Passavant Retirement And Healt
Inspection history, citations, penalties and survey trends for this long-term care facility in Zelienople, Pennsylvania.
- Location
- 105 Burgess Drive, Zelienople, Pennsylvania 16063
- CMS Provider Number
- 395001
- Inspections on file
- 21
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Passavant Retirement And Healt during CMS and state inspections, most recent first.
Surveyors found that the facility failed to follow a physician-ordered bowel protocol for a resident with prostate cancer, urinary retention, and diabetes, despite documentation showing several days without a bowel movement and only one dose of ordered laxative given, which led to hospitalization where imaging confirmed fecal impaction and stercoral proctitis and an enema was required. Staff interviews described a standard bowel protocol that should begin after three days without a BM, but the DON acknowledged there was no evidence the protocol was followed for this resident. In a separate finding, another resident with dementia, hypertension, and malnutrition had an order to wear Geri Sleeves for arm skin protection, yet was observed in a wheelchair without the sleeves, and an LPN confirmed the ordered skin-preventive treatment was not in place.
Surveyors identified that the dish room serving one household had two fans located above the clean side of the dish machine that were covered with a buildup of black substance, dirt, and grime, contrary to the facility’s infection control policy requiring appropriate disinfection of household dish rooms. During an interview, a household coordinator confirmed the dirty condition of the fans and acknowledged that this created a potential for cross contamination and food-borne illness.
Surveyors found that the facility did not ensure required information was sent to receiving providers during facility-initiated transfers and did not notify the Office of the Long-Term Care Ombudsman of transfers and a discharge. Two residents transferred to the hospital, one with hyperlipidemia, depression, and a fall history and another with HTN, hip fracture, and gait difficulty, lacked documented evidence that care plan goals and, in one case, advance directives, ongoing care instructions, representative information, and other needed clinical details were communicated to the hospital. A nurse manager stated that care plans are not sent with residents. Additionally, three residents, including one with DM, malnutrition, and coordination problems who was discharged home, had no documented written transfer or discharge notices sent to the Ombudsman, and the administrator confirmed that such notices were not provided.
Surveyors found that the facility installed bilateral bed enabler bars for three residents with conditions such as HTN, anemia, arthritis, hemiplegia, and hyperlipidemia based on physician orders for bed mobility, but did not obtain informed consent or document any discussion of risks and benefits with the residents or their representatives, despite a facility policy requiring education and consideration of the benefits-to-risk ratio for mobility bars/bedrails. A clinical nurse manager stated that consents were not obtained because enabler bars were not considered restraints, confirming the lack of required consent and documentation.
Surveyors found that medications and biologicals were not stored safely, securely, and in an orderly manner in three medication rooms (Larkspur, Allegheny, and Tionesta). Personal items, including coats and a bag with a thermos, were stored in one med room, and multiple products such as ostomy paste, lubricant jelly, saline wound wash, and hydrogen peroxide were not labeled with a resident name or date opened as required by facility policy. An LPN and an RN confirmed these observations and that the storage and labeling practices did not comply with the facility’s medication storage policy and applicable state regulations.
The facility failed to provide required Quality Assurance and Performance Improvement (QAPI) training to multiple staff members, including an LPN, a food service assistant, nurse aides, and an agency NA. Facility policies required annual in-service and continuing education for nurses and NAs, including at least 12 hours annually for NAs in accordance with OBRA, to be completed by each staff member’s anniversary date. Review of personnel files showed that five of seven sampled staff lacked documentation of annual QAPI in-service training for their most recent anniversary year, and the Clinical Nurse Educator confirmed that these staff had not received the required QAPI training.
The facility failed to provide required annual compliance and ethics training to several staff members, including an LPN, a food service assistant, a nurse aide, and an agency NA. Review of facility policies showed that nurses and NAs are to receive annual continuing education, including mandatory hours, yet personnel files for these staff did not contain documentation of annual ethics and compliance in-services for their respective anniversary periods. The clinical nurse educator confirmed that four of seven reviewed staff members had not received the required compliance and ethics training, constituting noncompliance with state staff development requirements.
The facility failed to follow its own policies and OBRA requirements for staff education by not ensuring that an RN, two NAs, and a food service assistant received required annual dementia management training, and by not ensuring that two NAs, including an agency NA, completed at least 12 hours of annual in‑service education. Review of personnel and training records showed missing documentation of dementia training for multiple staff and insufficient in‑service hours for two NAs, and the Clinical Nurse Educator confirmed that the facility could not provide evidence that these training requirements were met.
Surveyors found that the facility did not provide or document required behavioral health training for multiple staff members, including an RN, several NAs, an agency NA, and a food service assistant, despite policies requiring annual continuing education. Review of personnel files showed missing behavioral health in-service records for these employees for their most recent anniversary periods. The clinical nurse educator reported that dementia and behavioral training were offered at an annual skills fair but could not produce documentation of attendance and stated they were not responsible for the food service assistant. The facility ultimately could not show that these staff had received the mandated behavioral health training.
Surveyors found that the facility did not follow physician orders for Prevalon boots for two residents, one with a stage 4 heel pressure ulcer and another with a history of recurrent heel breakdown and diagnoses including dementia and malnutrition. Policy required that ordered treatments be provided, and both residents had orders to wear Prevalon boots continuously, with removal only for hygiene or, for one resident, when not in bed. During observations, both residents were seen up in wheelchairs without the prescribed boots in place, and an LPN confirmed that the facility had not ensured use of the devices as ordered for pressure ulcer treatment and prevention.
A resident with depression, dementia, Guillain-Barre syndrome, and an indwelling suprapubic catheter had a physician order to flush the catheter with 60 cc for blockage that did not specify the solution to be used. Facility catheter-care policy required procedures aimed at preventing UTIs and managing obstruction, including clear instructions for catheter irrigation. An RN confirmed that the order was incomplete and should have indicated what to use for the flush, demonstrating that appropriate and complete treatments and services for suprapubic catheter care were not ensured.
A resident with hypertension, hemiplegia, depression, and an ostomy appliance had a physician order for urostomy care that directed weekly and PRN appliance changes but did not specify the size or type of appliance to be used. The resident’s active care plan also lacked documentation of the size and type of the urostomy appliance. An RN confirmed that staff "cut to size" and acknowledged that both the order and care plan were incomplete, resulting in a failure to obtain a complete physician order for urostomy care in accordance with facility policy and state regulations.
The facility did not follow its immunization policy requiring education, consent, and documentation for COVID-19 vaccination. A resident with anemia, HTN, and dementia had an MDS indicating their COVID-19 vaccination was not up to date, yet the clinical record lacked any evidence that the vaccine was offered, administered, or declined, and no signed immunization consent form was found. The Infection Preventionist confirmed that accurate and timely documentation of the COVID-19 vaccine offer was not completed for this resident, resulting in noncompliance with state requirements for licensee responsibility and medical records.
The facility did not ensure that an LPN received required annual in-service education on effective communication, as mandated by facility policy for RNs and LPNs. Review of the LPN’s personnel file showed no documentation of effective communication training for a full anniversary year, despite a policy requiring nurses to complete annual in-services and coordinate with the nurse educator to meet those requirements. The clinical nurse educator confirmed that this training had not been provided, resulting in noncompliance with staff development regulations.
The facility failed to provide required Resident Rights training to an LPN and a NA, as identified through review of policies, in-service records, and personnel files. Facility policies require annual continuing education for nurses and at least 12 hours of annual education for NAs, including topics such as Resident Rights. However, the LPN’s file lacked documentation of Resident Rights in-service training for a full anniversary year, and the NA’s file similarly lacked this training for a subsequent annual period. The Clinical Nurse Educator confirmed that these two of seven staff reviewed had not received the mandated Resident Rights education.
Surveyors found that the facility did not provide a nurse aide with the required annual in-service education on abuse, neglect, and exploitation, as mandated by facility policy and OBRA-related requirements. Review of the aide’s personnel file showed no documented training on these topics for the relevant one-year period, despite a policy requiring at least 12 hours of annual continuing education to be completed before the aide’s annual review. The Clinical Nurse Educator confirmed that this staff member did not receive the required training, resulting in noncompliance with applicable state staff development regulations.
Surveyors found that the facility did not provide required annual infection control in-service education to a nurse aide, despite a policy requiring at least 12 hours of annual continuing education for NAs in line with OBRA regulations and completion prior to annual review. Review of the aide’s personnel file showed no documented infection control training for a full annual period, and the Clinical Nurse Educator confirmed that this staff member had not received the mandated infection control training, resulting in noncompliance with state staff development and licensee responsibility requirements.
Surveyors found that required postings for State agencies and advocacy groups were incomplete in all six neighborhoods, with missing addresses and email contacts for the State Agency and Adult Protective Services, a missing email address for the Medicaid Fraud Control Unit, and missing name, address, and email information for the State Long-Term Care Ombudsman program. Although various information was posted for residents, it did not meet regulatory requirements, and the NHA confirmed that the facility lacked the required complete contact information postings, constituting a management responsibility deficiency under state code.
A resident who was dependent on staff for transfers and required a Hoyer lift with two-person assistance sustained an abrasion to the forehead and a right tibial plateau fracture when staff failed to properly secure a lift pad loop during transfer. Both an LPN and a nurse aide participated in the transfer but did not ensure all loops were attached, resulting in the resident falling and sustaining actual harm.
A resident with significant mobility limitations and multiple diagnoses was being transferred with a Hoyer lift by two staff members when the front right pad loop was not properly secured, causing the resident to fall and sustain a forehead abrasion and a right tibial plateau fracture. Both staff members had received mechanical lift training, but failed to ensure all loops were attached, resulting in actual physical harm.
Staff failed to report and investigate multiple incidents where a resident with severe cognitive impairment physically struck another resident. Although staff intervened and no injuries were observed, the DON did not notify authorities or conduct an investigation, citing the absence of injury as the reason for not reporting.
A resident with anemia, dementia, and Parkinson's disease was observed self-administering medications without a documented assessment or physician order, contrary to the facility's policy. An LPN confirmed the resident's practice but was unaware of any formal assessment or orders, indicating a failure to follow the facility's medication self-administration policy.
The facility failed to provide a non-institutional dining experience by administering medications during breakfast for two residents. An LPN was observed giving medications to residents in the dining room, contrary to facility policy, which requires medications to be administered separately to ensure privacy and a homelike environment. The affected residents had various medical conditions, including anemia, dementia, hypertension, and diabetes.
The facility failed to ensure that the medication regimens for two residents were free from unnecessary psychotropic medications. Both residents, diagnosed with dementia and depression, were prescribed Quetiapine, which is not indicated for their conditions. The Director of Nursing confirmed the oversight, indicating a lapse in adherence to the facility's medication management policy.
The facility failed to properly label and store medications in three medication rooms and a resident's medication cabinet. Undated multi-dose vials and improperly stored insulin pens were found, along with expired catheters. These issues were confirmed by nursing staff and the DON, indicating non-compliance with facility policies and state regulations.
A facility failed to ensure a resident with moderate cognitive impairment understood a binding arbitration agreement. The resident, diagnosed with Non-Alzheimer's Dementia, diabetes, and Parkinson's disease, signed the agreement despite a BIMS score indicating moderate impairment. The care plan noted limitations in daily activities and confusion. The Marketing Coordinator confirmed the oversight.
A facility failed to implement droplet precautions for a resident with respiratory symptoms and did not update the care plan accordingly. Additionally, the facility did not maintain a sanitary environment in the Mountain Laurel Neighborhood kitchen, where items were improperly stored under the sink, risking cross-contamination.
A resident with a history of fractures and mental health conditions fell during a transfer to the commode due to inadequate supervision, as only one NA assisted instead of the required two. The fall resulted in an impacted proximal humerus fracture, highlighting a failure in following prescribed transfer protocols.
A resident with a history of Parkinson's disease and anxiety, initially assessed as not at risk for elopement, managed to leave the facility after asking a visitor to open a door. Despite having a wander guard, the resident exited through an unsupervised area and fell from their wheelchair, though they were not injured. Staff interviews revealed a lack of supervision and inadequate signage, contributing to the incident.
The facility failed to have a physician's order and care plan for a resident's indwelling catheter and did not provide appropriate catheter care for two residents. One resident had a Foley catheter without necessary documentation, while two others had issues with uncovered and improperly positioned urinary drainage bags.
The facility failed to conduct ongoing accurate assessments for bedrail usage for five residents, despite physician orders and care plans indicating their use. Staff interviews and clinical record reviews confirmed the lack of ongoing assessments, as required by regulations.
The facility failed to maintain the confidentiality of residents' medical information on the second floor Tionesta household. A medication cart/portable computer unit was left unattended with the screen open, displaying identifiable information. An LPN confirmed the breach of confidentiality, which violated the facility's policies on protecting resident information.
The facility failed to ensure that residents received neurological assessments after incidents involving falls. One resident with a history of high blood pressure and hemiplegia had incomplete neurological checks after a fall, and another resident with Alzheimer's and PTSD also had incomplete checks after being found with abrasions. The DON and an LPN confirmed the deficiencies.
The facility failed to ensure a physician order and care plan for a resident using a Bi-PAP/CPAP machine, despite the resident's diagnoses of obstructive sleep apnea, diabetes, and high blood pressure. The deficiency was confirmed by the Director of Nursing and observed in the resident's records and progress notes.
The facility failed to provide trauma-informed care to a resident with PTSD, as required by their policy. The resident's care plan did not include goals or interventions for PTSD, despite the diagnosis being documented. The Social Worker admitted to not including a PTSD-specific care plan, believing it would be redundant.
The facility failed to properly secure a medication drawer on four occasions in one of six households. Observations revealed that the portable computer unit medication drawer was left open, unattended, and out of sight of the medication nurse. LPNs and the Clinical Nurse Manager confirmed the failure to follow the facility's policy, and the DON confirmed the requirement to keep the drawer shut and locked.
The facility failed to follow infection control measures during blood sugar monitoring for two residents. An LPN did not allow the glucometer to air dry for the required two minutes after cleaning and did not perform hand hygiene after a finger stick blood sampling before preparing and administering insulin.
Failure to Follow Bowel Protocol and Skin Protection Orders
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician-ordered bowel protocol and to provide ordered skin-protective devices, resulting in care that was not consistent with professional standards of practice. For one resident (R10), who was admitted with diagnoses including malignant neoplasm of the prostate, urinary retention, and diabetes mellitus, the physician had ordered a bowel protocol consisting of polyethylene glycol, bisacodyl suppositories, Fleet enemas, and Milk of Magnesia to be used as needed for constipation. Facility policy on bowel management stated that each resident would be assessed and managed for adequate bowel elimination. Despite this, bowel and bladder tracking for R10 showed that five days (15 shifts) passed without a bowel movement between 12/12/25 and 12/16/25, with only a single dose of polyethylene glycol documented as given on 12/15/25. Progress notes for R10 on 12/19/25 documented pallor, visible shaking, the resident feeling cold, and complaints of abdominal and back spasms, after which the physician was contacted and the resident was sent out for evaluation. A CT scan of the abdomen and pelvis performed at the hospital on 12/19/25 showed a moderate to large stool burden in a rectum dilated up to 7 cm with wall thickening and surrounding inflammatory changes compatible with fecal impaction and stercoral proctitis. Hospital records indicated that an enema was administered there, resulting in a bowel movement. During interviews, multiple nursing staff, including LPNs and RNs, described a standard facility bowel protocol that should be initiated after three days without a bowel movement, progressing from Milk of Magnesia or prune juice to suppository, then enema, and then physician notification if ineffective. The DON confirmed the facility could not provide evidence that the ordered bowel protocol had been followed for R10. A second deficiency involved failure to provide ordered preventative skin care for another resident (R92). This resident, admitted with diagnoses including hypertension, dementia, and malnutrition, had a physician’s order dated 7/6/25 to wear Geri Sleeves on the arms in the morning and remove them at bedtime for skin protection. During an observation and interview on 2/25/26, the resident was seen up in a wheelchair without Geri Sleeves in place. An LPN confirmed that the resident was not wearing the ordered Geri Sleeves, indicating the facility did not ensure that the physician’s order for preventative skin care was implemented.
Unsanitary Dish Room Fans Above Clean Dishwashing Area
Penalty
Summary
Surveyors found that the facility failed to maintain sanitary conditions in the dish room for one of three households (Mountain Laurel, Brandywine). Review of the facility’s policy titled “Infection control for Household Dish room” dated 1/26/26 indicated that household dish rooms are to be appropriately disinfected. However, during an observation of the dish room on 2/24/26 at 10:00 a.m., two fans located above the clean side of the dish machine area were noted to have a buildup of a black substance, dirt, and grime. During an interview at 10:30 a.m. the same day, the Household Coordinator (Employee E15) confirmed the presence of the brown substance on the fans in the dish room and acknowledged that this condition had the potential to create cross contamination and food-borne illness. The deficiency was cited under 28 Pa Code 201.14(a), Responsibility of licensee. No specific residents or their medical conditions were mentioned in the report, and no direct resident impact was documented, only the potential for cross contamination and food-borne illness as confirmed by staff.
Failure to Communicate Key Transfer Information and Notify Ombudsman of Transfers/Discharge
Penalty
Summary
The deficiency involves the facility’s failure to ensure that necessary resident information was communicated to receiving health care providers during facility-initiated transfers, and the failure to provide required transfer or discharge notices to the Office of the Long-Term Care Ombudsman. Facility policy dated January 2026 required that when a resident is transferred to the hospital, all necessary information be sent to ensure continuity of care. For one resident with hyperlipidemia, depression, and a history of falls who was transferred to the hospital and later returned, the clinical record contained no documented evidence that specific information, including the resident’s care plan goals, was communicated to the hospital. For another resident with high blood pressure, a hip fracture, and difficulty walking who was transferred to the hospital, the clinical record lacked documented evidence that the facility communicated care plan goals, advance directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet that resident’s specific needs at the receiving facility. A clinical nurse manager stated that the facility does not send a copy of the care plan to the hospital. The deficiency also includes the facility’s failure to provide written transfer or discharge notifications to the Office of the Long-Term Care Ombudsman for three residents who experienced facility-initiated transfers or discharge. For the resident with hyperlipidemia, depression, and a history of falls who was hospitalized, there was no documented evidence of a written transfer notification to the Ombudsman’s office. For the resident with high blood pressure, hip fracture, and difficulty walking who was transferred to the hospital, and for another resident with diabetes, malnutrition, and lack of coordination who was discharged home, the clinical records similarly lacked documentation that written notifications were provided to the Ombudsman. During interviews, the clinical nurse manager confirmed the failure to ensure necessary information was communicated to receiving providers for two residents, and the nursing home administrator confirmed the facility’s failure to provide transfer or discharge notices to the Ombudsman for all three residents. These findings were cited under 28 Pa. Code: 201.14(a) and 201.29(a)(c.3)(2) regarding responsibility of the licensee and resident rights.
Failure to Obtain Informed Consent for Bed Rail (Enabler Bar) Use
Penalty
Summary
The deficiency involves the facility’s failure to obtain informed consent prior to the installation of bed rails (enabler bars) for three residents. Facility policy on Mobility Bars/Bedrails dated January 2026 states that residents who attempt to exit a bed through, between, over, or around mobility bars or bed rails are at risk of injury or death, and that the benefits-to-risk ratio of using such potentially restraining devices must always be considered. The policy further requires that staff and the resident and/or family member be educated about the risks of the device as part of a comprehensive person-centered care plan. Despite this, surveyors found that enabler bars were ordered and installed for three residents without documentation of informed consent or evidence that risks and benefits were reviewed with the residents or their representatives. For one resident with diagnoses including hypertension, hyponatremia, and hemiplegia, a physician ordered bilateral enabler bars for bed mobility, and surveyors observed these bars in place; however, the clinical record contained no signed consent or documentation of a risk–benefit discussion. A second resident with anemia, hypertension, and arthritis also had a physician order for bilateral enabler bars for bed mobility, and these were observed in place without any record of informed consent or risk–benefit review. A third resident with anemia, hypertension, and hyperlipidemia similarly had bilateral enabler bars ordered and observed in use, again with no documentation of consent or discussion of risks and benefits. During an interview, the Clinical Nurse Manager stated that the facility does not obtain consents for enabler bars because they are not considered restraints and confirmed that informed consent had not been obtained before installation of the bed rails for these three residents.
Improper Storage and Labeling of Medications and Biologicals in Multiple Medication Rooms
Penalty
Summary
Surveyors determined that the facility failed to store drugs and biologicals in a safe, secure, and orderly manner in three of six medication rooms (Larkspur, Allegheny, and Tionesta). Review of the facility’s “Storage of Medications” policy, last reviewed January 2026, showed that medications and biologicals were required to be stored safely, securely, properly, and in clean, well-lit, uncluttered areas. During observation of the Larkspur Hall medication room on 2/24/26 at 12:19 p.m., surveyors found a black winter coat, a black jacket, and a brown print bag containing a thermos stored in the medication room, along with one tube of ostomy paste that was not labeled with a resident name or date opened as required and bore an expiration date of 9/1/24. LPN Employee E11 confirmed these observations and stated that the coat, jacket, and bag belonged to them and that they believed the ostomy paste belonged to Resident R51. On 2/24/26 at 12:45 p.m., observation of the Allegheny Hall medication room revealed one tube of lubricant jelly and one can of saline wound wash, both of which lacked a resident name and date opened as required. LPN Employee E11 confirmed that these items were not labeled according to facility requirements. On 2/25/26 at 9:24 a.m., observation of the Tionesta medication room identified one bottle of hydrogen peroxide and one tube of lubricant jelly, each missing a resident name and date opened as required. RN Employee E9 confirmed these findings and acknowledged that the facility failed to store all drugs and biologicals in a safe, secure, and orderly manner in the Larkspur, Allegheny, and Tionesta medication rooms, in violation of 28 Pa. Code 211.10(c) and 211.12(d)(2)(3).
Failure to Provide Required QAPI Training to Multiple Staff Members
Penalty
Summary
The deficiency involves the facility’s failure to provide mandatory training on the Quality Assurance and Performance Improvement (QAPI) program to multiple staff members as required by facility policy and state regulations. Review of the facility’s policy "Inservice - Mandatory Hours for Registered Nurses (RN) and Licensed Practical Nurses" dated January 2026 stated that RNs and LPNs are to receive annual continuing education through in-services, self-studies, or seminars, and that each nurse is responsible for attending in-services each anniversary year. A separate policy, "Inservice - Mandatory Hours for Nurse Aides" dated January 2026, indicated that nurse aides must receive at least 12 hours of annual continuing education from in-services or seminars, in accordance with OBRA regulations, and that the facility has an obligation to provide continued training and education so team members can perform their jobs effectively. The policy also required nurse aides to complete the 12 hours of annual continuing education prior to their annual review. Personnel file reviews showed that five of seven sampled staff members did not have documentation of annual in-service training on the QAPI program for their most recent anniversary year. Specifically, the file for an LPN hired on 3/31/21 lacked QAPI training between 3/31/24 and 3/31/25; a food service assistant hired on 10/20/08 lacked QAPI training between 10/20/24 and 10/20/25; a nurse aide hired on 11/4/20 lacked QAPI training between 11/4/24 and 11/4/25; an agency nurse aide hired on 9/30/20 lacked QAPI training between 9/30/24 and 9/30/25; and a nurse aide hired on 8/21/18 lacked QAPI training between 8/21/24 and 8/21/25. During an interview on 2/25/26, the Clinical Nurse Educator confirmed that the facility failed to provide QAPI program training for these five staff members. The deficiency was cited under 28 Pa. Code 201.14(a) Responsibility of licensee and 201.20(a)(d) Staff development.
Failure to Provide Annual Compliance and Ethics Training to Multiple Staff
Penalty
Summary
The deficiency involves the facility’s failure to provide required annual training on compliance and ethics to multiple staff members, as identified through review of policies, personnel files, in-service documentation, and staff interviews. The facility’s policy for RNs and LPNs, dated January 2026, states that nurses will be provided opportunities for annual continuing education through in-services, self-studies, or seminars, and that each nurse is responsible for attending in-services each anniversary year, notifying the Nursing Educator if additional in-services are needed. A separate policy for nurse aides, also dated January 2026, states that NAs will be provided opportunities to obtain at least 12 hours of annual continuing education from in-services or seminars, as required by OBRA regulations, and that NAs must complete these 12 hours before their annual review. Review of personnel files showed that an LPN hired on 3/31/21 did not have documentation of annual in-service training on ethics and compliance for the period 3/31/24 through 3/31/25. A food service assistant hired on 10/20/08 lacked documentation of annual ethics and compliance in-service training for the period 10/20/24 to 10/20/25. A nurse aide hired on 11/4/20 did not have documented annual ethics and compliance training for 11/4/24 through 11/4/25. An agency nurse aide hired on 9/30/20 similarly lacked documentation of annual ethics and compliance training for 9/30/24 through 9/30/25. During an interview, the Clinical Nurse Educator confirmed that the facility failed to provide compliance and ethics training for four of seven reviewed staff members, in violation of 28 Pa. Code 201.14(a) and 201.20(a)(d) regarding responsibility of the licensee and staff development.
Failure to Provide Required Dementia Training and Annual In‑Service Hours for Staff
Penalty
Summary
The deficiency involves the facility’s failure to provide required dementia management training and sufficient annual in‑service education hours for certain staff members. Facility policy for RNs and LPNs, dated January 2026, states that nurses will be provided opportunities for annual continuing education and are responsible for attending in‑services each anniversary year. A separate policy for nurse aides, also dated January 2026, requires at least 12 hours of annual continuing education, as mandated by OBRA regulations, to be completed prior to the aide’s annual review. Review of personnel files showed that an RN hired on 2/23/98, a NA hired on 1/19/21, a food service assistant hired on 10/20/08, and another NA hired on 11/4/20 did not have documented annual in‑service training on dementia management for their respective anniversary periods in 2024–2026. In addition, review of nurse aide training records revealed that one NA hired on 11/4/20 and one agency NA hired on 9/30/20 did not receive the required minimum of 12 hours of in‑service training during their respective anniversary years. The facility was unable to provide documented evidence that these two NAs had met the 12‑hour annual in‑service requirement. During an interview, the Clinical Nurse Educator stated that dementia and behavioral training are conducted during the annual skills fair and indicated uncertainty about responsibility for the food service assistant’s training. The facility did not provide additional documentation to show that the identified RN, NAs, and food service assistant had received annual dementia management training or that the two NAs had completed the required 12 hours of in‑service education, and the Clinical Nurse Educator confirmed these training deficiencies.
Failure to Provide Required Behavioral Health Training to Staff
Penalty
Summary
The deficiency involves the facility’s failure to provide required behavioral health training to multiple staff members as identified through review of policies, personnel files, in-service documentation, and staff interviews. Facility policy for RNs and LPNs, dated January 2026, stated that nurses would be provided opportunities for annual continuing education through in-services, self-studies, or seminars, and that each nurse was responsible for attending in-services each anniversary year. A separate policy for nurse aides, also dated January 2026, required at least 12 hours of annual continuing education from in-services or seminars, in accordance with OBRA regulations, to be completed prior to their annual review. Despite these policies, review of personnel files showed that an RN hired in 1998, a NA hired in 2021, a food service assistant hired in 2008, two NAs hired in 2020, and a NA hired in 2018 did not have documentation of annual in-service training on behavioral health for their respective anniversary periods. During an interview, the Clinical Nurse Educator stated that dementia and behavioral training were conducted during the annual skills fair and indicated an intention to locate documentation of staff attendance, but also stated not being responsible for the food service assistant and being unsure of that employee’s departmental assignment. The facility was unable to provide additional documentation showing that the identified RN, NAs, agency NA, and food service assistant had completed annual behavioral health in-service training. The Clinical Nurse Educator confirmed that the facility failed to provide behavioral health training for six of seven reviewed staff members. The cited deficiency was referenced under 28 Pa. Code: 201.14(a) Responsibility of licensee and 28 Pa. Code: 201.20(a)(d) Staff development.
Failure to Follow Physician Orders for Prevalon Boots for Pressure Ulcer Treatment and Prevention
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary treatment and services for pressure ulcer care and prevention in accordance with physician orders and professional standards of practice for two residents. Facility policy on Treatment of Wounds, last reviewed in January 2025, states that the facility will provide treatment as ordered by the physician. One resident, identified as having diagnoses including hypertension, diabetes, and chronic pain, had an MDS dated 2/4/26 indicating a stage 4 pressure ulcer and was listed on the facility’s pressure ulcer list as having a stage 4 ulcer on the left heel. The clinical record contained a physician’s order dated 2/3/26 for the resident to wear Prevalon boots at all times, removing them only for hygiene and skin checks. During an observation on 2/25/26 at 11:37 a.m., the resident was seen up in a wheelchair without Prevalon boots, and an LPN confirmed the facility failed to ensure the resident was wearing the boots as ordered. A second resident, with diagnoses including hypertension, dementia, and malnutrition, had a physician’s order dated 3/4/25 to wear a Prevalon boot on the right foot at all times and on the left foot when in bed. During an observation on 2/25/26 at 11:35 a.m., this resident was also observed up in a wheelchair without Prevalon boots in place. The LPN stated that although this resident did not currently have a pressure injury on the heel, the area tended to reopen and the boot was ordered for prevention of recurrence or development of a pressure injury. The LPN confirmed that the facility failed to ensure this resident was wearing the ordered Prevalon boot for pressure injury prevention. These findings were cited under 28 Pa. Code 201.29(a) Resident Rights, 211.10(c)(d) Resident Care Policies, and 211.12(d)(1)(3)(5) Nursing services.
Incomplete Suprapubic Catheter Flush Order for a Resident
Penalty
Summary
The facility failed to ensure appropriate treatments and services were provided for a resident with a suprapubic catheter. Facility policy on urinary catheter care, last reviewed in January 2026, stated that the purpose of the procedure is to prevent infection of the urinary tract and that if catheter material contributes to obstruction, the physician should be notified and the catheter changed if instructed. The policy also noted that catheter irrigation may be ordered to prevent obstruction in residents at risk. For this resident, the clinical record showed an admission in 2023 and an MDS dated January 21, 2026, documenting an indwelling catheter. Physician orders dated April 20, 2023, specified that the resident had a suprapubic catheter. Further review of the physician orders dated August 7, 2025, revealed an order to flush the catheter with 60 cc for blockage, but the order did not specify what solution or substance should be used to perform the flush. During an interview on February 26, 2026, an RN confirmed that the order lacked this essential detail and acknowledged that it should have indicated what to use to flush the catheter. This omission demonstrated that the facility did not ensure that appropriate and complete orders were in place for the care of the suprapubic catheter, as required by facility policy and state regulations, for this resident with diagnoses including depression, dementia, and Guillain-Barre syndrome.
Incomplete Physician Order and Care Plan for Urostomy Care
Penalty
Summary
The facility failed to obtain a complete physician order for urostomy care for one resident who required such services. Facility policy on colostomy/ileostomy/urostomy care, last reviewed in January 2026, stated its purpose was to provide guidelines to prevent exposure of the resident's skin to fecal matter or urine. The resident, admitted on an unspecified date, had an MDS dated 2/11/26 documenting diagnoses of hypertension, hemiplegia, and depression, and indicating the presence of an ostomy appliance. Review of the clinical record showed a physician order dated 3/1/22 for urostomy care that directed staff to change the appliance/bag weekly and as needed, but the order did not specify the size and type of urostomy appliance to be used. Further review of the resident's active care plan also showed that it did not include the size and type of the urostomy appliance in use. During an interview on 2/26/26 at 10:30 a.m., an RN confirmed that the physician order lacked the required details regarding size and type of appliance and acknowledged that the care plan likewise did not contain this information. The RN stated that staff "cut to size" and confirmed that the facility failed to obtain a physician order for complete urostomy care for this resident, as required by facility policy and state regulations.
Failure to Document Offering of COVID-19 Vaccination to a Resident
Penalty
Summary
The facility failed to provide accurate and timely documentation related to offering the COVID-19 vaccination to a resident, as required by its Immunization Program policy dated January 2026. The policy states that when the COVID-19 vaccine is available, each resident will be offered the vaccine unless it is medically contraindicated or the resident has already been vaccinated. Upon admission, residents or their representatives are to receive educational materials on the benefits and risks of the COVID-19 vaccine and, after reviewing this information and the Immunization Consent form, are to sign the form indicating acceptance or refusal. All acceptance or refusal decisions must be documented on the Immunization Consent form. Clinical record review showed that one resident, identified as R88, was admitted on an unspecified date and had an MDS dated 2/4/26 indicating diagnoses of anemia, hypertension, and dementia, with item O0350 coded "no" for the resident’s COVID-19 vaccination being up to date. However, the resident’s clinical record did not contain documentation that the COVID-19 vaccine was offered, administered, or declined, contrary to facility policy. During an interview on 2/27/26, the Infection Preventionist confirmed that the facility failed to provide accurate and timely documentation related to offering the COVID-19 vaccination for this resident, resulting in noncompliance with 28 Pa. Code 201.14(a) and 211.5(f) regarding responsibility of the licensee and medical records.
Failure to Provide Required Effective Communication Training for an LPN
Penalty
Summary
The facility failed to provide required annual in-service training on effective communication for one of seven direct care staff members, specifically an LPN identified as Employee E3. Facility policy titled "Inservice - Mandatory Hours for Registered Nurses (RN) and Licensed Practical Nurses" dated January 2026 stated that RNs and LPNs would be provided opportunities to obtain annual continuing education through in-services, self-studies, or seminars, and that each nurse was responsible for attending in-services each anniversary year and notifying the Nursing Educator in advance if additional in-services were needed to meet their annual deadline. Review of LPN Employee E3’s personnel file, with a hire date of 3/31/21, showed no documentation of annual in-service training on Effective Communication for the period from 3/31/24 through 3/31/25. During an interview on 2/25/26 at 1:24 p.m., the Clinical Nurse Educator (Employee E8) confirmed that the facility failed to provide Effective Communication training for this LPN, resulting in noncompliance with the facility’s staff development requirements and applicable state regulations.
Failure to Provide Required Resident Rights Training to Nursing Staff
Penalty
Summary
The deficiency involves the facility’s failure to provide required training on Resident Rights to specific staff members. Facility policies titled "Inservice - Mandatory Hours for Registered Nurses (RN) and Licensed Practical Nurses" and "Inservice - Mandatory Hours for Nurse Aides," both dated January 2026, state that RNs and LPNs will be given opportunities for annual continuing education through in-services, self-studies, or seminars, and that each nurse is responsible for attending in-services each anniversary year. The policies also state that nurse aides must complete at least 12 hours of annual continuing education, as required by OBRA regulations, and that the facility has an obligation to provide continued training and education so team members can perform their jobs effectively. Review of personnel files showed that an LPN hired on 3/31/21 did not have documentation of annual in-service training on Resident Rights for the period 3/31/24 through 3/31/25. Similarly, a nurse aide hired on 11/4/20 did not have documentation of annual in-service training on Resident Rights for the period 11/4/24 through 11/4/25. Based on review of facility policy, in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Resident Rights for two of seven staff members reviewed. During an interview, the Clinical Nurse Educator confirmed that these two staff members had not received the required Resident Rights training.
Failure to Provide Required Abuse, Neglect, and Exploitation Training to a Nurse Aide
Penalty
Summary
The facility failed to provide required annual training on abuse, neglect, and exploitation for one of seven nurse aides, identified as Employee E5. Facility policy titled "Inservice - Mandatory Hours for Nurse Aides" dated January 2026 stated that nurse aides must receive at least 12 hours of annual continuing education through in-services or seminars, in accordance with OBRA regulations, and that these 12 hours must be completed prior to the aide’s annual review. Review of NA Employee E5’s personnel file, with a hire date of 11/4/20, showed no documentation of annual in-service training on abuse, neglect, and exploitation for the period from 11/4/24 through 11/4/25. During an interview on 2/25/26 at 1:24 p.m., the Clinical Nurse Educator (Employee E8) confirmed that the facility did not provide this required training to NA Employee E5, resulting in noncompliance with 28 Pa. Code 201.14(a) and 201.20(a)(d). No specific residents or clinical conditions were mentioned in relation to this deficiency, and the findings were based on review of facility policy, in-service documentation, personnel files, and staff interviews.
Failure to Provide Required Infection Control Training to a Nurse Aide
Penalty
Summary
The facility failed to provide required infection control training to one of seven nurse aides, resulting in noncompliance with its own infection prevention and control program and staff development policies. The facility’s policy titled “Inservice - Mandatory Hours for Nurse Aides,” dated January 2026, states that nurse aides must receive at least 12 hours of annual continuing education through in-services or seminars, in accordance with OBRA regulations, and that these 12 hours must be completed prior to the aide’s annual review. Review of the personnel file for one nurse aide (Employee E5), hired on 11/4/20, showed no documentation of annual in-service training on infection control for the period from 11/4/24 through 11/4/25. During an interview on 2/25/26 at 1:24 p.m., the Clinical Nurse Educator (Employee E8) confirmed that the facility failed to provide infection control training for this staff member. The deficiency is cited under 28 Pa. Code: 201.14(a) Responsibility of licensee and 28 Pa. Code: 201.20(a)(d) Staff development, based on the lack of documented infection control education for the identified nurse aide during the specified annual period.
Incomplete Posting of Required State Agency and Advocacy Group Contact Information
Penalty
Summary
Surveyors determined that the facility failed to post required information about pertinent State agencies and advocacy groups in areas accessible to all residents across all six neighborhoods (Brandywine, Mountain Laurel, Trillium, Tionesta, Allegheny, and Larkspur). During an observation conducted on 2/26/26 from 9:30 a.m. through 9:45 a.m., surveyors noted that while a variety of information was posted for residents, the postings did not include the address and email address for the State Agency and Adult Protective Services, did not include an email address for the Medicaid Fraud Control Unit, and did not include the name, address, and email for the State Long-Term Care Ombudsman program as required. In a subsequent interview on 2/27/26 at 11:30 a.m., the Nursing Home Administrator confirmed that the facility did not have the required postings with complete contact information for these entities, in violation of 28 Pa. Code 201.14(a) and 201.18(b)(3). No specific residents, medical histories, or clinical conditions were mentioned in the report; the deficiency pertains to facility-wide posting requirements and management responsibilities for ensuring that residents have access to complete contact information for State agencies and advocacy groups, including the State Survey Agency, Adult Protective Services, Medicaid Fraud Control Unit, and the State Long-Term Care Ombudsman program.
Failure to Ensure Safe Mechanical Lift Transfer Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to ensure a safe transfer for a resident who required total assistance with mobility and was ordered to be transferred using a Hoyer lift with the assistance of two staff members. The resident, who had diagnoses including diabetes, Parkinson's disease, and depression, was dependent on staff for all transfers and positioning. During a transfer from wheelchair to bed, the right front loop of the Hoyer lift pad was not properly secured to the lift, resulting in the resident falling forward from the lift. The incident led to the resident sustaining an abrasion to the right forehead and a right nondisplaced tibial plateau fracture, accompanied by pain and visible deformity of the leg. Documentation and staff interviews revealed that both staff members involved in the transfer, an LPN and a nurse aide, participated in attaching the Hoyer lift pad but failed to ensure all loops were properly secured. Neither staff member could confirm who attached which straps, and both had received prior education on mechanical lift use. The facility's investigation determined that the root cause of the incident was the failure to secure the right front Hoyer pad loop before lifting the resident. Observations and interviews with other staff confirmed the correct procedure for securing the lift pad, which was not followed during the incident. The facility's policies clearly prohibit neglect and require that all residents be protected from harm, including ensuring safe transfers. The failure to properly secure the Hoyer lift pad directly resulted in actual harm to the resident, as evidenced by the injuries sustained during the fall. The deficiency was confirmed by the DON and supported by witness statements, clinical documentation, and the facility's own investigation.
Failure to Secure Hoyer Lift Pad Results in Resident Injury During Transfer
Penalty
Summary
A deficiency occurred when staff failed to ensure that a resident was free from a preventable accident during a transfer using a Hoyer lift. The resident, who had diagnoses including diabetes, Parkinson's disease, and depression, was assessed as totally dependent for transfers and required the use of a Hoyer lift with the assistance of two staff members. Physician orders and the care plan both specified this requirement. During a transfer from wheelchair to bed, the front right loop of the Hoyer lift pad was not properly secured, resulting in the resident falling forward from the lift, striking her face and leg. The incident was witnessed by two staff members, an LPN and a nurse aide, who both participated in attaching the Hoyer lift pad. Neither staff member could confirm who was responsible for securing the specific loop that failed. Documentation and interviews revealed that the right front Hoyer pad loop was not properly attached to the lift prior to the transfer. As a result, the resident sustained an abrasion to the right forehead and a right nondisplaced tibial plateau fracture, accompanied by pain and abnormal leg positioning. The facility's policy required a safe environment and proper use of mechanical lifts, and both staff members involved had received prior education on mechanical lift safety. Despite this, the failure to ensure all loops were securely fastened directly led to the resident's fall and subsequent injuries. Observations and interviews with other staff confirmed the correct procedure for securing the Hoyer lift pad, highlighting the deviation from protocol during the incident.
Failure to Report and Investigate Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to report and investigate allegations of physical abuse involving two residents. Clinical record review and staff interviews revealed that a resident with severe cognitive impairment, including diagnoses of non-traumatic brain dysfunction, Alzheimer's disease, and a psychotic disorder, was observed on multiple occasions following, yelling at, and physically striking another resident. On two separate dates, staff documented that the resident slapped another resident in the face, and in one instance, attempted to do so again shortly after being redirected. In both cases, staff intervened, redirected the resident, and noted that the other resident did not sustain injuries or complain of pain. Despite these documented incidents of resident-to-resident physical abuse, the facility did not report the events to the State Agency as required, nor did they conduct an investigation into the allegations. The Director of Nursing confirmed during an interview that these incidents were not reported or investigated because there were no injuries, indicating a misunderstanding of reporting requirements. The facility only reported a later incident involving a push, not the slapping incidents, which were omitted from required notifications and follow-up.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to determine the ability of a resident to self-administer medications, as required by their policy. The policy states that residents have the right to self-administer medications if it is deemed safe, and a licensed nurse must complete an assessment for self-administration, with the attending physician being notified within 24 hours. However, for one resident, this process was not followed. The resident, who was diagnosed with anemia, dementia, and Parkinson's disease, was observed taking medications from a cup on his breakfast tray without an order for self-administration or an assessment being completed. During an interview, an LPN confirmed that the resident takes his medications with breakfast but was unaware if there were orders to leave the medications at the bedside or if an assessment had been completed. This oversight indicates that the facility did not adhere to its own policies regarding medication self-administration, as there was no documented assessment or physician order for the resident to self-administer his medications.
Medication Administration During Meal Service
Penalty
Summary
The facility failed to provide a non-institutional dining experience by administering medications during the breakfast meal service for two residents. This was observed during a survey where Licensed Practical Nurse (LPN) Employee E11 was seen giving medications to two residents, R3 and R66, while they were seated in the dining room for breakfast. The facility's policy on medication administration requires that if residents are not in their rooms or otherwise unavailable, the medication administration record (MAR) should be flagged, and the nurse should return to administer the medication after completing the medication pass. However, this procedure was not followed, leading to the administration of medications during meal service, which compromised the residents' right to a homelike dining environment. Resident R3, who has diagnoses of anemia, dementia, and anxiety, and Resident R66, who has anemia, hypertension, and diabetes, were both affected by this practice. The LPN confirmed during an interview that the residents received their medications with breakfast, acknowledging the failure to adhere to the facility's policy and the residents' rights to privacy and a non-institutional dining experience. This incident highlights a deficiency in the facility's adherence to its own policies and the regulations governing resident rights.
Failure to Ensure Medication Regimen Free from Unnecessary Psychotropic Medications
Penalty
Summary
The facility failed to ensure that the medication regimens for two residents were free from unnecessary psychotropic medications. Resident R46, who was diagnosed with dementia and depression, was prescribed Quetiapine for delirium, despite the medication's indications being for schizophrenia and bipolar disorder. Similarly, Resident R86, also diagnosed with dementia and depression, was prescribed Quetiapine for delusions-behavior, which is not aligned with the medication's approved uses. The facility's policy on medication management requires the interdisciplinary team to review residents' medication regimens for efficacy and potential medication-related problems on an ongoing basis, but this was not adhered to in these cases. During an interview, the Director of Nursing confirmed that the diagnoses of dementia and depression for Residents R46 and R86 were not included in the indications for Quetiapine, highlighting a failure to ensure the residents' medication regimens were free of unnecessary psychotropic medications. This deficiency was identified through a review of facility policy, clinical records, and staff interviews, indicating a lapse in the facility's adherence to its own medication management policy.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication labeling and storage protocols across multiple medication rooms and a resident's medication cabinet. In the Mountain Laurel medication room, two tuberculin multi-dose vials were found opened without a date, which was confirmed by RN Employee E7. Similarly, in the Trillium medication room, another tuberculin multi-dose vial was observed opened and undated, verified by RN Employee E9. In the Tionesta medication room, a Novolog flex pen was found without a label or resident name and was not stored in a box or individual bag as required. Additionally, six Coude foley catheters were discovered past their expiration date, as confirmed by LPN Employee E8. In a resident's room, specifically Resident R77's medication cabinet, a multi-dose nasal spray and eye drop container were found undated when opened, verified by LPN Employee E10. The Director of Nursing 2 confirmed these deficiencies, which included the failure to date opened medications, properly store and label medications in the medication rooms, discard expired nursing supplies, and properly store medications in the resident's medication cabinet. These findings indicate non-compliance with the facility's policies and state regulations regarding pharmacy and nursing services.
Failure to Ensure Resident Capacity for Arbitration Agreement
Penalty
Summary
The facility failed to ensure that Resident R67 had the capacity to understand the terms of a binding arbitration agreement. Resident R67, who was admitted to the facility, signed the arbitration agreement despite having a diagnosis of Non-Alzheimer's Dementia, diabetes, and Parkinson's disease. The Minimum Data Set (MDS) assessment indicated a Brief Interview for Mental Status (BIMS) score of 12, suggesting moderate cognitive impairment. Additionally, the resident's care plan noted limitations in performing activities of daily living due to Parkinson's disease and dementia, as well as issues with confusion and wandering. During an interview, the Marketing Coordinator, Employee E13, confirmed that the facility did not ensure Resident R67's capacity to comprehend the arbitration agreement. This oversight was identified as a deficiency in the facility's responsibility to ensure residents' understanding of legal agreements, as outlined in the relevant Pennsylvania Code sections.
Failure to Implement Droplet Precautions and Maintain Sanitary Kitchen Environment
Penalty
Summary
The facility failed to ensure droplet precautions were ordered and a care plan implemented for a resident who exhibited symptoms consistent with a respiratory infection. The resident, who had a history of coronary artery disease, hypertension, and diabetes, was noted to have a heavy wet nonproductive cough. Despite the physician being notified and new orders being initiated, including a rapid COVID test, PCR test, and chest x-ray, the resident's current physician orders did not include droplet precautions. Additionally, the resident's care plan was not updated to reflect the need for droplet precautions, as confirmed by the Director of Nursing. Furthermore, the facility did not maintain a safe and sanitary environment in one of its household kitchen areas, specifically the Mountain Laurel Neighborhood. During an observation, it was found that 15 boxes of disposable gloves and 15 compact disk cases were stored under the kitchen sink, contrary to the facility's infection control policy for household dining rooms. This was confirmed by the Household Coordinator and the Nursing Home Administrator, indicating a failure to prevent potential cross-contamination in the kitchen area.
Inadequate Supervision During Transfer Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision during a transfer for one of six residents, resulting in a fall. The resident, who was admitted to the facility with diagnoses including a right fibula fracture, anxiety, and depression, had physician orders indicating that toilet transfers should be completed with the assistance of two staff members. However, during a transfer to the commode, the resident slipped and fell, hitting the back of her head on a railing. Although no bleeding or lumps were noted, subsequent medical evaluations revealed an impacted proximal humerus fracture. The incident occurred when a Nurse Aid (NA) was transferring the resident alone, contrary to the prescribed assistance level. The NA's statement indicated that the resident slid while the NA was moving the wheelchair, and although the fall was partially broken, the resident still sustained injuries. The NA involved in the incident is no longer working at the facility and did not respond to follow-up communications. The Nursing Home Administrator confirmed the facility's failure to provide adequate supervision during the transfer, which led to the resident's fall.
Plan Of Correction
1) 12/30/24 R1 transfer status was reviewed with CNA's and Charge Nurses on R1 Nursing Household by Clinical Nurse Manager/DON. The CNA that was involved in the incident was interviewed, sent home, and terminated from the facility. 2) 12/31/24 Education was initiated by Clinical Coordinator/Designee to Charge Nurses and CNA's on all shifts regarding the transfer status, weight bearing status, resident profile, and Physician transfer orders. 3) 12/31/31/24 CNA's and Charge Nurses on each Nursing Household were interviewed by Clinical Nurse Manager/DON on the current transfer status order of each resident. 4) The Charge Nurse/Designee will monitor between the three shifts five residents on each nursing household for adequate supervision to ensure transfer status orders are being followed three times a week for three months or until substantial compliance is met.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent an elopement incident involving a resident, identified as Resident R1. The resident, who was admitted to the facility with diagnoses including benign prostatic hyperplasia, Parkinson's disease, and anxiety, was initially assessed as not being at risk for elopement. However, after an incident on July 12, 2024, where the resident was found attempting to exit the facility, a subsequent assessment on July 13, 2024, identified the resident as being at risk for elopement, and a wander guard was applied. Despite these measures, on September 2, 2024, Resident R1 managed to leave the facility after asking another resident's family member to open a door. The resident exited through the employee entrance and fell out of their wheelchair but was not injured. The resident was later found by staff and escorted back into the facility. The incident report noted that the resident's wander guard was in place and functioning, and the resident expressed a desire to enjoy fresh air. Interviews with facility staff revealed that at the time of the elopement, there was no staff present in the area to supervise the resident. Additionally, there was a lack of signage on the inside of the exit door to prevent unauthorized exits. The Nursing Home Administrator acknowledged the failure to provide adequate supervision, which resulted in the elopement incident.
Deficiencies in Catheter Care and Documentation
Penalty
Summary
The facility failed to have a physician's order and a care plan for the use of an indwelling catheter for one resident and failed to ensure appropriate treatment and services for two residents with indwelling urinary catheters. Resident R193 had an indwelling urinary catheter without a physician's order or a care plan, as confirmed by the Director of Nursing (DON) and a Registered Nurse (RN). The resident was observed with a Foley catheter connected to a drainage bag, but the necessary documentation was missing from the clinical records and care plan. Additionally, Resident R67 and Resident R73 did not receive appropriate catheter care. Resident R67's urinary drainage bag was observed uncovered and laying on his bed, and Resident R73's urinary drainage bag was attached to the bed frame above the level of the bladder, both of which were confirmed by an LPN. Furthermore, Resident R73's physician order did not specify a catheter size, and the privacy cover for the urinary drainage bags was not utilized for both residents. These deficiencies were confirmed by the DON and an LPN during interviews.
Failure to Conduct Ongoing Bedrail Assessments
Penalty
Summary
The facility failed to conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and to evaluate the risks associated with bedrail usage for five residents. According to Title 42 Code of Federal Regulations (CFR) S483.25(n), the facility must assess the resident for risk of entrapment from bed rails prior to installation and perform ongoing assessments. However, the clinical records for Residents R6, R14, R31, R32, and R34 did not reveal any ongoing assessments of the mobility bars, despite their continuous use as indicated by physician orders and care plans. Observations confirmed the presence of mobility bars on the beds of these residents, and staff interviews corroborated the lack of ongoing assessments. Resident R6, diagnosed with diabetes, overactive bladder, and spinal stenosis, had physician orders for continuous mobility bars, but no ongoing assessments were found in the clinical record. Similarly, Resident R14, with high blood pressure, heart failure, and coronary artery disease, had a left-side mobility bar for bed mobility without ongoing assessments. Resident R31, diagnosed with Alzheimer's Disease, anxiety, and depression, also had bilateral mobility bars without documented ongoing assessments. Resident R32, with a history of falling, anemia, and dementia, required substantial assistance with bed mobility and had bilateral mobility bars without current assessments. Resident R34, with high blood pressure, a history of falling, and Alzheimer's Disease, also had bilateral mobility bars without current assessments. Interviews with staff, including Nurse Aides and the Director of Nursing (DON), confirmed the lack of quarterly mobility bar assessments. The DON acknowledged that the facility failed to conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and to evaluate the risks associated with bedrail usage for the five residents mentioned. This deficiency was observed through clinical record reviews, staff interviews, and direct observations of the residents' beds with mobility bars.
Failure to Maintain Confidentiality of Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of residents' medical information on the second floor Tionesta household. During an observation, a medication cart/portable computer unit was left unattended outside of a resident's room with the computer screen open, displaying identifiable personal and medical information. This occurred on two separate occasions within a short time frame, allowing any passerby to view the confidential information. Licensed Practical Nurse Employee E7 confirmed during an interview that the computer screen was left open and that the facility did not maintain the confidentiality of resident information as required by their policies. The facility's policies on the use of laptops and medication administration clearly state that computer screens should be closed or turned away when not in use to protect resident privacy. The failure to adhere to these policies resulted in a breach of confidentiality for the residents in the Tionesta household.
Failure to Complete Neurological Assessments After Falls
Penalty
Summary
The facility failed to ensure that residents received neurological assessments after incidents involving falls for two residents. Resident R9, who had a history of high blood pressure, hemiplegia, and previous falls, experienced a fall on 9/19/23 after sliding out of a mechanical lift in the shower. Despite sustaining multiple lacerations and an abrasion, only nine out of the required 15 neurological checks were completed. The Director of Nursing (DON) confirmed that the neurological checks were not completed per facility policy and was unable to locate additional checks in the resident's clinical record. Similarly, Resident R69, who had diagnoses of high blood pressure, Alzheimer's Disease, and PTSD, was found with abrasions on her forehead and nose on 2/6/24. Due to a language barrier, the cause of the abrasions was unclear, and neurological checks were initiated based on a presumed fall. However, only 11 out of the required 15 neurological checks were completed. An LPN confirmed the inability to locate additional neurological checks in the resident's clinical record and acknowledged that the facility failed to complete the assessments as required by policy.
Failure to Document and Plan Respiratory Care
Penalty
Summary
The facility failed to ensure a physician order for the use and cleaning of a Bi-PAP/CPAP machine and did not develop a plan of care for a resident (R58) who required this therapy. The facility's policies on respiratory care documentation and equipment changes were not followed. Specifically, the policy required nurses to complete the electronic treatment administration record (eTAR) for residents with physician orders for CPAP/Bi-PAP therapy and outlined maintenance procedures for the equipment. However, a review of Resident R58's records revealed no physician order for Bi-PAP/CPAP therapy and no corresponding care plan, despite the resident using the machine at night for breathing, as confirmed by both the resident and the Director of Nursing (DON2). The resident's progress notes and observations further confirmed the use of the Bi-PAP/CPAP machine without proper documentation or care planning in place. Resident R58, who was admitted to the facility with diagnoses including obstructive sleep apnea, diabetes, and high blood pressure, was observed using a Bi-PAP/CPAP machine. Despite this, there was no physician order or care plan documented for the use of the machine. The facility's failure to adhere to its own policies and ensure proper documentation and care planning for the resident's respiratory therapy was confirmed by the Director of Nursing. This deficiency was identified during a review of the facility's policies, resident observations, clinical records, and staff interviews.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care to Resident R69, who has a diagnosis of Post Traumatic Stress Disorder (PTSD). The facility's policy on Trauma-Informed Care, dated 1/23/24, mandates culturally competent, trauma-informed care to mitigate potential triggers for residents with past or present trauma. However, a review of Resident R69's care plan on 3/28/24 revealed that it did not include any goals or interventions related to PTSD, despite the resident's diagnosis being documented in the Minimum Data Set (MDS) dated 1/18/24. The resident's diagnoses also included high blood pressure and Alzheimer's Disease. During an interview on 3/28/24, the Social Worker (Employee E3) admitted to not including a PTSD-specific care plan for Resident R69, believing it would be redundant since the resident was already care planned for mood and behaviors. Employee E3 also mentioned that the PTSD diagnosis might be related to an incident involving the resident's daughter. The failure to provide a trauma-informed care plan was confirmed by Employee E3, indicating a lapse in adhering to the facility's policy and potentially exposing the resident to re-traumatization triggers.
Failure to Secure Medication Drawer
Penalty
Summary
The facility failed to properly secure a medication drawer on four occasions in one of six households (Tionesta household). The facility policy, last reviewed on 1/23/24, indicates that during the administration of medications, the medication cart/portable computer unit is to be kept closed and locked when out of sight of the medication nurse. However, observations on 3/26/24 and 3/27/24 revealed that the portable computer unit medication drawer was left open, unattended, and out of sight of the medication nurse on four separate occasions. These observations were confirmed by Licensed Practical Nurses (LPNs) Employee E7 and Employee E8, who acknowledged the failure to secure the medication drawer as per the facility's policy. During interviews, LPN Employee E8 admitted to not knowing the specific policy concerning the medication drawer, while the Clinical Nurse Manager stated that the drawer is usually not closed when in sight but should be shut and locked if leaving the area. The Director of Nursing (DON2) confirmed that the medication drawer on the portable computer units is to be shut and locked, and the computer screen is to be closed. The facility's failure to secure the medication drawer was confirmed to be a deficiency in one of the six households, violating the 28 Pa. Code: 211.9(a)(1)(h)(k)(l)(1) Pharmacy services and 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.
Infection Control Deficiency During Blood Sugar Monitoring
Penalty
Summary
The facility failed to implement proper infection prevention and control measures during finger stick blood sugar monitoring for two residents. During an observation, an LPN did not allow the glucometer to remain wet for the required two minutes after cleaning it with a Sani-cloth wipe before placing it back into its case. This action was observed after obtaining a blood glucose reading from one resident. Additionally, the same LPN did not perform hand hygiene after completing a finger stick blood sampling and before preparing and administering insulin to another resident. The facility's policies on hand hygiene and the use of glucometers were not followed. The hand hygiene policy requires staff to wash hands before and after performing tasks that include invasive procedures, such as finger stick blood sampling. The glucometer policy mandates disposing of the lancet, gloves, and used strip in a designated container, washing hands, and wiping the glucometer with a germicidal wipe, allowing it to air dry for two minutes. The LPN confirmed during an interview that these steps were not followed, leading to potential cross-contamination risks.
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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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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