Oxford Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Oxford, Pennsylvania.
- Location
- 7 East Locust Street, Oxford, Pennsylvania 19363
- CMS Provider Number
- 395367
- Inspections on file
- 24
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Oxford Health Center during CMS and state inspections, most recent first.
The facility failed to follow its infection surveillance and outbreak policies for residents with GI symptoms. Policy required nursing staff to report residents with multiple loose stools or other infection indicators so the DON or IC coordinator could enter them on a surveillance line list and monitor for trends, and to initiate an outbreak investigation when an emerging infectious disease was suspected. Several residents on one unit with more than one loose bowel movement in 24 hours were entered on an outbreak line list, but two additional residents with documented multiple loose stools and vomiting were not added. The IC nurse, who worked part-time and had the line list handed off from a prior DON, could not explain the omission of these residents and confirmed that no investigation was completed to determine the source of the GI symptoms.
A resident with Alzheimer's disease, osteoarthritis, and a history of falls sustained a skin tear during a transfer using a stand-up lift when staff, unaware of her updated transfer requirements, did not provide the necessary assistance and cues. The assignment sheet used by CNAs was not updated to reflect her need for a two-person transfer and specific precautions, resulting in inadequate supervision and an accident.
The facility did not maintain the smoke resistance of smoke barrier walls, as observed in the basement Linen Storage Room where two unprotected penetrations were found after pipe removal. This issue, confirmed by the Maintenance Manager, affected two of the 14 smoke compartments, compromising the smoke barrier's integrity.
The facility did not maintain the fire resistance of common walls, affecting one smoke compartment. Observations revealed four unprotected penetrations in the wall separating the 01 and 02 Components, located above the ceiling and doors. Three penetrations were around wires, and one was empty. The Maintenance Manager confirmed these findings.
The facility did not maintain the fire resistance of an exit stairtower enclosure, affecting one smoke compartment. The fire exit hardware on the 1st floor Rosewood East Stairwell door was missing an end cap, compromising its fire resistance. This was confirmed by the Maintenance Manager.
The facility failed to maintain smoke resistance in a hazardous area enclosure, affecting one of 14 smoke compartments. The basement door to the Maintenance Storage Room, over 100 square feet, lacked an automatic closure. This was confirmed by the Maintenance Manager.
A portable fire extinguisher in the basement Elevator Machine Room was found unsecured on the floor, having been removed from its wall bracket. This was confirmed by the Maintenance Manager during a survey.
The facility failed to monitor the use of surge suppressors and extension cords, leading to a deficiency. Observations revealed a surge suppressor powering an extension cord for communications equipment in the basement and a receptacle multiplying power tap supplying a surge suppressor in the Chapelwood Communications Closet. These setups were confirmed by the Maintenance Manager.
The facility failed to ensure accurate MDS assessments for three residents, with errors in documenting insulin administration and pressure ulcers. Staff interviews confirmed discrepancies between MDS entries and clinical records, highlighting inaccuracies in resident status documentation.
The facility failed to ensure timely responses to call bells on two floors, with an average response time of 28.07 minutes and some extending up to 111.05 minutes. Residents and a family member reported concerns about prolonged waits, with one resident experiencing delays of 45 to over 60 minutes. The NHA confirmed these findings, noting that response times over 40 minutes are investigated.
Failure to Accurately Track and Investigate GI Symptoms Under Infection Control Program
Penalty
Summary
The facility failed to implement its infection prevention and control surveillance policies for residents with gastrointestinal (GI) symptoms. The written policy "Surveillance for Infection/Infectious Disease" required nursing staff to notify the charge nurse when residents had a temperature of 100°F or greater, two or more loose watery stools in 24 hours, skin inflammation or purulent drainage, or a hospital transfer due to infection, and required the DON or Infection Control (IC) Coordinator to enter such data on a Weekly Surveillance Line Listing Report to monitor trends. The "Outbreak Plan" policy required an outbreak investigation when there was evidence of a possible outbreak of an emerging infectious disease. Facility records showed that one resident had more than one loose bowel movement (LBM) in 24 hours on January 30, 2026, and seven additional residents on the Transitional Care Unit (TCU) had more than one LBM in 24 hours between February 1 and February 2, 2026, and these residents were listed on the Outbreak Case-Patient Line List. However, nursing progress notes documented that another resident had two episodes of loose stools on two separate dates in early February 2026, and a different resident had multiple episodes of vomiting and multiple episodes of loose bowel movements, but these two residents were not included on the facility’s Outbreak Case-Patient Line List. During an interview, the IC nurse reported that residents with potential infectious symptoms were communicated to the DON during daily morning meetings or by verbal reporting and stated they only worked three days per week. The IC nurse explained that the previous DON initiated the GI symptom line list and then handed it off on February 2, 2026, but could not explain why the two additional symptomatic residents were not captured on the surveillance report and confirmed that no investigation was conducted to determine the source of the residents’ GI symptoms. The surveyors concluded that the facility failed to ensure appropriate surveillance, monitoring, and tracking for residents showing GI symptoms, citing 28 Pa. Code 201.18(b)(1), 211.5(f), and 211.12(d)(1)(3)(5).
Failure to Update Assignment Sheet Leads to Resident Injury During Transfer
Penalty
Summary
The facility failed to prevent accidents by not ensuring that the assignment sheet accurately reflected the care needs of a resident with Alzheimer's disease, osteoarthritis, and a history of repeated falls. The resident was involved in an incident where, while being transferred using a stand-up lift, she moved her left arm and did not hold onto the bar, resulting in a skin tear to her left forearm. Occupational therapy notes indicated that the resident had limited standing tolerance and required significant assistance and constant cues to keep her feet on the lift platform. It was also documented that transfers using the sit-to-stand lift should only be performed by CNAs familiar with her behavior and who had been educated on her specific needs. Despite these documented requirements, staff involved in the transfer were not fully aware of the resident's current transfer status, with one employee stating they believed the resident was cleared for the sit-to-stand lift based on previous information. The assignment sheet, which is used by CNAs to determine transfer statuses, was not updated to reflect the resident's need for a two-person transfer and the specific precautions required. Although competency evaluations and orientation for mechanical lift use were in place, the lack of accurate and updated information on the assignment sheet contributed to the incident.
Failure to Maintain Smoke Barrier Wall Integrity
Penalty
Summary
The facility failed to maintain the smoke resistance of smoke barrier walls, which is a requirement for ensuring fire safety within the building. During an observation, it was noted that there were two unprotected penetrations in the basement Linen Storage Room wall, where two pipes had been removed. This deficiency was confirmed through an interview with the Maintenance Manager, who acknowledged the unprotected penetrations of the smoke barrier wall. This issue affected two out of the 14 smoke compartments within the component, compromising the smoke resistance of the barrier walls.
Plan Of Correction
The two penetrations of the basement Linen Storage Room will be corrected by the Maintenance Manager using an approved through penetration fire stop system. The Maintenance Manager or designee will conduct an audit of corridor walls weekly for one month, then bi-weekly for one month. Monthly fire walls inspections will be added to PM schedule to check for penetrations and caulking in place and ensure that the facility is maintaining the rating of the smoke barrier wall. Deficient findings will be reported to DES and QAPI meeting.
Failure to Maintain Fire Resistance of Common Walls
Penalty
Summary
The facility failed to maintain the fire resistance of building separating common walls, which affected one of the 14 smoke compartments within the component. During an observation, it was noted that there were four unprotected penetrations in the common wall separating the 01 and 02 Components. These penetrations were located above the suspended ceiling, above the double doors, on the 01 Component side. Specifically, three penetrations were found around groups of wires, and one penetration was empty. This deficiency was confirmed through an interview with the Maintenance Manager, who acknowledged the unprotected penetrations of the fire wall.
Plan Of Correction
The four penetrations of the common wall, separating the 01 and 02 components above the suspended ceiling above the double doors will be corrected by the Maintenance Manager using an approved through penetration fire stop system. The Maintenance Manager or designee will conduct an audit of corridor walls weekly for one month. Monthly fire walls inspections will be added to PM schedule to check for penetrations and caulking in place to ensure the facility maintains the rating of the common wall. Deficient findings will be reported to DES and QAPI meeting.
Fire Resistance Deficiency in Stairwell Enclosure
Penalty
Summary
The facility failed to maintain the fire resistance of exit stairtower enclosures, specifically affecting one of the 14 smoke compartments. During an observation, it was noted that the fire exit hardware on the 1st floor Rosewood East Stairwell door was missing an end cap. This deficiency was confirmed through an interview with the Maintenance Manager, who acknowledged the compromised fire resistance of the fire exit hardware.
Plan Of Correction
1. The end cap on the fire exit hardware for Rosewood east stairwell door will be replaced. 2. The Maintenance Manager or designee will conduct an audit of the fire exit hardware weekly for one month. 3. Fire door hardware inspection will be added to the PM checklist to ensure all parts are on the fire doors. 4. Deficient findings will be reported to DES and QAPI meeting.
Deficiency in Smoke Resistance of Hazardous Area Enclosure
Penalty
Summary
The facility failed to maintain the smoke resistance of hazardous area enclosures, specifically affecting one of the 14 smoke compartments within the component. During an observation on January 28, 2025, at 12:30 PM, it was noted that the basement door to the Maintenance Storage Room, which is over 100 square feet, lacked an automatic closure. This deficiency was confirmed through an interview with the Maintenance Manager at the same time, who acknowledged that the door did not automatically close.
Plan Of Correction
A door closure will be installed on the basement maintenance storage. The Maintenance Manager or designee will conduct a facility wide audit on hazardous doors, and then random doors on a quarterly basis. Education will be provided to all staff on when to report doors missing hardware. Deficient findings will be reported to DES and QAPI meeting.
Unsecured Portable Fire Extinguisher in Facility
Penalty
Summary
The facility failed to secure a portable fire extinguisher, which was observed during a survey. The deficiency was identified in one of the 14 smoke compartments within the facility. Specifically, on January 28, 2025, at 12:20 PM, a portable fire extinguisher located in the basement Elevator Machine Room, near the vending machines, was found removed from its wall bracket and placed unsecured on the floor. This observation was confirmed through an interview with the Maintenance Manager at the same time.
Plan Of Correction
Fire extinguisher located within the elevator Machine Room was reinstalled onto the wall bracket. The Maintenance Manager, or designee will audit fire extinguisher placement for one month. Add to our monthly Fire Extinguishers checklist to ensure extinguisher is in mounting bracket. Education will be provided to all staff on the proper mounting of fire extinguishers, and the reporting when a bracket or cabinet is damaged. Deficient findings will be reported to DES and QAPI meeting.
Improper Use of Surge Suppressors and Extension Cords
Penalty
Summary
The facility failed to properly monitor the use of surge suppressors and extension cords, which led to a deficiency in one of the 14 smoke compartments. During an observation on January 28, 2025, at 12:45 PM, it was found that a surge suppressor was supplying electrical power to an extension cord, which then powered communications equipment in the basement Communications Room. This setup was confirmed by the Maintenance Manager during an interview at the same time. Additionally, another observation on the same day at 1:09 PM revealed a receptacle multiplying power tap supplying electrical power to a surge suppressor within the Chapelwood Communications Closet. This was also confirmed by the Maintenance Manager during an interview. These findings indicate a failure to adhere to the proper use of electrical equipment as per the NFPA standards, contributing to the deficiency noted in the report.
Plan Of Correction
An additional electrical outlet will be installed to supply electricity to the communication equipment. The multiplying power tap in the Chaplewood Communication closet has been removed. The Maintenance Manager or designee will conduct an audit for unauthorized electrical equipment not less than quarterly, and more frequently during high decoration holidays such as Christmas and Easter. Deficient findings will be reported to DES and QAPI meeting.
Inaccurate Resident Assessments in MDS Documentation
Penalty
Summary
The facility failed to ensure the accuracy of resident assessments, as evidenced by discrepancies in the Minimum Data Set (MDS) for three residents. For Resident 18, the quarterly MDS inaccurately indicated that the resident was receiving insulin, despite the absence of physician orders or documentation in the Medication Administration Record (MAR) confirming insulin administration. Similarly, Resident 31's MDS incorrectly noted insulin administration, which was not supported by physician orders or the MAR. These inaccuracies were confirmed through staff interviews. Additionally, Resident 52's MDS failed to reflect the presence of an unstageable pressure ulcer on the right heel, as documented in the resident's wound and skin records. The MDS inaccurately reported no unhealed pressure ulcers, contradicting the clinical documentation. These errors in the MDS assessments were confirmed by staff interviews, indicating a failure to accurately document and assess the residents' medical conditions.
Plan Of Correction
The following Resident Assessments were resubmitted for accuracy: Resident 18 Quarterly MDS 12/17/2024 was modified and resubmitted on 1/21/2025. Resident 31 Quarterly MDS 12/6/2024 was modified and resubmitted on 1/21/2025. Resident 52 Quarterly MDS 10/11/2024 was modified and resubmitted on 1/21/2025. An MDS audit for current residents' last assessment will be completed for resident assessments coded as receiving insulin and resident assessments coded as having wounds to ensure accuracy. Any identified modifications resulting in resubmission will occur. MDS staff received re-education on MDS completion by Nursing Home Administrator on 1/21/2025, accuracy and RAI guidelines. A weekly audit of 3 quarterly resident assessments for MDS accuracy will be completed by the NHA or designee x one-month. Random audits of 3 quarterly resident assessments for MDS accuracy x 2 months will be completed by NHA or designee. Findings will be reported to Quality Assurance for review and recommendations as appropriate.
Delayed Call Bell Response Times
Penalty
Summary
The facility failed to ensure that call bells were answered in a timely manner on both the first and second floors, as evidenced by a review of facility records and interviews with staff and residents. The facility's 'Call Bell Response' policy, which was undated, stated that call lights should be responded to promptly to promote a secure atmosphere for residents. However, a call bell response time report from November 1 to November 30, 2024, revealed an average response time of 28.07 minutes for 283 call alarms, with some response times extending up to 111.05 minutes. Interviews with several residents and a visiting family member confirmed concerns about prolonged call bell response times. One resident reported experiencing response times of more than 10 minutes but less than 60 minutes, while another reported waiting 20 minutes or more. Another resident experienced response times ranging from 45 minutes to over 60 minutes, corroborated by a family member who noted a 45-minute wait the previous night. The Nursing Home Administrator confirmed the lengthy response times and stated that response times over 40 minutes are investigated, often finding that staff were assisting other residents at the time.
Plan Of Correction
Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. 1. Based upon the 2567, the facility is unable to determine which residents provided statements to the surveyor. An audit was conducted of the call bell response report for the entire month of November 2024. There was a total of 6,112 events with an average response time of 6.58 mins for all of them. An audit of Incident reports and the Grievance log for November 2024 did not indicate any incidents or complaints about prolonged wait for call bell response and no harm or injury was identified. 2. To prevent this from reoccurring, re-education for Nursing staff on the call bell policy and the importance of properly clearing call bell devices. 3. Ongoing monitoring for compliance, DON/designee will review call bell response time reports daily x 2 weeks than weekly x 2 months and investigate any prolonged wait times to ensure proper staff response to call bells. 4. Results will be presented at QAPI for review and revision.
Latest citations in Pennsylvania
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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