Penn Highlands Jefferson Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Brookville, Pennsylvania.
- Location
- 417 Route 28, Brookville, Pennsylvania 15825
- CMS Provider Number
- 395626
- Inspections on file
- 27
- Latest survey
- February 3, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Penn Highlands Jefferson Manor during CMS and state inspections, most recent first.
A resident with dementia, anxiety, colon cancer, and osteoporosis had physician and PT orders and a care plan requiring assistance of two staff when standing at a handrail for transfers and toileting. Despite these directives, one NA alone stood the resident at a grab bar after a shower and attempted to apply an incontinence brief, during which the resident’s hand slipped and the resident fell to the floor. A nurse noted leg shortening and pain, and hospital communication confirmed a hip fracture requiring surgical repair. The NHA acknowledged that required two-person assistance was not obtained, constituting neglect under the facility’s abuse/neglect policy.
A resident with dementia, anxiety, colon cancer, osteoporosis, and documented dependence for transfers and toileting had physician and PT orders requiring assistance of two staff while standing at a handrail for toileting. Despite these orders, one NA stood the resident at a grab bar after a shower and attempted to apply an incontinence brief without a second staff member present. The resident’s hand slipped from the bar, the resident fell to the floor, and was later found to have sustained a left hip fracture requiring surgical repair.
The facility's sprinkler system was found to have several maintenance deficiencies. Observations revealed dirty sprinkler heads in the kitchen dishwashing and laundry areas, and wires and cables attached to the sprinkler system in the mechanical room. These issues were confirmed by the maintenance supervisor.
The facility did not maintain HVAC equipment as required by NFPA 101 standards. Documentation confirming the fire/smoke damper inspection within the last four years was missing, as confirmed by the maintenance supervisor.
The facility failed to maintain self-closing doors on four floors, with issues such as doors failing to latch and self-closing devices being disconnected. These deficiencies were confirmed by the maintenance supervisor.
The facility failed to maintain smoke barrier requirements in one of its wings. Observations revealed missing ceiling tiles in the kitchen dishwashing area, allowing smoke transfer. This deficiency was confirmed by the maintenance supervisor.
An oxygen cylinder in the first-floor staffing office was found unsecured and unlabeled, violating NFPA standards for gas equipment storage. The maintenance supervisor confirmed the deficiency.
The facility was found to have exit signage deficiencies on all three floors. The first floor's main lobby lacked exit signs to the main door, and the front entrance was mislabeled. The second and third floors had missing exit signs around the nurse stations. These issues were confirmed by the maintenance supervisor.
The facility was found to have combustible decorations on fire doors in the Walnut Street wing, near a resident room, that exceeded allowable coverage and lacked documentation of fire-proofing treatment. This deficiency was confirmed by the maintenance supervisor during the survey.
The facility failed to ensure GFCI protection for an electrical receptacle in the chemical storage room, with an unprotected outlet located within six feet of a water basin. This deficiency was confirmed by the maintenance supervisor.
A facility failed to ensure consistency between a resident's physician orders and their POLST, leading to a discrepancy between a CPR order and a DNR request. The inconsistency was confirmed by a Registered Nurse Supervisor, highlighting a failure to honor the resident's documented treatment preferences.
The facility failed to maintain a clean environment in the Memory Lane unit, as observed with two residents' wheelchairs. One resident's wheelchair had a dry, white, food-like substance on the seat cushion and armrests, while another's had a dried tan substance on the seat cushion and base. An LPN confirmed the wheelchairs were unclean and acknowledged they should not be dirty.
The facility inaccurately coded the MDS for two residents, leading to deficiencies in their care assessments. One resident with a tracheostomy and gastrostomy tube was not marked as having a feeding tube, while another resident with Alzheimer's and diabetes was incorrectly coded for weight loss and gain despite no evidence of such changes. These errors were confirmed by the DON and a Dietary Technician.
The facility failed to follow physician's orders for two residents. One resident with Alzheimer's and diabetes was not repositioned every two hours as required, while another resident with dementia and hypertension did not have pillow boots on as ordered to prevent skin breakdown. These deficiencies were confirmed by LPNs during observations.
The facility failed to follow physician's orders for oxygen administration and did not maintain cleanliness of respiratory equipment for two residents. One resident's oxygen concentrator was set incorrectly, and both residents had concentrator filters covered in dust, indicating a lack of proper cleaning.
The facility failed to label a multi-dose insulin vial with the date it was opened and did not secure medications for a resident permitted to self-administer. An LPN confirmed the insulin vial should be dated to ensure timely disposal. Additionally, a resident's medications were left unsecured in their room throughout the day, contrary to facility policy.
The facility failed to maintain accurate documentation for two residents, leading to deficiencies in care. A resident with a tracheostomy and gastrostomy tube had discrepancies in enteral feeding and water flush documentation, while another resident with a UTI had inaccurate records of antibiotic administration. The DON confirmed these inaccuracies.
A facility failed to follow its infection control policy for Enhanced Barrier Precautions (EBP) during tracheostomy care for a resident with a tracheostomy, gastrostomy tube, and spastic quadriplegic cerebral palsy. Despite signage and available PPE, an RN did not wear a gown as required, citing the absence of infection or COVID as justification. This was identified as a deficiency in infection control practices.
The facility failed to provide written notice of its bed-hold policy to two residents upon transfer to a hospital, as required by regulations. Despite the facility's policy mandating this information be given at the time of transfer, there was no evidence that the residents or their representatives received the notice. The deficiency was confirmed by the Nursing Home Administrator.
The facility did not document orientation for three employees within the required timeframe. Records for a dietary aide, a housekeeping aide, and a nurse aide lacked evidence of orientation within one week of their start dates. The Nursing Home Administrator confirmed this deficiency during an interview.
A facility failed to assess and monitor a resident's pressure ulcer within required timeframes. The resident, with a history of diabetes, diverticulitis, and venous thrombosis, had an open area on the coccyx observed but not initially assessed or measured. Subsequent assessments were delayed, with gaps of 10 and 14 days between evaluations, contrary to the facility's policy.
The facility failed to ensure RN involvement in wound assessments for two residents, as required by state regulations and facility policy. Despite the policy mandating RN-led assessments, LPNs conducted the evaluations for residents with wounds, including one with diabetes and another with dementia, without RN oversight. This was confirmed by the Nursing Home Administrator and DON.
The facility failed to implement sufficient safety precautions to prevent a resident with a history of suicide ideations from attempting to inflict self-harm. Despite multiple incidents where the resident used a call bell cord to attempt self-harm, the facility did not adequately prevent access to potentially harmful items, resulting in an Immediate Jeopardy situation.
The facility failed to follow physician's orders for safe transfers, as five residents confirmed that mechanical lifts were often operated by only one staff member instead of the required two, contrary to facility policy.
The facility failed to update care plans for a resident with severe psychiatric conditions, including Bipolar Disorder and PTSD. Despite physician's orders to keep a tap bell within reach, the care plans were not revised, leading to confusion and inadequate care.
The NHA and DON failed to manage the facility effectively, resulting in inadequate supervision and self-harm prevention interventions. Despite their job descriptions requiring adherence to Federal, State, and Local standards, the facility did not consistently maintain safety measures to prevent self-harm among residents.
The facility failed to provide sufficient nursing staff, leading to missed care and unmet staffing ratios. Residents did not receive ordered treatments, and staff reported being overwhelmed and unable to complete their duties. The Nursing Home Administrator confirmed the facility's failure to meet required staffing levels.
The facility failed to maintain clean and sanitary common areas and resident rooms on the second floor. Observations revealed thick layers of dirt, debris, and dry, sticky spots on floors. Residents expressed dissatisfaction with housekeeping, noting unclean conditions, including dry fecal matter on the floor. The Nursing Home Administrator acknowledged housekeeping issues within the facility.
The facility failed to perform and document tracheostomy care per physician's orders for a resident with cerebral palsy, aphasia, respiratory failure, and hypoglycemia. A review of the resident's ETAR for February and March 2024 revealed 19 days without evidence of completed tracheostomy care. Staff interviews confirmed the lack of documentation and incomplete care.
The facility failed to document wound dressing changes for a resident with wounds on five days in February 2024, despite physician orders. The DON confirmed the incomplete records during an interview. The resident had diagnoses including pain, weakness, seizures, and chronic kidney disease.
Failure to Provide Required Two-Person Assist Resulting in Hip Fracture
Penalty
Summary
The facility failed to protect a resident from neglect by not following established care plan and physician/PT orders requiring two-person assistance while the resident was standing at a handrail/grab bar. The facility’s abuse/neglect policy defines neglect as the failure to provide goods and services necessary to avoid physical harm, including failure to follow the resident’s plan of care. The resident, admitted with dementia, anxiety, colon cancer, and osteoporosis, had a care plan and physician/PT directives indicating the need for assistance of two staff members when standing at a handrail for transfers and toileting. Despite these orders and care plan interventions, the resident was assisted by only one nurse aide during post-shower care while standing and holding onto a grab bar. According to facility documentation and staff statements, the nurse aide showered the resident, then stood the resident at a grab bar in the shower room and attempted to apply an incontinence brief while the resident was supported only by the grab bar and a single staff member. During this process, the resident’s hand slipped from the bar, and the resident fell to the floor. A nurse responding to the incident found the resident on the bathroom floor, noted one leg appeared shorter than the other, and documented the resident’s complaint of pain. Subsequent communication with the hospital confirmed that the resident sustained a left hip fracture requiring surgical repair. The Nursing Home Administrator confirmed that the resident required two-person assistance at the handrail and that the nurse aide did not obtain the required second staff member, resulting in the fall and injury.
Failure to Provide Required Two-Person Assist During Standing Resulting in Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to follow established safety measures requiring two-person assistance for a dependent resident while standing at a handrail, which resulted in a fall and left hip fracture. The resident was admitted with dementia, anxiety, colon cancer, and osteoporosis, and an MDS assessment showed the resident was dependent for transfers, changing position in bed, and toilet use. A physician’s order and a physical therapy recommendation directed that the resident be assisted by two staff members while standing at a handrail for toileting. Despite these orders, facility documentation revealed that the resident was left standing, holding onto a handrail bar, while a single staff member attempted to put on an incontinence brief. According to the nurse’s progress note and incident documentation, after a shower the nurse aide stood the resident at a grab bar in the main bathroom/shower room and, while attempting to apply a brief and dry the resident, the resident’s hand slipped from the bar and the resident fell to the floor. The nurse responding to the incident observed that one of the resident’s legs appeared shorter than the other and the resident complained of pain, and subsequent communication with the hospital confirmed a broken hip requiring transfer for further treatment. During an interview, the Nursing Home Administrator confirmed that the resident required assistance of two staff members while standing at a handrail and that the nurse aide did not obtain the required second staff member, leading to the fall.
Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain its sprinkler system, as evidenced by several deficiencies observed during a survey. On January 14, 2025, between 9:57 a.m. and 10:23 a.m., surveyors identified multiple issues with the sprinkler system. In the kitchen dishwashing area, a sprinkler head was found to be dirty, which could reduce its efficiency during an emergency. In the mechanical room near the boilers, wires and cables were improperly attached to the sprinkler system. Additionally, in the laundry room, sprinkler heads were observed to be dust-covered and dirty, which could also impair their functionality in an emergency. These deficiencies were confirmed by the maintenance supervisor during an interview conducted at the time of the survey.
Plan Of Correction
The sprinkler head identified was cleaned. Maintenance director advised maintenance staff that all other sprinkler heads to be reviewed and cleaned. Audits of 10 random sprinklers will be done weekly for 6 weeks to ensure cleanliness and free of debris. Audits will then be monthly thereafter.
Failure to Document Fire/Smoke Damper Inspection
Penalty
Summary
The facility failed to maintain its heating, ventilating, and air conditioning (HVAC) equipment in compliance with NFPA 101 standards. During a document review, it was found that the facility did not have documentation to confirm that the fire/smoke damper inspection had been performed within the previous four years. This deficiency was confirmed during an interview with the maintenance supervisor, who acknowledged the unavailability of the required documentation at the time of the survey.
Plan Of Correction
Maintenance director and maintenance department staff educated on the deficiency and proper timeliness of maintenance. Fire/smoke damper inspection has been scheduled to be performed and will be scheduled from there on. Nursing Home Administrator will set reminder to ensure this process is completed within the appropriate range to meet regulatory standards. This process will be reviewed in our Quality Assurance Performance Improvement Plan Quarterly for Performance Improvement.
Failure to Maintain Self-Closing Doors
Penalty
Summary
The facility failed to maintain doors with self-closing devices on four of over twenty floors, as observed during a survey on January 14, 2025. Specific deficiencies included the kitchen door to the trash hall failing to latch in the frame, basement corridor doors near the laundry having disconnected self-closing devices and failing to close and latch, the laundry door between the wet and dry rooms failing to latch, and the corridor door to the therapy room having a disconnected self-closing device and failing to close and latch. These observations were confirmed through an interview with the maintenance supervisor.
Plan Of Correction
Maintenance staff have been educated on the need for proper operating functions of self-closing doors and how to identify the need for them. Self-closing doors have been ordered and will be placed on each door. This process will be audited in our Quality Assurance Performance Improvement Plan quarterly, with random auditing performed by the maintenance director to ensure self-closing doors are in operation and closing appropriately.
Smoke Barrier Deficiency in Kitchen Area
Penalty
Summary
The facility failed to maintain smoke barrier requirements in one of its three wings. During an observation on January 14, 2025, at 9:54 a.m., it was noted that the smoke barriers on the main floor, specifically in the kitchen dishwashing area, were not properly maintained. The deficiency was evidenced by the presence of missing ceiling tiles, which allowed for the transfer of smoke. This observation was confirmed through an interview with the maintenance supervisor at the same time.
Plan Of Correction
Ceiling tiles were replaced as advised. Maintenance staff educated on replacing ceiling tiles during & after providing maintenance services to ensure a proper smoke barrier. Maintenance director will audit for missing tiles weekly for 6 weeks and monthly thereafter.
Improper Storage of Oxygen Cylinder in Staffing Office
Penalty
Summary
The facility failed to maintain proper gas equipment storage requirements in one of its rooms. During an observation on January 14, 2025, at 9:31 a.m., it was noted that an oxygen cylinder in the first-floor staffing office was not properly secured or labeled as full or empty. This observation indicates a lapse in adherence to the National Fire Protection Association (NFPA) standards for gas equipment storage, which require that cylinders be properly secured and labeled to ensure safety and compliance. An interview with the maintenance supervisor at the same time confirmed the deficiency in gas equipment storage. The NFPA 101 standards specify that gas cylinders must be stored in a manner that prevents them from being a hazard, including proper labeling and securing of cylinders. The failure to comply with these standards in the staffing office represents a significant oversight in the facility's safety protocols for handling and storing gas equipment.
Plan Of Correction
Oxygen tank identified was secured. Facility was checked to determine if any other oxygen cylinders were unsecured and did not determine any. All staff were educated on the procedure for securing an oxygen cylinder as well as the appropriate labeling of the tank. Maintenance director will audit tanks weekly for 6 weeks and monthly thereafter.
Exit Signage Deficiencies Across Facility Floors
Penalty
Summary
The facility failed to maintain proper exit signage on all three floors, as observed during a survey on January 14, 2025. On the first floor, the main lobby was missing exit signs directing to the main door, and the front entrance door was incorrectly labeled as 'not a fire exit.' On the second floor, the center core area around the nurse station lacked exit signs. Similarly, the third floor's center core around the nurse station also had missing exit signs. These deficiencies were confirmed through an interview with the maintenance supervisor.
Plan Of Correction
Facility removed the signage front door identifying it to not be an exit. Additional exit signage has been placed around the nursing stations and residents area to provide detailed signage for exiting the building. This information was reviewed in resident council as well as all-staff education.
Combustible Decoration Deficiency in Facility
Penalty
Summary
The facility failed to comply with NFPA 101 standards regarding combustible decorations. During an observation on January 14, 2025, it was noted that the fire doors in the Walnut Street wing, specifically near resident room #245, had decorations that exceeded the allowable coverage of materials. Additionally, there was no documentation available to confirm that these decorations had been treated with fire, flame, or smoke-proofing applications. This deficiency was confirmed through an interview with the maintenance supervisor, who acknowledged the presence of the combustible decoration issue at the time of the survey.
Plan Of Correction
The decorative item was removed from the door. All doors in the facility were checked to ensure the allowable coverage was not compensated. All staff were educated in monthly in-service meetings of code and appropriate allotment of coverage along with advising maintenance when something is on a door. The NHA & facility maintenance director will audit weekly for one month and monthly thereafter.
Electrical Receptacle Deficiency in Chemical Storage Room
Penalty
Summary
The facility failed to maintain electrical receptacles in compliance with safety standards in one of over twenty rooms. During an observation on January 14, 2025, at 9:38 a.m., it was noted that the chemical storage room on the first floor lacked ground fault circuit interrupter (GFCI) protection. An unprotected electrical receptacle was found within six feet of a water basin, which is a violation of the safety requirements. This deficiency was confirmed through an interview with the maintenance supervisor at the same time and date.
Plan Of Correction
The receptacle was taken out of use and replaced with an appropriate, code quality receptacle. Maintenance director and staff educated on code. Maintenance director will audit all other areas of building to determine we are in compliance with code.
Inconsistency in Resident's Advance Directive and Physician Orders
Penalty
Summary
The facility failed to ensure consistency between physician orders and the resident's Physician Order for Life Sustaining Treatment (POLST) for one resident. The facility's policy requires that the Director of Nursing Services or designee notify the attending physician of any advance directives or changes to them, ensuring that appropriate orders are documented in the resident's medical record and plan of care. However, for Resident R13, there was a discrepancy between the physician's order, which indicated cardiopulmonary resuscitation (CPR), and the POLST, which specified a Do Not Resuscitate-Allow Natural Death (DNR) order with limited additional interventions. Resident R13 was admitted with diagnoses including Type I diabetes, hypertension, and vitamin D deficiency. The inconsistency was confirmed during an interview with the Registered Nurse Supervisor, who acknowledged that the physician's orders and the POLST were not aligned. This discrepancy indicates a failure to honor the resident's documented treatment preferences as outlined in their advance directive.
Plan Of Correction
Nursing staff identified the proper code status with family for resident R13 to ensure the proper treatment plan is in process and updated. The Facility has educated staff on the policy of advanced directives along with accuracy. Facility has done an audit of all residents to determine appropriate code status is correct per resident's wishes and matches in the EMR along with the POLST. DON or designee will audit all new admissions for 6 weeks for accurate documentation of POLST vs order in the EMR. POLST will be reviewed with care plan meetings. We will review this as part of our Quality Assurance Performance Improvement meeting (QAPI) and audit quarterly.
Failure to Maintain Clean Wheelchairs in Memory Lane Unit
Penalty
Summary
The facility failed to maintain a clean and homelike environment in one of its units, Memory Lane. During observations, it was noted that two residents' wheelchairs were unclean. On January 6, 2025, Resident R70 was observed lying in bed with a wheelchair beside them that had a dry, white, food-like substance on the seat cushion and bilateral armrests. On January 7, 2025, Resident R1's wheelchair, located in the hallway, was observed with a dried tan substance running down the left side of the seat cushion and base. Later that day, both residents were observed in their wheelchairs, with the substances still present. An LPN confirmed the unclean state of the wheelchairs and acknowledged that they should not be dirty.
Plan Of Correction
R1 and R70's wheelchairs were taken to the wheelchair cleaning station and cleaned. The facility did a whole-house review on all wheelchairs and cleanliness to determine other residents were not impacted. It was determined the facility failed to have a policy in place that addressed maintaining wheelchair cleanliness through the facility. All facility staff have been educated on the process needed to identify wheelchair cleanliness. Facility housekeeping department staff have been educated on the wheelchair cleaning schedule to ensure compliance. The housekeeping manager will monitor all chairs on a given cycle to ensure they are being cleaned timely and as outlined in the policy. The housekeeping manager will review each chair on the cycle as they are to be cleaned weekly for 6 weeks and monthly thereafter. All resident wheelchairs were taken to be cleaned. Education on a new policy to address the cleanliness of wheelchairs as part of a preventative measure has been created by the Nursing Home Administrator (NHA), Director of Nursing (DON), and housekeeping manager. The policy has been reviewed and staff educated. The facility has identified this as a performance improvement program for their Quality Assurance Performance Improvement (QAPI) Program. We will review quarterly with QAPI and track progress.
Inaccurate MDS Coding for Nutritional Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two residents, leading to deficiencies in the assessment of their care needs. Resident R1, who has a tracheostomy, gastrostomy tube, and spastic quadriplegic cerebral palsy, was receiving continuous Jevity 1.5 tube feedings as per a physician's order. However, the MDS with an Assessment Reference Date (ARD) of 11/11/24 did not indicate the presence of a feeding tube in Section K0520B, which was confirmed as an error by the Director of Nursing during an interview. Resident R46, diagnosed with Alzheimer's Disease and diabetes, had no evidence of weight loss or gain in the last month or six months. Despite this, the MDS assessments with ARDs of 7/12/24, 9/10/24, and 12/09/24 were incorrectly coded to indicate weight loss and gain. This was verified by a Dietary Technician, who confirmed that the sections related to weight loss and gain were inaccurately coded for Resident R46.
Plan Of Correction
Residents R1 and R46 were reviewed, corrected and resubmitted for accuracy. The facility did a look back from 05/01/2024 to determine inaccurate coding in the MDS. All inaccurate MDS have been modified for accuracy and reviewed by the interdisciplinary team (IDT Team). IDT team has been educated on accurate MDS completion based on the RAI manual. Nursing home administrator, director of nursing or designee will audit 5 full MDS per week every week times 2 weeks and then 5 a month for the next 60 days thereafter. Facility will identify this as a focus area needing improvement and review at QAPI (Quality Assurance Improvement Plan).
Failure to Follow Physician's Orders for Resident Care
Penalty
Summary
The facility failed to adhere to physician's orders for two residents, leading to deficiencies in care. Resident R46, diagnosed with Alzheimer's Disease and diabetes, had a physician's order dated 11/17/24 to be turned and repositioned every two hours due to impaired mobility. However, observations on 1/07/25 revealed that the resident remained in the same position on their buttocks throughout the day, indicating non-compliance with the care plan. This was confirmed by LPN Employee E8, who acknowledged the requirement for repositioning every two hours. Similarly, Resident R56, with diagnoses of dementia and hypertension, had a physician's order dated 9/26/24 for pillow boots to be worn on both feet at all times except during care to prevent skin breakdown. Observations on 1/06/25, 1/07/25, and 1/08/25 showed the resident sitting in a wheelchair without the pillow boots, which were found lying on the bedside stand or nightstand. LPN Employee E10 confirmed the absence of pillow boots on the resident's feet, acknowledging the failure to follow the physician's orders.
Plan Of Correction
R46 was turned and repositioned; the concern was identified. Orders were reviewed with the physician and nursing supervisor to determine appropriate measures are in place and being followed. R56 pressure relieving devices were applied per physician order. Orders were reviewed with care staff to ensure the facility was in compliance with physician orders. The facility has reviewed the policy for pressure ulcer prevention and repositioning. The interdisciplinary team (IDT Team) met for policy revisions and updated the turning and repositioning policy. The use of pressure reducing devices will be individualized based on the patient's needs, RN assessment, as well as the Braden Scale. Facility education to all nursing staff regarding the policy change in turning and repositioning of residents and the need for an individualized plan to prevent skin breakdown, including pressure reducing devices, has been provided. The facility has reviewed care plans and orders of residents to determine who was at risk for skin breakdown and preventative measures put in place. Audits will be performed on all residents on individualized repositioning programs and with pressure reducing devices weekly for 8 weeks and monthly thereafter for 3 months. We will be auditing all residents on individualized care repositioning plans. The facility has identified this as a performance improvement program for their Quality Assurance Performance Improvement (QAPI) Program. We will review quarterly with QAPI and track progress.
Failure to Adhere to Oxygen Orders and Equipment Cleanliness
Penalty
Summary
The facility failed to provide oxygen according to physician's orders and did not maintain cleanliness of respiratory care equipment for two residents. Resident R51, diagnosed with chronic obstructive pulmonary disease and peripheral vascular disease, had a physician's order for oxygen at 3 liters per minute (lpm) via nasal cannula. However, observations revealed that the oxygen concentrator was set at 4 lpm, contrary to the physician's order. Additionally, the filters on the oxygen concentrator were covered with a gray fluffy substance, indicating they had not been cleaned as required by the physician's order. Similarly, Resident R1, who had a tracheostomy and other complex medical conditions, had a physician's order for oxygen at 4 lpm via trach mask. Observations showed that the oxygen concentrator filter contained a gray dusty substance, suggesting it had not been cleaned according to the physician's order. A Registered Nurse confirmed the presence of the dusty substance but was unsure of the cleaning schedule. These deficiencies indicate a failure to adhere to physician's orders and maintain proper infection control practices.
Plan Of Correction
R51 as well as R1 assistive breathing device was cleaned and replaced with new equipment including a nasal cannula. Orders were reviewed and appropriate Liter per minute setting was put in place to match the physician order. Facility verified and addressed all residents were receiving oxygen per physician orders. All breathing apparatus were checked for cleanliness and cleaned per policy. Facility has educated nursing staff on the policy for cleaning breathing assisted devices and following physician orders. Director of Nursing or designee will audit 5 residents that receive oxygen therapy weekly for 6 weeks and once a month for 3 months to ensure the order matches what the resident is receiving with liters as well as cleanliness of the machines. Facility has identified this as a performance improvement program for their Quality Assurance Performance Improvement (QAPI) Program. We will review quarterly with QAPI and track progress.
Failure to Label Insulin Vial and Secure Self-Administered Medications
Penalty
Summary
The facility failed to properly label a multi-dose insulin vial and ensure the secure storage of medications for self-administration. During an observation, it was noted that a medication cart contained an opened, undated multi-dose Lantus insulin vial, which should have been labeled with the date it was opened to ensure timely disposal according to the manufacturer's instructions. A Licensed Practical Nurse (LPN) confirmed that the vials should be dated upon opening to prevent usage past expiration. Additionally, the facility did not secure medications for a resident who was permitted to self-administer. The resident's room contained a plastic storage bin with multiple medications left unsecured on a bedside tray table throughout the day. Interviews with LPNs revealed that the medications were left in the resident's room from morning until evening, contrary to the facility's policy that requires medications to be stored securely when not in use.
Plan Of Correction
Facility has done a full sweep to identify if any other residents have been impacted by the concern. No other residents were impacted. All other medication carts in the facility were reviewed by director of nursing or RN supervisor to determine no other inappropriate labeling or lack thereof had occurred. Inter-disciplinary team (IDT) reviewed the patient's care plan as well as physician orders with resident. Resident R22 understands there is a safety risk for other residents for leaving meds unattended in the room and is agreeable to keeping medications secured in the medication cart outside of medication administration times. Resident requests at the time of the medication needing given that medications be brought to bed-side, then R22 will prepare medications and take them supervised with nurse. The medications will be locked again and secured in med cart. R22 expresses the safety factor and is willing to participate. Nursing Staff have been educated on the new process in regard to this resident. Care plan and orders have been updated. Education was also provided to nursing staff on labeling vials. DON or designee will audit that this new process is happening 3 times a week for 4 weeks and then weekly for 6 weeks. Audits will be completed on multi-dose labeling and audited 3 times weekly for 6 weeks and once weekly for one month. Facility has identified this as a performance improvement program for their Quality Assurance Performance Improvement (QAPI) Program. We will review quarterly with QAPI and track progress.
Documentation Failures in Resident Care
Penalty
Summary
The facility failed to maintain complete and accurate documentation for two residents, leading to deficiencies in care. For Resident R1, who has a tracheostomy, gastrostomy tube, and spastic quadriplegic cerebral palsy, the clinical records showed discrepancies in the documentation of enteral feeding and water flushes. The records indicated that Resident R1 received less than the ordered amount of water flushes and formula on multiple occasions, and there were instances where no documentation was available for the water flushes and formula intake. The Director of Nursing confirmed the inaccuracies in Resident R1's clinical record regarding the tube feeding formula and water flushes. For Resident R37, who has diabetes, high blood pressure, and a urinary tract infection (UTI), the clinical records inaccurately documented the administration of Keflex, an antibiotic prescribed for the UTI. Although the last dose was administered on 12/21/24, progress notes continued to indicate that Resident R37 was receiving Keflex for several days afterward. The Director of Nursing confirmed the inaccuracies in Resident R37's clinical record related to the administration of Keflex. These documentation failures were identified during a review of facility policy, clinical records, and staff interviews.
Plan Of Correction
Facility has reviewed all other residents and determined no others were affected. Education has been provided on policy for enteral feeds and flushes with all licensed nursing staff to ensure care plans and physician orders are being followed and recorded accurately. Documentation of med administration policy has been educated and reviewed with all nursing staff. Director of Nursing or designee will audit 5 charts for errors in antibiotics as well as flushes and feeds being documented appropriately daily for 2 weeks and 3 times weekly for 6 weeks. R1 care-plan was reviewed along with current status; it was determined R1 did not receive any adverse effects. Residents' weight is maintained with no evidence of dehydration. R37 also did not have adverse effects because the antibiotic was completed in the 7 day course. Facility has identified this as a performance improvement program for their Quality Assurance Performance Improvement (QAPI) Program. We will review quarterly with QAPI and track progress.
Failure to Follow Enhanced Barrier Precautions During Tracheostomy Care
Penalty
Summary
The facility failed to adhere to its infection control practices regarding Enhanced Barrier Precautions (EBP) during tracheostomy care for a resident. The facility's policy, dated 6/11/24, mandates the use of gown and gloves for high-contact resident care activities, such as tracheostomy care, to prevent the spread of multi-drug resistant organisms. Despite this policy, an observation on 1/06/25 revealed that a registered nurse (RN) did not wear a gown while performing tracheostomy care on a resident, even though signage on the resident's door indicated the requirement for EBP and personal protective equipment (PPE) was readily available. The resident involved had a tracheostomy, gastrostomy tube, and spastic quadriplegic cerebral palsy, with a physician's order for EBP dated 10/24/24. During an interview, the RN confirmed the omission of the gown, justifying the action by stating that additional PPE was unnecessary if the resident was not infected or had COVID. This failure to follow the established EBP policy was identified as a deficiency in the facility's infection control practices.
Plan Of Correction
Nursing Home Administrator (NHA), Director of Nursing (DON) & infection preventionist reviewed education & procedure again individually with the staff member that failed to follow policies & procedures related to Enhanced Barrier Precautions (EBP). Facility reviewed all residents under EBP and found none to be at risk. Part of our review determined all residents on EBP do have the proper PPE available. NHA & DON re-educated on EBP and how it impacts them in their roles and to follow care plan for EBP. R1 CarePlan reviewed and educated staff member individually on following policy for EBP with R1 specifically as well as all other residents under the same precautions. Director of Nursing or designee will audit proper use of EBP when providing care to 3 residents under precautions every shift time two weeks, and then 5 residents monthly for 3 months. Staff have been educated and are aware how and when to utilize PPE for EBP residents. This process will be reviewed in our QAPI (Quality Assurance Performance Improvement) plan and updated as needed based on ongoing audits.
Failure to Provide Bed-Hold Policy Notice Upon Transfer
Penalty
Summary
The facility failed to provide written notice of its bed-hold policy to residents and their representatives upon transfer to a hospital, as required by §483.15(d)(1)(2). This deficiency was identified for two residents during a review of facility policy, clinical records, and staff interviews. The facility's policy, titled "Bed-Holds and Returns" and dated 6/11/24, mandates that written bed-hold information be given to residents and their representatives at the time of transfer. However, there was no evidence that this policy was followed for Residents R21 and R51. Resident R21, admitted on 8/28/20 with diagnoses including high blood pressure, anxiety, depression, and heart failure, was transferred to the hospital on 12/04/24. Similarly, Resident R51, admitted on 5/2/23 with chronic obstructive pulmonary disease and peripheral vascular disease, was transferred on 10/18/24. In both cases, there was no documentation indicating that the residents or their representatives received the required bed-hold policy notice. The Nursing Home Administrator confirmed the absence of such documentation during an interview on 1/08/25.
Failure to Document Employee Orientation
Penalty
Summary
The facility failed to ensure that employees received orientation to the facility and their assigned positions prior to or within one week of their start date. This deficiency was identified through a review of employee personnel records and staff interviews. Specifically, the records for three employees—Dietary Aide Employee E3, Housekeeping Aide Employee E4, and Nurse Aide Employee E5—lacked evidence of the required orientation. Dietary Aide Employee E3 began working on August 27, 2024, Housekeeping Aide Employee E4 on August 1, 2024, and Nurse Aide Employee E5 on October 15, 2024. During an interview on January 8, 2025, the Nursing Home Administrator confirmed the absence of orientation documentation for these employees.
Plan Of Correction
The facility identified a break down in the orientation process effecting non-clinical staff. IDT (Interdisciplinary Team) team has been educated on providing effective, facility-based orientation to all staff upon hire. All staff employed at the building were provided a facility-based orientation to determine they have the proper resources and education. Facility looked back 4 months to identify any staff members that did not receive the adequate orientation to the facility and provided them this information. Moving forward the Nursing Home Administrator (NHA) or designee will audit 50% of new hire files to determine facility-based orientation is being provided. This process will be reviewed in our Quality Assurance Performance Improvement (QAPI) plan and updated as needed based on ongoing audits.
Failure to Monitor Pressure Ulcers as Required
Penalty
Summary
The facility failed to comprehensively assess and monitor pressure ulcers within required timeframes for a resident identified as R14. According to the facility's policy dated 6/11/24, pressure ulcers must be documented in the electronic medical record, and the Wound Nurse/RN is required to complete weekly skin rounds and measure pressure ulcers. However, Resident R14's clinical records revealed a lack of initial assessment, including description and measurement, when an open area was observed on the coccyx on 7/11/24. The pressure ulcer was not assessed or measured again until 7/12/24, and then there was a gap of 10 days until the next assessment on 7/22/24, followed by another gap of 14 days until 8/5/24. Resident R14 had a medical history that included diabetes, diverticulitis, and venous thrombosis. The Director of Nursing confirmed during an interview on 8/15/24 that the pressure ulcer was not assessed or measured as frequently as required from 7/12/24 through 8/5/24. This failure to adhere to the facility's policy and the required assessment schedule led to the deficiency being identified during the survey.
Failure to Conduct RN-Led Wound Assessments
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) conducted initial and follow-up wound assessments for two residents with wounds, as required by state regulations and facility policy. According to Title 49, Professional and Vocational Standards, the RN is responsible for assessing human responses and planning, implementing, and evaluating nursing care. However, the facility's policy on Pressure Ulcer Assessment/Prevention mandates that the Wound Nurse/RN complete weekly skin rounds and document findings in the electronic medical record. Despite these requirements, the assessments for the wounds of two residents, identified as R14 and R15, were conducted by Licensed Practical Nurses (LPNs) without the oversight or involvement of an RN. Resident R14, who had diagnoses including diabetes, diverticulitis, and venous thrombosis, had a coccyx wound assessed by LPNs on multiple occasions without RN involvement. Similarly, Resident R15, with diagnoses of dementia, osteoarthritis, and peripheral vascular disease, had a right hip wound assessed by LPNs over several weeks, again without RN oversight. The Nursing Home Administrator and Director of Nursing confirmed that the wound assessments were conducted by LPNs, contrary to the facility's policy and state regulations, which require RN involvement in such assessments.
Failure to Prevent Self-Harm in Resident with Suicidal Ideations
Penalty
Summary
The facility failed to implement sufficient safety precautions to prevent a resident with a history of suicide ideations from attempting to inflict self-harm. Resident R3, who had multiple diagnoses including Bipolar Disorder with severe psychotic features, major depressive disorder, generalized anxiety disorder, Agoraphobia with panic disorder, and post-traumatic stress disorder, was admitted to the facility with a history of suicidal statements and delusional thoughts. Despite this history, the facility did not adequately prevent the resident from accessing potentially harmful items, such as a call bell cord, which the resident repeatedly used in attempts to self-harm. Resident R3's clinical record revealed multiple instances where the resident attempted to use the call bell cord to inflict self-harm. On several occasions, the resident was found with the call bell cord wrapped around their neck, chanting, and exhibiting other behaviors indicative of severe distress and suicidal ideation. Despite these incidents, the facility's care plans and safety measures were insufficient to prevent further attempts. The resident's care plans included instructions to keep the call bell within reach, but these measures were not effective in preventing the resident from using the cord to attempt self-harm. Interviews with the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the facility failed to take adequate safety measures to prevent Resident R3 from accessing the call bell cord. The facility's failure to implement appropriate interventions and supervision for a resident with a known history of suicidal ideation and attempts resulted in an Immediate Jeopardy situation, putting the resident at significant risk of harm.
Removal Plan
- Educate all direct care staff on signs and symptoms of suicidal ideations and appropriate action to take regarding resident safety.
- Resident on return to facility will not have a corded call bell. She will be given a tap bell and screened by nursing staff for signs or symptoms of increasing depression or suicidal ideations.
- DON with LNAC will audit current resident records for histories of suicidal ideation or attempts.
- LNAC will update care plans of current residents to reflect these histories and include interventions, which will become standard for any resident entering with history of suicidal ideation or attempts.
- Administrator and DON will educate RNAC, LNAC, and Social Worker on standard care plan interventions related to historical suicidal ideation or attempts. These will include ensuring there is no access to common suicidal methods and will be individualized based on resident history and current assessment.
- The Columbia Suicide Severity Rating Scale (CSSRS) will be administered by an RN on all new admissions. A licensed nurse (RN or LPN) will administer the CSSRS weekly, indefinitely, for those residents with a known suicidal ideation history. Residents scoring low risk with no history will require no follow up. Residents scoring low risk with a history of suicidal ideation will continue to be monitored and standard interventions in place with no additional referrals or notifications needed. Residents scoring moderate risk with or without a history of suicidal ideations or attempts will be referred for behavioral health consult and MD notified. Residents scoring high risk, with or without a history of suicidal ideations or attempts will immediately provide supervision until an evaluation has been completed and the resident deemed safe or sent to acute care for an evaluation. MD will be notified for further review and recommendations.
- Educate all direct care staff on each resident's individual care plan needs regarding suicidal ideations.
- All Items in this action plan will be reviewed at quarterly QAPI.
Failure to Follow Physician's Orders for Safe Transfers
Penalty
Summary
The facility failed to follow physician's orders related to safe transfers for five residents. The facility policy requires at least two qualified nursing personnel to operate mechanical lifts, but observations and interviews revealed that this policy was not consistently followed. Residents R6, R10, R11, R16, and R17 were all observed sitting in their wheelchairs on mechanical lift slings, and each confirmed that sometimes only one staff member assisted with the lift, contrary to the physician's orders and facility policy. Resident R6, with diagnoses including a broken right lower leg and spinal stenosis, had a physician's order for transfer with a mechanical lift and assistance of two. Similarly, Resident R11, with diagnoses including heart failure and muscle weakness, had a physician's order for a full mechanical lift with assistance of two. Both residents confirmed that sometimes only one helper was present during transfers. Resident R16, with heart disease and high blood pressure, and Resident R17, with chronic inflammatory demyelinating polyneuropathy, also had similar orders and confirmed the same issue. Resident R10, diagnosed with multiple sclerosis and paraplegia, also had a physician's order for transfer with a mechanical lift and assistance of two. This resident confirmed that transfers often occurred with only one staff member, citing staffing concerns. Interviews with employees E1 and E2 corroborated these findings, as they admitted to using the mechanical lifts by themselves due to difficulties in finding additional help. The Director of Nursing confirmed that all mechanical lift transfers should be done with two staff members, highlighting a clear deviation from the established protocol.
Failure to Update Care Plans for Resident with Severe Psychiatric Conditions
Penalty
Summary
The facility failed to review and revise comprehensive care plans to reflect the current necessary care and services for one resident (Resident R3). Resident R3 had multiple diagnoses, including Bipolar Disorder with severe psychotic features, major depressive disorder, generalized anxiety disorder, agoraphobia with panic disorder, and post-traumatic stress disorder. The resident had a history of suicidal statements and delusional thoughts, which led to hospital admissions. Physician's orders included keeping a tap bell within reach at all times and at the bedside, but the care plans were not updated accordingly. Resident R3's care plans included interventions for potential falls, impaired mobility, potential for infection, physical behaviors related to bipolar disorder, and self-care deficits. However, the care plans related to call bell use and tap bell use were found to be confusing and not updated when the tap bell was ordered. This discrepancy was confirmed during an interview with the Nursing Home Administrator and Director of Nursing. The failure to update the care plans as per the physician's orders led to the deficiency noted in the report.
Failure to Implement Supervision and Self-Harm Prevention
Penalty
Summary
The Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to ensure proper supervision and self-harm prevention interventions were implemented. The job descriptions for both the NHA and DON outline their responsibilities to plan, organize, and direct the facility's operations in accordance with Federal, State, and Local standards. However, the facility did not consistently supervise and maintain safety interventions to prevent self-harm among residents, indicating a failure to fulfill these essential job duties and adhere to regulatory guidelines.
Insufficient Nursing Staff and Missed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple instances of missed care and unmet staffing ratios. The facility's policy dated 2/14/24 stated that sufficient nursing staff should be provided to ensure the highest practicable well-being of residents. However, resident council minutes and staff interviews indicated that call bells were not answered timely, and staff were often required to float between different areas, leading to missed treatments and care tasks. Specific dates were noted where Certified Nursing Assistant (CNA) ratios and minimum Per Patient Day (PPD) requirements were not met, affecting both day and night shifts. Clinical documentation revealed that several residents did not receive ordered care due to staff shortages. For example, Resident R3 did not have vital signs taken as ordered, Resident R4's monthly vital signs were not completed, and Resident R5 was not weighed daily as required. Additionally, Resident R8 did not receive a weekly skin evaluation, Resident R6 did not have 15-minute visual safety checks, and Resident R7 did not receive prescribed topical treatment. Resident R2 did not receive tracheostomy care on a specific date, as confirmed by staff interviews. Staff members reported being overwhelmed and unable to complete their duties due to floating between floors and managing multiple medication carts. Interviews with residents and staff further highlighted the impact of insufficient staffing. Residents expressed concerns about the lack of timely assistance and the visible stress and overwhelm of the staff. Staff members described working alone with large numbers of residents, leading to delays in care and unsafe conditions. The Nursing Home Administrator confirmed the facility's failure to meet required CNA ratios and minimum PPD on several dates, acknowledging the need for improved staffing levels.
Failure to Maintain Clean and Sanitary Conditions
Penalty
Summary
The facility failed to maintain clean and sanitary common areas and resident rooms on the second floor. Observations revealed thick layers of dirt, debris, straw wrappers, napkins, fuzzy dust on and under furniture, and dry, sticky spots on hallway floors and in resident rooms. Only one housekeeper was observed cleaning a resident's room, with no cleaning activity in the common areas. Resident R11 reported dissatisfaction with housekeeping, noting dry fecal matter on the floor next to their roommate's bed, which had been there for a couple of days. Observations confirmed dirt, dust, and debris under all beds in R11's room, with footwear sticking to the floor due to the unclean conditions. Resident R10 also expressed dissatisfaction with the dirty floors in their room and the hallway, which was confirmed by observations of thick dirt layers. Resident R5 pointed out dust on their stands, which was also observed during the inspection. During a tour and interview, Registered Nurse Employee E1 confirmed the dirty conditions in the common areas and resident rooms on the second floor, including the dry fecal matter on Resident R11's floor and the sticky floor conditions. The Nursing Home Administrator acknowledged that housekeeping was an issue within the facility. The report highlights the facility's failure to provide a safe, clean, comfortable, and homelike environment for its residents, as required by regulations.
Failure to Perform and Document Tracheostomy Care
Penalty
Summary
The facility failed to perform tracheostomy care per physician's orders for a resident with cerebral palsy, aphasia, respiratory failure, and hypoglycemia. The facility policy required registered nurses to document tracheostomy care in the resident's electronic medical record (EMR). However, a review of the resident's electronic treatment administration record (ETAR) for February and March 2024 revealed 19 days where there was no evidence that tracheostomy care was completed as ordered. Interviews with staff, including a registered nurse and the Director of Nursing, confirmed the lack of documentation and incomplete tracheostomy care for the resident.
Incomplete Documentation of Wound Dressing Changes
Penalty
Summary
The facility failed to have complete and accurate documentation regarding wound dressing changes for one resident (R1) with wounds. The facility's policy required treatments to be charted in the Electronic Treatment Administration Record (ETAR) as soon as possible to ensure accuracy. However, a review of Resident R1's ETAR for February 2024 revealed that there were five days (2/21/24, 2/22/24, 2/23/24, 2/24/24, and 2/25/24) without documentation indicating that the wound dressing changes were completed as ordered by the physician. The Director of Nursing confirmed the incomplete documentation during an interview on 3/07/24. Resident R1 had diagnoses including pain, weakness, seizures, and chronic kidney disease, and was admitted on an unspecified date.
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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