Mountain Top Rehabilitation & Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mountain Top, Pennsylvania.
- Location
- 185 South Mountain Boulevard, Mountain Top, Pennsylvania 18707
- CMS Provider Number
- 395542
- Inspections on file
- 26
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Mountain Top Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
A resident with chronic respiratory failure, hypoxia, diabetes, and moderate cognitive impairment, who required two-person assistance for bed mobility, was left unattended on her side in bed by a nurse aide during incontinence care. The resident rolled out of bed and sustained a facial injury and nasal fracture. The bed was not in the lowest position, and the DON confirmed the resident should not have been left alone.
The facility failed to maintain two doors with self-closing devices, affecting one smoke compartment. Observations revealed that the doors at Nurse's Station 2 and Resident Room 62 did not positively latch into their frames. This issue was confirmed during an exit interview with the Facility Administrator and Facilities Manager.
The facility failed to maintain the sprinkler system, affecting one of two floors. Three sprinkler heads in the basement laundry were found loaded with lint. This was confirmed during an exit interview with the Facility Administrator and Facilities Manager.
The facility failed to ensure the right set of double doors in the Main dining room positively latched into the frame, as observed during a survey. This deficiency was confirmed in an interview with the Facility Administrator and Facilities Manager.
Mountain Top Rehabilitation and Healthcare Center failed to transmit MDS assessments to the CMS QIES ASAP System within the required 14-day timeframe for six residents. The assessments, including quarterly and end-of-stay evaluations, were not completed or submitted on time, as confirmed by the RNAC. This non-compliance was identified during a survey completed in April 2025.
A facility failed to accurately reflect a resident's hospice care status in their MDS assessment. The resident, admitted with Alzheimer's and malnutrition, was receiving hospice services, but the MDS assessment incorrectly noted otherwise. This was confirmed by the DON during an interview.
A resident with dementia experienced significant weight loss, but the facility failed to update the care plan to reflect this change. Despite nutritional interventions by the dietitian, the care plan had not been revised since the resident's admission, and the oversight was confirmed by the Nursing Home Administrator during a survey.
The facility did not document the accounting and disposition of medications for a resident upon discharge. The resident was admitted and later discharged, but by the time of the survey, there was no evidence in the clinical record regarding the medications' accounting or disposition. This was confirmed during an interview with the Nursing Home Administrator.
The facility failed to develop comprehensive care plans for three residents, omitting critical medical devices and treatments. A resident with cardiovascular conditions and wounds lacked a care plan for their pacemaker and wound treatment. Another resident's care plan did not include their cardiac pacemaker, and a third resident's use of TED stockings was not documented. The DON confirmed these deficiencies.
The facility failed to follow physician orders for two residents, leading to deficiencies in care. One resident did not receive the prescribed bowel protocol despite not having a bowel movement for six days, with no evidence of timely physician notification. Another resident was observed not wearing TED stockings as ordered for edema management. Staff interviews confirmed these oversights, indicating a lack of adherence to professional standards and physician orders.
The facility failed to address significant weight loss in two residents, with one losing 7.93% of body weight in 29 days and the other 10.7% over 180 days. The dietitian did not identify or act on these changes, and the care plans lacked necessary interventions. The physician and resident representatives were not notified, leading to a deficiency in maintaining nutritional health.
A resident with a prescription for a Lidocaine pain patch experienced delays in administration, with the patch often applied more than an hour late, causing significant pain. The facility's policy requires medications to be administered within one hour of the prescribed time, but this was not followed, as confirmed by staff and records.
The facility failed to follow pharmacy procedures for controlled drug reconciliation on two medication carts. The policy requires nurses to count and sign off on controlled medications at shift changes, but signatures were missing on several dates. Interviews confirmed the expectation for nurses to sign the logs, and the DON acknowledged this requirement.
A resident with acute systolic congestive heart failure experienced a significant weight gain, which was not reported to the physician as required by the facility's policy. The resident's weight increased by 8.8 pounds in one day, a 6.48% gain, but no re-weight was taken the next day, and the physician was not notified. The facility dietitian confirmed this failure to follow protocol.
Failure to Provide Required Assistance During Bed Mobility Resulting in Resident Fall
Penalty
Summary
A resident with chronic respiratory failure, hypoxia, and diabetes, who was moderately cognitively impaired and required extensive assistance for personal hygiene and bed mobility, was not provided the necessary care and services to prevent a fall from bed. According to the resident's care plan, two staff members were required to assist with bed mobility. However, during incontinence care, a nurse aide left the resident unattended on her side in bed to obtain washcloths, despite the resident's need for two-person assistance for bed mobility. As a result, the resident rolled out of bed and landed on her face, sustaining a raised bluish/purple area on the forehead and an acute fracture of the bony nasal septum, as confirmed by a CT scan. The bed was not in the lowest position at the time of the incident. The nurse aide involved confirmed leaving the resident alone, and the DON verified that the resident should not have been left unattended during care, which directly led to the fall.
Failure to Maintain Self-Closing Doors
Penalty
Summary
The facility failed to maintain two doors with self-closing devices, which affected one of six smoke compartments. During an observation on April 30, 2025, between 10:14 am and 10:21 am, it was noted that the doors did not positively latch into their frames. Specifically, the door at Nurse's Station 2 and the door of Resident Room 62, which is tied into the fire alarm system, were identified as not latching properly. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager at 11:00 am on the same day.
Plan Of Correction
The Nurse's Station 2 door and Resident Room 62 door assembly was adjusted to provide positive latching by facility maintenance department. The Maintenance Director/designee will conduct a facility wide audit to identify doors requiring adjustment to fully latch and coordinate repairs as identified. The Nursing home Administrator will provide re-education to the Maintenance Director on proper door latching requirement. The Maintenance Director will conduct audits on latching doors to verify compliance weekly x 4 weeks, then monthly x 2 months. The results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee for compliance.
Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the sprinkler system in one location, specifically affecting one of two floors. During an observation on April 30, 2025, at 9:55 am, it was found that three sprinkler heads within the basement laundry area were loaded with lint. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager on the same day at 11:00 am.
Plan Of Correction
The 3 basement laundry sprinkler heads were thoroughly cleaned of lint. The Maintenance Director will conduct an audit of sprinkler heads within the basement laundry to verify that the sprinklers are lint free. The Nursing Home Administrator/designee will provide re-education to the Maintenance Director for the requirements for sprinkler heads being free from lint. The Maintenance Director/designee will conduct audits of random sprinkler heads to confirm that they are free of lint and verify compliance weekly audits x 4 weeks, then monthly x 2 months. The results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee for compliance.
Failure to Maintain Corridor Door Latching
Penalty
Summary
The facility failed to maintain a corridor opening as required by regulations, specifically concerning the doors in the Main dining room. During an observation on April 30, 2025, at 10:46 am, it was noted that the right set of double doors in the Main dining room did not positively latch into the frame. This deficiency affects one of the two floors in the facility. The issue was confirmed during an exit interview with the Facility Administrator and the Facilities Manager on the same day at 11:00 am. The failure of the doors to positively latch is a violation of the requirements for corridor doors, which are supposed to resist the passage of smoke and have positive latching hardware, especially in fully sprinklered smoke compartments.
Plan Of Correction
The main dining room right set of double doors' door assembly was adjusted to provide positive latching by facility maintenance department. The Maintenance Director/designee will conduct a facility wide audit of double doors to identify doors requiring adjustment to fully latch and coordinate repairs as identified. The Nursing home Administrator will provide re-education to the Maintenance Director on proper door latching requirement. The Maintenance Director will conduct audits on latching doors to verify compliance weekly x 4 weeks, then monthly x 2 months. The results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee for compliance.
Failure to Timely Transmit MDS Assessments
Penalty
Summary
Mountain Top Rehabilitation and Healthcare Center was found to be non-compliant with the requirements of 42 CFR Part 483 Subpart B, specifically regarding the encoding and transmission of Minimum Data Set (MDS) assessments. The facility failed to transmit MDS assessments to the Centers for Medicare and Medicaid Services (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) System within the required 14-day timeframe for six residents. These residents' assessments, which included quarterly and end-of-stay evaluations, were not completed or submitted on time, as evidenced by the clinical record reviews and staff interviews. The Registered Nurse Assessment Coordinator (RNAC) confirmed that the MDS assessments for the residents were not completed and submitted within the mandated period. The assessments for Residents 70, 77, 58, 100, 78, and 47 were all delayed, with some remaining incomplete and unsubmitted through the survey's conclusion. This failure to adhere to the required timelines for MDS data submission was identified during the Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance survey completed on April 18, 2025.
Plan Of Correction
F0640 - Encoding /Transmitting Resident Assessment A. Corrective action taken for residents identified: Residents #70, #77, #58, #100, #78, #47 - outstanding MDS completed and submitted. B. Registered Nurse Assessment Coordinator or designee will conduct an initial audit of open MDS assessments to review for timely completion. Findings will be addressed and corrected. C. Nursing Home Administrator or designee will re-educate on the required assessment completion and transmission timeframes per CMS regulations. D. Nursing Home Administrator or designee will complete an MDS tracking form weekly x6 weeks of completed assessments, to for timeliness. Any variances of completion or submission within regulatory timeframes will be addressed, and results will be shared with QA committee for review.
Inaccurate MDS Assessment for Hospice Care
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for a resident, leading to a deficiency. Resident 49, who was admitted with Alzheimer's disease and protein-calorie malnutrition, was receiving hospice services. However, the quarterly MDS assessment dated December 20, 2024, inaccurately indicated that the resident was not receiving hospice care. This discrepancy was confirmed during an interview with the Director of Nursing on April 17, 2025, who acknowledged that the resident was indeed receiving hospice care during the period in question.
Plan Of Correction
F0641 - Accuracy of Assessments A. Resident #49: MDS assessment modified and resubmitted to reflect the accurate assessment. B. Registered Nurse Assessment Coordinator will conduct an initial audit to identify other residents/MDS assessments with coding discrepancies for item 00110K1 (hospice). All findings will be addressed. C. Nursing Home Administrator or designee will re-educate the Registered Nurse Assessment Coordinator on RAI Manual guidelines related to 00110K1 coding. D. Nursing Home Administrator or designee will audit 00110K1 of completed MDS assessments, weekly x6 weeks, to ensure accuracy. Inaccurate coding will be addressed upon identification and results will be shared with QA committee for review.
Failure to Update Care Plan for Resident's Weight Loss
Penalty
Summary
The facility failed to review and revise the care plan for a resident who experienced significant weight loss. The resident, admitted with diagnoses including dementia, showed an 8.5% weight loss over 90 days as of March 18, 2025. Despite the registered dietitian implementing nutritional interventions, the care plan had not been updated since December 13, 2023, to reflect the resident's current nutritional status and needs. During a survey conducted in April 2025, it was found that the care plan did not include updates or new interventions addressing the resident's weight loss. The Nursing Home Administrator confirmed the oversight, acknowledging that the care plan should have been reviewed and revised in response to the significant change in the resident's condition.
Plan Of Correction
F Tag 0657: 1. Resident 91's plan of care was updated to reflect weight changes with implementation of appropriate interventions. 2. Director of Nursing or Designee will conduct an initial of residents with significant weight changes to verify that their individualized plans of care were completed addressing current weight significant changes and implementation of interventions as warranted. 3. Director of Nursing or Designee will be provided re-education to the Interdisciplinary Care Team on Comprehensive Plans of Care updating/reviewing reflecting weights. 4. Director of Nursing or designee will conduct audits on residents identified as having significant weight changes to verify care plans and implementation of interventions as warranted. The audits will be conducted weekly x 4 weeks and monthly x 3 months. Results of these audits will be brought to the QAPI Committee for review and recommendations.
Failure to Document Medication Disposition for Discharged Resident
Penalty
Summary
The facility failed to document the accounting and disposition of medications for Resident 109 upon discharge. Resident 109 was admitted on November 6, 2024, and discharged on January 29, 2025. However, by the time of the survey, which concluded on April 18, 2025, there was no documented evidence in the resident's clinical record regarding the accounting of remaining medications or their disposition at the time of discharge. This deficiency was confirmed during an interview with the Nursing Home Administrator on April 18, 2025, at 10:30 AM.
Plan Of Correction
P 5280 - Disposition of Medications 1. The facility cannot retroactively correct said deficiency. 2. Residents discharged within the last 14 days will be reviewed by the Director of Nursing or Designee to verify proper documentation for disposition of medications occurred. 3. Director of Nursing or Designee will re-educate licensed nurses on documentation of disposition of medications. 4. Director of Nursing or Designee will conduct audits of discharged residents daily x 2 weeks, weekly x 4 weeks and monthly x 2 months to ensure proper documentation of disposition of medications occurred. Results of these audits will be reviewed by the facility's QAPI Committee for review and recommendations.
Deficiency in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, leading to deficiencies in meeting their medical and treatment needs. Resident 53, who was admitted with multiple cardiovascular conditions and wounds, had a care plan that did not address the presence of an implantable pacemaker or the treatment for arterial and venous wounds on the lower extremities. Similarly, Resident 55's care plan did not include the presence of a cardiac pacemaker, despite the resident's admission with acute systolic congestive heart failure and other cardiovascular issues. Resident 64, with a history of venous thrombosis and embolism, had a physician's order for the use of TED compression stockings, which was not reflected in the care plan. The Director of Nursing confirmed that the facility did not ensure comprehensive care plans were developed to meet the residents' medical and treatment needs, as required by 28 Pa. Code 211.12 (d)(5) Nursing services.
Failure to Follow Physician Orders for Bowel Protocol and Compression Stockings
Penalty
Summary
The facility failed to adhere to physician orders for two residents, resulting in deficiencies in care. For one resident, the facility did not follow a prescribed bowel protocol, which included administering Milk of Magnesia, Dulcolax suppository, and a Fleet enema as needed for constipation. Despite the resident not having a bowel movement for six days, there was no documented evidence that the bowel protocol was administered, nor was there timely notification to the physician. The resident's clinical records showed multiple blank entries regarding bowel activity, indicating either incomplete tasks or failure to document by the staff. Another resident had a physician's order for the application of TED stockings to the right lower extremity to manage edema. Observations over several days revealed that the resident was not wearing the TED stocking as ordered. Interviews with staff confirmed the oversight, and the Nursing Home Administrator acknowledged that the staff did not follow the physician's order for the application and removal of the TED stocking. These failures indicate a lack of adherence to professional standards of practice and physician orders, as required by the facility's regulations.
Failure to Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to accurately and consistently assess the nutritional status of two residents, leading to significant weight loss that was not timely addressed. Resident 75 experienced a weight loss of 7.93% in 29 days and 6.19% in 43 days, which was not identified or acted upon by the dietitian. The dietitian confirmed that the significant weight loss in March 2024 was not recognized, and no nutritional support measures were developed or implemented at that time. Additionally, the physician and resident representative were not notified of the weight loss. Resident 51 also experienced significant weight loss, with a 10.7% decrease over 180 days. Despite the resident's history of weight loss and increased nutrient needs, the care plan did not include new interventions to address the ongoing weight loss. The dietitian did not address the weight loss until May 14, 2024, and there was no evidence that the physician or representative were notified of the weight loss. The resident's care plan did not include the intervention of sugar-free Healthshakes, which the resident was receiving three times a day. The Nursing Home Administrator confirmed that the facility was unable to demonstrate that the dietitian had identified the residents' weight loss and implemented timely measures to maintain acceptable nutritional parameters. The facility's failure to act upon the significant weight changes and notify the appropriate parties resulted in a deficiency in maintaining the residents' nutritional health.
Failure to Administer Pain Medication Timely
Penalty
Summary
The facility failed to provide timely and appropriate pain management for a resident, identified as Resident 64, who was prescribed a Lidocaine External Patch for pain relief. The resident was scheduled to receive the patch at 9:00 AM daily, but records and interviews revealed that the administration of the patch was frequently delayed by one hour or more on multiple occasions throughout June 2024. The resident reported experiencing significant pain due to these delays, and an interview with the Assistant Director of Nursing confirmed that the patch was not applied as scheduled. The facility's policy on medication administration, which requires medications to be administered within one hour of their prescribed time, was not adhered to. The Nursing Home Administrator acknowledged that the late administration of the pain patch was inconsistent with professional standards for pain management. The deficiency was identified through a review of clinical records, facility policy, and interviews with the resident and staff, highlighting a repeated failure to provide person-centered pain management in accordance with professional standards.
Failure to Reconcile Controlled Drugs
Penalty
Summary
The facility failed to implement proper pharmacy procedures for the reconciliation of controlled drugs on two medication carts, Med cart A and Med cart D. According to the facility's policy on controlled substances, which was last reviewed on June 12, 2024, controlled medications are to be counted at the end of each shift by both the on-coming and off-going nurses, with any discrepancies reported immediately to the Director of Nursing (DON). However, during observations on June 26, 2024, it was found that the required signatures verifying the completion of the controlled drug count were missing on several dates for both medication carts. Specifically, for Med cart A, the signatures were absent on June 18, 23, and 24, 2024, and for Med cart D, the signatures were missing on June 21 and 24, 2024. Interviews with the involved staff, including an LPN and an RN, confirmed the absence of signatures and acknowledged the expectation that licensed nurses sign the count verification at shift changes. The DON also confirmed that it is the facility's expectation for nursing staff to sign the controlled substance logs at shift changes to ensure timely identification of any discrepancies. This deficiency was identified under the regulations 28 Pa. Code 211.19(a)(1)(k) Pharmacy services and 28 Pa. Code 211.12 (d)(3)(5) Nursing services.
Failure to Notify Physician of Significant Weight Gain
Penalty
Summary
The facility failed to timely consult with the physician regarding a significant weight gain experienced by a resident. The resident, who was admitted with acute systolic congestive heart failure and had a cardiac pacemaker, showed an 8.8-pound weight gain in one day, which constituted a 6.48% increase. According to the facility's policy, any weight change of 5% or more should be retaken the next day for confirmation, and significant weight changes should be reported to the physician. However, there was no documented evidence that the physician was notified of this significant weight gain, nor was a re-weight taken the following day as required by the policy. The dietitian's note indicated that weight fluctuations were reviewed, and the physician was to be notified if a 5-pound weight gain in 7 days was noted. Despite this, the significant weight gain recorded on May 30, 2024, was not communicated to the physician, and the policy for re-weighing was not followed. An interview with the facility dietitian confirmed the failure to notify the physician in a timely manner. This oversight was a violation of the facility's policy and the state code 28 Pa Code 211.12 (d)(3)(5) regarding nursing services.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
