Act. The document review revealed the absence of a carbon monoxide alarm evacuation policy plan and associated staff in-service training. Furthermore, the facility failed to provide accurate portable floor plans, which are required for the Life Safety Code Survey. The provided floor plans lacked indications of smoke barrier walls, fire barrier walls, horizontal exits, rated rooms, required exits, and shaft walls. These deficiencies were confirmed during an exit interview with the facility's administration and maintenance staff.
Plan Of Correction
We notified Norristown Department of DSI on 1/30/2025. We needed to gather more documentation for DSI. This documentation will be completely acquired and submitted by 2/28/25.
Failure to Maintain Kitchen Hood Suppression System
Penalty
Summary
The facility failed to maintain and inspect the kitchen hood suppression system, which affected the entire facility. During a document review on December 18, 2024, it was revealed that the facility did not conduct the required semi-annual testing of the kitchen hood suppression system within six months of February 27, 2024. This was confirmed during an exit interview with the Administrator, Administrator in training, and Maintenance Director, who acknowledged the lack of documentation. Additionally, an observation and interview conducted on the same day at 12:40 p.m. revealed that the kitchen hood suppression system did not undergo the necessary monthly quick checks throughout the entire survey year. This was also confirmed during the exit interview with the facility's administrative staff.
Plan Of Correction
Kitchen Hood Fire Suppression system was inspected on December 19th, 2024, by an outside vendor. The equipment has been placed on an automatic inspection schedule with this vendor. Maintenance will monitor the automatic scheduling dates.
Fire Alarm System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain its fire alarm system components in operable condition, affecting the entire facility. During a document review on December 18, 2024, it was found that the fire alarm report from December 16, 2024, listed two deficiencies and one high priority recommendation without verification of repair. The first deficiency involved the inability to use the Xaap device for system inspection due to lack of cellular and WiFi reception in the basement where the Fire Alarm Control Panel (FACP) is located. The second deficiency was a repeat issue from the previous year's inspection, involving a functional failure of a pull station located on the first floor, C Wing by the activities room. Additionally, there was a high priority recommendation to update all smoke detectors to a newer model for improved sensitivity testing and troubleshooting. These findings were confirmed during an exit interview with the Facility Administrator, Administrator in training, and the Director of Maintenance.
Plan Of Correction
We have contacted Johnson Controls, who is our service contractor. They are scheduled to come to the facility on January 18th, 2025. We are anticipating that all needed repairs will be completed by January 20th, 2025.
Emergency Generator Maintenance Deficiency
Penalty
Summary
The facility failed to maintain and inspect its emergency generator, which affected the entire facility. During a document review, it was found that the facility could not provide documentation for an annual fuel quality test and a 3-year, 4-hour load test. These tests are essential for ensuring the generator's reliability and compliance with NFPA standards. The absence of these records indicates a lapse in the facility's maintenance and testing protocols for its emergency power systems. Additionally, an observation revealed that the newly installed generator was in alarm for 'over-cranking.' This issue was confirmed during an exit interview with the Administrator, Administrator in training, and the Director of Maintenance. The alarm condition suggests a potential malfunction or improper setup of the generator, further highlighting the facility's failure to ensure the emergency generator's operational readiness and compliance with required safety standards.
Plan Of Correction
An outside vendor was brought in to do required testing on our generator: Annual Fuel Quality and 3 year, 4 hour load test. We were told the report would be given to us by January 22nd, 2025. The over cranking was repaired the same day as the survey.
Facility Fails to Obtain Required Approvals and Update Policies
Penalty
Summary
The facility failed to obtain the required Pennsylvania Department of Health Final Occupancy Inspection approval for the replacement of the facility's emergency power generator and other essential electrical system components. This deficiency was identified during an observation, interview, and documentation review conducted on December 18, 2024. The facility did not notify the Norristown Department of Division of Safety Inspection in writing about the approved PA DOH Stamped Drawing Index of H-22-0230, indicating when construction started and when it was completed. This lack of notification was confirmed during an exit interview with the Administrator, Administrator in training, and Maintenance Director. Additionally, the facility did not update its policies in accordance with the 2016 Act 48 - Care Facility Carbon Monoxide Alarms Standards Act. The document review revealed the absence of a carbon monoxide alarm evacuation policy plan and associated staff in-service training. Furthermore, the facility failed to provide portable, accurate floor plans required for the Life Safety Code Survey. The provided floor plans lacked indications of smoke barrier walls, fire barrier walls, horizontal exits, rated rooms, required exits, and shaft walls. This deficiency was also confirmed during the exit interview with the facility's administrative staff.
Plan Of Correction
1. The initial notification in writing of the generator had been completed. The addition of the Docking Station on 12/17/24 was just completed the day before the annual Life Safety survey, so we had not had the time yet to write a notification. Upon the exit interview, there was confusion on our part that the notification needed to be done in writing. That is being submitted today, 1/8/25. 2. The Carbon Monoxide alarm evacuation policy plan has been attained and staffing education will be completed by Friday, January 10th, 2025. 3. Maintenance will update the floor plan to include the items that are needed to make the floor plan correct. The following will be added: a. Smoke Barrier Walls (outside wall to outside wall) b. Fire Barrier Walls (2-hour walls) c. Horizontal Exits d. Rated Rooms (Storage Rooms, Soiled Utility Rooms, designated Medical Gas Rooms) will be clearly designated. It is the facility's responsibility to have all Rated Rooms indicated on their Life Safety Code Floor Plan. e. Required Exits should be clearly noted; and f. Shaft Walls This will be completed by January 15th, 2025.
Failure to Maintain Self-Closing Doors
Penalty
Summary
The facility failed to maintain doors with self-closing devices on both levels of the building, as observed during a survey conducted on December 18, 2024. Several doors intended to be self-closing were found propped open or not functioning correctly. Specifically, the staff lounge ice room door was propped open with a door wedge, the A Wing lining closet door did not latch, and the B wing break room door was held open with a trash bag tied from the door handle to a handrail. Additionally, the chapel door was propped open with a chair, the sprinkler/janitor room door had a large gap between the door and frame when latched, the basement storage door was propped open with an installed kick down door stop, and the C wing clean lining door was propped open with a door stop. These deficiencies were confirmed during an exit interview with the Facility Administrator, Administrator in training, and the Director of Maintenance.
Plan Of Correction
All doorways will be kept closed at all times. Maintenance will do daily audits each day times 30 days. Then they will do weekly checks times 60 days. All stops whether portable or installed have been removed. A new door latch has been installed on the door on A Wing. A door will be installed at the Sprinkler Room as we have been unable to fix the gap. This will be completed by 1/30/25.
Emergency Lighting Deficiency in Maintenance Area
Penalty
Summary
The facility failed to maintain emergency lighting in operable condition, as observed during a survey. On December 18, 2024, at 11:37 a.m., an inspection of the loading dock and maintenance shop revealed that the emergency lighting and exit sign combination device had damaged emergency spot lighting. The spot lighting was found detached from the sign housing and hanging from the combination device. This deficiency was confirmed during an exit interview with the Administrator, Administrator in training, and the Director of Maintenance on the same day at 1:45 p.m.
Plan Of Correction
All emergency signs will be repaired by January 31st, 2025. They will be audited weekly times one month. After one month they will be checked monthly. All auditing will be done by Maintenance and logged in an audit book.
Deficiency in Hazardous Area Enclosures
Penalty
Summary
The facility failed to maintain proper hazardous area enclosures on one of its two levels, as observed during a survey. Specifically, all laundry room doors, approximately four in total, were found propped open with door wedges, compromising their ability to function as fire barriers. Additionally, the C wing soiled laundry room lacked a door closer, further failing to meet the required standards for hazardous area enclosures. The maintenance area also had double doors propped open with door wedges, which was confirmed during an exit interview with the Administrator, Administrator in training, and the Director of Maintenance.
Plan Of Correction
All door wedges have been removed and proper door closures will be installed by January 15th, 2025. The fire doors will be kept closed. Maintenance will audit the fire doors daily for one month, then quarterly thereafter. All audits will be kept in an audit binder.
Failure to Maintain Sprinkler Systems
Penalty
Summary
The facility failed to maintain and inspect the sprinkler systems as required, affecting the entire facility. During an observation on December 18, 2024, at 12:40 p.m., physical damage was noted in the C wing supply closet, specifically to the ceiling grid and the sprinkler escutcheon surrounding the sprinkler head. This deficiency was confirmed during an exit interview with the Administrator, Administrator in training, and the Director of Maintenance on the same day at 1:45 p.m.
Plan Of Correction
C Wing closet repairs have been completed. Maintenance will check sprinkler heads for damage monthly times 6 months then quarterly on going. All audits will be logged in the Maintenance Audit Binder.
Unsealed Penetrations in Smoke Barrier Walls
Penalty
Summary
The facility failed to maintain smoke barrier walls free of unsealed penetrations, as required by NFPA 101 standards. During an observation on December 18, 2024, at 12:15 p.m., it was noted that there were unsealed penetrations above the smoke barrier doors next to room 110. This issue arose due to the installation of a newly run data line, which compromised the integrity of the smoke barrier. The deficiency was confirmed during an exit interview with the Administrator, Administrator in training, and the Director of Maintenance on the same day at 1:45 p.m.
Plan Of Correction
Fire caulk has been used to fill in the opening created by the installation of the data line. Maintenance will check smoke barriers on a routine monthly basis and document findings in the Maintenance Audit Book. All penetrations have been and will be corrected moving forward using a UL approved stop gap penetration system.
Non-GFCI Outlet Near Sink in Women's Room
Penalty
Summary
The facility failed to comply with NFPA 70, National Electric Code, specifically regarding electrical wiring and equipment. During an observation on December 18, 2024, at 11:43 a.m., it was found that there was a non-GFCI outlet located within 6 feet of a sink in the women's room/locker room. According to NFPA 70 210.8(B)5, a GFCI outlet is required in such locations to ensure safety. This deficiency was confirmed during an exit interview with the Administrator, Administrator in training, and the Director of Maintenance on the same day at 1:45 p.m.
Plan Of Correction
A GFCI has been installed in the Ladies Locker Room. Maintenance will check quarterly to make sure all GFCIs are working properly. All checks will be documented in the Maintenance Audit Log.
Failure to Conduct Quarterly Fire Drills on Each Shift
Penalty
Summary
The facility failed to conduct fire drills once per shift per quarter, affecting the entire facility. During a document review on December 18, 2024, it was found that the facility could not provide correct and accurate documentation of shift and staff participation in monthly fire drills for the months of July 2024 through November 2024. An exit interview with the Facility Administrator, Administrator in training, and the Director of Maintenance confirmed the reuse of shift and participation documentation for these months.
Plan Of Correction
While paperwork was present, there was missing information. Fire Drill paperwork will be completely redone by January 15th, 2025, to fill in the missing information. Information will be checked monthly for accuracy.
Electrical Panel Cover Missing in Facility
Penalty
Summary
The facility failed to maintain and inspect its electrical system requirements according to NFPA 70 and NFPA 99 standards. During an observation on December 18, 2024, at 11:43 a.m., in the basement's electrical room, it was found that an electrical panel was missing its cover. This deficiency was confirmed during an exit interview with the Administrator, Administrator in training, and the Director of Maintenance later that day at 1:45 p.m.
Plan Of Correction
The electrical panel has been replaced. Maintenance will check all electrical panels quarterly to make sure all covers in place. Findings will be documented in the Maintenance Audit Log.
Improper Use of Electrical Equipment in Facility
Penalty
Summary
The facility was found to have several deficiencies related to the improper use of electrical equipment, as observed during a survey on December 18, 2024. Specifically, the surveyors noted that two lighted decorative Christmas trees in the lobby were powered by extension cords running through windows, which is not compliant with the regulations. Additionally, an orange extension cord was in use in the environmental services area, and a refrigerator in the laundry room was plugged into a power strip, both of which are against the established guidelines for electrical safety. Further observations revealed that a heat/blower hand dryer in the main office bathroom was powered by an outlet multiplier located in an adjacent hallway, and both a refrigerator and a microwave in the administrator's office were plugged into a power strip. These findings were confirmed during an exit interview with the Administrator, Administrator in training, and the Director of Maintenance, indicating a failure to adhere to the required standards for electrical equipment use within the facility.
Plan Of Correction
All extension cords were removed from Holiday decorations the day of the survey. Power strips were removed and replaced with hospital grade outlet extenders. Office hand dryer will be removed and replaced with paper towels by Friday, January 10th, 2025. Maintenance will do random audits to check facility for continued compliance.
Improper Storage of Oxygen and Gas Cylinders
Penalty
Summary
The facility failed to maintain proper storage of oxygen and gas cylinders, as observed during a survey on December 18, 2024. Freestanding oxygen and gas cylinders were found in several locations, including the C wing oxygen room, the Activities Room, and the B Wing oxygen room. Specifically, three oxygen cylinders were observed in the C wing oxygen room, and two helium tanks were found in the Activities Room. Additionally, the door to the B Wing oxygen room was propped open using a full oxygen cylinder storage rack, indicating improper storage practices. During the exit interview with the Administrator, Administrator in training, and the Director of Maintenance, it was confirmed that the freestanding cylinders and the propped door were indeed present. This deficiency highlights the facility's failure to adhere to the NFPA 101 standards for gas equipment storage, which require specific storage conditions to ensure safety and compliance. The improper storage of these cylinders poses potential safety risks, as they were not secured or stored according to the required guidelines.
Plan Of Correction
All observations were corrected the same day as the survey. Maintenance will check weekly times one month for compliance and then will check quarterly. All audits will be documented in the Maintenance Log.
Deficiency in Emergency Preparedness Planning
Penalty
Summary
The facility was found deficient in its emergency preparedness planning, specifically in failing to develop and document policies and procedures concerning its role under a waiver declared by the Secretary of the Department of Health, in accordance with section 1135 of the Act. This deficiency was identified during a document review conducted on December 18, 2024, which revealed that the facility did not have an Emergency Preparedness Plan that included the necessary provisions for care and treatment at an alternate care site as identified by emergency management officials. During the exit interview with the Administrator, Administrator in training, and Maintenance Director, it was confirmed that the facility lacked the required documentation. This deficiency affects the entire facility, as it does not have the necessary policies and procedures in place to guide its actions under a waiver declared by the Secretary, potentially impacting its ability to provide care and treatment at alternate care sites during emergencies.
Plan Of Correction
Paperwork has been downloaded regarding the waiver of the Secretary of State regarding section 1135 of the Act. This will be implemented and added to our Emergency Preparedness plan by January 1st, 2025.
Non-compliance with Smoke Compartment Size Requirements
Penalty
Summary
The facility failed to comply with the NFPA 101 requirements for smoke compartments on one of its four smoke compartments. During an observation and document review conducted on December 18, 2024, it was found that the smoke compartments, specifically the front and back hallways, exceeded the maximum allowable size of 22,500 square feet. Additionally, the travel distance within these compartments surpassed the 200-foot limit from any point in the compartment to a door in the smoke barrier. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director, where it was acknowledged that the B Wing smoke compartment exceeded the specified size limit.
Plan Of Correction
Ken Walters, Director of Maintenance, will contact the Department of Health to request a FSES.
Lack of Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that physician's orders were obtained for oxygen therapy for one resident. During an initial tour, it was observed that the resident was using a nasal cannula connected to an oxygen concentrator at 4 liters per minute. The resident confirmed that she had been on oxygen since a recent hospitalization. Subsequent observations confirmed the continued use of oxygen at the same rate. A review of the resident's medical record revealed no physician's order for the oxygen therapy. The Director of Nursing confirmed that the resident returned from an emergency room visit on continuous oxygen, as noted in the hospital discharge summary, but the nurse had not obtained a physician's order for the therapy.
Plan Of Correction
Education provided to all licensed nurses regarding Policy #1901- Respiratory Care and Oxygen Equipment. Nurse Managers will conduct Oxygen Order Audit weekly times four weeks, then biweekly times two months, then monthly times three months to ensure that all residents receiving Oxygen have appropriate physician orders per policy. All data will be reported at QAPI. Other residents who potentially could be affected by not having an order in place will be identified through the audit. R45 had a physician's order put into place immediately on discovering that her readmission orders did not have her previous O2 order in place.
Improper Storage of Controlled Drugs in Medication Room
Penalty
Summary
The facility failed to ensure that controlled drugs subject to abuse were stored and labeled in accordance with professional standards in the B wing medication room. During an observation, it was found that the door to the medication room had a coded lock, but the code was written on the door jamb, making it easily accessible. This was confirmed by the unit manager, Employee E8, during an interview at the time of the observation. Additionally, the medication refrigerator inside the B wing medication room was not locked, and it contained a transparent plastic box with an opened bottle of Lorazepam 2m/ml with 30 ml of liquid inside. The plastic box was not permanently affixed to the refrigerator, which was also confirmed by Employee E8 during the observation. These findings indicate a failure to adhere to the facility's policy on the safe, secure, and proper storage of medications and biologicals.
Plan Of Correction
Education provided to all licensed nurses regarding policy #4.2 the Storage of Controlled Substances. Nurse Managers will conduct audits on all units of the facility medication rooms to ensure that the narcotic box located in each medication refrigerator remains secured and locked as per above policy. The audits will be conducted daily times 4 weeks, then bi-weekly times two months, then monthly times 3 months. Door codes have been removed from door jams and included in above audit to ensure compliance.
Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide-to-resident ratios as mandated by the regulation effective July 1, 2024. Specifically, the facility did not provide the minimum of one nurse aide per 10 residents during the day shift, one nurse aide per 11 residents during the evening shift, and one nurse aide per 15 residents during the night shift on multiple occasions across three separate weeks. These deficiencies were identified through a review of facility census data, nursing schedules, and staff punch reports. The specific dates of non-compliance included July 3, 5, 6, and 7, 2024; October 31, 2024, through November 2, 2024; and December 5, 7, 8, and 9, 2024. An interview with the Scheduler, Employee E7, confirmed the failure to meet the required staffing ratios on these dates.
Plan Of Correction
Director of Nursing will conduct a random audit of 15 days throughout the quarter. Findings will be reported quarterly at QAPI.
LPN Staffing Deficiencies in 2024
Penalty
Summary
The facility failed to maintain the required staffing ratios for Licensed Practical Nurses (LPNs) during various shifts over several weeks in 2024. Specifically, the facility did not meet the minimum LPN staffing requirements during the day, evening, and overnight shifts on multiple occasions. For instance, on July 4, 2024, during the day shift, the facility provided only 40.50 LPNs, while the required number was 41.92. Similar deficiencies were noted on other dates, such as July 6, 2024, and November 3, 2024, where the facility consistently fell short of the required LPN staffing levels. The review of nursing staff schedules and punch reports confirmed these deficiencies, as discussed with the facility's Scheduler, Employee E7. The report highlights specific dates and shifts where the facility did not meet the mandated LPN-to-resident ratios, indicating a pattern of non-compliance with staffing regulations. These findings were based on a comprehensive review of the facility's staffing data over the specified periods.
Plan Of Correction
Director of Nursing will conduct a random audit of 30 days throughout the quarter and findings will be reported quarterly at QAPI. Scheduler and Nursing Leadership were educated as to the need for full staffing requirement for all three shifts, seven days each week at a 3.20 HPPD. Our issue is call-outs so we have been following our disciplinary process as well as putting extra staff on.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.20 hours of direct nursing care per resident per day on 11 out of 21 days reviewed. This deficiency was identified through a review of nursing time schedules, punch reports, and staff interviews. Specific dates where the facility did not meet the required staffing levels include July 2, July 4, July 5, July 6, July 7, October 28, October 31, November 1, November 2, November 3, and December 8, 2024. On these dates, the facility's census ranged from 127 to 135 residents, and the direct nursing care hours provided per resident varied from 2.70 to 3.14 hours, all falling short of the mandated 3.20 hours. The deficiency was confirmed during a review with the Scheduler, Employee E7, on December 12, 2024. The review of staffing calculations, nursing staff schedules, and staff punch reports corroborated the finding that the facility did not meet the required staffing minimum on the specified dates. This failure to provide adequate nursing care hours is a direct violation of the regulation effective July 1, 2024, which mandates a minimum of 3.20 hours of direct nursing care per resident per day.
Plan Of Correction
Director of Nursing will conduct a random audit of 30 days throughout the quarter and findings will be reported quarterly at QAPI. Scheduler and Nursing Leadership were educated as to the need for full staffing requirement for all three shifts, seven days each week at a 3.20 HPPD. Our issue is call-outs so we have been following our disciplinary process as well as putting extra staff on.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for residents on two of its nursing units, B Unit and C Unit. During an observation on August 21, 2024, several deficiencies were noted. In B Unit, multiple rooms had exposed bedpans and basins stored improperly, missing tiles, and dirty linen, with a strong odor of feces present. Additionally, an exposed electrical baseboard heater was found in the hallway leading to the C Wing resident area. These issues were confirmed by the unit manager, Employee E1, and maintenance staff, Employee E3, who admitted that the work in one of the rooms had been started but left incomplete. In C Wing, the first shower room was cluttered with various personal and medical items, rendering it unusable. The second shower was being used as a storage space, filled with a mattress, wheelchair, commode, and other items, making it non-functional as a shower. These observations were also confirmed by the unit manager. A resident residing in one of the affected rooms reported that the bathroom floor and baseboard had been ripped out two months prior and never finished, highlighting the prolonged nature of the deficiencies.
Failure to Implement Person-Centered Care Plan for Communication
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident 75, who has diagnoses including Corticobasal degeneration, paralysis of the vocal cords and larynx, and a rare progressive neurological disorder. Despite the resident's intact cognition, as indicated by the BIMS score, the care plan did not address the resident's strong preference for using paper and pen to communicate. This preference was confirmed through interviews with the resident, the unit manager, a nursing aide, and a speech therapist. The resident became frustrated and screamed when alternative communication methods, such as a communication board or an iPad, were attempted, indicating a clear need for the care plan to reflect her preferred communication method. The deficiency was identified through a review of the facility's policy on Resident Assessment & Care Planning, clinical records, and staff interviews. The policy mandates that a licensed nurse, in coordination with the interdisciplinary team, develops and implements an individualized care plan to provide effective, person-centered care. However, the care plan for Resident 75 did not include any interventions to support her preferred method of communication, leading to frustration and ineffective communication. This oversight was confirmed by multiple staff members, including the unit manager and the speech therapist.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to identify, implement, monitor, and modify interventions consistent with the residents' assessed needs to maintain acceptable parameters of nutritional status for two residents. Resident R65 experienced significant weight loss beginning in November 2023, with a documented weight drop from 190.2 pounds to 141.0 pounds by March 2024. Despite the critical weight loss, timely interventions were not implemented. The dietary note on December 20, 2023, recommended adding a nutritional supplement, but the weight loss continued, and the Registered Dietitian was unable to explain the lack of timely assessment and intervention. Resident R30, who had diagnoses of dementia and dysphagia, also experienced significant weight loss. The resident's weight dropped from 170.4 pounds in September 2024 to 143 pounds by January 2024. Weekly weights were ordered but not documented, and the resident's nutritional status was not reassessed or addressed in a timely manner. The Registered Dietitian did not reassess the resident and modify interventions until 16 days after the identified weight loss in both October 2024 and January 2024. Interviews with the Registered Dietitian revealed an inability to explain why the weights and nutritional status were not being monitored or addressed in a timely manner. The facility's failure to follow its policy on weight monitoring and tracking, as well as the lack of timely interventions, contributed to the significant weight loss experienced by both residents.
Failure to Provide Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of Resident R45, specifically in acquiring, receiving, and administering medications. The facility's policy on Medication Management/Medication Unavailability requires that if medications are unavailable, the licensed nurse must notify the provider and request an alternate treatment, document the notification, and activate backup pharmacy procedures. However, Resident R45 did not receive Pregabalin 50 mg on multiple occasions due to the medication being unavailable and awaiting delivery from the pharmacy. There was no documented evidence that the physician was informed of the missed doses or that an alternate treatment was requested. Additionally, the backup pharmacy process and procedures were not activated by the nursing staff. The Director of Nursing confirmed that Resident R45 missed doses of Pregabalin and that the nursing staff did not follow the facility's policy and procedure to acquire and administer the medication. This deficiency was identified through a review of the facility policy, clinical records, and interviews with staff. The failure to follow the established procedures resulted in Resident R45 not receiving the necessary medication for pain caused by nerve damage on several occasions.
Failure to Ensure Understanding of Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents and their representatives had the capacity to understand the terms of a binding arbitration agreement. This deficiency was identified for four residents (R35, R48, R93, R113) who were found to have signed the arbitration agreements without a proper explanation in a language they could understand. The review of the facility's policy on Binding Arbitration revealed that the agreements were missing key elements, such as the statement that arbitration is not a condition of admission, the right to rescind the agreement within 30 days, and the prohibition of language that discourages communication with federal, state, or local officials. During the Resident Council meeting, four residents reported that the facility did not explain the arbitration agreement in a manner they could comprehend, leading them to wish to revoke their signatures. Interviews with the Admission Director confirmed that the arbitration agreements were read to the residents or their representatives without ensuring they understood the terms. Additionally, the Admission Director was unaware of the time frame to rescind the arbitration agreement. The facility's failure to provide a clear and understandable explanation of the arbitration agreements to the residents and their representatives resulted in a lack of informed consent. This oversight was confirmed through document reviews, resident interviews, and staff interviews, highlighting a significant lapse in the facility's responsibility to ensure residents' rights and understanding of legal agreements.
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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