Norriton Square Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Norristown, Pennsylvania.
- Location
- 1700 Pine Street, Norristown, Pennsylvania 19401
- CMS Provider Number
- 396009
- Inspections on file
- 26
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Norriton Square Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A nurse aide improperly emptied and cleaned a bedside commode by carrying an unlabeled bag dripping reddish liquid to a resident’s bathroom, placing the bag in the resident’s trash, dumping the liquid into the toilet, and rinsing the urine collection basin in the resident’s hand sink before returning it to the commode without a new liner. The aide then removed gloves, dropped one on the floor, initially attempted to leave it there, and later picked it up with bare hands and discarded it. The Unit Manager, Infection Preventionist, and Nursing Home Administrator all confirmed these actions did not follow the facility’s infection control procedures for handling bedside commode waste and equipment.
A resident with chronic pain and cancer diagnoses was affected when 30 tablets of prescribed oxycodone went missing due to failures in controlled drug procedures. Inventory count sheets and staff interviews revealed discrepancies during shift changes, including missing signatures and improper documentation by an agency nurse. The DON confirmed the medication was not found and had to be replaced, resulting in noncompliance with management, pharmacy, and nursing service regulations.
The facility did not maintain accurate and orderly records for controlled substances, resulting in discrepancies between medication containers and record sheets during shift changes for two residents receiving oxycodone. There were also mismatches between the Medication Administration Records and Controlled Drug Record sheets, with staff unable to explain the inconsistencies.
Two agency nurses did not have documented training on abuse, neglect, exploitation, or misappropriation of resident property as required by facility policy. The DON was unable to provide verification of completed training for these nurses, including one involved in an incident where a resident's oxycodone was unaccounted for.
Essential dining equipment, including multiple refrigerators and an ice machine, was found to be non-operational on two floors. Staff were unaware of proper procedures for addressing equipment issues, and a resident's dietary needs were not immediately met due to the lack of functioning refrigeration in the dining area.
Surveyors found that multiple food items in the kitchen's walk-in refrigerator were not labeled or dated according to facility policy, with some items past their use-by dates and others missing required 'Use By' labels. The Director of Dining Services confirmed these items were improperly stored and labeled, in violation of professional food safety standards.
A resident with severe cognitive impairment and a complex medical history, including a hip fracture and pressure ulcer, was neglected in their incontinence care at Norriton Square. The resident was found soiled with urine, and their wound dressing was also soiled, due to the oversight of a nursing assistant overwhelmed with the care of eighteen patients. The facility's policies on abuse and neglect were not followed, leading to a substantiated report of neglect.
A facility failed to provide adequate nursing staff on the 2nd floor, resulting in neglect of a resident with severe cognitive impairment and complex medical needs. The resident was found soiled with urine and a soiled wound dressing, indicating neglect. The nursing assistant responsible admitted to overlooking the resident due to being assigned eighteen patients and insufficient help. The facility's staffing was below state requirements, confirmed by the DON.
Two residents experienced inadequate accommodations in the facility. One resident, with multiple health conditions, was not provided a bariatric bed upon admission, causing discomfort and requiring extensive assistance. Another resident faced issues with a malfunctioning heater, leaving them cold in their room. The facility had the necessary equipment but failed to implement it in a timely manner.
A facility failed to follow physician orders for a resident with diabetes by not notifying the physician of multiple instances where the resident's blood glucose levels exceeded 400. Despite elevated readings recorded over several months, there was no documentation of physician notification, as confirmed by the unit manager.
The facility failed to monitor weights for two residents with a history of weight loss, leading to gaps and inconsistencies in weight records. One resident with Huntington's Disease had missing and disputed weights without re-weigh attempts, while another resident with dementia had missing weights, hindering nutritional assessments. A third resident experienced significant weight loss over six months, with no documentation of daily weights as ordered, despite multiple hospitalizations.
The facility did not maintain respiratory equipment according to professional standards for two residents. One resident was using an oxygen concentrator at an incorrect flow rate, and their oxygen tubing was not dated. Another resident's humidifier bottle and oxygen tubing were also not dated, despite facility policy requiring weekly changes.
The facility failed to keep medication carts locked and medications properly stored. Medication Cart A was found unlocked and unsupervised with aspirin on top, while Medication Cart B had a mucus relief expectorant bottle improperly used to support a computer. Both incidents involved licensed nurses who confirmed the inappropriate handling of the carts.
The facility failed to provide meals according to the dietary preferences of three residents, all of whom follow vegetarian diets. One resident received a fish sandwich instead of a vegetarian burger, while two others did not receive their requested vegetarian meal items. The food service director could not explain the oversight, indicating a possible communication issue among staff.
The facility failed to maintain food safety standards by not properly labeling and storing food items. Observations revealed mislabeled or unlabeled bins of food substances, and improperly labeled items in the freezer, refrigerator, and dry storage. Staff interviews confirmed these deficiencies, indicating a breach of the facility's food handling policy.
The facility failed to ensure proper licensing and registration of staff, with a registered nurse working on an expired license and two nurse aides not registered in the state registry. This was discovered during an audit following the identification of the expired license.
A facility failed to maintain an effective infection control program for a resident with MDRO risk. An employee provided care without proper PPE, believing precautions were only for the resident's roommate. The resident, with Type 2 diabetes and a diabetic foot ulcer, required assistance for all ADLs. The care plan noted a risk for skin breakdown, but the Kardex lacked enhanced barrier precaution instructions.
The facility did not meet the required 12 hours of annual in-service training for a nurse aide, Employee E9, who only completed courses on hand hygiene and personal protective equipment. This was confirmed by personnel records and an interview with the Nursing Home Administrator.
The facility failed to meet required nurse aide staffing ratios on two consecutive days, with significant shortfalls in care hours during the day and evening shifts. Despite a census of 93-94 residents, the facility did not provide the necessary hours of care, and no higher-level staff were available to compensate for the deficiency.
The facility consistently failed to meet the required nurse aide staffing ratios over several months, as evidenced by staff schedules and punch reports. Despite a regulation requiring specific staffing levels based on resident census, the facility fell short on 17 out of 19 days reviewed, with no additional staff available to compensate for the deficiencies.
The facility failed to meet the required LPN staffing ratios on six occasions, with insufficient LPN hours provided during evening shifts. The census data showed that the required LPN hours were not met, and no additional higher-level staff were available to compensate for the shortfall. The Nursing Home Administrator confirmed these deficiencies during a review.
The facility did not meet the required minimum of 2.87 hours of direct nursing care per resident on two consecutive days. With a census of 94 and 93 residents, the facility provided only 2.53 and 2.33 hours of care per resident, respectively. This was confirmed through a review of nursing schedules and punch reports, and acknowledged by the Nursing Home Administrator.
The facility did not meet the required 3.2 hours of direct nursing care per resident on 15 out of 19 days reviewed. The census ranged from 88 to 95 residents, with care hours per resident varying from 2.65 to 3.18, consistently below the mandated level. The Nursing Home Administrator confirmed the shortfall in staffing ratios.
A pharmacy error led to a resident receiving 21 doses of Lithium instead of the prescribed Lisinopril. Facility staff discovered the error, but the pharmacy had not confirmed the medication identity. The facility failed to ensure accurate dispensing of medication.
The facility failed to provide fresh air breaks for residents, despite their expressed desire and the availability of a secure courtyard. Interviews and documentation reviews confirmed that no outdoor activities were scheduled, impacting the residents' quality of life.
The facility failed to maintain sufficient nursing staff levels, leading to significant delays in care for residents. Observations and interviews revealed issues such as residents not receiving timely assistance, family members performing care duties, and extended wait times for call bell responses. The administrator confirmed the facility's staffing shortages, impacting the quality of care.
A registered nurse left a medication cart unattended with the computer screen open, revealing a resident's identifiable information. This incident violated the facility's HIPAA compliance policy, which requires securing patient records to prevent unauthorized access.
A licensed nurse was observed borrowing Eliquis 5 mg from one resident to administer to another without consent, which was confirmed as misappropriation of medication by the Unit Manager. This action violated the facility's policy on Abuse Prohibition.
The facility failed to evaluate and obtain consent for the use of an abdominal binder as a restraint for a resident with multiple medical conditions. The binder was used to secure the resident's enteral feed, but the facility did not recognize it as a restraint and did not conduct the required reassessments or obtain consent.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in their care. One resident's care plan lacked an intervention for an abdominal binder, another's did not reflect a new diagnosis of suicidal attempts or required checks, and a third resident's care plan did not include oxygen usage despite an active order.
The facility failed to follow a physician order to obtain weekly weights for a resident with severe protein-calorie malnutrition and abnormal weight loss. Despite a significant unplanned weight loss, no weekly weight measurements were documented for two weeks, as confirmed by the Registered Dietician.
A facility failed to maintain a hazard-free environment by leaving a medication cart unattended and unlocked with unsecured medications. A nurse left the cart in the hallway with Furosemide and Ampicillin on top, and later left it unlocked again while attending to a resident.
The facility failed to provide oxygen as ordered for two residents. One resident received incorrect oxygen levels, causing discomfort, while another had outdated oxygen equipment despite not using supplemental oxygen for months. The Director of Nursing acknowledged the discrepancies.
The facility failed to ensure food was served according to professional standards. A dietary aide used picnic-style paper plates and reheated mashed potatoes in the microwave without covering them. A nursing aide then checked the food temperature with her finger before feeding it to a resident with severe cognitive impairment, contrary to facility policy.
A resident with a history of anxiety, dementia, and major depressive disorder attempted self-harm and expressed suicidal ideation. The incident was not reported to the Department of Health within the required time frames, as confirmed by the Director of Nursing and the Administrator.
Improper Handling and Cleaning of Bedside Commode and Waste
Penalty
Summary
The deficiency involves a failure to follow the facility’s infection prevention and control procedures for care and maintenance of a bedside commode on the second floor. During an observation in a resident room, a nurse aide (Employee E4) emptied a bedside commode by lifting out the urine collection basin and removing an unlabeled grey plastic bag that was dripping a reddish-colored liquid. The aide placed the bag into the urine collection basin, carried it into the resident’s bathroom, removed the bag from the basin, placed the bag into the resident’s bathroom trash can, and dumped the liquid into the toilet. The aide then filled the urine collection basin about halfway with water from the resident’s hand sink, dumped this water into the toilet, flushed, and returned the basin to the commode without a bag, stating she would need to get another bag. After removing her gloves and washing her hands, the aide took the plastic can liner out of the resident’s bathroom trash can, dropped a glove on the floor, and initially attempted to leave the room. When questioned about the glove on the floor, she returned, picked up the soiled glove with bare hands, placed it into the trash bag, and then took the bag to the soiled utility room, disposed of it in a large trash can, and washed her hands. The Unit Manager (Employee E3) and the Infection Preventionist (Employee E2) both stated that the aide’s actions did not follow facility infection control procedures, explaining that the soiled contents of the bedside commode, including the basin, should have been placed in a red biohazard bag, transported to the soiled utility room, emptied into the wall-mounted service sink, and cleaned with soap and water using the spray hose before being returned in a clean biohazard bag. The Nursing Home Administrator confirmed that the aide did not follow facility infection control procedures.
Failure to Prevent Misappropriation of Resident Medication
Penalty
Summary
The facility failed to ensure that a resident was free from misappropriation of property, specifically related to missing medication. According to the facility's abuse prohibition policy, misappropriation includes the wrongful use of a resident's belongings without consent. In this case, a resident with diagnoses including cancer and chronic pain, who was prescribed oxycodone for pain management, was affected when 30 tablets of oxycodone were found to be missing from the narcotic drawer. Review of documentation showed that the medication was delivered to the facility and was present in the narcotic drawer, as confirmed by inventory count sheets and pharmacy shipping records. During a series of shift changes, discrepancies in the narcotic count were noted. Employee E7, a licensed nurse, and Employee E8, an agency licensed nurse, were responsible for the medication cart during the relevant shifts. The count sheets indicated inconsistencies, including missing signatures and a lack of proper documentation at the end of Employee E8's shift. Employee E7 discovered the missing medication during her shift and reported it immediately to her supervisor. Interviews confirmed that the controlled drug procedures were not followed, leading to the loss of the medication. The Director of Nursing verified that the medication was not found in the facility and had to be replaced. Employee E8, who was identified as the alleged perpetrator, did not respond to requests for an interview. The incident was reported to the Pennsylvania Department of Health, and the facility was found to be noncompliant with regulations regarding management, pharmacy services, and nursing services.
Failure to Maintain Accurate Controlled Substance Records and Reconciliation
Penalty
Summary
The facility failed to maintain accurate and orderly drug records and did not ensure that all controlled drugs were properly accounted for and periodically reconciled, as required by policy and state regulations. Specifically, for two residents receiving oxycodone for pain management, there were discrepancies between the number of medication containers and controlled drug record sheets during shift changes, with missing signatures and unexplained differences in counts. On several occasions, the number of medication containers did not match the number of record sheets, and staff were unable to explain these inconsistencies during interviews. Additionally, there were mismatches between the Medication Administration Records (MARs) and the Controlled Drug Record sheets for both residents. Doses of oxycodone were documented as administered on the Controlled Drug Record sheets but were not reflected on the MARs, and vice versa. The Director of Nursing was unable to provide explanations for these discrepancies. These findings indicate that the facility did not follow its own policy for controlled substance management and failed to maintain an accurate account of controlled drugs for the residents involved.
Failure to Ensure Agency Nurses Received Required Abuse and Neglect Training
Penalty
Summary
The facility failed to ensure that nursing staff, specifically two agency licensed nurses, received required training on abuse, neglect, exploitation, and misappropriation of resident property. Facility policy mandates that all employees receive such training during orientation, through code of conduct training, and at least annually. However, review of personnel files and interviews revealed that one agency nurse, on her first day, could not specify the topics covered in her pre-employment online training, and the facility was unable to provide documentation verifying completion of the required training for either of the two agency nurses reviewed. Additionally, an incident occurred in which a licensed nurse discovered that 30 tablets of oxycodone for a resident were missing from the narcotic drawer, and one of the agency nurses was identified as the alleged perpetrator. The Director of Nursing stated that agency staff are expected to complete required trainings through their agencies but was unable to obtain or provide records confirming that the two agency nurses had completed training specific to abuse, neglect, exploitation, and misappropriation of resident property. The facility was therefore unable to verify compliance with its own policies and state regulations regarding staff development and personnel procedures.
Failure to Maintain Safe and Functional Dining Equipment
Penalty
Summary
Essential equipment in the dining service areas on both the second and third floors was not maintained in safe and operating condition. On the third floor, an ice machine was observed to be leaking, with a saturated towel and visible water present on the floor. Dietary staff confirmed the leak but were unaware of the appropriate response, indicating it was the responsibility of another department. Additionally, two refrigerators in the third floor dining area were not operational; one had a 'Do Not Use' sign and visible condensation, while the other was a clear display refrigerator that staff stated had not been working. On the second floor, three refrigerators in the dining service area were also found to be inoperable, with staff reporting they had not worked for at least a few months. During lunch service, dietary staff noted that a resident required a turkey and cheese sandwich due to dietary preferences, but the broken refrigerator meant no cold sandwiches were available on hand. The sandwich was eventually provided after a request to the Director of Dining, who delivered it from the dietary department.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, as evidenced by multiple items in the walk-in refrigerator that were either undated or improperly labeled. During a kitchen tour, surveyors observed containers of prepared shredded carrots, deli ham, chopped ham and cheese, deli cheese, thawed raw ground beef, chopped fruit, prepared peas, raviolis, and finely chopped herbs that were missing required 'Use By' dates. Some items, such as the shredded carrots, appeared dry with residue, and the herbs and hard-boiled eggs were past their use-by dates and should have been discarded according to facility policy. The Director of Dining Services confirmed that the labeling and storage practices did not align with the facility's policy, which requires all foods to be wrapped or covered, labeled, dated, and arranged to prevent cross-contamination. The policy also mandates adherence to FDA Food Code guidelines for storing time/temperature control for safety (TCS) foods. The observed deficiencies were based on direct observation, staff interviews, and a review of facility policy, with no mention of specific residents or their conditions.
Neglect in Incontinence Care for a Resident
Penalty
Summary
Norriton Square was found to be non-compliant with the requirement to ensure residents are free from neglect, as outlined in 42 CFR Part 483.12(a)(1). The deficiency was identified during an abbreviated survey following complaints, where it was determined that a resident, identified as R12, did not receive adequate incontinence care. The facility's policy on abuse and neglect, which prohibits mistreatment and mandates effective communication and training, was not adhered to in this instance. The resident, who had severe cognitive impairment and was dependent on staff for toileting hygiene due to a left hip fracture, was found soiled with urine, and their wound dressing was also soiled. This neglect was attributed to a nursing assistant, Employee E3, who admitted to overlooking the resident due to being overwhelmed with the care of eighteen patients. Resident R12 had a complex medical history, including a non-displaced intertrochanteric fracture of the left femur, chronic embolism and thrombosis of the vein, diabetes with neuropathy, and a personal history of transient ischemic attack. The resident's care plan highlighted the need for regular monitoring for skin irritation and repositioning every two hours to prevent skin breakdown, as the resident had a stage three pressure ulcer on the sacrum. Despite these documented needs, the facility failed to provide the necessary care, resulting in the substantiated report of neglect. The nursing home administrator confirmed the neglect after an investigation and noted that Employee E3 had prior disciplinary actions related to care concerns.
Plan Of Correction
1. R12 has discharged from the facility. 2. NPE or designee will re-educate staff on OPS300 Abuse Prohibition policy with review of the definition of Neglect. 3. The Director of Nursing or designee will conduct an initial audit of incontinent residents to ensure incontinence care was provided. 4. The Director of Nursing or designee will conduct random weekly audits x 12 weeks of 10 incontinent residents to ensure incontinence care was provided. 5. NHA or designee to review the results of these audits will be reviewed at the monthly QAPI meeting x 3 months.
Inadequate Staffing Leads to Neglect of Resident Care
Penalty
Summary
The facility failed to ensure an adequate number of nurse aides to meet the needs of residents on the 2nd floor, as evidenced by the case of Resident R12. Resident R12 had a complex medical history, including a non-displaced intertrochanteric fracture of the left femur, chronic embolism and thrombosis of the vein, diabetes with neuropathy, and a history of transient ischemic attack. The resident was assessed with severe cognitive impairment and was dependent on staff for toileting hygiene due to the left hip fracture. The care plan included interventions for skin care and repositioning every two hours due to a stage three pressure ulcer on the sacrum. On February 12, 2025, Resident R12 was found soiled with urine, and the wound dressing was also soiled, indicating neglect in care. The charge nurse discovered the issue while performing wound care. The nursing assistant, Employee E3, who was responsible for Resident R12, admitted to overlooking the resident due to being assigned eighteen patients and a lack of sufficient help. The facility's staffing sheet confirmed that the number of nurse aides scheduled was below the required state regulation, with only eight nurse aides for a census of 95 residents. The Director of Nursing confirmed the staffing inadequacy on the day of the incident.
Plan Of Correction
1. R12 has discharged from the facility. 2. The Director of Nursing or designee will educate nursing staff to review CNA assignments to divide assignments related to acuity of residents care needs. 3. The Director of Nursing or designee will conduct an initial audit of CNA assignments to ensure the assignments are divided related to acuity of residents care needs. 4. The Director of Nursing or designee will conduct weekly audits X 12 weeks of CNA assignments to review that assignments are divided related to acuity of residents care needs. 5. NHA or designee to review the results of these audits will be reviewed at the monthly QAPI meeting x 3 months.
Failure to Provide Adequate Accommodations for Residents
Penalty
Summary
The facility failed to provide reasonable accommodations for two residents, leading to deficiencies in care. Resident R251, who was admitted with conditions including respiratory failure, chronic congestive heart failure, type 2 diabetes, and morbid obesity, was not provided with a bariatric bed upon admission. Despite the facility having the necessary equipment, the resident was observed lying in a regular-sized hospital bed, which was too small and caused discomfort. It took three days after admission for the bed to be adjusted to a bariatric setting, during which time the resident required extensive assistance for repositioning. Resident R248 experienced issues with the heating system in their room. The resident was observed sitting in a chair with a sheet wrapped around them due to feeling cold. The heater was initially thought to be functioning correctly, but further inspection by the Regional Maintenance Director revealed that it was not working properly. The heater's safety mechanism was supposed to prevent overheating, but it was confirmed that the unit was malfunctioning, failing to provide adequate warmth for the resident.
Plan Of Correction
1. Resident 251 has been issued a Bariatric bed and mattress to accommodate his needs. Resident 248 heater has been replaced and is functioning. 2. Maintenance Director or designee to conduct an initial audit of residents requiring a bariatric bed to ensure appropriate bed and mattress in place. Maintenance Director or designee to conduct an initial audit of all resident room heaters to ensure proper functioning. 3. NPE or designee to educate maintenance and nursing staff regarding identification of bariatric bed equipment needs and when resident room heaters are not functioning to notify maintenance utilizing TELS platform. 4. The Maintenance Director or Designee will audit weekly for 12 weeks for both PTech units and bariatric mattresses to ensure compliance. 5. NHA or designee to review the results of these audits at the monthly QAPI meeting for 3 months.
Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to adhere to physician orders regarding diabetes management for a resident, identified as Resident R24. The resident, who was admitted to the facility in March 2021, had a diagnosis of diabetes, which requires careful monitoring of blood glucose levels. According to the physician's order dated May 23, 2023, the facility was required to check the resident's blood glucose levels and notify the physician if the levels exceeded 400. However, the facility did not comply with this order. The clinical records revealed multiple instances where Resident R24's blood glucose levels exceeded 400, specifically on several dates between November 2025 and January 2025, with levels ranging from 407 to 427. Despite these elevated readings, there was no documentation indicating that the physician was notified as required. This deficiency was confirmed during an interview with Employee E13, the unit manager, who acknowledged the findings.
Plan Of Correction
1. Physician reviewed resident R24 blood glucose levels for last 7 days with no changes to orders. 2. The Director of Nursing or designee will conduct an initial audit of current residents with physician orders for blood glucose levels with parameters for the last 7 days to ensure out of range parameters are reported to the physician. 3. NPE or designee will educate current licensed nurses on diabetes management and ensure physician is notified when blood glucose parameters are out of range. 4. The DON or designee will conduct weekly random audits of 5 residents per week x 12 weeks of residents with accu-checks to ensure that blood sugars out of range were reported to the physician. 5. DON or designee to review the results of these audits at the monthly QAPI meeting x 3 months.
Failure to Monitor Resident Weights
Penalty
Summary
The facility failed to ensure that weekly weights were obtained for two residents with a history of weight loss. Resident R39, who has Huntington's Disease, dysarthria, and dysphagia, had a physician's order for monthly weights, but there were significant gaps and inconsistencies in the weight records. Notably, there were no weights recorded for July 2024, and the resident refused to be weighed in August 2024 without any documented re-weigh attempts. Additionally, a disputed weight in December 2024 was not rechecked, as confirmed by the Regional Nurse. Resident R74, with a history of alcohol abuse and dementia, also experienced lapses in weight monitoring. The resident's care plan indicated a potential nutritional risk, yet weights for May and July 2024 were missing. This lack of documentation hindered the ability to assess weight changes, as noted in a nutrition assessment from August 2024. Resident R240 experienced a significant weight loss of 57.8 pounds over six months, with multiple hospitalizations during this period. Despite physician orders for daily weights, there was no documentation of these weights being obtained. The resident's nutritional assessments indicated regular diet intake, but the weight loss was attributed to hospitalizations. The Registered Dietitian noted the significant weight loss and recommended interventions, but the cause of continued weight loss post-hospitalization remained unclear.
Plan Of Correction
1. Resident R39 and R74 had not suffered any adverse effects. Resident 240 signed onto hospice services with admitting diagnosis of Failure to Thrive. 2. The Director of Nursing or designee will conduct an initial audit of current residents with a physician order for weekly weights obtained as ordered and comply with the Genesis Weight policy for the last 7 days. 3. NPE/IP or designee will educate current licensed nurses to ensure residents with weekly weights are obtained per physician orders and comply with the Genesis Weight policy. 4. The DON or designee will conduct weekly random audits of 5 residents per week x 12 weeks of residents with orders for weekly weights, to ensure compliance with the Genesis Weight policy. 5. DON or designee to review the results of these audits at the monthly QAPI meeting x 3 months.
Failure to Maintain Respiratory Equipment Standards
Penalty
Summary
The facility failed to maintain respiratory equipment according to professional standards of practice for two residents. Resident R17, who has a history of chronic diastolic congestive heart failure and atrial fibrillation, was observed using an oxygen concentrator at 3 liters per minute via nasal cannula, contrary to the physician's order of 2 liters per minute. Additionally, the oxygen tubing for Resident R17 was not dated, which was confirmed by a licensed nurse during the observation. Resident R56, diagnosed with chronic obstructive pulmonary disease and chronic respiratory failure, was observed using an oxygen concentrator at 6 liters per minute via nasal cannula. The humidifier bottle and oxygen tubing for Resident R56 were also not dated, as confirmed by the same licensed nurse. The facility's policy requires oxygen tubing to be changed weekly, but the lack of dating on the equipment indicates non-compliance with this policy.
Plan Of Correction
1. Resident R17 and R56 had not suffered any adverse reactions and oxygen tubing was changed/dated. 2. The Director of Nursing or designee will complete an initial audit of all residents receiving oxygen therapy to ensure oxygen tubing changed per Physician order for the last 7 days. 3. NPE/IP or designee will re-educate licensed nurses on Oxygen Therapy Management to ensure oxygen tubing changed per physician order. 4. DON or designee will conduct weekly audits x 12 weeks on 5 random residents to ensure Oxygen tubing was changed per physician order to ensure compliance. 5. DON or designee to review the results of these audits at the monthly QAPI meeting x 3 months.
Medication Cart Security and Storage Deficiency
Penalty
Summary
The facility failed to ensure that medication carts were kept locked when not in use and that medications were properly stored, as observed with two medication carts. On February 9, 2025, at 8:35 a.m., Medication Cart A was found unlocked and unsupervised in the hall of the second floor, with a bottle of over-the-counter aspirin placed on top. Employee E7, a licensed nurse, confirmed that the cart was her responsibility and admitted to leaving it unattended to assist a resident. Similarly, Medication Cart B was observed during a medication pass at 8:49 a.m. on the same day. The cart was found with a bottle of over-the-counter mucus relief expectorant being used to support the medication cart computer. Employee E23, another licensed nurse, confirmed that the medication bottle was not being used appropriately. These observations indicate a failure to adhere to the facility's medication storage policy, which requires medication carts to be locked when not in use and attended by authorized personnel.
Plan Of Correction
1. No resident was adversely impacted due to unsecured medications in an unattended, unlocked medication cart. Employee E7 and E23 were re-educated by NPE on Medication Cart Safety/Management to ensure medications are secured and not left unattended on top of the med cart and med carts are locked while unattended. 2. NPE or designee to conduct an initial house audit to ensure all medication carts are locked and free from unsecured medications. 3. NPE or designee will re-educate all licensed nurses on Medication Cart Safety/Management to ensure medications are secured and not left unattended on top of the med cart and med carts are locked while unattended. 4. DON or designee will conduct 5 random weekly audits x 12 weeks to ensure medications are secured and not left unattended on top of the med cart and med carts are locked while unattended. 5. DON or designee to review the results of these audits at the monthly QAPI meeting x 3 months.
Failure to Honor Dietary Preferences
Penalty
Summary
The facility failed to provide meals in accordance with the dietary preferences and needs of three residents, leading to a deficiency in meeting the requirements for accommodating resident allergies, intolerances, and preferences. Resident R43, who is on a lacto-ovo vegetarian diet and is at nutritional risk due to being underweight, received a fish sandwich instead of the ordered vegetarian burger. This error was confirmed by a medical supply coordinator and a dietary employee, who acknowledged the mistake and corrected it immediately. Similarly, Resident R42, who follows a vegetarian diet, did not receive the requested vegetarian meal items, as confirmed by a nurse aide and the resident's family member. Resident R19, also on a vegetarian diet, did not receive the vegetarian burger patty or any protein source with her meal, despite the availability of these items in the kitchen. The food service director could not explain why the residents' preferences were not honored, suggesting a lack of communication or awareness among the weekend kitchen staff.
Plan Of Correction
1. Resident R43 was provided with the appropriate diet for lunch. Resident R42 was provided with the appropriate diet for lunch. Resident R19 was provided with the appropriate diet for lunch. 2. Food Service Director or designee to complete an initial audit of all residents with food preferences and substitutes to ensure compliance. 3. Food Service Director or designee to re-educate all kitchen staff to ensure residents are receiving the appropriate diet and food preferences. NPE or designee to educate all nursing staff on verifying meal ticket with food tray prior to delivery. 4. Food Service Director or designee to conduct 5 random weekly audits to ensure appropriate diet and food preferences are accurate. 5. Director of Dietary or Designee to review findings monthly during the Quality Improvement Committee x 3 months.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by improper labeling and storage of food items. During a kitchen inspection, it was observed that several plastic bins containing various food substances such as corn starch, sugar, flour, and panko were either mislabeled or not labeled at all. Additionally, items in the freezer and refrigerator, including mixed pasta, sandwiches, a loaf of bread, and plates of salad, were not labeled. In the dry storage room, cereal, uncooked spaghetti, fettuccini, rice crispies, and cornflakes were found without proper labeling, with some items exposed to air due to improper sealing. Interviews with dietary staff confirmed the mislabeling and lack of labeling for these food items. The facility's policy on safe food handling, which requires all food items to be appropriately labeled and dated, was not followed. This oversight in food storage and labeling practices was confirmed during a follow-up tour with the District Manager and kitchen supervisor, highlighting a significant lapse in maintaining food safety standards.
Plan Of Correction
1. All food items not labeled or dated were removed and discarded. 2. Food Service Manager to conduct an initial audit to ensure all food is stored, labeled and dated as per regulations. 3. Food Service Manager or designee to re-educate dietary staff to ensure food is stored, labeled and dated as per policy. 4. Food Service Manager or Designee to complete random weekly audits X 12 to ensure food is labeled, stored and dated. 5. NHA or Designee to review findings monthly during the Quality Improvement Committee x 3 months.
Staff Licensing and Registration Deficiency
Penalty
Summary
The facility failed to ensure that staff were licensed and registered in accordance with State laws for three of the eleven personnel files reviewed. Employee E21, a registered nurse, was found to be working with an expired nursing license, which had expired on October 31, 2024. The facility discovered this lapse on December 18, 2024, and subsequently provided education to Employee E21 regarding the policy that mandates maintaining an active nursing license at all times. Employee E21 reactivated her nursing license on December 20, 2024. Additionally, the facility conducted an audit of all employees with nursing licenses and nurse aide registries, which revealed that Employees E17 and E16, both nurse aides, were not included in the audit. Further review showed that neither employee was enrolled in the Pennsylvania nurse aide registry, a requirement for employment in a nursing care facility receiving Medicare or Medicaid reimbursement. Employee E17 was hired on October 22, 2024, and Employee E16 on November 19, 2024, both having completed a nurse aide training course prior to their hiring. However, they were not registered to work as nurse aides in Pennsylvania, as confirmed by the Nursing Home Administrator.
Plan Of Correction
1. Employee E21 provided no direct care and caused no harm to residents. Employee E17 and E16 are no longer employed at the facility. 2. Employee E21 was educated on his responsibility to ensure his license is renewed timely and active. 3. NPE or designee to educate licensed nursing staff on the importance of timely license renewal. 4. NPE or designee will conduct an initial audit of licensed nursing staff then monthly audits x 3 months to ensure compliance. 5. NHA or designee to review results of these audits at the monthly QAPI meeting x 3 months.
Inadequate Infection Control for Resident with MDRO Risk
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically in the case of a resident identified as R35. The deficiency was observed when Employee E16 provided incontinence care to Resident R35 without wearing the appropriate personal protective equipment (PPE), specifically a gown, despite the resident being at risk for multi-drug resistant organism (MDRO) transmission. The facility's policy on Enhanced Barrier Precautions (EBP) requires the use of targeted PPE during high-contact resident activities to reduce the transmission of MDROs. However, the employee was only wearing gloves and was unaware that PPE was required for Resident R35, mistakenly believing that the enhanced barrier precaution sign on the door was only for the resident's roommate. Resident R35 entered the facility with a diagnosis of Type 2 diabetes and was assessed as having a diabetic foot ulcer. The resident required assistance and was dependent on staff for all activities of daily living due to paralysis and weakness on the left side. The resident's care plan indicated a risk for skin breakdown related to an actual pressure ulcer, and the clinical record included instructions to monitor for skin breakdown. However, the Kardex did not indicate that Resident R35 was on enhanced barrier precautions, contributing to the oversight in infection control measures.
Plan Of Correction
1. Resident R35 was placed on Enhanced Barrier Precautions. 2. IP or designee to conduct initial house audit to ensure all residents are identified for enhanced barrier precautions. 3. Infection Preventionist or designee will educate all staff on Enhanced Barrier Precautions. 4. Infection Preventionist or designee will conduct 5 random weekly audits x 12 weeks to ensure staff are compliant with EBP. 5. DON or designee to review the results of these audits at the monthly QAPI meeting x 3 months.
Deficiency in Required In-Service Training for Nurse Aide
Penalty
Summary
The facility failed to ensure that nurse aides received the required 12 hours of in-service education per year, as mandated by regulations. Specifically, Employee E9, a nurse aide hired on June 20, 2019, did not complete the necessary annual in-service training hours between February 11, 2024, and February 10, 2025. During this period, Employee E9 only completed two courses related to hand hygiene and personal protective equipment. This deficiency was confirmed through a review of personnel records and an interview with the Nursing Home Administrator, who acknowledged the shortfall in meeting the training requirements.
Plan Of Correction
1. Employee E9 completed their 12 hours annual inservice education. 2. NPE or designee to conduct an initial audit of all CNA's to ensure 12 hour annual in-servicing is in compliance. 3. NPE will be re-educated by the DON on the importance of ensuring all Nurse Aides completed at least 12 hours of inservice education annually. 4. NPE will conduct random monthly audits to ensure all Nurse Aides completed at least 12 hours of inservice education annually X 3 months. 5. DON or designee to review the results of these audits at the monthly QAPI meeting x 3 months.
Staffing Ratio Deficiency
Penalty
Summary
The facility failed to maintain the required staffing ratios for nurse aides during the day, evening, and overnight shifts on June 29 and 30, 2024. On June 29, the facility had a census of 94 residents, necessitating 58.75 hours of nurse aide care during the evening shift. However, only 43.00 hours of care were provided, with no additional higher-level staff available to compensate for the shortfall. Similarly, on June 30, the facility had a census of 93 residents, requiring 58.13 hours of nurse aide care during both the day and evening shifts. The facility only provided 37.50 hours of care for each of these shifts, again without any higher-level staff to make up for the deficiency. The deficiency was confirmed during a review of staffing calculations, nursing staff schedules, and punch reports with the Nursing Home Administrator on February 11, 2024. The administrator acknowledged that the required staffing ratios were not met on the specified dates. The report does not mention any corrective actions or follow-up measures taken to address the staffing shortfall.
Plan Of Correction
1. All residents received care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly x4 weeks then monthly for two months. 5. Results will be taken to the QAPI for review and revision as needed.
Facility Fails to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to maintain the required staffing ratios for nurse aides on 17 out of 19 days reviewed. The regulation mandates a minimum of one nurse aide per 10 residents during the day, one per 11 residents during the evening, and one per 15 residents overnight. However, the facility consistently fell short of these requirements across multiple shifts and dates, as evidenced by the review of nursing staff schedules, punch reports, and interviews with staff. On July 1, 2024, the facility had a census of 92 residents, necessitating 69 hours of nurse aide care during the day shift, 62.73 hours during the evening shift, and 46 hours overnight. The facility only provided 60, 42, and 37.5 hours of care, respectively, with no additional higher-level staff available to compensate for the deficiency. Similar shortfalls were observed on subsequent days, with the facility repeatedly failing to meet the required hours of nurse aide care based on the census data. The deficiency persisted over several months, with specific instances noted on September 28 and 29, October 1 to 4, and February 3 to 9, 2025. Each of these dates showed a consistent pattern of understaffing, with the facility unable to provide the necessary hours of nurse aide care required by the resident census. The Nursing Home Administrator confirmed the failure to meet staffing ratios during a review on February 11, 2024.
Plan Of Correction
1. All residents received care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly x4 weeks then monthly for two months. 5. Results will be taken to the QAPI for review and revision as needed.
LPN Staffing Deficiency
Penalty
Summary
The facility failed to maintain the required staffing ratios for Licensed Practical Nurses (LPNs) on six specific dates. The regulation mandates a minimum of one LPN per 25 residents during the day, one LPN per 30 residents during the evening, and one LPN per 40 residents overnight. However, on June 29, July 2, 4, and 5, 2024, and February 4 and 6, 2025, the facility did not meet these staffing requirements during the evening shifts. The census data indicated that the number of LPN hours required was not met, and there were no additional higher-level staff available to compensate for the deficiency. On June 29, 2024, the facility had a census of 94 residents, requiring 25.07 hours of LPN care, but only 24.00 hours were provided. Similar deficiencies were noted on July 2, 4, and 5, 2024, and February 4 and 6, 2025, where the required LPN hours were not met, with the most significant shortfall occurring on July 5, 2024, when only 16.00 hours of LPN care were provided against a requirement of 24.27 hours. The Nursing Home Administrator confirmed these deficiencies during a review of staffing calculations, nursing staff schedules, and punch reports on February 11, 2024.
Plan Of Correction
1. All residents received care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly x4 weeks then monthly for two months. 5. Results will be taken to the QAPI for review and revision as needed.
Deficiency in Direct Nursing Care Hours
Penalty
Summary
The facility failed to meet the required minimum of 2.87 hours of direct nursing care per resident on two consecutive days, June 29 and 30, 2024. On June 29, with a census of 94 residents, only 237.50 direct nursing staff hours were provided, resulting in 2.53 hours of care per resident. On June 30, with a census of 93 residents, 217.00 direct nursing staff hours were provided, equating to 2.33 hours of care per resident. These deficiencies were confirmed through a review of nursing time schedules, punch reports, and staff interviews, and were acknowledged by the Nursing Home Administrator during a review session on February 11, 2024.
Plan Of Correction
1. All residents received care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly x4 weeks then monthly for two months. 5. Results will be taken to the QAPI for review and revision as needed.
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 on 15 out of 19 days reviewed. This deficiency was identified through a review of nursing time schedules, punch reports, and staff interviews. Specific dates where the facility did not meet the required staffing ratios include July 1-5, 2024; September 28-30, 2024; October 1-4, 2024; and February 7-9, 2025. On these dates, the facility's census ranged from 88 to 95 residents, and the direct nursing care hours provided per resident varied from 2.65 to 3.18 hours, consistently falling short of the mandated 3.2 hours on most days. The Nursing Home Administrator confirmed the shortfall in staffing ratios during a review of staffing calculations, nursing staff schedules, and staff punch reports on February 11, 2024. The deficiency was evident as the facility consistently failed to provide the required level of direct nursing care, impacting the quality of care provided to the residents. The report does not mention any corrective actions or plans to address this deficiency, focusing solely on the failure to meet the required staffing levels on the specified dates.
Plan Of Correction
1. All residents received care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly for 4 weeks, then monthly for two months. 5. Results will be taken to the QAPI for review and revision as needed.
Pharmacy Dispensing Error and Delayed Response
Penalty
Summary
The pharmacy failed to timely respond to an inquiry regarding a possible medication dispensing error for a resident. The facility's policy required the pharmacy to accurately dispense medications based on authorized prescriber orders. However, a licensed nurse discovered that the medication card for a resident's prescribed Lisinopril did not match the description of the medication actually packaged. Upon further investigation by the nurse and the unit manager, it was determined that the medication card contained 450 milligrams of Lithium instead of the prescribed 40 milligrams of Lisinopril. This error resulted in the resident receiving 21 doses of Lithium over three weeks, which was not prescribed to them. Interviews with facility staff revealed that the pharmacy was notified of the error, but the pharmacy had not yet confirmed the identity of the medication dispensed. The Nursing Home Administrator and the Director of Nursing acknowledged that the true verification of the medication administered needed to be determined by the pharmacy. The facility failed to ensure that pharmacy services accurately dispensed medication for the resident, as required by state regulations.
Lack of Fresh Air Breaks for Residents
Penalty
Summary
The facility did not ensure that residents were treated with dignity and care in a manner that promotes the enhancement of their quality of life, specifically related to providing fresh air breaks. During a resident council meeting, twelve alert and oriented residents expressed a strong desire for fresh air breaks during the day and could not recall the last time they were allowed outside, except for approved leave of absence visits. A review of three months of Resident Council minutes and four months of activity calendars revealed that residents had requested fresh air time, but no outside activities were scheduled. The activity director confirmed that there were no fresh air activities on the calendar and mentioned plans to implement them once a week in the future. Recreation assessments for several residents indicated that outdoor time was important to them for activities such as sitting, relaxing, and bird watching. Despite the facility having a gated courtyard that provides a secure space for residents to enjoy fresh air, it was observed that this area was not being utilized for the residents' benefit. The deficiency was confirmed through interviews with residents and staff, as well as a review of facility documentation and observations.
Insufficient Nursing Staff Levels
Penalty
Summary
The facility failed to maintain sufficient nursing staff levels to provide adequate care and services for five of the 19 residents reviewed. Observations and interviews revealed that residents experienced significant delays in receiving necessary care. For instance, Resident R80 was found in bed with a strong odor of feces, indicating a lack of timely assistance. Resident R78's family member had to perform morning care due to insufficient staffing, and there was an expectation from the staff for the family member to assist regularly. Resident R90 reported a general shortage of staff, while Resident R73 did not receive a shower for a week and a half, missing a shower before an Easter celebration. The assigned nurse aide, Employee E4, confirmed that high resident-to-staff ratios often prevent timely care, with priorities shifting to meal service over morning care. Resident R198, a new admission, reported unresponsive call bell service and a delay in receiving a bedpan during the night shift. A resident council meeting with 12 alert and oriented residents further confirmed the facility's staffing issues, leading to extended wait times for call bell responses. A unit manager, Employee E7, verified that the second-floor unit was understaffed, with only three nurse aides scheduled for 41 residents, and one aide arriving late. The administrator, Employee E1, confirmed that the facility lacked a sufficient number of certified nursing aides and licensed nursing employees, as evidenced by a review of three weeks of schedules. These findings indicate a systemic issue with staffing levels, directly impacting the quality of care provided to residents.
Confidentiality Breach of Resident's Medical Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the third floor. During a medication administration, a registered nurse left the medication cart unattended with the computer screen open, revealing identifiable information of a resident. This incident was observed and confirmed by the nurse, violating the facility's HIPAA compliance policy, which mandates securing patient records to prevent unauthorized access. The deficiency was noted during an observation on April 4, 2024, at 9:10 a.m., and confirmed through an interview with the involved employee shortly after.
Misappropriation of Medication
Penalty
Summary
The facility failed to ensure that one resident was free from misappropriation of medication. Specifically, a licensed nurse, Employee E10, was observed preparing medication for Resident R23 and found that there was no Eliquis 5 mg available in the resident's drawer. Employee E10 then decided to borrow Eliquis from another resident, Resident R74, without consent. This action was confirmed as misappropriation of Resident R74's medication by Employee E7, the Unit Manager. The facility's policy on Abuse Prohibition, which prohibits misappropriation of resident property, was not followed in this instance.
Failure to Evaluate and Obtain Consent for Restraint Use
Penalty
Summary
The facility failed to ensure ongoing evaluation of a resident's need and use of restraints, specifically an abdominal binder, for one resident. The resident, who had multiple medical conditions including chronic obstructive pulmonary disease, chronic kidney disease, and parkinsonism, was observed with an abdominal binder to secure his enteral feed. The facility's policy required reassessment of restraints monthly for three months, then quarterly, and with any significant change in condition, but no such assessments were conducted for this resident. Additionally, the facility did not obtain consent for the use of the abdominal binder, as they did not recognize it as a restraint. The resident's clinical records and nursing documentation confirmed that the abdominal binder remained in place and that the resident consistently complied with and tolerated the intervention. However, there was no documentation indicating that the resident had attempted to remove the binder, nor was there any indication of upper extremity limitations that would prevent the resident from doing so. The facility's failure to recognize the abdominal binder as a restraint and to follow their own policy for reassessment and consent led to this deficiency.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in their care. Resident R6, admitted with multiple serious conditions including acute respiratory failure and chronic kidney disease, had a physician order for an abdominal binder to be worn at all times. However, the care plan initiated on March 9, 2023, did not include this intervention. This omission was confirmed by a unit manager on April 4, 2024, despite the resident being observed with the abdominal binder in place. Similarly, Resident R83, who had a history of severe mental health issues and a recent suicide attempt, was placed on 15-minute checks per a physician's order. However, the care plan dated September 9, 2023, did not reflect this new diagnosis or the required checks, a fact confirmed by the Director of Nursing and the Administrator on April 5, 2024. Resident R86, who had a diagnosis of lung cancer and a blood clot, was observed with an unused portable oxygen cylinder on her wheelchair. Despite an active physician order for continuous oxygen at 2 L/min, no care plan had been developed for her oxygen usage. This was confirmed by the Director of Nursing on April 2, 2024, who acknowledged that a care plan should have been in place. These deficiencies indicate a failure to develop and implement comprehensive care plans that meet the residents' needs, as required by regulatory standards.
Failure to Follow Physician Order for Monitoring Weight Loss
Penalty
Summary
The facility did not ensure that a physician order was followed related to unplanned weight loss for one of 19 residents reviewed. Resident R6, who was admitted with multiple diagnoses including severe protein-calorie malnutrition and abnormal weight loss, experienced a significant unplanned weight loss of 5.76% over two weeks. A physician order was initiated to obtain weekly weights for four weeks starting on March 8, 2024. However, clinical records indicated that there were no weekly weight measurements documented between March 21, 2024, and April 4, 2024. This was confirmed by an interview with the Registered Dietician, Employee E8, who acknowledged the absence of the required weekly weights during this period.
Unattended and Unlocked Medication Cart
Penalty
Summary
The facility failed to maintain an environment free from hazards related to an unlocked medication cart and unsecured medications on the cart for one of two nursing units. During an observation of medication administration, a licensed nurse left the medication cart unattended and unlocked in the second-floor hallway. The cart had two medications, Furosemide and Ampicillin, left on top of it. The nurse confirmed this observation upon returning to the cart. Additionally, the nurse was observed preparing medication for a resident and left the cart unlocked with medications on top and unsecured inside the cart while attending to the resident. This was confirmed again when the nurse returned to the cart.
Failure to Provide Oxygen as Ordered
Penalty
Summary
The facility failed to provide oxygen as ordered for two residents. Resident R43, who was admitted with chronic obstructive pulmonary disease and acute and chronic respiratory failure, had a physician's order for three liters of oxygen via nasal cannula continuously. However, observations on two separate days revealed that the resident was receiving either 3.5 liters or 2.5 liters of oxygen instead of the prescribed amount. During an interview, the resident expressed discomfort due to inadequate oxygen, and a licensed nurse confirmed the discrepancy and adjusted the oxygen level to the correct amount. Resident R86, admitted with diagnoses including malignant neoplasm of the lung and acute deep vein embolism, had an active order for two liters of oxygen via nasal cannula continuously and for weekly oxygen tubing changes. Despite this, the resident had not used supplemental oxygen for months and still had a portable oxygen cylinder attached to her wheelchair with outdated tubing. The Director of Nursing acknowledged that the order should have been modified or discontinued and that the tubing should have been changed weekly as per the physician's order.
Improper Food Handling and Serving Practices
Penalty
Summary
The facility did not ensure that food was served in accordance with professional standards for food service safety for one resident. During lunch dining, a dietary aide ran out of plates and began using white picnic-style paper plates. The aide reheated mashed potatoes on a paper plate in the microwave without covering them, contrary to the facility's policy. The reheated food was then placed on the counter without checking its temperature with a dial thermometer as required by the policy. A nursing aide subsequently touched the mashed potatoes with her pinky finger to check the temperature before feeding them to the resident. This action was also against the facility's policy, which mandates the use of a thermometer to ensure food safety. The resident involved had multiple severe medical conditions, including hemiplegia, hemiparesis, aphasia, hydrocephalus, Parkinson's Disease, apraxia, dysphagia, vascular dementia, and cognitive communication deficit, with a BIMS score of 00 indicating severe cognitive impairment. Interviews with the dietary aide and nursing aide confirmed the improper handling and reheating of food. The Food Service Director acknowledged that there were adequate supplies of plates and that the staff failed to follow the proper procedures for reheating and serving food.
Failure to Report Resident's Self-Harm Incident
Penalty
Summary
The facility failed to report a reportable incident involving a resident to the local Department of Health within the required and appropriate time frames. Resident R83, who had a history of anxiety disorder, dementia, major depressive disorder, and adjustment disorder, attempted self-harm by trying to wrap a bed remote cord around his neck and expressed suicidal ideation. The incident occurred on December 23, 2023, and the resident was subsequently sent to the nearest emergency room. Upon returning to the facility on December 29, 2023, the resident was placed on 15-minute checks every shift. However, it was confirmed on April 5, 2024, by the Director of Nursing and the Administrator that the incident was not reported to the Department of Health as required.
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Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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