Manor At Penn Village, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Selinsgrove, Pennsylvania.
- Location
- 51 Route 204, Selinsgrove, Pennsylvania 17870
- CMS Provider Number
- 395172
- Inspections on file
- 33
- Latest survey
- December 5, 2025
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Manor At Penn Village, The during CMS and state inspections, most recent first.
A resident with a history of exit-seeking behaviors repeatedly attempted to leave the unit, activated the wander guard alarm, and ultimately exited the building without effective intervention. The facility's wander guard system only triggered alarms and was not integrated with doors or elevators to prevent exit, and the front doors remained unlocked during the day without staff monitoring. This lack of effective supervision and environmental controls allowed the resident to elope and demonstrated a failure to prevent accident hazards.
A review of staffing schedules and census data showed that the facility did not meet state-mandated minimum nurse aide (NA) staffing ratios for day, evening, and night shifts on multiple days. The number of NAs scheduled was consistently below the required levels for the resident census, as confirmed by staff interviews and documentation review.
A review of staffing records and interviews with facility leadership revealed that the facility did not consistently provide the required 3.2 hours of direct nursing care per resident per day, with multiple days falling below this standard.
The facility failed to comply with Pennsylvania's LTC licensure regulations by not maintaining the required nurse aide-to-resident ratios during various shifts over a 21-day period. The day, evening, and night shifts were understaffed on multiple occasions, as confirmed by the Nursing Home Administrator and DON.
The facility did not meet the required 3.2 hours of direct resident care per patient day for seven days within a reviewed period. Nursing care hours ranged from 2.76 to 3.15, as confirmed by the Nursing Home Administrator and DON.
Staff did not ensure proper housekeeping and maintenance on two units, resulting in multiple wheelchairs with debris, a shower gurney with torn padding, unclean shower rooms with soiled equipment, and resident care items that were not properly stored or labeled. Broken equipment and unaddressed spills were also observed, compromising the cleanliness and safety of the environment.
The facility failed to implement physician-ordered restorative nursing programs for two residents, leading to deficiencies in maintaining their mobility. One resident with severe cognitive impairment did not receive the recommended ambulation program, while another resident's ambulation program was not completed as ordered. A third resident did not receive the recommended restorative program after therapy discharge, with no evidence of implementation or completion.
The facility failed to conduct annual performance evaluations for two nurse aides, as required by regulations. A review of personnel records and staff interviews revealed that the evaluations were not completed, which was confirmed by a human resources employee. This issue had been previously cited, indicating a recurring compliance problem.
The facility failed to ensure that attending physicians addressed pharmacy recommendations for three residents, leading to deficiencies in drug regimen reviews. A resident's prolonged use of Ativan and inappropriate timing of an antidepressant were not addressed for months. Another resident's medication evaluations and dose reductions were ignored, and a third resident's use of methenamine and CNS active medications were not reevaluated despite recommendations. Staff confirmed the lack of physician response.
The facility failed to ensure proper use of psychotropic medications for three residents. One resident received Ativan without documented rationale for continued use beyond 14 days, while another had a similar issue with Ativan being discontinued months later. A third resident received double doses of Lorazepam due to a transcription error, leading to excessive sleepiness and family concerns.
A facility failed to maintain a medication error rate below five percent, resulting in a ten percent error rate. An LPN improperly crushed and administered medications to a resident, including an incorrect dosage of Pantoprazole. Another LPN failed to prime a Humalog Kwikpen before administering insulin to a resident. These errors were confirmed in staff interviews and discussed with facility leadership.
A resident with visible dental decay and missing teeth had not seen a dentist since 2019, despite expressing a desire for dental care in 2023. The facility failed to coordinate necessary dental services, as confirmed by the Nursing Home Administrator, and only recently added the resident to the list for the next dental visit.
The facility failed to ensure residents and a staff member were educated, offered, and received the COVID-19 vaccine if consented. Five residents were not documented as having been offered updated vaccines or educated on them, and a registered nurse was not screened, offered, or educated about the vaccine. This deficiency was confirmed by the infection control preventionist.
A facility failed to align a resident's advance directives with physician orders, resulting in a discrepancy where the resident was initially marked as 'Full Code' despite documentation indicating a Do Not Resuscitate (DNR) preference. This inconsistency was identified and confirmed by the Nursing Home Administrator and Director of Nursing, leading to an update in the physician's order.
The facility failed to prevent falls and investigate incidents for two residents. One resident had a physician's order for bilateral fall mats, but only one was placed, and staff allowed the resident to sit on the bed for meals against the care plan. Another resident had unexplained bruises, and the facility did not conduct a thorough investigation or implement preventive measures. These issues were confirmed in staff interviews.
Two residents experienced significant weight loss due to the facility's failure to implement necessary nutritional interventions. One resident, with a history of strokes and a PEG tube, was not adequately monitored or provided with supplemental feeding despite declining weight. Another resident experienced rapid weight loss without timely physician notification or intervention. The facility's inaction led to severe nutritional deficiencies.
The facility failed to provide proper respiratory care for two residents. One resident with COPD was receiving less oxygen than ordered, while another resident had no documented oxygen saturation assessments despite a physician's order. The care plan for the second resident lacked an intervention for supplemental oxygen.
The facility failed to provide sufficient nursing staff to meet the schedules for activities of daily living for two residents. One resident was observed in bed later than his preferred time due to staff shortages, while another had to eat breakfast in bed against her preference. A nurse aide confirmed the delay was due to insufficient staffing, which was addressed with the Nursing Home Administrator and the DON.
A facility failed to accurately document the administration of a Prenatal Oral Tablet for a resident. The MAR showed the medication was administered on several days, despite notes indicating it was unavailable. The issue was due to a documentation error, and the medication order was not updated in the electronic health record.
The facility failed to provide recommended pneumococcal immunizations for three residents. One resident did not receive a follow-up PPSV23 vaccine after a previous Prevnar 13 vaccination, another resident was not assessed or offered the vaccine within 30 days of admission, and a third resident did not receive a follow-up PCV15 or PCV20 vaccine after a prior PPSV23 vaccination. These deficiencies were confirmed by the infection control preventionist.
The facility did not follow CDC guidelines for pre-employment TB screening for a newly hired employee. The deficiency was identified through personnel records and staff interviews, showing non-compliance with the requirement for TB testing upon hire.
The facility failed to comply with TB testing requirements for an Occupational Therapist hired without complete testing documentation. Additionally, the facility did not meet the required nurse aide staffing levels during various shifts over a 21-day period, with specific shortfalls noted in the day, evening, and night shifts.
The facility did not meet the required LPN staffing levels during an overnight shift, scheduling only 2.63 LPNs for 109 residents, when 2.73 were needed. This deficiency was confirmed by the scheduler.
The facility did not meet the required 3.2 hours of direct nursing care per resident per day for 10 out of 21 days reviewed. Nursing care hours ranged from 2.91 to 3.18 PPD, as identified through staffing hours review and staff interviews. This issue was discussed with the Nursing Home Administrator and the DON.
The facility failed to maintain proper latching of corridor doors, as observed in the Therapy room and Resident Room 307, where doors did not latch into the frame, compromising smoke resistance. This was confirmed during an exit conference with facility representatives.
The facility failed to maintain smoke barrier doors according to NFPA 101 standards, affecting multiple areas. Observations revealed that doors near the exit and employee lounge did not fully close when released from hold open devices, compromising their ability to resist fire and smoke.
The facility failed to maintain proper hazardous area enclosures, affecting one floor. A door to the copy room was held open by an unapproved door wedge, as observed and confirmed during an interview with the administrator and maintenance representative.
The facility failed to maintain the automatic sprinkler system, as observed in two locations affecting one floor. The Dietary Walk-In freezer and Storage Room were both missing escutcheons. This deficiency was confirmed during an interview with the administrator and maintenance representative.
The facility was found to have a deficiency due to the unauthorized use of a surge protector to power a microwave in the Employee Lounge. This was observed and confirmed during an interview with the administrator and maintenance representative.
A resident at The Manor at Penn Village was admitted with fragile skin and developed pressure ulcers due to inadequate skin assessments and failure to implement wound care recommendations. The facility did not conduct required weekly evaluations or document the condition of wounds, leading to a deterioration in the resident's condition.
A resident's discharge planning process was deficient due to inadequate communication and involvement of the resident's POA and family. The facility failed to document discussions about the resident's care needs and did not effectively communicate with a potential transfer facility, leading to delays and lack of updates on the resident's discharge status.
A resident with a history of falls and dementia was observed crossing a busy road with a walker, intending to buy cigarettes. Despite being retrieved by staff, the incident was not documented in the clinical record, and no assessment or safety measures were implemented. Staff interviews revealed inconsistencies in understanding the resident's permissions to go outside unattended.
The facility failed to provide written notice to residents and their responsible parties before moving them to different rooms. Seven residents were affected by room moves due to consolidation efforts, and notifications were made via telephone, often just hours before the moves. In one case, a responsible party was not notified at all. The deficiency was acknowledged by the NHA and DON.
The facility failed to assist residents with bathing and meal positioning. A resident with dysphagia did not receive proper meal positioning as recommended by Speech Therapy, and three residents did not receive showers according to their preferences. The facility lacked documentation and instructions for staff to follow care plans and resident preferences, as confirmed by interviews with the DON and Nursing Home Administrator.
The facility failed to ensure that staff with appropriate competencies provided care for residents, as Employee 4, lacking necessary certification, documented completion of care tasks for nine residents. These tasks included essential daily living activities and restorative nursing programs, highlighting a significant deficiency in staff training and certification.
The facility failed to provide a clean and homelike environment, with significant dust and debris found in heating/air conditioning units across multiple rooms, including those of several residents. Additionally, a dead insect and unemptied trash cans were observed in a resident's room, despite indications of recent cleaning. These issues were confirmed by housekeeping staff and discussed with the facility's administration.
A facility failed to develop a baseline care plan within 48 hours of a resident's admission. The care plan, documented days later, lacked person-centered interventions. Comprehensive care plans for community involvement, ADL deficits, and swallowing issues were delayed, indicating a failure to provide timely, person-centered care. These findings were reviewed with the Nursing Home Administrator and DON.
A facility failed to ensure accurate medication administration and documentation for a resident with Crohn's disease. The resident's prescribed Budesonide was not consistently administered due to pharmacy delays, and there was no follow-up with the pharmacy or documentation of physician notification. Additionally, several other medications lacked documentation of administration, refusal, or unavailability. The facility did not maintain accurate records, leading to a deficiency in pharmaceutical services.
A resident, assessed as cognitively intact, eloped from the facility through an improperly armed egress door with a non-functioning alarm. The resident was found at a nearby supermarket. The facility's investigation was incomplete, lacking statements from involved parties and failing to determine why the alarm system failed.
The facility failed to document the administration of medications and treatments for four residents, including Levothyroxine, Omeprazole, Vancomycin, and Gabapentin, as well as various treatments like enteral residual checks, colostomy care, and PICC line maintenance. These deficiencies were noted on multiple dates in March and April 2024.
The facility failed to implement necessary treatment and services to promote pressure ulcer healing and prevent new ulcers for two residents. One resident did not receive a custom wheelchair cushion as recommended, and daily wound treatments were not documented on several dates. Another resident's sacral wound worsened significantly, and a second pressure ulcer developed due to lack of timely assessment and intervention.
The facility failed to maintain acceptable nutritional status for two residents, with missed weight assessments and undocumented feedings for one resident, and inadequate response to severe weight loss for another. The issues were discussed with the Nursing Home Administrator and the DON.
The facility failed to secure medications and biologicals on one nursing unit, leaving the medication prep room and treatment carts unlocked and unattended while maintenance staff installed a padlock on the refrigerator. A resident had access to the unsecured room, which contained various over-the-counter medications and medicated treatments.
The facility failed to provide palatable food on two nursing units. Residents reported cold and tough food, and observations confirmed that food temperatures were below acceptable levels. Interviews with the Nursing Home Administrator and DON revealed no policy to ensure food temperatures met palatable standards at the point of service.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Environmental Controls
Penalty
Summary
The facility failed to implement effective interventions to prevent resident elopement for one resident with a known history of exit-seeking behaviors. Clinical records documented multiple instances where the resident was observed attempting to leave the unit, activating the wander guard alarm, and being found near facility exits or on the elevator. Despite these repeated behaviors, the interventions in place, such as the wander guard system and periodic checks, were insufficient to prevent the resident from leaving the building. On one occasion, the resident successfully eloped by walking out the front door and was found outside near a highway before being redirected back into the facility by staff. The wander guard system did sound alarms when the resident approached restricted areas, but it was not integrated with the doors or elevators to physically prevent exit. The front doors were only locked during nighttime hours, leaving them accessible during the day, and there was no staff present at the front desk during the surveyor's visit, allowing for unmonitored exit from the facility. Interviews with the Nursing Home Administrator confirmed that the wander guard system only triggered alarms and did not lock doors or elevators, and that residents could exit the building if staff did not respond to alarms in a timely manner. The lack of effective supervision and environmental controls contributed to the resident's ability to elope, demonstrating a failure to ensure the area was free from accident hazards and to provide adequate supervision to prevent accidents.
Failure to Meet Minimum Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to comply with Pennsylvania state regulations regarding minimum nurse aide (NA) staffing levels across all three shifts. A review of nursing staff care hours and interviews with staff revealed that, for multiple days within the reviewed periods, the number of NAs scheduled did not meet the required ratios based on the resident census. Specifically, during the day shift, the facility did not provide at least one NA per 10 residents for 11 out of 21 days reviewed. During the evening shift, the required ratio of one NA per 11 residents was not met for 19 out of 21 days, and during the night shift, the ratio of one NA per 15 residents was not met for 19 out of 21 days. The deficiency was identified through a detailed review of staffing schedules and resident census data for several weeks. On numerous specific dates, the number of NAs scheduled was consistently below the minimum required for the census present on each shift. These findings were confirmed and discussed with the Nursing Home Administrator and the Director of Nursing during the survey process. No information about individual residents or their medical conditions was provided in the report.
Plan Of Correction
The facility cannot retroactively correct past nursing aide ratios. The facility will continue to take measures to adequately provide nurse-aid staff to ensure the needs of the residents are met. Measures will be put in place to adequately provide staff with the required nurse aide to resident ratios. These measures include continuing our retention committee, increased advertising efforts, utilization of agency staff, and sign-on bonuses. The Director of Nursing/designee will educate minimum staffing ratios to RN Supervisors, HR, and the nursing scheduler who are responsible to maintain adequate staffing ratios. The Director of Nursing/designee will audit the daily schedules 5x week x 6 weeks to ensure that the minimum number of nurse aide staff to resident ratios have been scheduled. The results of the audits will be reviewed at the facility's QAPI meeting for recommendations.
Failure to Meet Minimum Nursing Care Hours Requirement
Penalty
Summary
The facility failed to provide the required minimum of 3.2 hours of direct nursing care per resident per day over a 24-hour period, as mandated effective July 1, 2024. A review of nursing staffing hours for selected dates in June, July, and August 2025 revealed that on 16 out of 21 days reviewed, the facility did not meet this minimum standard. Specific daily nursing care hours ranged from 2.70 to 3.20 hours per resident per day, with several days falling below the regulatory requirement. This deficiency was identified through a review of facility records and confirmed during an interview with the Nursing Home Administrator and Director of Nursing. The report does not mention any specific residents or their medical conditions, nor does it provide details about the impact on individual patient care. The findings are based solely on the documented nursing care hours provided during the reviewed periods.
Plan Of Correction
The facility cannot retroactively correct past PPD staffing levels. The facility will continue to take measures to adequately provide nursing staff to ensure the needs of the residents are met. Measures will be put in place to adequately provide staff. These measures include, continuing our retention committee, increased advertising efforts, utilization of agency staff, and sign-on bonuses. The Director of Nursing/designee will educate RN Supervisors, HR, and the nursing scheduler about PPD staffing levels, who are responsible for maintaining adequate staffing ratios. The Director of Nursing/designee will audit the daily schedules 5 times a week for 6 weeks to ensure that the minimum PPD staffing levels have been scheduled. The results of the audits will be reviewed at the facility's QAPI meeting for recommendations. Jeanne Parici Jeanne Parisi Deputy Secretary for Quality Assurance Pennsylvania Debra L. Bogu MD Debra L. Bogen, MD, FAAP Secretary of Health Department of Health THIS IS A CERTIFICATION PAGE PLEASE DO NOT DETACH THIS PAGE IS NOW PART OF THIS SURVEY
Non-Compliance with Nurse Aide Staffing Ratios
Penalty
Summary
The facility was found to be non-compliant with the Commonwealth of Pennsylvania Long Term Care Licensure Regulations regarding nursing services. Specifically, the facility failed to maintain the required nurse aide-to-resident ratios during various shifts over a 21-day review period. On two occasions during the day shift, the facility did not meet the minimum requirement of one nurse aide per 10 residents. Similarly, the evening shift fell short of the required one nurse aide per 11 residents on one occasion. The night shift was particularly problematic, with four instances where the facility did not meet the required one nurse aide per 15 residents. The specific dates and staffing levels were documented, showing that on April 20 and April 27, the day shift was understaffed, while the evening shift on April 20 and the night shifts on April 23, 27, 28, and 29 were also below the required staffing levels. Interviews with the Nursing Home Administrator and Director of Nursing confirmed these deficiencies, acknowledging that the facility did not meet the regulatory nurse aide-to-resident ratios as required by the state regulations.
Plan Of Correction
The facility cannot retroactively correct past Nursing aide ratios. The facility will continue to take measures to adequately provide nurse-aid staff to ensure the needs of the residents are met. Measures will be put in place to adequately provide staff with the required nurse aide to resident ratios. These measures include continuing our retention committee, increased advertising efforts, utilization of agency staff, and sign on bonuses. The Director of Nursing/designee will educate minimum staffing ratios to RN Supervisors, HR, and the nursing scheduler who are responsible to maintain adequate staffing ratios. The Director of Nursing/designee will audit the daily schedules 5x week x 6 weeks to ensure that the minimum number of nurse aide staff to resident ratios have been scheduled. The results of the audits will be reviewed at the facilities QAPI meeting for recommendations.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per patient day (PPD) for seven out of the 21 days reviewed. This deficiency was identified through a review of nursing care hours from March 30, 2025, to April 29, 2025. Specific dates where the facility did not meet the required hours include April 20, 23, 25, 26, 27, 28, and 29, 2025, with PPD ranging from 2.76 to 3.15. An interview with the Nursing Home Administrator and Director of Nursing on April 30, 2025, confirmed the facility's failure to meet the required nursing care hours.
Plan Of Correction
The facility cannot retroactively correct past PPD staffing levels. The facility will continue to take measures to adequately provide nursing staff to ensure the needs of the residents are met. Measures will be put in place to adequately provide staff. These measures include continuing our retention committee, increased advertising efforts, utilization of agency staff, and sign-on bonuses. The Director of Nursing/designee will educate PPD staffing levels to RN Supervisors, HR, and the nursing scheduler who are responsible to maintain adequate staffing ratios. The Director of Nursing/designee will audit the daily schedules 5x week x 6 weeks to ensure that the minimum PPD staffing levels have been scheduled. The results of the audits will be reviewed at the facility's QAPI meeting for recommendations.
Failure to Maintain Clean and Safe Resident Environment
Penalty
Summary
Facility staff failed to maintain a clean, safe, and homelike environment on two nursing units, as evidenced by multiple observations of unclean and poorly maintained equipment and areas. On Nursing Unit C, several wheelchairs, some without resident identifiers, were found with significant accumulations of crumbs and debris under the seat cushions. One wheelchair also had an unidentified piece of metal on the seat. The shower room on this unit contained a shower gurney with multiple tears in the padding, exposing the underlying foam, and a shower chair piled with several resident lift slings and a padded foam heel boot. A basin in the shower room held various shower supplies, some labeled with different resident initials, with at least one item leaking onto others, including an unused brief. On Nursing Unit F, the shower room contained a bucket used for a bedside commode that was partially filled with a brownish-tinged liquid and a brown object resembling a bowel movement. A hair comb with a significant accumulation of white flakes and hair was found among other combs. Additional observations included a resident's wheelchair that was wet with an unidentified liquid, a Geri-chair with broken plastic trays exposing jagged edges, and another wheelchair with debris in the cupholder, a missing protective cap on the frame, accumulated dirt and debris, and rust. These findings were reviewed with facility leadership.
Failure to Implement Restorative Nursing Programs
Penalty
Summary
The facility failed to provide physician-ordered services to maintain mobility for two residents and did not maintain a restorative nursing program for two residents. Resident 85, who had a severe cognitive impairment, was discharged from physical therapy with a recommendation to ambulate 200 to 300 feet with a rolling walker and supervision. However, documentation revealed that the restorative nursing program was only completed once between October 2024 and December 2024, despite the therapy recommendations. Resident 73 had an active physician's order to ambulate 100 feet with a roller walker and supervision, but the restorative ambulation program was not completed twice daily as ordered. Documentation showed that the program was not completed at least once on several days in January 2025. Resident 73 reported that staff had not walked with her as required, and staff comments suggested a lack of follow-through on the restorative program. Resident 98, who had been discharged from therapy with a good prognosis for maintaining his current level of functioning, did not receive the recommended restorative nursing program. The program included ambulating up to 250 feet with a rolling walker and performing range of motion exercises. There was no evidence that this program was ordered, implemented, or completed after the resident's therapy ended. Interviews with staff confirmed these deficiencies in the restorative nursing programs for the residents.
Plan Of Correction
The facility is unable to retroactively provide physician ordered services for residents 73 and 98 and maintain the restorative nursing programs for residents 85 and 98. Orders for restorative programs will be reviewed to determine if they are still applicable. Orders that are still appropriate will be implemented. The facility will review physician ordered restorative nursing programs to ensure that the restorative nursing services are provided as ordered. Education will be provided to Licensed Nurses on implementing orders for restorative programs. The facility will educate CNAs on the importance of following physician orders for restorative nursing. The DON or designee will audit restorative nursing programs of 3 residents x5 a week for 8 weeks to ensure completion. The results of the audits will be reviewed at the facilities QAPI meeting for recommendations.
Failure to Conduct Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete a performance evaluation of each nurse aide at least once every 12 months, as required by §483.35(d)(7). This deficiency was identified during a review of employee personnel records and staff interviews. Specifically, two nurse aides, hired on May 29, 2013, and October 27, 1998, respectively, did not have documented evidence of annual performance evaluations. An interview with a human resources employee confirmed that these evaluations were not completed for the two nurse aides in question. This issue was previously cited on January 26, 2024, indicating a recurring problem with compliance in this area.
Plan Of Correction
The performance reviews for employees 8 and 9 were completed. All employees eligible for an annual performance review received one. Education was provided to the facility DON to ensure the completion of annual performance reviews. The Administrator or designee will conduct weekly audits for 12 weeks to ensure that eligible employees receive a performance review. The results of the audits will be reviewed at the facility's QAPI meeting for recommendations.
Failure to Address Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that the attending physicians addressed pharmacy recommendations for three residents, leading to deficiencies in drug regimen reviews. For Resident 77, the consultant pharmacist identified irregularities in the medication regimen, including the prolonged use of Ativan without a stop date and the inappropriate timing of an activating antidepressant. Despite these recommendations, there was no documented evidence of physician review or response until several months later, indicating a significant delay in addressing the pharmacist's concerns. Resident 20's clinical records revealed multiple pharmacy recommendations for medication evaluations and dose reductions, which were not reviewed or responded to by the attending physician. These recommendations included evaluating medications for an annual dose reduction and assessing potential contributors to a fall. The lack of timely physician response to these recommendations highlights a failure in the facility's process for addressing pharmacist-identified irregularities. Similarly, Resident 63's records showed repeated pharmacy recommendations to reevaluate the use of methenamine and the combination of central nervous system active medications. Despite these recommendations, there was no documented physician response, indicating a failure to act on the pharmacist's advice. Interviews with facility staff confirmed the lack of documented evidence of physician review or response to the pharmacist's recommendations for all three residents.
Plan Of Correction
The pharmacy recommendations for residents 77, 20, and 63 were addressed by their attending physicians. A 30 day look back was completed to ensure that all pharmacy recommendations were addressed. The DON and ADON were educated on ensuring that pharmacy recommendations are addressed timely. The Administrator or designee will audit pharmacy recommendations monthly x2 to ensure they are addressed by a physician. The results of the audits will be reviewed at the facilities QAPI meeting for recommendations.
Failure to Ensure Proper Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents' medication regimens were free from potentially unnecessary psychotropic medications, as evidenced by the cases of three residents. Resident 69 was prescribed Ativan for anxiety, with an order allowing administration every six hours as needed. However, there was no documented rationale from the physician for the continued use of Ativan beyond the 14-day limit, as required by regulations. The medication was only discontinued after surveyors questioned the order. Similarly, Resident 77 was also prescribed Ativan with a similar order, but again, there was no documented rationale for its continued use beyond 14 days. The medication was discontinued nearly six months after it was initially prescribed, following the surveyors' review. This indicates a pattern of non-compliance with the requirement to document the necessity of continued psychotropic medication use. Resident 85's case involved a medication error where the resident received double doses of Lorazepam due to a transcription issue and confusion with the medication card from the pharmacy. The resident, who had a severe cognitive impairment, was noted to be excessively sleeping, and the family expressed concerns about lethargy. Despite staff awareness of the error, there was no documentation of an investigation or corrective action taken to address the medication error during the specified dates.
Plan Of Correction
The orders for residents 69 and 77 were discontinued. The order for resident 85 was corrected on 1/6/25. An audit of prn psychotropic medications for current residents was completed to ensure that each order included a 14 day stop. An audit of current residents with orders for psychotropic medications was completed to ensure the delivered medication matches the physician's order. Education will be provided to all licensed nurses to ensure orders received for prn-psychotropic medications include a 14 day stop, and to identify and report any discrepancies with delivered medications and physician orders for administration. The DON or designee will complete audits of new psychotropic medication orders to ensure that prn medications include a 14 day stop and that delivered medications match physician orders x8 weeks. The results of the audits will be reviewed at the facilities QAPI meeting for recommendations.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a ten percent error rate based on 30 medication opportunities with three errors. One incident involved a resident whose medications were improperly crushed and administered by an LPN. The resident was prescribed Isosorbide Mononitrate ER and Pantoprazole Sodium DR, both of which should not be crushed. The LPN crushed these medications and administered an incorrect dosage of Pantoprazole, giving 40 mg instead of the prescribed 20 mg. This error was confirmed during an interview with the LPN, and the facility's documentation indicated that these medications were on a list of drugs that should not be crushed. Another incident involved the administration of insulin to a different resident using a Humalog Kwikpen. The LPN failed to prime the pen before administering the insulin, which is a necessary step to ensure the correct dosage is delivered. This oversight was confirmed in an interview with the LPN. The facility's failure to adhere to proper medication administration protocols was discussed with the Nursing Home Administrator, Director of Nursing, and Assistant Director of Nursing.
Plan Of Correction
The facility is unable to retroactively correct the medication errors for residents 40 and 66. A house audit of current residents' medication was completed to ensure proper orders for administration were in place for crushed medications and insulin. Licensed nurses were educated on appropriate crushing of medications and proper use of insulin syringes. The DON or designee will complete med pass observations of 3 licensed staff a week x 8 weeks to ensure appropriate administration. If variances are identified, the nurse will receive re-education. The results of the audits will be reviewed at the facility's QAPI meeting for recommendations.
Failure to Provide Necessary Dental Services
Penalty
Summary
The facility failed to provide necessary dental services for a resident who was observed to have visible black and decayed lower teeth with multiple teeth missing. The resident, who had been admitted to the facility in 2018, stated she did not recall seeing a dentist since her admission. A review of her clinical records revealed that her last confirmed dental visit was in 2019, despite a care plan initiated in 2019 indicating the need for dental care coordination due to oral health problems related to poor nutrition and dentition. A facility 'Request for Service' form from 2023 showed the resident expressed a desire to be seen for dental care, yet there was no evidence of any dental appointments being made or attended since 2019. The Nursing Home Administrator confirmed the lack of coordinated dental services for the resident since 2019. An email from the facility's dental provider dated January 2025 indicated the resident was only recently added to the list for the next dental visit, highlighting the facility's failure to ensure timely dental care for the resident.
Plan Of Correction
A dental referral was made for resident 20. A house audit of current residents was completed to ensure that eligible residents received dental referrals. Education will be provided to the IDT on ensuring dental referrals are made for eligible residents. The DON or designee will audit new residents for 60 days to ensure that dental referrals are made for eligible residents. The results of the audits will be reviewed at the facilities QAPI meeting for recommendations.
Failure to Offer and Document COVID-19 Vaccination
Penalty
Summary
The facility failed to ensure that residents were educated, offered, and received the COVID-19 vaccine if they consented. This deficiency was identified for five residents who were reviewed for immunizations. Specifically, Resident 4 had not been offered an updated COVID-19 vaccine or provided education regarding its risks and benefits since her last vaccine in November 2022. Resident 16, who was admitted in 2022, also lacked documentation of being offered an updated vaccine or receiving education. Similarly, Residents 21 and 53, who last received vaccines in February 2023, were not documented as having been offered updated vaccines or educated on them. Resident 85, admitted in August 2024, had no documented COVID-19 vaccination history, offer, or education. The facility also failed to screen, educate, and offer the COVID-19 vaccine to an employee reviewed, identified as Employee 12, a registered nurse hired in September 2024. There was no documented evidence that the facility screened her for vaccine eligibility, offered the vaccine, or provided education about its risks and benefits. This oversight was confirmed during an interview with the infection control preventionist. The facility's policies for both residents and staff indicated that they would be educated about and offered the COVID-19 vaccine in accordance with CDC and FDA guidelines. However, the review revealed a lack of adherence to these policies, as evidenced by the absence of documentation for the residents and the employee involved. The deficiency was previously cited in January 2024, indicating a recurring issue with the facility's compliance with COVID-19 immunization requirements.
Plan Of Correction
The facility offered Covid vaccinations to residents 4, 16, 21, 53, 85, and to staff member 12. The facility will screen employees and current residents for Covid vaccine eligibility and offer the vaccine or educate on the risks and benefits. The facility's infection preventionist will receive education on the facility's "Covid 19 Vaccine" policy. The DON or designee will audit new hires and newly admitted residents to ensure a Covid vaccine is offered to eligible persons and provide them or their responsible party with education regarding its risks and benefits. The results of the audits will be reviewed at the facility's QAPI meeting for recommendations.
Failure to Align Advance Directives with Physician Orders
Penalty
Summary
The facility failed to establish clear advance directives for a resident, identified as Resident 108, which led to a discrepancy between the resident's documented wishes and the physician's orders. Upon admission on January 3, 2025, Resident 108 was recorded as a 'Full Code' in the physician's orders, indicating that resuscitation efforts should be made in the event of cardiac or respiratory arrest. However, the facility's 'Advanced Directives Discussion Document' and the resident's Living Will, both signed by the resident's Power of Attorney and a registered nurse, indicated that the resident did not want cardiopulmonary resuscitation (CPR). This inconsistency was not addressed until a meeting with the Nursing Home Administrator and Director of Nursing on January 29, 2025. The discrepancy was identified during a review of the resident's records, which revealed that the resident's care plan and physician orders were not aligned with the resident's advance directives. The facility documentation showed that the resident's wishes to withhold CPR were clearly marked, yet the physician's order initially indicated otherwise. This oversight was confirmed in a follow-up interview with the Nursing Home Administrator and Director of Nursing, who acknowledged the error and subsequently updated the physician's order to reflect the resident's Do Not Resuscitate (DNR) status.
Plan Of Correction
The facility clarified the advanced directives for resident 108. An audit of the advanced directives for all current residents was conducted to ensure that a written copy of the advanced directives was on file, and that the written copy matched each resident's orders and care plan. Education on ensuring accurate advanced directives was provided to facility licensed staff and the interdisciplinary team. Audits will be conducted by the Administrator of all new admissions x60 days to ensure that the advanced directives match the orders and the care plan. The results of the audits will be reviewed at the facilities QAPI meeting for recommendations.
Failure to Implement Fall Prevention and Investigate Incidents
Penalty
Summary
The facility failed to thoroughly investigate incidents and implement interventions to prevent future falls or accidents for two residents. For Resident 83, there was a physician's order for bilateral fall mats beside the bed, but the plan of care did not include this intervention. Observations revealed that only one fall mat was placed on the left side of the bed, contrary to the physician's order. Additionally, staff assisted Resident 83 to sit on the side of the bed for meals, which was against the plan of care that required him to be in a wheelchair or sit up in bed with a tray table. These discrepancies were confirmed during staff interviews. For Resident 164, nursing documentation noted large bruises on her abdominal area, and the resident was unaware of how they occurred. The facility's investigation suggested that the bruises might have been caused by bumping into the side of her chair or bathroom rail, but there was no documented evidence of further staff interviews or implemented interventions to prevent future occurrences. The facility's failure to conduct a thorough investigation and implement preventive measures was confirmed in interviews with the Administrator and Director of Nursing.
Plan Of Correction
The care plan for resident 83 was corrected to include the use of bilateral fall mats and to allow resident to eat while in bed. The facility is unable to retroactively provide appropriate interventions for resident 164. The facility will audit the use of fall mats to ensure that those interventions are accurately care planned and deployed as needed. The facility will review the previous 2 weeks of falls to ensure that an appropriate intervention has been implemented. Education will be provided for the CNAs to ensure that fall mats are provided for each resident as indicated in the Kardex. Education will also be provided to licensed nurses to ensure all falls have an investigation initiated that includes an immediate intervention. The IDT will be educated to ensure that all initiated facility investigations are completed and reviewed to ensure an appropriate plan is in place to prevent recurrence. The DON or designee will complete audits x5 a week for 8 weeks of 3 residents to ensure that fall mats are in place in accordance with each resident's care plan. Additional audits of resident fall investigations will occur consisting of 5 a week x 8 weeks to ensure that the facility investigation was completed and an appropriate plan was put in place to prevent recurrence. The results of the audits will be reviewed at the facility's QAPI meeting for recommendations.
Failure to Maintain Nutritional Status for Residents
Penalty
Summary
The facility failed to implement necessary interventions to maintain acceptable nutritional parameters for two residents, resulting in significant weight loss. Resident 100, who had a history of multiple strokes and a PEG tube insertion, was admitted to the facility with a regular diet and a sodium restriction due to congestive heart failure. Despite the resident's high nutritional risk and initial weight loss, the facility did not utilize the PEG tube for supplemental feeding or adjust the dietary plan adequately. The resident's weight continued to decline significantly over the following months without appropriate monitoring or intervention. Resident 100's weight was not consistently monitored, with significant gaps in weight assessments and dietary evaluations. The resident's meal intake records indicated a decline in consumption, yet no adjustments were made to address the nutritional needs. The facility's failure to implement timely interventions, such as utilizing the PEG tube or adjusting the diet, contributed to a severe weight loss of 15.7% since admission. Similarly, Resident 101 experienced a rapid and significant weight loss over a short period. The facility failed to notify the resident's physician of the continued weight loss and did not implement additional interventions to prevent further decline. The lack of timely and adequate response to the residents' nutritional needs highlights the facility's deficiency in maintaining acceptable nutritional status for its residents.
Plan Of Correction
The facility is unable to retroactively put in place interventions to prevent weight loss for residents 100 and 101. Both residents will receive an evaluation by the facility RD and have their care plans reviewed. The facility will complete a 30-day look back of significant weight changes to ensure physician notification was provided and appropriate interventions were implemented. The facility will notify the RD and physician of any identified significant weight changes for additional evaluation, and the resident's care plan will be reviewed. The facility RD, licensed nursing staff, and IDT will be educated on the facility weight policy. The DON or designee will complete audits of 5 residents a week for 8 weeks to ensure that weights have been obtained and documented as ordered and that unplanned significant weight changes have been communicated to the physician and that care plan updates occurred if applicable. The results of the audits will be reviewed at the facility's QAPI meeting for recommendations.
Deficiency in Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for two residents. Resident 96, who has a diagnosis of respiratory failure with hypoxia and COPD, was ordered to receive supplemental oxygen at 4 LPM via nasal cannula with humidification. However, observations revealed that the resident was receiving oxygen at only 1.5 LPM, contrary to the physician's order. This discrepancy was confirmed by a licensed practical nurse who then adjusted the oxygen flow to the correct rate. For Resident 49, there was an active physician's order to administer supplemental oxygen if the pulse oximeter reading fell below 92 percent. However, the order did not specify the oxygen flow rate, and no supplemental oxygen was observed in use. Additionally, there were no documented oxygen saturation assessments for this resident, despite the physician's order. The care plan for Resident 49 did not include an intervention for supplemental oxygen, and the intervention for oxygen was discontinued, although the physician's order remained active.
Plan Of Correction
The facility corrected the O2 settings for resident 96. The order for resident 49's supplemental oxygen was discontinued. An audit of current residents with oxygen was conducted to ensure that oxygen settings matched each resident's orders. An education was provided to facility CNAs and licensed nursing staff to ensure accurate O2 settings in accordance with each resident's care plan. The DON or designee will complete observations of 5 residents a week x 8 weeks to ensure that resident O2 settings are in place in accordance with each resident's care plan. The results of the audits will be reviewed at the facility's QAPI meeting for recommendations.
Insufficient Nursing Staff Affects Resident Schedules
Penalty
Summary
The facility was found to have insufficient nursing staff to meet the residents' schedules for activities of daily living, specifically for two residents who were reviewed for concerns regarding resident choices. Resident 66 was observed in bed at 9:13 AM, although he preferred to be out of bed by 6:30 AM. He stated that his ability to get out of bed depended on the number of nurse aides available. Similarly, Resident 25 was assisted out of bed at 8:00 AM, despite her preference to be up by 6:30 AM to avoid eating breakfast in bed, which she dislikes due to the risk of dropping food. An interview with a nurse aide, Employee 11, confirmed that the delay in assisting Residents 66 and 25 was due to only three nurse aides being assigned to the unit at the time. The following day, with four nurse aides on duty, residents were able to follow their preferred schedules. These concerns were discussed with the Nursing Home Administrator and the Director of Nursing, highlighting the facility's failure to provide sufficient nursing staff to meet the residents' needs and preferences.
Plan Of Correction
The facility is unable to retroactively ensure sufficient staffing to meet the immediate needs of residents 66 and 25, but was able to provide appropriate assistance later that same morning. A 2-week look back will be conducted of the facilities' staffing to identify trends and an appropriate intervention to ensure sufficient staffing in the facility. Education will be provided to the facility scheduler and RN supervisors on ensuring sufficient staffing. Measures will be put in place to adequately provide staff. These measures include continuing our retention committee, increased advertising efforts, utilization of agency staff, and sign on bonuses. The Director of Nursing/designee will educate ppd staffing levels to RN Supervisors, HR, and the nursing scheduler who are responsible to maintain adequate staffing ratios. The DON or designee will complete audits x5 a week x 8 weeks to ensure that the facility maintains sufficient staffing. Weekly staffing reviews will occur between the DON and Administrator. The results of the audits will be reviewed at the facilities QAPI meeting for recommendations. The performance reviews for employees 8 and 9 were completed. All employees eligible for an annual performance review received one. Education was provided to the facility DON to ensure the completion of annual performance reviews. The Administrator or designee will conduct weekly audits x 12 weeks to ensure that eligible employees receive a performance review. The results of the audits will be reviewed at the facilities QAPI meeting for recommendations.
Inaccurate Documentation of Medication Administration
Penalty
Summary
The facility failed to ensure accurate clinical documentation for a resident, identified as Resident 108, regarding the administration of a Prenatal Oral Tablet. Physician orders indicated that Resident 108 was to receive a prenatal vitamin with ferrous fumarate-folic acid daily. However, the Medication Administration Record (MAR) for January 2025 showed discrepancies. Staff documented the administration of the medication on several days, while other notes indicated the medication was unavailable due to it not being in house stock. Despite this, the medication was recorded as administered on multiple occasions. The issue was brought to the attention of the Nursing Home Administrator and Director of Nursing, and it was revealed that the medication order was not updated in the electronic health record. A licensed practical nurse, identified as Employee 13, confirmed that the inconsistency was due to a documentation issue. The Prenatal Oral Tablet was eventually discontinued, and a new order for a Multivitamin-Minerals Oral Tablet was placed after the surveyor's review.
Plan Of Correction
The order for resident 108 was discontinued and replaced with an appropriate order. A house audit of current resident's medications will be completed to ensure that all medication is available. Nursing staff will be re-educated on the importance of accurate documentation. The DON or designee will complete weekly audits of 5 residents x 8 weeks to ensure that resident medications are available and the medical record has accurate documentation of the medication administration. The results of the audits will be reviewed at the facilities QAPI meeting for recommendations.
Failure to Provide Recommended Pneumococcal Immunizations
Penalty
Summary
The facility failed to provide recommended pneumococcal immunizations for three residents, as evidenced by a review of clinical records and facility policies. Resident 21, admitted in June 2021, had previously received a pneumococcal vaccine (Prevnar 13) in 2016, but there was no documentation indicating that the facility offered her the necessary follow-up PPSV23 vaccine as per CDC guidelines. Resident 53, admitted in October 2022, had no documented evidence in his clinical record showing that the facility assessed his eligibility for the pneumococcal vaccine or offered it within 30 days of admission. Similarly, Resident 85, admitted in August 2024, had received a PPSV23 vaccine prior to her admission in 2008, but there was no documentation indicating that the facility offered her the required follow-up PCV15 or PCV20 vaccine. An interview with the infection control preventionist confirmed these findings, indicating a failure in the facility's immunization procedures for these residents.
Plan Of Correction
The facility offered Pneumococcal vaccinations to residents 85, 21, and 53. The facility will offer the Pneumococcal vaccinations to all eligible current residents and document acceptance and refusals. The facilities infection preventionist will receive education on the facilities "Pneumococcal vaccine" policy. The DON or designee will audit newly admitted residents to ensure a pneumococcal vaccine is offered to eligible residents within 30 days of admission. The results of the audits will be reviewed at the facilities QAPI meeting for recommendations.
Failure to Implement Pre-Employment TB Screening
Penalty
Summary
The facility failed to implement pre-employment tuberculosis (TB) screening procedures for one of five newly hired employees reviewed, identified as Employee 3. According to the Centers for Disease Control and Prevention (CDC) recommendations, all U.S. health care personnel should be screened for TB upon hire using either a TB blood test or a two-step TB skin test. The baseline individual TB risk assessment should be used to interpret the results of these tests. If a previous documented negative TB result is available from less than 12 months before new employment, only a single test is required. The deficiency was identified through a review of select personnel records and staff interviews, indicating non-compliance with the CDC guidelines for TB screening in health care settings.
Plan Of Correction
The facility cannot retroactively obtain a TB result for employee 3. A TB result has since been obtained. A review of current employees hired within the last 6 months was completed to ensure that each had obtained the appropriate TB results prior to beginning employment. The HR Coordinator and representatives from the facilities contracted partners will be educated on ensuring TB surveillance and pre-employment screening. The Administrator or designee will complete audits of all new hires to ensure that each receives the appropriate TB screening prior to employment. The results of the audits will be reviewed at the facilities QAPI meeting for recommendations.
Deficiencies in TB Testing and Nurse Aide Staffing
Penalty
Summary
The facility failed to ensure compliance with tuberculosis testing requirements for Employee 3, an Occupational Therapist, who was hired on October 28, 2024. The personnel file review revealed that Employee 3 provided evidence of a negative QuantiFERON Gold blood test dated December 20, 2023, but there was no evidence of any further testing, such as a one-step test, blood test, or chest x-ray, being completed prior to their employment. This deficiency was confirmed by the Nursing Home Administrator during an interview on January 31, 2025. Additionally, the facility did not meet the required staffing levels for nurse aides during various shifts over a 21-day period. Specifically, the facility failed to provide the minimum number of nurse aides per resident during the day shift on three occasions, the evening shift on two occasions, and the overnight shift on nine occasions. For example, on December 29, 2024, the day shift had 10 nurse aides for a census of 115 residents, requiring 11.50 aides, and the night shift had 7.20 aides for a census of 115 residents, requiring 7.67 aides. These staffing deficiencies were identified through a review of nursing care hours and staff interviews.
Plan Of Correction
The facility cannot retroactively correct past Nursing aide ratios. The facility will continue to take measures to adequately provide nurse-aid staff to ensure the needs of the residents are met. Measures will be put in place to adequately provide staff with the required nurse aide to resident ratios. These measures include continuing our retention committee, increased advertising efforts, utilization of agency staff, and sign on bonuses. The Director of Nursing/designee will educate minimum staffing ratios to RN Supervisors, HR, and the nursing scheduler who are responsible to maintain adequate staffing ratios. The Director of Nursing/designee will audit the daily schedules 5x week x 6 weeks to ensure that the minimum number of nurse aide staff to resident ratios have been scheduled. The results of the audits will be reviewed at the facilities QAPI meeting for recommendations.
LPN Staffing Deficiency on Overnight Shift
Penalty
Summary
The facility failed to meet the regulatory requirement of having a minimum of one LPN per 40 residents during the overnight shift. This deficiency was identified during a review of nursing staffing hours and confirmed through a staff interview. Specifically, on the overnight shift of January 27 into 28, 2025, the facility scheduled only 2.63 LPNs for a resident census of 109, which required 2.73 LPNs. This shortage was acknowledged by Employee 5, the scheduler, during an interview conducted on January 31, 2025.
Plan Of Correction
The facility cannot retroactively correct past LPN ratios. The facility will continue to take measures to adequately provide LPN staff to ensure the needs of the residents are met. Measures will be put in place to adequately provide staff with the required LPN to resident ratios. These measures include continuing our retention committee, increased advertising efforts, utilization of agency staff, and sign-on bonuses. The Director of Nursing/designee will educate minimum staffing ratios to RN Supervisors, HR, and the nursing scheduler who are responsible to maintain adequate staffing ratios. The Director of Nursing/designee will audit the daily schedules 5x week x 6 weeks to ensure that the minimum number of LPN staff to resident ratios have been scheduled. The results of the audits will be reviewed at the facilities QAPI meeting for recommendations.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day (PPD) for 10 out of 21 days reviewed. This deficiency was identified through a review of nursing staffing hours and staff interviews. Specifically, on several days between December 29, 2024, and January 30, 2025, the facility's nursing care hours fell below the mandated threshold, with PPD ranging from 2.91 to 3.18. The deficiency was discussed with the Nursing Home Administrator and the Director of Nursing during an interview on January 30, 2025.
Plan Of Correction
The facility cannot retroactively correct past PPD staffing levels. The facility will continue to take measures to adequately provide nursing staff to ensure the needs of the residents are met. Measures will be put in place to adequately provide staff. These measures include continuing our retention committee, increased advertising efforts, utilization of agency staff, and sign-on bonuses. The Director of Nursing/designee will educate PPD staffing levels to RN Supervisors, HR, and the nursing scheduler who are responsible to maintain adequate staffing ratios. The Director of Nursing/designee will audit the daily schedules 5x week x 6 weeks to ensure that the minimum PPD staffing levels have been scheduled. The results of the audits will be reviewed at the facility's QAPI meeting for recommendations.
Failure to Maintain Corridor Door Latching
Penalty
Summary
The facility failed to maintain corridor doors in compliance with NFPA 101 standards, as evidenced by two separate observations. On February 3, 2025, during an inspection, it was observed that the Therapy door did not latch into the frame when tested. This deficiency was confirmed during an exit conference with the administrator and maintenance representative, indicating a lack of positive latching, which is required to resist the passage of smoke. Additionally, on the same day, another observation revealed that the door to Resident Room 307 on the 3rd floor also failed to latch in the frame when tested. This issue was similarly confirmed during the exit conference, highlighting a consistent problem with the facility's corridor doors not meeting the required standards for positive latching hardware, as mandated by CMS regulations.
Plan Of Correction
1. The Therapy door latch that failed to latch into the frame when tested will be repaired to proper function. 2. Additional corridor doors will be reviewed for proper function. 3. The Executive Director/ designee will educate the Maintenance Director on the importance of maintaining corridor doors to proper function in accordance with NFPA standards. 4. Any findings will be reported to the monthly QAPI Committee for further review. --- 1. The corridor door for resident room 307 that failed to latch will be repaired to proper function. 2. Additional corridor doors will be reviewed for proper function. 3. The Executive Director/ designee will educate the Maintenance Director on the importance of maintaining corridor doors for proper function in accordance with NFPA standards. 4. Any findings will be reported to the monthly QAPI Committee for further review.
Failure to Maintain Smoke Barrier Doors
Penalty
Summary
The facility failed to maintain smoke barrier doors in compliance with NFPA 101 standards, affecting multiple areas within the building. During an observation on February 3, 2025, at 11:29 am, it was noted that the smoke barrier doors at the top of the ramp near the exit did not fully close when released from the hold open devices. This issue was confirmed during an interview with the administrator and maintenance representative at the exit conference on the same day, indicating that the doors did not close smoke tight as required. Additionally, another deficiency was observed on the same day at 11:07 am on the 1st floor, where the right leaf of the smoke barrier doors near the employee lounge failed to completely close and latch when released from the hold open devices. This was also confirmed during the exit conference interview with the administrator and maintenance representative. These deficiencies indicate a failure to maintain the smoke barrier doors in a manner that ensures they function properly to resist fire and smoke, as required by the NFPA 101 standards.
Plan Of Correction
1. The smoke barrier door at the top of the ramp that failed to close when tested will be repaired to proper function. 2. Additional smoke barrier doors will be reviewed for proper function. 3. The Executive Director/ designee will educate the Maintenance Director on the importance of maintaining smoke barrier doors to proper function in accordance with NFPA standards. 4. Any findings will be reported to the monthly QAPI Committee for further review. 1. The smoke barrier door near the employee lounge that failed to latch will be repaired to proper function. 2. Additional smoke barrier doors will be reviewed for proper function. 3. The Executive Director/ designee will educate the Maintenance Director on the importance of maintaining smoke barrier doors for proper function in accordance with NFPA standards. 4. Any findings will be reported to the monthly QAPI Committee for further review.
Hazardous Area Enclosure Deficiency
Penalty
Summary
The facility failed to maintain proper hazardous area enclosures, specifically affecting one of the three floors. During an observation on February 3, 2025, at 11:05 a.m., it was noted that the door to the copy room on the first floor was held open by an unapproved means, specifically a door wedge. This deficiency was confirmed during an interview at the exit conference with the administrator and maintenance representative on the same day at 12:15 p.m.
Plan Of Correction
1. The copy room door that was held open by an unapproved means will be repaired to proper function. 2. Additional hazardous area enclosures will be reviewed for proper function. 3. The Executive Director/ designee will educate the Maintenance Director on the importance of maintaining hazardous area enclosures to proper function in accordance with NFPA standards. 4. Any findings will be reported to the monthly QAPI Committee for further review.
Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the automatic sprinkler system in two specific locations, affecting one of the three floors. During an observation on February 3, 2025, it was noted that the Dietary Walk-In freezer was missing an escutcheon at 11:12 am, and the Dietary Storage Room was also missing an escutcheon at 11:13 am. This deficiency was confirmed during an interview at the exit conference with the administrator and maintenance representative on the same day at 12:15 pm.
Plan Of Correction
1. The sprinkler in the dietary walk-in freezer that was missing the escutcheon and the sprinkler in the dietary storage room will be repaired to proper function. 2. Additional sprinklers will be reviewed for proper function. 3. The Executive Director/ designee will educate the Maintenance Director on the importance of maintaining sprinklers for proper function in accordance with NFPA standards. 4. Any findings will be reported to the monthly QAPI Committee for further review.
Unauthorized Use of Surge Protector in Employee Lounge
Penalty
Summary
The facility failed to monitor for the unauthorized use of a surge protector, as evidenced by an observation on February 3, 2025. During this observation, it was noted that a microwave in the Employee Lounge on the 1st floor was being powered by a surge protector. This finding was confirmed during an interview at the exit conference with the administrator and maintenance representative on the same day.
Plan Of Correction
1. The microwave being powered by a surge protector inside the employee lounge will be removed. 2. Additional electrical devices will be reviewed for unauthorized use of surge protectors. 3. The Executive Director/ designee will educate the Maintenance Director on the importance of maintaining electrical devices without the use of unauthorized surge protectors in accordance with NFPA standards. 4. Any findings will be reported to the monthly QAPI Committee for further review.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The Manor at Penn Village was found to be non-compliant with federal and state regulations regarding the treatment and prevention of pressure ulcers. The facility failed to conduct comprehensive skin assessments and implement necessary interventions for a resident identified as at risk for pressure ulcers. Specifically, the facility did not perform weekly skin evaluations as required, nor did they document the size and condition of existing wounds upon admission. A resident, admitted with a self-care deficit and fragile skin, was noted to have moisture-associated skin damage on the buttocks upon admission. However, the facility did not document the size of the wound or conduct further assessments until a significant deterioration was observed over a month later. A full-thickness wound on the sacrum was identified, but the facility failed to provide adequate documentation or monitoring of the wound's progression and response to treatment. Additionally, a pressure ulcer on the resident's heel was not identified until a nurse aide discovered it, despite it being present on admission. The facility did not implement or document the wound care recommendations provided by a third-party service, such as off-loading the wound and using pressure off-loading boots. This lack of timely assessment and intervention contributed to the worsening of the resident's condition.
Plan Of Correction
The facility is unable to retroactively provide comprehensive skin assessments and implement interventions consistent with professional standards of practice, to promote healing of the pressure ulcer for resident CR1. The facility will complete a whole house audit to assess residents for changes in skin condition. All newly identified changes will have implemented interventions consistent with professional standards of practice to promote healing. The DON or designee will educate licensed staff on following physician orders as related to providing comprehensive skin assessments and implementing interventions consistent with professional standards of practice to promote healing. The DON or designee will complete daily audits 5x week x 2 weeks and then weekly x 8 to ensure physician ordered interventions for changes in skin conditions are being followed. Results of those audits will be reviewed monthly at the facilities QAPI.
Deficient Discharge Planning Process
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for a resident, identified as Resident CR1, who was admitted for rehabilitation following compression fractures of the spine and difficulty walking. The resident, who had some cognitive impairment, expressed a goal to return home with services. However, the facility did not adequately involve the resident's power of attorney (POA) or family in the discharge planning process, as evidenced by the absence of family or responsible party at the care plan meeting and lack of documented discussions regarding the resident's ability to return home or alternative care options. Despite the resident reaching maximum potential in therapy and requiring assistance for transfers, the facility did not document any discussions with the resident or POA about the next steps in care. A Notice of Medicare Non-Coverage was issued, but there was no evidence of communication regarding the resident's continued care needs or discharge plans. The facility also failed to document the family's request for referrals to other nursing facilities and did not provide updates on the status of these referrals. The facility's communication with a potential transfer facility was inadequate, with delays in sending referrals and a lack of follow-up to confirm receipt. There was no documentation of communication with the resident or POA about the transfer status or bed availability at the transfer facility. The facility's failure to maintain timely and effective communication with all parties involved led to a deficiency in the discharge planning process, as confirmed by interviews with social services staff and the Director of Nursing.
Failure to Investigate Elopement and Ensure Resident Safety
Penalty
Summary
The facility failed to investigate an incident of elopement and reassess and implement measures to ensure resident safety for a resident who was observed leaving the facility unattended. The resident, who was alert and oriented with a BIMS score of 13/15, was seen crossing a busy main road with a rolling walker, intending to go to a grocery store to purchase cigarettes. Despite being retrieved safely by staff, there was no documentation of the incident in the resident's clinical record, nor was there evidence of an assessment for injuries or a reassessment of the resident's safety measures. Interviews with staff revealed that the incident was not considered an elopement because the resident was under staff observation the entire time. However, the Director of Nursing was initially unaware of the incident, and the Assistant Director of Nursing admitted to following up with the resident without documenting it. The resident's clinical record did not reflect any recent incidents or assessments related to the event, and there was no evidence of resident education or additional safety measures being implemented following the incident. The resident had a history of repeated falls, unsteadiness, and dementia, with physician orders allowing her to go out with a responsible party and to smoke per facility policy. Despite this, the resident indicated she had been going outside to smoke by herself since the incident. Staff interviews and a review of facility documents showed inconsistencies in the understanding of whether the resident was allowed to go outside unattended, and there was no evidence of any measures being put in place to prevent the resident from exiting the facility unattended after the incident.
Failure to Provide Written Notice for Room Moves
Penalty
Summary
The facility failed to provide written notice, including the reason for the change, prior to moving residents to another room. This deficiency was identified for seven residents who were moved on June 4, 2024, as part of a consolidation effort due to low census and staffing. The Nursing Home Administrator (NHA) acknowledged that the residents and their responsible parties were only notified via telephone, and in one case, the responsible party was not notified at all. The facility's grievance log included a complaint from the family of one resident who was upset about the lack of communication regarding the room move. The surveyor reviewed the clinical records of the affected residents and found that notifications were made via telephone, often just hours before the moves occurred. In some cases, the notifications were documented in progress notes after the moves had already taken place. The NHA and Director of Nursing were informed of these concerns during a meeting on June 13, 2024. The facility's actions did not comply with the requirement to provide written notice to residents and their responsible parties before room changes.
Failure to Assist Residents with Bathing and Meal Positioning
Penalty
Summary
The facility failed to ensure that dependent residents received appropriate assistance with bathing and meal positioning. For Resident CR1, the facility did not document or implement the necessary positioning for meals as recommended by Speech Therapy. Despite a physician's order and speech therapy documentation indicating that Resident CR1 should be out of bed for meals to improve swallowing safety, there was no evidence in the clinical record or care plan that staff were instructed to follow this recommendation. The Director of Nursing confirmed the lack of documentation and instructions regarding meal positioning for Resident CR1. Additionally, the facility did not provide adequate bathing assistance for three residents. Resident 1, who required substantial assistance with bathing, did not receive showers according to her preferred schedule, and there was no documentation to suggest she refused or preferred an alternative. Similarly, Residents 2 and 3, who also needed significant assistance, did not receive showers as per their established schedules. The facility could not provide evidence that these residents refused bathing assistance or preferred different arrangements. The deficiencies were confirmed through interviews with the Director of Nursing and the Nursing Home Administrator. The facility's failure to document and adhere to care plans and resident preferences for bathing and meal positioning led to these deficiencies, as outlined in the report.
Inadequate Staff Competency in Resident Care
Penalty
Summary
The facility failed to ensure that staff with appropriate competencies and skills provided care for residents' needs, as evidenced by the clinical record review and staff interview. Employee 4, who did not possess a nurse aide certification or had completed any competencies pertinent to resident care, was found to have initialed the completion of care for nine residents. The care tasks included bed mobility, dressing, personal hygiene, toilet use, transferring, ambulation, bowel and bladder functioning, eating, and participation in restorative nursing programs. The deficiency was identified during the evening shift on May 4, 2024, when Employee 4 documented the completion of various care activities for residents 7 through 15. These activities included essential daily living tasks and specific restorative nursing programs. The interview with Employee 4 confirmed the lack of necessary certification and competencies, which is a violation of the facility's obligation to ensure that staff are adequately trained and certified to meet the residents' care needs.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment across three of the four nursing units reviewed. Observations on May 30, 2024, revealed significant accumulations of dust and debris in the heating/air conditioning units in multiple rooms, including those of Residents 7, 8, 4, and 6, as well as in empty rooms that were supposed to have been terminally cleaned. Additionally, a brown-colored liquid was found dried and crusted on the vents in Resident 4's room. These observations were confirmed by a housekeeper, Employee 2, who acknowledged that the vents should have been cleaned during the terminal cleaning process. Further issues were noted in Resident 3's room, where a dead insect with dust debris was found on the floor, and both trash cans were half-full despite the presence of a wet floor sign indicating recent cleaning. Employee 1, another housekeeper, confirmed that she had mopped the floor but had not swept it to remove the insect. These deficiencies were discussed with the Nursing Home Administrator and Director of Nursing on the same day.
Failure to Implement Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident, identified as Resident CR1. Upon review of the closed clinical record, it was found that the resident was admitted on an unspecified date, but the baseline care plan was not documented until May 2, 2024. This care plan, although signed by a registered nurse and the resident, lacked person-centered interventions necessary for effective care. The care plan included various goals related to discharge, routine preferences, safety, skin integrity, nutrition, mood, psychosocial well-being, cognition, communication, vision/hearing, oral health, cardiac/respiratory function, elimination, pain, fracture, and diabetes management, but did not specify the interventions required to achieve these goals. Further examination of the electronic health record (EHR) revealed that comprehensive care plans addressing community life involvement, ADL self-care performance deficits, and swallowing problems were not initiated until several days after the resident's admission, specifically on May 6 and May 7, 2024. This delay in establishing a baseline care plan and comprehensive care plans indicates a failure to provide timely, person-centered care that meets professional standards. The findings were discussed with the Nursing Home Administrator and Director of Nursing on May 30, 2024.
Failure to Ensure Accurate Medication Administration and Documentation
Penalty
Summary
The facility failed to ensure the accurate acquisition and administration of medications for a resident with a history of Crohn's disease. The resident was admitted to the facility and had a physician's order for Budesonide Extended-Release oral tablet to be administered daily. However, the Medication Administration Record (MAR) showed that the medication was not documented as administered on multiple days, with notes indicating that the medication was pending pharmacy arrival or unavailable. Despite electronic requests for the medication, there was no follow-up with the pharmacy regarding the delay, and no documented evidence after the initial notification that the physician was made aware of the ongoing issue. Additionally, the MAR for the resident revealed several other medications with no documented administration, refusal, or indication of unavailability. These included medications for Parkinson's disease, high blood pressure, depression, and dietary supplements, among others. The Director of Nursing believed the medications were not administered due to the resident's recent admission, but this was not documented on the MAR. The facility failed to accurately document the administration, refusal, or unavailability of the resident's medications, leading to a deficiency in pharmaceutical services.
Failure to Prevent and Investigate Resident Elopement
Penalty
Summary
The facility failed to prevent and thoroughly investigate an elopement incident involving a resident. The resident, who was admitted to the facility and assessed as cognitively intact with a BIMS score of 14, was found missing during dinner tray distribution. The resident was later located at a nearby supermarket. Prior to the elopement, the resident had been demonstrating odd behavior, which was reported to the oncoming shift with a suggestion to keep a close eye on her. However, the resident managed to leave the facility through an egress door that was not properly armed, and the door alarm did not sound as it should have. This was confirmed by another resident who witnessed the elopement and noted that the door was not latched correctly and the alarm did not activate. The investigation into the incident revealed several deficiencies. There were no statements taken from the eloping resident or the witnessing resident. Additionally, the investigation did not provide any conclusive information on why the door was not armed properly or why the alarm did not sound. The DON confirmed that the alarm system could be turned off with a key, which was accessible to staff but kept out of residents' reach. The lack of thorough investigation and failure to ensure the door alarm system was functioning properly contributed to the resident's elopement, which was confirmed by the Nursing Home Administrator and the DON.
Failure to Document Medication and Treatment Administration
Penalty
Summary
The facility failed to provide the highest practicable care regarding physician-ordered medications and treatments for four residents. For Resident 1, there were multiple instances where staff did not document the administration of medications such as Levothyroxine Sodium, Omeprazole, and Famotidine, as well as treatments like petroleum jelly application, enteral residual checks, and colostomy care. These omissions were noted on specific dates in March and April 2024, indicating a pattern of non-compliance with physician orders and documentation requirements. Resident 2's clinical records revealed similar issues, with staff failing to document the administration of Vancomycin HCL, Gabapentin, and the flushing of a PICC or Midline catheter. Additionally, there were lapses in documenting the measurement of upper arm circumference and external catheter length, as well as the changing of PICC or Midline dressings. These deficiencies occurred on multiple dates in March and April 2024, further highlighting the facility's failure to adhere to prescribed medical protocols. For Resident 3, the facility did not document the completion of oxygen tubing changes, Foley flushes, and the application of Zinc Oxide cream and Betadine swabs. These omissions were recorded on various dates in March and April 2024. Similarly, Resident 4's records showed that staff did not document circulation checks, the use of hipsters, Wanderguard function checks, and the application of Biofreeze gel. These deficiencies were noted on specific dates in March 2024. The surveyor discussed these concerns with the Nursing Home Administrator and the Director of Nursing on April 8, 2024.
Failure to Implement Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to implement necessary treatment and services to promote pressure ulcer healing, prevent pressure ulcer worsening, and prevent new ulcers from developing for two residents. For Resident 1, the facility did not provide a custom wheelchair cushion as recommended by the wound consultant, and there was no evidence that the cushion was delivered. Additionally, the facility failed to document daily wound treatment on several dates, leading to the worsening of Resident 1's pressure ulcer on the left lower buttock, which increased in surface area from 7 cm to 7.5 cm. For Resident 2, the facility did not assess the sacral wound after the initial assessment on admission, despite the resident being at high risk for pressure ulcers. The wound worsened significantly in size and appearance, and a second pressure ulcer developed. The facility's consulting wound care provider noted the deterioration and changed the wound care instructions, but there was no evidence that staff evaluated the effectiveness of the interventions or intervened timely. The facility's failure to follow its own policies and procedures for pressure ulcer care and prevention resulted in the worsening of existing pressure ulcers and the development of new ones for both residents. The deficiencies were discussed with the Nursing Home Administrator and the Director of Nursing, who acknowledged the lack of documentation and timely intervention.
Failure to Maintain Nutritional Status for Residents
Penalty
Summary
The facility failed to implement interventions to maintain acceptable parameters of nutritional status for two residents reviewed for weight loss concerns. For Resident 1, who had diagnoses including cerebral palsy and dysphagia, the facility did not obtain required weight assessments on multiple specified dates and failed to document the provision of prescribed bolus feedings on several occasions. Resident 1's weight fluctuated significantly, indicating a lack of consistent nutritional monitoring and intervention by the facility staff. For Resident 4, the facility did not respond adequately to severe weight loss. Despite significant weight loss documented over a short period, there was no timely intervention or assessment by the registered dietitian or nutritional staff. The facility's documentation did not reflect an appropriate response to the weight loss, and there was a delay in implementing and evaluating nutritional interventions. Resident 4's clinical record lacked evidence of an assessment of food preferences and timely follow-up on the severe weight loss. The surveyor discussed these concerns with the Nursing Home Administrator and the Director of Nursing, highlighting the facility's failure to thoroughly assess and respond to the nutritional needs of the residents. The facility did not maintain acceptable parameters of nutrition for the residents, as required by their policies and procedures.
Failure to Secure Medications and Biologicals
Penalty
Summary
The facility failed to ensure the security of medications and biologicals on one of its nursing units. During an observation of the second-floor nursing unit, it was noted that the door to the medication prep room was open, and the cabinet doors within the room were also open, exposing numerous over-the-counter medications and treatment carts containing various medicated treatments. This observation occurred while maintenance staff were installing a padlock on the refrigerator in the medication prep room, and the licensed practical nurse (LPN) responsible for the area was completing her medication pass elsewhere, leaving the room unattended and unsecured. Additionally, a resident in a wheelchair approached the doorway of the open medication prep room to request ice, indicating that residents had access to the unsecured medications and treatments. The medications and treatments observed included acetaminophen, multivitamins, hydrogen peroxide, low-dose aspirin, milk of magnesia, iron supplements, diclofenac sodium, Premarin vaginal cream, nystatin topical powder, fluocinolone acetonide topical solution, nicotine patches, and dermasyn hydrogel wound dressing. This lack of security for medications and biologicals was previously cited as a deficiency in January 2024, highlighting a recurring issue in the facility's pharmacy and nursing services.
Failure to Provide Palatable Food
Penalty
Summary
The facility failed to provide residents with palatable food on two of four nursing units. The policy entitled 'Food: Quality and Palatability' did not specify any temperatures to ensure food was served at a palatable temperature. Resident 2 on the second floor reported that the food was often cold, and Resident 3 on the same floor requested an alternative meal because the pork chop was too tough to eat. On the third floor, Resident 5 received a meal where the carrots were barely warm. Observations confirmed that the food temperatures were below acceptable levels, with the pork chop at 122.9°F, white rice at 115.6°F, and carrots at 109.8°F. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed that there was no policy or procedure in place to ensure food temperatures met palatable standards at the point of service. The deficiency was noted under 28 Pa. Code 201.14(a) and 28 Pa. Code 201.18(b)(3)(d)(e)(2)(3), indicating a failure in management and responsibility of the licensee to provide nourishing, palatable, and well-balanced diets to residents.
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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