Platinum Ridge Ctr For Rehab & Healing
Inspection history, citations, penalties and survey trends for this long-term care facility in Brackenridge, Pennsylvania.
- Location
- 1050 Broadview Boulevard, Brackenridge, Pennsylvania 15014
- CMS Provider Number
- 395011
- Inspections on file
- 41
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Platinum Ridge Ctr For Rehab & Healing during CMS and state inspections, most recent first.
Surveyors found that the facility discharged two residents without obtaining required physician orders for discharge. One resident with a thoracic vertebra fracture, UTI, and muscle weakness and another resident with atrial fibrillation, diabetes mellitus, and protein-calorie malnutrition both had current diagnoses documented on their MDS assessments, and facility records showed they were discharged. However, review of their most recent physician orders revealed no discharge orders, and the DON confirmed that physician orders for these discharges were not obtained as required.
Surveyors found that the facility did not document or communicate required clinical and administrative information to receiving hospitals for three residents who experienced facility-initiated transfers, including care plan goals, advance directives, specific ongoing care instructions, and representative contact details. For the same three residents, the facility also failed to provide written notice of its bed-hold policy at the time of hospital transfer, despite a policy requiring such information to be given both at admission and at transfer. The DON confirmed these lapses in communication and notification during interview.
Over a three-month period, the facility did not act on or document follow-up to concerns repeatedly raised in Resident Council meetings. Residents reported systemic issues with call bells not being answered timely, agency staff turning off call bells without providing assistance, poor care on weekends, and medications not being delivered on time. Although facility policy requires that all Resident Council feedback be addressed in writing, the follow-up sections of the council minutes for each month were left blank, and the NHA confirmed that residents' views and concerns about care and daily life were not promptly considered or addressed.
Surveyors determined that the facility failed to obtain and document ordered lab results and to notify practitioners and resident representatives for two residents. One resident with a history of stroke, hemiplegia, and UTI had an order for a CMP, and another resident with anemia, heart failure, and hypertension had an order for a one-time BMP; in both cases, there was no documentation that results were obtained or communicated. An LPN reported that lab results were not in the clinical record and that only a supervisor could access the lab computer system, and the DON confirmed these failures, which were inconsistent with facility policies on lab services and change in condition, as well as state nursing services regulations.
The facility did not employ a qualified Food Service Director for several months, assigning the role to an employee who was not a Certified Dietary Manager and for whom no documentation of required qualifications could be produced. During staff interviews, the NHA confirmed the employee had been functioning as the FSD and acknowledged the lack of evidence that she met position requirements, while the FSD reported that an RD typically visited once per week. This resulted in noncompliance with state management requirements for food and nutrition services.
The facility did not provide coffee to about half of its residents due to supply and approval delays, despite residents' preferences and repeated requests. Staff confirmed that running out of coffee was a recurring problem, and the administrator acknowledged the failure to meet resident preferences.
Surveyors observed that food items in the Main Kitchen, including frozen vegetables, chopped onions, and gelatin mix, were not properly labeled or dated according to facility policy. The Dietary Supervisor confirmed the failure to follow required procedures for food storage.
The facility did not individualize care plans for two residents with complex nutritional needs, omitting specific interventions for prescribed diets, supplements, and tube feedings. Additionally, staff were not adequately informed about a resident's physician-ordered fluid restriction, as the order lacked details on fluid distribution between departments. These deficiencies were confirmed by staff interviews and review of clinical records.
The facility did not ensure that monthly medication regimen reviews were completed and documented by a licensed pharmacist for several residents, including those with dementia, chronic pain, and mental health conditions. In some cases, pharmacy-identified irregularities were not addressed by the physician in a timely manner, and for two months, no review was documented for a resident with multiple psychiatric diagnoses. The DON confirmed these lapses in required medication review processes.
A resident with Alzheimer's disease, anxiety, and depression who developed a pressure ulcer on the right heel did not receive care in a manner that maintained dignity when an RN wrote on the dressing after it was applied. The RN acknowledged this action did not uphold the resident's right to dignity, as required by facility policy and state regulations.
Two residents received psychotropic medications without proper clinical justification or required monthly medication regimen reviews. For one resident, an antipsychotic was prescribed without an appropriate diagnosis and the physician did not address the pharmacist's recommendation. For another, multiple psychotropic medications were prescribed, but documentation of required pharmacist reviews was missing.
A resident with a history of cancer, malnutrition, and depression was administered enteral feeding without a physician order following a hospital return. The DON confirmed that enteral feeding was provided for several days without the required order, resulting in a deficiency related to appropriate treatment and services for residents with feeding tubes.
Two residents with physician orders for nebulizer treatments were found to have their nebulizer machines and mouthpieces left on bedside tables, not stored in bags as required by facility policy. An LPN confirmed the equipment was not properly stored when not in use, resulting in a failure to provide appropriate respiratory care.
A resident with end stage renal disease and a history of heart transplant did not have complete dialysis communication forms for multiple dialysis sessions, as required by facility policy. Staff and DON confirmed the failure to consistently provide the necessary communication with the dialysis center.
A resident with a history of sexual abuse did not receive appropriate behavioral health services, as their care plan failed to include specific interventions or considerations related to their trauma history, such as the gender of staff providing care. This was identified through review of clinical records, facility policy, and staff interviews.
Two residents with significant mobility and transfer needs did not have comprehensive care plans specifying required assistance levels. As a result, one resident, dependent on total assist for transfers and bed mobility, was rolled out of bed by a single staff member and sustained bilateral leg fractures. Staff confirmed that care plans lacked critical details for both residents.
A resident with a history of anemia and on anticoagulant therapy experienced a fall, after which staff observed ongoing bruising and pain but did not notify the physician as required. Despite critical INR lab results indicating excessive anticoagulation, there was no timely documentation of physician notification or intervention. The resident later suffered a fractured knee and required a blood transfusion due to a critically low hemoglobin level.
A resident with multiple medical conditions who required total assistance for bed mobility was not provided the necessary support, leading to a fall from bed and subsequent bilateral leg fractures. The care plan lacked clear instructions for bed mobility assistance, and staff did not follow existing orders, resulting in delayed recognition and treatment of injuries.
A resident with anemia, renal failure, and osteoarthritis rolled out of bed onto their knees during care and was assisted back to bed by staff using a Hoyer lift. The incident, documented in the resident's progress notes, was not reported to the state field office as an allegation of neglect within the required 24-hour period, as confirmed by the DON.
A resident with multiple medical conditions experienced a fall during care, resulting in ongoing bruising that was documented over several days. Despite these findings, there was no timely physician assessment of the fall or the bruising, and the resident was later hospitalized with severe anemia and elevated INR, requiring a blood transfusion. Facility leadership confirmed the lack of timely physician involvement following the incident.
A resident with severe cognitive impairment and total dependence on staff was sexually abused by her husband, who was observed by staff inappropriately touching her despite prior warnings. The resident was unable to resist or report the abuse due to her condition, and staff confirmed the incident and the resident's distress. Facility policies prohibiting abuse were not effectively enforced, resulting in actual harm and psychosocial distress for the resident.
Staff failed to timely recognize and report suspicions of sexual abuse involving a resident who was nonverbal and unable to advocate for herself. Multiple nurse aides and LPNs observed ongoing suspicious behaviors by the resident's husband, such as torn briefs and interference with medical devices, and communicated their concerns to nursing leadership. However, these suspicions were not formally reported or acted upon until inappropriate touching was directly witnessed by a staff member.
A resident with severe cognitive impairment and multiple medical conditions did not receive necessary services or adequate protection from inappropriate contact by a frequent visitor. Despite repeated staff concerns and reports of the visitor interfering with medical devices and engaging in inappropriate touching, facility leadership failed to implement effective safety measures or restrictions, resulting in ongoing risk to the resident.
The Nursing Home Administrator and DON failed to manage the facility in a way that ensured necessary care and services were provided to prevent sexual abuse, resulting in actual harm to a resident, including psychosocial and physical harm. The facility did not follow professional standards, policies, or resident rights.
The facility failed to provide timely dental services to three residents, resulting in a deficiency. One resident was not seen by a dentist due to consent and prepayment issues, another was removed from the dental list due to preauthorization problems, and a third was not seen because consent was not obtained. Staff interviews confirmed these failures.
A resident at Platinum Ridge Center for Rehab and Healing experienced a significant change in condition, including blood in their colostomy bag, requiring a medication adjustment. The facility failed to notify the resident's family of this change within the required 24-hour period, delaying communication for 36 days. This breach of protocol was confirmed through staff interviews and a complaint from the resident's representative.
A resident with cerebral infarction, high blood pressure, and aphasia had blood detected in their colostomy bag. Despite a physician's order on December 9 to schedule a colonoscopy, the facility failed to make the appointment by January 13. The resident's representative raised a concern, and the DON confirmed the delay.
The facility did not meet the required nurse aide staffing levels on a specific day, failing to provide adequate coverage during both the day and evening shifts. The day shift had insufficient hours of nurse aide coverage for 88 residents, and the evening shift did not meet the required staffing ratio. These issues were identified through a review of staffing documents and staff interviews.
The facility failed to provide the required number of LPNs during an evening shift, with only 17.26 hours of coverage instead of the required 21.70 hours for 84 residents. This deficiency was confirmed by the Nursing Home Administrator.
The facility failed to maintain proper admission documentation for three residents. A resident with moderate cognitive impairment inappropriately signed their own admission packet, while two other residents lacked signed admission packets altogether. This indicates a lapse in the facility's admission procedures and a violation of residents' rights.
The facility failed to label and date food products in the nursing unit pantries, leading to potential cross-contamination. Observations revealed unlabeled and undated items in the 3rd and 2nd floor nursing pantry refrigerators and storage areas. An LPN confirmed this failure, which posed a risk for foodborne illness.
The facility failed to meet the required nurse aide staffing levels over an 18-day period, with shortages during day, evening, and night shifts. The census ranged from 84 to 87 residents, but the number of nurse aides present was consistently below the required ratios. The Nursing Home Administrator confirmed these deficiencies, with no additional higher-level staff available to compensate.
The facility did not meet the required LPN staffing levels during a night shift, with only 3.04 LPNs present for 86 residents, instead of the required 3.44. This deficiency was confirmed by the Nursing Home Administrator.
The facility did not provide the required 3.2 hours of direct resident care per resident in a 24-hour period on ten out of eighteen days. Nursing schedules and census data revealed that the provided nursing care hours per resident per day (PPD) were below the required threshold, with PPDs ranging from 2.91 to 3.19. The Nursing Home Administrator confirmed this deficiency.
The facility failed to maintain accurate narcotic count sheets and document the disposition of narcotics, leading to discrepancies between MAR and narcotics count sheets for three residents. Documentation showed missing signatures on shift count sheets and inconsistencies in narcotic administration and destruction records. These issues were confirmed by the NHA and DON, indicating a failure to manage controlled substances as per regulations.
A resident with medical conditions was improperly transferred by two nurse aides, resulting in pain, bruising, and a fractured rib. The facility failed to maintain accurate Kardexes and care plans for residents' mobility transfer statuses, leading to confusion among staff and creating an Immediate Jeopardy situation for multiple residents.
The facility experienced significant staffing shortages, particularly on weekends, leading to delayed response times to call bells and inadequate resident care. Residents reported waiting long periods for assistance, and staff struggled to provide timely care due to understaffing. Additionally, there was a lack of linen, forcing residents to use towels or bare mattresses. These issues affected the well-being of several residents.
The facility failed to maintain sanitary conditions in the Main Kitchen, as water was observed dripping from air conditioning vents onto carts holding dish lids. Dietary staff retrieved items from these carts for resident trays, potentially compromising food safety. The Food Service Director confirmed the unsanitary conditions.
The NHA and DON failed to manage the facility effectively, leading to improper resident transfers. This resulted in a resident sustaining bruising and a fractured rib due to inaccurate Kardexes and care plans. The oversight placed the facility in immediate jeopardy.
The facility consistently failed to meet state-mandated staffing requirements for nurse aides and LPNs across multiple surveys from September 2023 to July 2024. The deficiencies included not providing the required number of nurse aides per residents during various shifts and failing to meet the required number of LPNs per residents during the day, evening, and night shifts.
The facility failed to communicate necessary resident information during hospital transfers for five residents, including care plan goals and advanced directives. This deficiency was confirmed by staff interviews, revealing a lack of documentation in the medical records.
The facility failed to notify the Office of the Long-Term Care Ombudsman Division about the hospital transfers of three residents, as required by their policy. These residents, with various medical conditions, were transferred without documented evidence of notification to the Ombudsman, a deficiency confirmed by the Nursing Home Administrator.
The facility failed to notify residents or their representatives in writing about the bed-hold policy during hospital transfers, affecting five residents with various medical conditions. Interviews revealed that the facility did not document the communication of this policy, which was confirmed by the Nursing Home Administrator as a violation of resident rights.
The facility failed to provide beautician services for several residents, as required by their ADLs policy. Despite the facility's admission packet indicating the availability of a styling salon and hairdresser, interviews and observations revealed that the facility has been without a beautician for several months. Residents expressed dissatisfaction with unmet grooming needs, and staff confirmed the absence of a beautician, which the Nursing Home Administrator acknowledged.
The facility failed to conduct ongoing assessments for bedrail usage for four residents, despite policy requirements. Residents with conditions such as dementia, high blood pressure, and Parkinson's disease had side rails on their beds without documented ongoing assessments. Observations confirmed the presence of side rails, and interviews with staff verified the deficiency.
The facility failed to provide appropriate care for two residents receiving medications via feeding tube. One resident with metabolic encephalopathy and dysphagia had orders to flush the G-Tube with water and mix medications, which was against facility policy. Another resident with quadriplegia and dysphagia had similar orders. The DON confirmed the facility's failure to follow proper medication administration protocols.
The facility failed to provide the required 12 hours of in-service education for five nurse aides, as mandated by their policy and the Pennsylvania Code. Each of the nurse aides received only between 9.5 to 10 hours of training within their employment year. This deficiency was confirmed by the DON during an interview.
The facility did not provide required behavioral health training to five nurse aides, as mandated by a facility assessment. Despite a policy requiring regular in-service training, records showed no documentation of such training for these staff members. The DON confirmed this deficiency.
A facility failed to accommodate a visually impaired resident's needs. The resident, with anxiety, depression, and muscle weakness, required assistance with eating due to macular degeneration. Staff often left meal trays without describing the contents, confirmed by an LPN who assisted the resident without describing the tray's items.
A resident with quadriplegia, anxiety, and depression did not receive prescribed wound care for a pressure injury on the left index finger. The dressing was not changed as ordered, and staff interviews confirmed the neglect. The facility failed to provide an environment free from neglect, as required by policy and state regulations.
Failure to Obtain Physician Orders for Resident Discharges
Penalty
Summary
The deficiency involves the facility’s failure to obtain required physician discharge orders for two residents prior to their discharge. For one resident admitted with a thoracic vertebra fracture, urinary tract infection, and muscle weakness, review of the admission MDS dated 12/11/25 showed these diagnoses remained current, and facility documents showed the resident was discharged on a later date; however, the most recent physician orders contained no order authorizing discharge. For a second resident admitted with atrial fibrillation, diabetes mellitus, and protein-calorie malnutrition, review of the 5-day MDS dated 3/2/26 indicated the diagnoses remained current, and facility documents showed this resident was also discharged on a later date, again without any corresponding physician discharge order in the clinical record. During an interview on 3/18/26 at 1:45 p.m., the Director of Nursing confirmed that there were no physician orders for these discharges as required under 28 Pa. Code 211.12(d)(1)(5) for nursing services. These findings were based on review of clinical records, MDS assessments, facility-provided discharge documentation, and staff interview, which together demonstrated that the facility discharged two of three reviewed residents without documented physician authorization for discharge.
Failure to Communicate Transfer Information and Provide Bed-Hold Notices
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to receiving health care providers during facility-initiated transfers for three of four sampled residents and failed to provide required written bed-hold policy notifications at the time of hospital transfer. Facility policies dated 5/19/25 required that, upon transfer or discharge, details be documented in the medical record and appropriate information be communicated to the receiving provider, and that residents or their representatives receive written information about bed-hold policies both in advance (at admission) and at the time of transfer. For each of the three residents, clinical record review showed no documented evidence that specific information such as care plan goals, advance directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident’s specific needs was communicated to the hospital. Resident 1, with diagnoses including atherosclerotic heart disease, COPD, and dysphagia, was transferred to the hospital and remained there, but the record lacked documentation of the required transfer information and written bed-hold policy notice at the time of transfer. Resident 2, with high blood pressure, depression, and muscle weakness, was transferred to and returned from the hospital the same day, yet the record similarly lacked documentation of communicated care plan goals, advance directives, ongoing care instructions, representative information, and written bed-hold policy notice. Resident 3, with atrial fibrillation, high blood pressure, and cerebral infarction, was transferred to the hospital and returned the following day, and the record again showed no documented evidence of the required transfer communication or written bed-hold policy notice at the time of transfer. In an interview, the Director of Nursing confirmed these failures for the three residents, in violation of 28 Pa. Code: 201.29 (a)(c.3)(2) regarding resident rights.
Failure to Address Resident Council Concerns on Call Bells and Medication Timeliness
Penalty
Summary
The facility failed to honor residents' rights to have their views considered and to receive prompt action on concerns raised through the Resident Council over a three-month period. The facility’s Resident Council policy dated 5/19/25 states that the council is intended to provide a forum for discussion of concerns and suggestions for improvement, and that all feedback and requests from the council are to be addressed in writing to the council. However, review of Resident Council meeting minutes for December 2025, January 2026, and February 2026 showed that residents repeatedly raised systemic concerns about care and services, but the “follow up” sections of the forms were left blank, with no documented response or action by the facility. In December 2025, the Resident Council minutes documented ongoing concerns about call bells not being answered timely, with residents reporting that call bell wait times were too long, agency staff were turning off call bells without entering rooms to provide assistance, and agency staff were providing poor care on weekends, including not answering call bells and using their phones instead of giving care. In January 2026, the minutes again documented old/unfinished business regarding call bells not being answered timely, with no further information or follow-up recorded. In February 2026, residents reported systemic concerns about medications not being delivered timely, and again the follow-up section was blank. During an interview on 2/23/26, the Nursing Home Administrator confirmed that the facility failed to consider the views of residents and act promptly on concerns and recommendations regarding resident care and life in the facility for all three months reviewed.
Failure to Obtain and Communicate Ordered Laboratory Results
Penalty
Summary
Surveyors found that the facility failed to obtain and document laboratory results as ordered by physicians and failed to document notification of those results to the ordering practitioners and resident representatives for two of three residents reviewed. For one resident with diagnoses including stroke, hemiplegia, and urinary tract infection, a physician order dated 2/18/26 directed staff to obtain a CMP in the morning for monitoring. The clinical record contained no documentation that the CMP results were obtained, and there was no evidence that the physician or the resident representative were notified of any results. An LPN stated that the lab results were not in the clinical record and that she did not have access to the computer system where lab results are stored, indicating only the supervisor had such access. For another resident with diagnoses including anemia, heart failure, and hypertension, a physician order dated 2/11/26 directed staff to obtain a one-time BMP on 2/12/26. The clinical record contained no documentation that the BMP results were obtained, and there was no evidence that the physician or the resident representative were notified of the results. The resident’s representative reported that blood work had been done a few weeks prior and that, despite multiple inquiries, no one could provide the lab results. The same LPN again indicated that lab results were not in the clinical record and that she lacked access to the lab computer system. The DON confirmed that the facility failed to obtain laboratory results as ordered and failed to provide evidence of notification to the physician or resident representative for these two residents, in violation of facility policies on laboratory services/reporting and change in condition/status, and 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
Failure to Employ a Qualified Food Service Director
Penalty
Summary
The facility failed to employ a qualified Food Service Director (FSD) with appropriate competencies and credentials to manage the daily operations of the Dietary Department for four of twelve months, from October 20, 2025, through January 8, 2026. During an interview on January 8, 2026, at 11:00 a.m., the Nursing Home Administrator stated that Employee E1 had been employed as the FSD since October 20, 2025, and acknowledged that she was not a Certified Dietary Manager. In a separate interview at 11:10 a.m., FSD Employee E1 reported that the Registered Dietitian typically comes to the facility once per week. At 11:30 a.m. the same day, the Nursing Home Administrator confirmed that the facility could not provide documented evidence that FSD Employee E1 met the qualifications required for the Food Service Director position, resulting in noncompliance with Pa Code: 201.18(e)(6) regarding management requirements. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency in the report.
Failure to Provide Food Products Based on Resident Preferences
Penalty
Summary
The facility failed to provide food products based on resident preferences, specifically by not supplying coffee to approximately 38 out of 76 residents. Multiple residents reported not receiving coffee with their breakfast, and staff interviews confirmed that coffee was unavailable due to supply issues. The Certified Dietary Manager stated that coffee orders required third-party approval, which delayed delivery, and that there was no coffee in the building on the day in question. Staff also indicated that running out of coffee was a recurring issue, and purchasing coffee from a store depended on the availability of petty cash. Observations during meal service revealed residents requesting coffee and being informed by staff that none was available. The Nursing Home Administrator confirmed the failure to provide coffee as a food product based on resident preferences. The deficiency was documented under Pa Code: 201.14(a) Responsibility of licensee.
Failure to Label and Date Food Products in Main Kitchen
Penalty
Summary
The facility failed to comply with its policy regarding the labeling and dating of food products stored in the Main Kitchen. During an observation, surveyors found a bag of frozen vegetables in the walk-in freezer without a receive date, an opened bag of chopped onions in the reach-in refrigerator with no label or date, and four bags of gelatin mix in the dry storage room with no receive date. The Dietary Supervisor confirmed that these food items were not properly labeled or dated as required by facility policy.
Failure to Individualize Nutritional Care Plans and Communicate Fluid Restrictions
Penalty
Summary
The facility failed to individualize care plans to address specific nutritional concerns for two residents and did not ensure staff awareness of fluid restriction orders for another resident. For one resident with Alzheimer's disease, osteoporosis, and swallowing difficulties, the care plan did not include resident-specific interventions for the prescribed pureed diet, thickened liquids, and nutritional supplements, despite physician orders for these items. The care plan only listed general interventions such as providing the ordered diet and supplements, without detailing how these should be implemented for the resident's unique needs. Another resident with cancer, malnutrition, and depression experienced significant weight loss and received more than half of their calories through tube feeding. The care plan for this resident failed to document the ongoing weight loss, the resident's tendency to pull out or refuse the feeding tube, or specific interventions related to the prescribed tube feeding formula. Staff interviews confirmed that these individualized concerns and interventions were not reflected in the care plan. Additionally, a resident with high blood pressure, end stage renal disease, and a history of heart transplant had a physician order for a fluid restriction of 1800 mL per 24 hours. However, the order did not specify how the fluid allowance should be divided between nursing and dietary departments, and direct care staff were not made aware of the fluid restriction details. Facility staff acknowledged that the lack of clear breakdown and communication failed to ensure that acceptable nutritional parameters were maintained for this resident.
Failure to Complete and Act on Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed and documented monthly medication regimen reviews (MRR) for several residents, as required by facility policy. For one resident with Alzheimer’s disease, hypertension, and diabetes, the MRR for one month only listed current medications without any recommendations or evidence that the medications were reviewed. The Director of Nursing (DON) confirmed that monthly medication reviews were not completed as required. Another resident with high blood pressure, dementia, and chronic pain had an MRR that identified an antipsychotic medication order without an appropriate diagnosis, but there was no documentation that the physician addressed or signed off on the pharmacist’s recommendation. The DON confirmed that irregularities reported by pharmacy were not acted upon in a timely manner for this resident. Additionally, for a resident with anxiety, depression, and bipolar disorder, there was no documentation that MRRs were completed by the consultant pharmacist for two consecutive months. The DON confirmed the absence of these reviews. These findings indicate that the facility did not consistently provide documentation of completed MRRs or ensure timely follow-up on pharmacy-identified irregularities for multiple residents.
Failure to Maintain Resident Dignity During Wound Care
Penalty
Summary
A deficiency was identified when a registered nurse (RN) provided wound care to a resident diagnosed with Alzheimer's disease, anxiety, and depression, who had developed a pressure ulcer on the right heel. During the wound care observation, the RN wrote on the dressing after it had already been placed on the resident's heel. The RN later confirmed that this action failed to maintain the resident's dignity, as required by facility policy and resident rights outlined in the admission agreement. The incident was documented as a failure to provide care in a manner that maintains resident dignity, in violation of state regulations.
Failure to Ensure Medication Regimens Free from Unnecessary Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents' medication regimens were free from potentially unnecessary psychotropic medications for two residents. For one resident with diagnoses including high blood pressure, dementia, and chronic pain, the consultant pharmacist identified that an order for Seroquel, an antipsychotic medication, lacked an appropriate diagnosis and requested physician review. However, there was no documentation that the physician addressed or signed off on this recommendation, as required by facility policy. For another resident with anxiety, depression, and Bipolar Disorder, the clinical record showed multiple psychotropic medications prescribed, including Diazepam, Lorazepam, Sertraline, and Trazodone. The facility was unable to provide documentation that the required monthly medication regimen reviews (MRRs) were completed by the consultant pharmacist for two specific months. The DON confirmed the absence of this documentation and acknowledged the failure to ensure the medication regimens were free from potentially unnecessary psychotropic medications.
Failure to Obtain Physician Order for Enteral Feeding After Hospital Return
Penalty
Summary
The facility failed to ensure that a resident with an enteral feeding tube received appropriate treatment and services, as required. Clinical record review showed that the resident, who had diagnoses of cancer, malnutrition, and depression, was admitted with a physician's order for enteral feeding, which was discontinued prior to a hospital transfer. Upon the resident's return from the hospital, there was no physician order for enteral feeding from the date of return through several days, despite documentation that the feeding was being administered. This lapse was confirmed by the Director of Nursing, who acknowledged the absence of a physician's order for the enteral feeding during this period.
Failure to Properly Store Nebulizer Equipment for Two Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents who required nebulizer treatments. According to facility policy, nebulizer equipment must be completely dry and stored in a plastic bag when not in use. However, during observations, both residents' nebulizer machines and mouthpieces were found on their bedside tables, not stored in bags as required. This was confirmed by a Licensed Practical Nurse, who acknowledged that the equipment was not properly stored when not in use. Resident R30 had diagnoses including high blood pressure, atrial fibrillation, and asthma, and had a physician's order for albuterol sulfate nebulization as needed for shortness of breath. Resident R38 had diagnoses of high blood pressure, anxiety, and hypothyroidism, with a physician's order for ipratropium-albuterol inhalation solution as needed for wheezing. Despite these orders and the residents' medical needs, the facility did not adhere to its own policy for safe and appropriate respiratory care, as evidenced by the improper storage of nebulizer equipment.
Failure to Ensure Consistent Communication with Dialysis Center
Penalty
Summary
The facility failed to provide consistent and complete communication with the dialysis center for a resident who required hemodialysis services. According to facility policy, ongoing communication and collaboration with the dialysis facility is required, including the use of a dialysis communication form to be sent with the resident and reviewed upon return for each dialysis session. Review of the clinical record for a resident with diagnoses of high blood pressure, end stage renal disease, and heart transplant status revealed that the required communication forms were incomplete for eight separate dialysis dates within a specified period. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that the communication forms were not consistently completed as required by policy. This deficiency was identified through review of clinical records, facility policy, and staff interviews, and was cited under relevant state codes for responsibility of licensee, resident care policies, and nursing services.
Failure to Provide Behavioral Health Services for Resident with Trauma History
Penalty
Summary
The facility failed to provide necessary behavioral health services for a resident with a documented history of sexual abuse. Review of the resident's care plan showed that, although it acknowledged the history of sexual abuse and aimed to minimize traumatic symptoms, it did not include specific behavioral health interventions or considerations, such as the gender of staff providing care, that would address the resident's trauma history. The trauma assessment for the resident indicated no identified triggers or severity, despite the hospital record noting an assessment for possible sexual assault. Facility policy on trauma-informed and culturally competent care requires individualized care plans that incorporate trauma history and preferences, including those related to personal care and staff assignments. However, the resident's care plan lacked these individualized behavioral health supports. This deficiency was confirmed through review of clinical records, facility policy, and staff interviews, demonstrating a failure to ensure the resident received appropriate behavioral health services to maintain their highest practicable well-being.
Failure to Develop Comprehensive Care Plans Resulting in Resident Harm
Penalty
Summary
The facility failed to develop and implement comprehensive care plans to address the specific care needs of two residents, resulting in harm to one resident. For one resident with diagnoses including anemia, renal failure, and osteoarthritis, physician orders and MDS assessments indicated a need for total assist of two persons via Hoyer lift for transfers and dependence on staff for bed mobility. However, the resident's care plan did not specify the required level of assistance for bed mobility or transfers. During care, the resident rolled out of bed while only one staff member was present, resulting in bilateral leg fractures and subsequent hospitalization. Staff interviews confirmed that the care plan lacked necessary details regarding bed mobility assistance at the time of the incident. Another resident with muscle weakness, ataxic gait, and obesity also had physician orders requiring total assist of two via Hoyer lift for transfers, but the clinical record did not include a care plan for transfer status or bed mobility. Staff interviews confirmed the absence of a care plan addressing these needs. The deficiency was confirmed by the Nursing Home Administrator and Director of Nursing, who acknowledged the failure to develop comprehensive care plans for both residents.
Failure to Provide Timely Care and Physician Notification After Fall and Critical Lab Results
Penalty
Summary
The facility failed to provide appropriate care and treatment for a resident with a history of anemia, renal failure, and osteoarthritis, who was also at risk for bleeding due to anticoagulant (Warfarin) use. After the resident experienced a fall, staff observed bruising and pain, but there was no evidence that the physician was notified of these symptoms as required by the care plan and facility policy. The resident continued to exhibit bruising and pain over several days, and documentation failed to show timely physician notification or intervention regarding these ongoing symptoms of bleeding. Laboratory monitoring of the resident's INR, which is critical for patients on Warfarin, revealed dangerously high values on multiple occasions. Despite these critical lab results, the clinical record did not include evidence of timely notification to the physician or documentation of interventions in response to the abnormal findings. The resident's Warfarin was not discontinued until after a critical INR was reported, and there was a lack of documentation regarding the physician's response to the critical lab values and the resident's ongoing symptoms. Ultimately, the resident developed a significant bruise and pain in the left knee, which was later found to be fractured. The resident was transferred to the hospital, where laboratory results showed a critically low hemoglobin level and a supratherapeutic INR, necessitating a blood transfusion. The facility's failure to follow its own policies for monitoring, notification, and intervention after a fall and in response to abnormal lab results led to harm for the resident.
Failure to Provide Required Assistance for Bed Mobility Resulting in Resident Harm
Penalty
Summary
The facility failed to ensure that appropriate assistance for bed mobility was provided to a resident, resulting in the resident rolling out of bed and sustaining bilateral leg fractures. The resident had significant medical conditions, including anemia, renal failure, osteoarthritis, and was non-ambulatory and bed-bound at baseline. Physician orders and the Minimum Data Set indicated the resident required total assistance of two persons for transfers via Hoyer lift and was dependent for bed mobility. However, the resident's care plan did not specify the required level of assistance for bed mobility or transfers, and staff did not consistently follow the documented requirements. On the day of the incident, a nurse aide was providing care to the resident alone and attempted to reposition the resident without the required second staff member. During this process, the resident rolled out of bed onto their knees while holding onto the bed rail. The resident was subsequently assisted back to bed by three staff members using a Hoyer lift. Following the fall, the resident developed extensive bruising and later complained of pain, which was initially managed with Tylenol. Despite ongoing documentation of bruising and pain, there was a lack of timely physician notification and assessment regarding the resident's injuries. Over the following weeks, the resident continued to exhibit bruising and pain, and eventually was found to have sustained bilateral leg fractures, requiring hospitalization and a blood transfusion due to a critically low hemoglobin level. Interviews with staff revealed confusion and inconsistency regarding the documentation and implementation of bed mobility and transfer assistance requirements. The facility's investigation confirmed that the appropriate assistance was not provided, and the care plan did not adequately address the resident's needs for bed mobility, directly contributing to the resident's injuries.
Failure to Timely Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect within 24 hours to the local state field office for one resident. The resident, who had a history of anemia, renal failure, and osteoarthritis, was involved in an incident where they rolled out of bed onto their knees while being assisted by staff. The event was documented in the resident's progress notes, and the resident was assisted back to bed by three staff members using a Hoyer lift, with no redness observed on the knees at the time. However, a review of documentation submitted to the state field office showed that this incident was not reported as required. The Director of Nursing confirmed during an interview that the facility did not report the allegation of neglect within the mandated timeframe.
Failure to Ensure Timely Physician Assessment After Resident Fall
Penalty
Summary
A deficiency was identified when the facility failed to ensure a timely physician assessment was completed after a resident experienced a fall. The resident, who had a history of anemia, renal failure, and osteoarthritis, was admitted and later readmitted to the facility. On the evening of the fall, an LPN was called to the resident's room after the resident rolled out of bed during care. Subsequent clinical records documented ongoing bruising to the resident's right shin over several days following the incident. Despite these findings, there was no evidence in the clinical record that a physician assessed the resident's fall or the resulting bruising in a timely manner. The resident was later admitted to the hospital with significant medical concerns, including a critically low hemoglobin level and supratherapeutic INR, requiring a blood transfusion. A late entry progress note by the Medical Director, entered more than a month after the fall, did not address the fall or the bruising. Facility leadership confirmed that a timely physician assessment was not completed after the fall.
Failure to Protect Resident from Sexual Abuse by Family Member
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment and multiple medical conditions, including dementia, multiple sclerosis, anxiety disorder, and neurogenic bladder, from sexual abuse by her husband. The resident was completely dependent on staff for all activities of daily living and was unable to provide a description of the incident due to her cognitive status. Staff observed the resident's husband inappropriately touching her genital area, specifically with his gloved fingers inside her vagina, while the resident appeared teary-eyed and unable to resist or stop the abuse. Prior to the incident, staff had frequently heard the husband being told by nursing staff not to touch his wife inappropriately, to which he responded that he could touch her if he wanted because she was his wife. On the day of the incident, a staff member witnessed the abuse and immediately reported it to nursing staff, who then found the husband at the bedside with a glove on and the resident's brief ripped, containing an unusual amount of pubic hair. The resident confirmed through nodding and verbal responses that her husband had touched her inappropriately and that she did not want him to continue visiting. The facility's policies clearly defined abuse, including sexual abuse, and emphasized the right of residents to be free from such mistreatment. Despite these policies, the facility did not prevent the abuse or ensure the resident's safety, resulting in actual harm, psychosocial distress, and physical discomfort for the resident. The deficiency was confirmed by both the Nursing Home Administrator and the Director of Nursing.
Failure to Timely Recognize and Report Suspected Sexual Abuse
Penalty
Summary
The facility failed to recognize and report timely suspicions of sexual abuse for a resident, despite multiple staff members having ongoing concerns about inappropriate behavior by the resident's husband. Staff interviews revealed that nurse aides and LPNs had observed suspicious behaviors over an extended period, such as the resident's briefs being repeatedly torn, the husband wearing a glove on one hand, and the resident's catheter and G-tube being disturbed after his visits. Staff frequently had to instruct the husband to stop touching the resident and to seek assistance from staff if the resident needed care. Despite these repeated observations and suspicions, no formal report was made until a staff member directly witnessed inappropriate touching. The resident in question was nonverbal and unable to advocate for herself, making her particularly vulnerable. Staff described feeling uncomfortable with the husband's actions, noting that he often asked to see the resident's rectum and was observed lingering near her genital area. Staff communicated their concerns to nursing leadership, including the DON and administrators, but the behavior was dismissed as normal or attributed to the husband's affection. The lack of direct evidence led to inaction, and the suspicions were not escalated or formally reported as potential abuse until the incident was witnessed firsthand. Facility policy and federal regulations require the identification, assessment, and timely reporting of all possible incidents of abuse, including sexual abuse. In this case, the facility's failure to act on staff suspicions and observations resulted in a delay in recognizing and reporting the abuse. The deficiency was confirmed by the facility's own leadership, who acknowledged that suspicions were not reported until the abuse was directly observed.
Failure to Ensure Safety and Provide Necessary Services for Resident with Dementia
Penalty
Summary
The facility failed to provide necessary services and appropriate treatment for a resident diagnosed with dementia, resulting in a lack of safety measures and inadequate protection of the resident's rights. The resident, who had severe cognitive impairment as indicated by a low BIMS score and diagnoses including dementia, multiple sclerosis, anxiety disorder, and neurogenic bladder, was admitted to the facility and had a care plan that included monitoring cognitive function and providing psychosocial support. Despite these documented needs, the facility did not ensure the resident's safety or address ongoing concerns related to the resident's husband’s behavior during visits. Multiple progress notes and staff interviews revealed that the resident's husband frequently visited, interfered with medical devices such as the G-tube and Foley catheter, and repeatedly engaged in inappropriate touching of the resident's genital area. Staff members reported longstanding suspicions and discomfort regarding the husband's actions, including torn briefs, requests to see the resident's rectum, and the use of gloves during visits. These concerns were communicated to nursing leadership and administration over an extended period, but no effective interventions were implemented to prevent or address the inappropriate behavior until a direct incident was witnessed by an employee. The facility's failure to document and act upon these repeated concerns, as well as to implement safety restrictions or protections as outlined in their own policies, resulted in the resident being subjected to ongoing inappropriate contact and a lack of necessary services to ensure her safety. The deficiency was confirmed by the Nursing Home Administrator and Director of Nursing, who acknowledged that the facility did not provide the required services or protections for the resident with dementia.
Failure to Prevent Sexual Abuse Due to Ineffective Facility Management
Penalty
Summary
The facility's Nursing Home Administrator and Director of Nursing did not effectively manage the facility to ensure that necessary care and services were provided to prevent sexual abuse. Review of job descriptions, clinical records, and staff interviews revealed that the facility failed to protect Resident R1 from sexual abuse, resulting in actual harm, including psychosocial and/or physical harm and physical discomfort. The facility did not provide care and treatment in accordance with professional standards of practice, facility policies, and resident rights, as required by federal and state regulations.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide necessary dental services to meet the needs of three residents, resulting in a deficiency. Resident CR1 was admitted with a physician's order for dental evaluation and treatment, but despite being placed on a dental list after a missing tooth was reported, there was no evidence of a dental visit from August 2024 to January 2025. The facility's documents indicated a lack of consent and prepayment issues as reasons for the delay. Resident R2, admitted with a history of stroke and muscle weakness, had a dental evaluation and a denture impression taken in September 2024. However, due to preauthorization issues, the resident was removed from the dental list, and there was no evidence of a follow-up dental visit in January 2025. The resident expressed frustration over the delay in receiving dentures. Resident R3, with a history of high blood pressure and cancer, was also not seen by a dentist due to the facility's failure to obtain consent for treatment. Despite being scheduled for a dental visit, the resident was removed from the list. Interviews with staff confirmed the facility's failure to provide timely dental services to these residents, as required by regulations.
Plan Of Correction
There were no ill effects noted to patients CR1, R2 and R3. CR1 has discharged out of facility, and therefore was unable to rectify. All consents were obtained for R2 and R3 and called in to Facility Dental Services. R2, R3, and family was notified of consents and dental status. Dentist has verified consent and list for upcoming appointments with resident R2 and R3. Nursing notes for the last week have been reviewed for any indications that any dental services are necessary. Dental lists continue to be checked daily for any new dental issues. If urgent situation arises, facility will send to outside dentist. Nursing home administrator (NHA) educated Medical Records clerk and Appointment Scheduler on facility protocol of Dental Services. NHA will educate all nursing Staff on documentation of needs of dental services and dental lists that are to be utilized at each nursing station in a timely manner. Audits to be completed by Director of Nursing or Designee for 3 times a week times 2 weeks, 2 times a week times 2 weeks, and 1 time a week times 2 weeks. This plan of correction will be monitored at the monthly Quality Assurance meeting until substantial compliance has been met.
Failure to Notify Family of Resident's Condition Change
Penalty
Summary
Platinum Ridge Center for Rehab and Healing was found to be non-compliant with federal and state regulations regarding the notification of changes in a resident's condition. The facility failed to promptly inform the family of a significant change in the medical condition of a resident, identified as Resident CR1. The resident, who had a history of cerebral infarction, ileostomy, and aphasia, experienced a change in condition when blood was noted in their colostomy bag. This incident required a change in medication, specifically a reduction in the dosage of Eliquis, a blood thinner. The facility's policy mandates that the physician and resident representative be notified within 24 hours of any significant change in a resident's condition. However, in this case, the resident's responsible party was not informed of the change in condition or the medication adjustment until 36 days after the event. This delay in communication was confirmed through a review of clinical records and staff interviews, including an admission by the Director of Nursing that the notification was not timely. The deficiency was further highlighted by a concern raised by the resident's representative, who reported not receiving updates about the resident's condition or medication changes. Interviews with staff, including an LPN and the Director of Nursing, corroborated the failure to adhere to the notification policy. This lapse in communication violated the resident's rights and the facility's responsibility to keep family members informed of significant changes in the resident's health status.
Plan Of Correction
There were no adverse effects or harm to resident CR1. CR1 has been discharged from the facility. The Director of Nursing (DON) / Designee will educate the nursing staff on notifying the resident, resident's physician, and resident representative when there is an injury, decline, transfer, discharge, room change, or medication change. DON / designee will perform audits daily x2 weeks, 3x a week for 1 week, and then 2x a week for one week. To ensure that notification of injury, decline, transfer, discharge, room change, and medication changes are being completed. This plan of correction will be monitored in daily clinical meetings and monthly Quality Assurance Meetings until facility compliance is met.
Failure to Timely Schedule Colonoscopy for Resident
Penalty
Summary
The facility failed to schedule an appointment for outside services in a timely manner for a resident, identified as CR1, who was admitted with diagnoses including cerebral infarction, high blood pressure, and aphasia. On December 9, 2024, a nurse aide reported blood in the resident's colostomy bag to an LPN, who confirmed the presence of blood and notified the RN supervisor. The RN tested the stool, which was positive for blood, and the physician was informed, resulting in a new order to schedule a colonoscopy. However, a review of the resident's clinical record from December 10, 2024, through January 13, 2025, showed no attempt was made to schedule the colonoscopy. A concern was raised by the resident's representative on January 16, 2025, about the failure to schedule the procedure. The Director of Nursing confirmed during an interview on January 30, 2025, that the facility did not schedule the appointment in a timely manner.
Plan Of Correction
Appointment was not able to be rectified with patient CR1 as resident was discharged from the facility. Order was placed for colonoscopy for facility to facility transfer that was sent with patient. All orders for the previous week have been addressed for any appointments that need to be made and done so in a timely manner. Nursing home administrator to educates Medical Records Clerk and Appointment Scheduler on appointment orders and having appointments made within a timely manner. After appointments are made, the resident and responsible party will be notified of the appointments. Audits will be performed on appointment orders by Director of Nursing or Designee 3 times a week x3 weeks, 2 times a week x2 weeks, and 1 time a week x2 weeks. This plan of correction will be monitored at the Monthly Quality Assurance meeting until substantial compliance has been met.
Staffing Deficiency in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides on both the day and evening shifts on January 20, 2025. Specifically, during the day shift, the facility had a census of 88 residents but provided only 64.06 hours of nurse aide coverage instead of the required 66.00 hours. Similarly, on the evening shift, the facility did not meet the required staffing ratio of one nurse aide per 11 residents. These deficiencies were identified through a review of staffing documents and staff interviews conducted by the surveyors.
Plan Of Correction
There were no adverse effects to the residents of our facility as a result of the decreased nurse aide ratio on 1/20/25. The Director of Nursing, Human Resources, and the Schedule will be re-educated on new July 1 nurse aide to resident ratios by the Nursing Home Administrator or designee. To ensure sufficient nursing aide staffing ratios to comply with state laws, staffing meetings will be held 3 days a week to review staffing and the projected nursing assistant staff ratios for the current day, as well as the upcoming week. If projected staffing levels are below the required minimum staffing ratios, then the facility will reach out to current staff and to the staffing agencies to enlist staff to meet the minimum staffing and ratio requirement. Facility will continue to recruit CNAs through all platforms and utilize bonuses and outside staffing agencies. Audits of nurse aide ratios will be completed weekly x4 by the NHA/designee to ensure nurse aide ratios are met. Results of the audits will be reported to our QAPI committee monthly for review and recommendations.
Staffing Deficiency in LPN Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nursing assistants and licensed practical nurses (LPNs) on specific shifts. On 1/17/25, during the evening shift, the facility did not provide the minimum required number of LPNs, with only 17.26 actual hours of LPN coverage against the required 21.70 hours for a census of 84 residents. This deficiency was confirmed by the Nursing Home Administrator during an interview on 1/24/25. Additionally, the facility did not provide the necessary nursing assistants on certain shifts, as confirmed by the Nursing Home Administrator, although specific details of these shifts were not provided in the report.
Plan Of Correction
There were no effects to the residents of our facility as a result of decreased licensed nurse staffing ratios on 1/17/25. The Director of Nursing, Human Resources, and the Scheduler will be re-educated on the New July 1 licensed nurse to resident ratios by the Nursing Home Administrator or Designee. Staffing meetings will be held 3 days a week to review the licensed nursing staff ratios for the previous and current day, as well as the upcoming week to ensure appropriate staffing levels. If projected staffing levels are below the state mandated ratios, then the facility will reach out to current staff and to the staffing agencies to enlist staff to meet the minimum requirement. The facility will continue to recruit nursing staff through all platforms as well as utilize bonus structures and outside agencies. Audits of licensed nursing staff will be completed weekly x4 by the NHA/Designee to ensure licensed staff ratios meet the state minimums. Results of the audits will be reported to our QAPI committee monthly for review and recommendations.
Failure to Maintain Proper Admission Documentation
Penalty
Summary
The facility failed to maintain proper admission documentation for three out of seven residents reviewed. Resident R1, who was admitted with a BIMS score indicating moderate cognitive impairment, was found to have signed their own admission packet, which is inappropriate given their cognitive status. This indicates a lapse in ensuring that residents with cognitive impairments are provided with the necessary support during the admission process. Additionally, the facility did not have signed admission packets for Residents R2 and R3. Resident R2 was admitted with diagnoses including encephalopathy, chronic kidney disease, and anemia, while Resident R3 was admitted with multiple rib fractures, a urinary tract infection, and lack of coordination. The absence of signed admission documentation for these residents suggests a failure in the facility's admission procedures, which is a violation of the residents' rights and the facility's admission policy.
Plan Of Correction
Residents R1, R2, R3 admission paperwork has been corrected. A whole house audit of correct admission paperwork will be completed for all residents to ensure that patients with a BIMS of 13 or higher or family have reviewed and signed all proper paperwork. Education with the Admission Director and Concierge on facility and state regulation of admission paperwork will be performed to ensure all paperwork is done upon admission. BIMS will be checked prior to the patient signing. Admissions paperwork will be signed by residents with a BIMS of 13-15, which indicates the patient is cognitively intact. Audits will be completed by Admissions or designee 3 times a week for 2 weeks, 2 times a week for 2 weeks, and 1 time a week for 2 weeks. This plan of correction will be monitored at the monthly Quality Assurance meeting until substantial compliance has been met.
Failure to Label and Date Food Products in Nursing Pantries
Penalty
Summary
The facility failed to properly label and date food products in the nursing unit pantries, which created the potential for cross-contamination. During an observation of the 3rd floor nursing pantry refrigerator, several items were found without labels or dates, including a milkshake, cottage cheese with fruit, a Celsius drink, an acai bowl in the freezer, a frozen sandwich, and pumpkin cheesecake ice cream. Additionally, the 3rd floor nursing pantry storage contained two bowls of raisin bran and a box of donuts without labels or dates. On the 2nd floor, a container of ramen and a square package of ramen were also found without labels or dates. During an interview, an LPN confirmed that the facility's failure to properly label and date food products created the potential for foodborne illness. This deficiency was noted under the regulations 28 Pa. Code: 201.18(b)(1) Management, 28 Pa. Code: 211.6(c) Dietary services, and 28 Pa. Code: 201.14(a) Responsibility of license.
Plan Of Correction
1st, 2nd, and 3rd floor nursing kitchen pantries were cleaned and all food items without dates have been removed. All new food items and resident snacks will have proper date and will be discarded after 3 days per protocol. Education to Dietary Director and dietary employees on labeling and dating all food/drink items that are distributed from kitchen. Education also provided to nursing staff that all non-patient related items are not permitted in patient pantries. Audits to be performed by Director of Nursing or Designee 3 times a week x2 weeks, 2 times a week x2 weeks, 1 time a week x2 weeks to ensure all pantries are clean, organized, and proper dates are used. This plan of correction will be monitored at the monthly Quality Assurance meeting until substantial compliance has been met.
Nurse Aide Staffing Deficiency
Penalty
Summary
The facility failed to meet the required nurse aide staffing levels as per the regulation effective July 1, 2024. Specifically, the facility did not provide the minimum required number of nurse aides per resident during various shifts over an 18-day period. During the day shift, the facility was short of the required nurse aide staffing on eleven days, with the census ranging from 85 to 87 residents, but the number of nurse aides present was consistently below the required ratio of one nurse aide per 10 residents. Similarly, during the evening shift, the facility failed to meet the required staffing levels on eleven days, with the census ranging from 84 to 87 residents, but the number of nurse aides present was below the required ratio of one nurse aide per 11 residents. Additionally, the facility did not meet the required staffing levels during the night shift on three days, with the census ranging from 85 to 87 residents, but the number of nurse aides present was below the required ratio of one nurse aide per 15 residents. The Nursing Home Administrator confirmed these deficiencies during an interview, acknowledging the failure to provide the minimum required nurse aide staffing levels across the different shifts. There was no indication of additional higher-level staff being available to compensate for these deficiencies.
Plan Of Correction
There were no adverse effects to the residents of our facility as a result of the decreased nurse aide to resident ratios on 12/1/24 through 12/18/24. The Director of Nursing, Human Resources, and the Scheduler will be re-educated on new July 1 nurse aide to resident ratios by the Nursing Home Administrator or Designee. To ensure sufficient nursing aide staffing ratios to comply with state laws, staffing meetings will be held 3 days a week to review staffing and the projected nursing assistant staff ratios for the current day, as well as the upcoming week. If projected staffing levels are below the required minimum staffing ratios, then the facility will reach out to current staff and to the staffing agencies to enlist staff to meet the minimum staffing and ratio requirement. The facility will continue to recruit CNAs through all platforms and utilize bonuses and outside staffing agencies. Audits of nurse aide ratios will be completed weekly x4 by the NHA/designee to ensure nurse aide ratios are met. Results of the audits will be reported to our QAPI committee monthly for review and recommendations.
LPN Staffing Shortage on Night Shift
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) during the night shift on December 14, 2024. According to the nursing time schedules reviewed for the period from December 1, 2024, to December 18, 2024, the facility did not provide the minimum of one LPN per 40 residents, as mandated by the regulation effective July 1, 2023. On the night of December 14, 2024, the facility had a census of 86 residents, requiring 3.44 LPNs, but only 3.04 LPNs were present. This staffing shortage was confirmed by the Nursing Home Administrator during an interview on December 19, 2024, at 2:00 p.m., who acknowledged the failure to meet the staffing requirement without any additional higher-level staff to compensate for the deficiency.
Plan Of Correction
There were no adverse effects to the residents of our facility as a result of decreased licensed nurse staffing ratios on 12/14/24. The Director of Nursing, Human Resources, and the Scheduler will be re-educated on new July 1 licensed nurse to resident ratios by the Nursing Home Administrator or Designee. Staffing meetings will be held 3 days a week to review the licensed nursing staff ratios for the previous and current day, as well as the upcoming week to ensure appropriate staffing levels. If projected staffing levels are below the state mandated ratios, then the facility will reach out to current staff and to the staffing agencies to enlist staff to meet the minimum requirement. The facility will continue to recruit nursing staff through all platforms as well as utilize bonus structures and outside agencies. Audits of licensed nursing staff ratios will be completed weekly x4 by the NHA/designee to ensure licensed staff ratios meet the state minimums. Results of the audits will be reported to our QAPI committee monthly for review and recommendations.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident in a 24-hour period on ten out of eighteen days. This deficiency was identified through a review of nursing schedules and census information from December 1, 2024, to December 18, 2024. On specific dates, the facility's provided nursing care hours per resident per day (PPD) fell below the required threshold, with PPDs ranging from 2.91 to 3.19. The Nursing Home Administrator confirmed the failure to meet the required nursing hours during an interview conducted on December 19, 2024.
Plan Of Correction
There were no adverse effects to the residents of our facility as a result of decreased HPPD on 12/1/24 through 12/17/24. The Director of Nursing, HR and Scheduler will be re-educated on the state requirement for HPPD by the Nursing Home Administrator or Designee. Staffing meetings will be held 3 days a week to review HPPD from the previous day and the projected HPPD, as well as the upcoming week to ensure appropriate staffing levels. If projected staffing levels are below the minimum of 3.2 HPPD, then the facility will reach out to current staff and staffing agencies to enlist staff to meet the minimum requirement. The facility will continue to recruit staff through all platforms. Audits of HPPD will be completed 5 days a week x4 by the NHA/designee to ensure HPPD meets the state minimums. Results of the audits will be submitted to the QAPI committee monthly for review and recommendations.
Inaccurate Narcotic Documentation and Discrepancies in LTC Facility
Penalty
Summary
The facility failed to maintain accurate narcotic count sheets and document the disposition of narcotics accurately, leading to discrepancies between Medication Administration Records (MAR) and narcotics count sheets for three of five closed record residents. The facility's policy on the management of controlled drugs requires that Schedule II to V controlled drugs be disposed of in accordance with federal and state regulations. However, the review of facility documentation revealed several instances where the shift count sheets were incomplete, with missing signatures from nurses coming on or going off duty on multiple dates. This lack of documentation accuracy was confirmed during an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON). For the residents involved, the facility's documentation showed inconsistencies in the administration and destruction of narcotics. One resident, admitted with acute kidney failure and diabetes mellitus, had a fentanyl patch and hydrocodone marked as destroyed, but the quantity destroyed was not documented. Another resident, with thrombocytopenia and unspecified cirrhosis of the liver, had discrepancies in the recorded administration of morphine between the MAR and the narcotic count sheet. A third resident, with acute kidney failure and hypertension, had tramadol marked as destroyed without indicating the amount. These documentation failures were acknowledged by the NHA and DON, highlighting the facility's inability to accurately track and manage controlled substances as required by regulations.
Inadequate Supervision and Improper Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision, assistance, and proper equipment during a transfer, resulting in a resident sustaining injuries. The resident, who was cognitively intact and had medical conditions including high blood pressure and atrial fibrillation, was improperly transferred by two nurse aides. The aides lifted the resident by her armpits, causing pain and bruising, which led to a hospital visit where a fractured rib was diagnosed. The incident highlighted a lack of adherence to the facility's policies on safe lifting and movement of residents. The facility's failure extended to maintaining accurate and updated Kardexes and care plans for residents' mobility transfer statuses. The resident's transfer order was not correctly reflected in the Kardex, leading to confusion among staff about the appropriate transfer method. This confusion was evident in staff interviews, where inconsistencies in understanding the transfer order were noted. The lack of clarity and proper documentation contributed to the improper transfer and subsequent injury. The deficiency created an Immediate Jeopardy situation for multiple residents, as the facility's failure to maintain accurate records and provide proper supervision posed a risk to their safety. The report detailed similar issues with other residents, where transfer orders were not included in their care plans or Kardexes, indicating a systemic problem within the facility's management of resident care policies and nursing services.
Removal Plan
- Resident R47's transfer status will be verified with therapy and care plan and Kardex will be updated by the facility Director of Rehabilitation.
- All resident transfer statuses and physician orders will be reviewed for accuracy and updated as needed by facility Director of Rehabilitation.
- All resident's physician ordered transfer status will be reviewed for accuracy and updated as needed on the resident's care plan by the facility assessment office and Director of Rehabilitation.
- All resident physician ordered transfer status and corresponding resident's Kardex will be reviewed for accuracy by the facility assessment office and Director of Rehabilitation.
- The Safe Lifting and Resident Movement policy has been reviewed by the facility Administrator and Director of Nursing and accepted as written.
- Education on the Safe Lifting and Resident Movement policy as well as finding the transfer orders and how to have the transfer orders properly reflected on the Kardex will be provided to facility rehabilitation and nursing staff, by the Director of Nursing, or designee(s). All remaining nursing staff shall complete the education prior to duty.
- Audits will be completed daily by the Director of Nursing, or designee, five days a week for eight weeks. The results of the audits will be communicated to the Quality Assurance and Performance Improvement Committee as needed.
Inadequate Staffing and Linen Shortages in LTC Facility
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple reports of inadequate staffing levels, particularly on weekends. The Payroll-Based Journal (PBJ) Staffing Data Reports for Quarter 4 of 2023 and Quarter 2 of 2024 both indicated a one-star staffing rating and excessively low weekend staffing. Resident council minutes from March to July 2024 consistently highlighted concerns about delayed response times to call bells, with reports of residents waiting up to three hours for assistance. Additionally, there were complaints about a lack of linen, with residents sometimes having to use towels or bare mattresses. Interviews with residents and staff further corroborated these issues. Residents reported long wait times for assistance, and staff described difficulties in providing timely care due to understaffing. One nurse aide mentioned that morning care sometimes wasn't completed until the afternoon, and a family member noted that residents were not being fed properly due to staff shortages. The facility's scheduler confirmed the staffing issues, noting that new hires frequently failed to show up for their shifts. These deficiencies were found to impact the physical, mental, and psychosocial well-being of several residents.
Unsanitary Food Service Conditions in Main Kitchen
Penalty
Summary
The facility failed to serve food in a sanitary manner in the Main Kitchen, which could potentially lead to foodborne illness. During an observation, water was noted dripping from air conditioning vents located approximately one to two feet behind the tray line. The condensation was observed on four vents, with water dripping sporadically onto carts that held lids used to cover plates and other dishes. Dietary employees were seen retrieving items from these carts for use on resident trays, and water droplets were present on top of the carts. The Food Service Director confirmed the unsanitary conditions during an interview.
Improper Resident Transfer Due to Management Failures
Penalty
Summary
The Nursing Home Administrator (NHA) and Director of Nursing (DON) failed to effectively manage the facility to ensure that necessary care and services were provided to residents, specifically regarding safe resident mobility transfers. The facility did not identify proper transfer statuses of residents and failed to maintain accurate Kardexes and care plans. This oversight led to an improper resident transfer, which resulted in the resident sustaining bruising and a fractured rib. The deficiency was identified through a review of facility policies, documents, observations, and staff interviews. The job descriptions for both the NHA and DON emphasize their responsibility to manage the facility in accordance with federal, state, and local standards and to ensure the highest degree of quality care. However, their failure to fulfill these duties placed the facility in an immediate jeopardy situation, as it created the potential for additional improper transfers.
Facility Fails to Meet Mandated Staffing Requirements
Penalty
Summary
The facility failed to ensure sufficient nursing staff to comply with state laws regarding mandated minimum staffing requirements as outlined in the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations. Specifically, the facility did not meet the required staffing levels for nurse aides and licensed practical nurses (LPNs) on multiple occasions across several surveys conducted between September 2023 and July 2024. The deficiencies included not providing the minimum number of nurse aides per residents during various shifts and failing to meet the required number of LPNs per residents during the day, evening, and night shifts. The surveys revealed consistent non-compliance with the staffing requirements, with specific dates highlighted where the facility did not meet the mandated staffing levels. For instance, during the survey conducted on September 8, 2023, the facility failed to provide the required number of nurse aides and LPNs on several days. Similar deficiencies were noted in subsequent surveys, including those conducted in October and November 2023, and April, May, June, and July 2024. The Nursing Home Administrator confirmed the facility's failure to maintain sufficient nursing staff during an interview on August 8, 2024.
Failure to Communicate Resident Information During Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider for five residents who were transferred to the hospital and expected to return. The clinical records of these residents lacked documentation of essential information such as care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the residents' specific needs at the receiving facility. Resident R6, who had diagnoses of high blood pressure, bipolar disorder, and diabetes, was transferred to the hospital without the required communication of specific information. Similarly, Resident R44, with high blood pressure, ataxic gait, and heart failure, was transferred without documented evidence of communication. Resident R51, diagnosed with high blood pressure, septicemia, and muscle weakness, also lacked documented communication upon transfer. Resident R62, with high blood pressure, depression, and diabetes, was transferred without a physician's order and without the necessary communication. Lastly, Resident R83, with high blood pressure, diabetes, and end-stage renal disease, was transferred without the required documentation. During interviews, a registered nurse and the Nursing Home Administrator confirmed the facility's failure to communicate necessary information for these residents. The nurse mentioned that while certain documents like POLST forms, orders, face sheets, and labs are typically sent, they are not usually documented in the medical record. This lack of documentation and communication was identified as a deficiency under 28 Pa. Code 201.29 (a) (c.3) (2) regarding resident rights.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide a transfer notice to the Office of the Long-Term Care Ombudsman Division for three residents who were transferred to the hospital. According to the facility's policy dated 8/24/23, a resident and/or their representative should receive a thirty-day advance notice of an impending transfer or discharge, or as soon as practicable in urgent medical situations. Additionally, a copy of these notices should be sent to the Office of the State Long-Term Care Ombudsman. However, the facility did not have documented evidence of sending such notifications for the hospitalizations of Residents R51, R62, and R83. Resident R51, diagnosed with high blood pressure, septicemia, and muscle weakness, was transferred to the hospital on 7/15/24. Resident R62, with high blood pressure, depression, and diabetes, was transferred on 7/10/24. Resident R83, suffering from high blood pressure, diabetes, and end-stage renal disease, was transferred on 2/8/24. In each case, the facility failed to document that a written transportation notification was provided to the Ombudsman. This deficiency was confirmed by the Nursing Home Administrator during an interview on 8/6/24.
Failure to Notify Residents of Bed-Hold Policy
Penalty
Summary
The facility failed to notify residents or their representatives in writing about the bed-hold policy during hospital transfers, as required by their policy dated 8/24/23. This deficiency was identified for five residents who were transferred to the hospital and later returned to the facility. The clinical records of these residents did not contain documented evidence that they or their representatives were informed of the bed-hold policy at the time of their transfers. The residents involved had various medical conditions, including high blood pressure, bipolar disorder, diabetes, ataxic gait, heart failure, septicemia, muscle weakness, depression, and end-stage renal disease. During interviews, a registered nurse acknowledged that the facility now has a bed-hold policy but admitted that they did not document that the policy was communicated to residents or their representatives. The Nursing Home Administrator confirmed the facility's failure to notify the residents or their representatives about the bed-hold policy for the five hospital transfers. This oversight is a violation of resident rights as per 28 Pa. Code 201.29 (a) (c.3) (2).
Failure to Provide Beautician Services
Penalty
Summary
The facility failed to provide beautician services for four out of seven residents, as required by their Activities of Daily Living (ADLs) policy. This policy, last reviewed on August 24, 2023, mandates that residents who are unable to perform ADLs independently should receive appropriate support and assistance, including grooming. The facility's admission packet also indicated that a styling salon and hairdresser services would be available on Thursdays. However, interviews and observations revealed that the facility has been without a beautician for several months, affecting residents' grooming needs. Resident R32, who has diagnoses of anxiety, depression, and muscle weakness, expressed dissatisfaction with the lack of haircuts, stating she had been without one for about a year. Other residents, including R6, R24, and R61, also reported or were observed to have unmet grooming needs, such as long beards or hair. Staff interviews confirmed the absence of a beautician, and the Nursing Home Administrator acknowledged the facility's failure to provide these services. This deficiency was identified under several Pennsylvania Code regulations related to resident care policies and management responsibilities.
Failure to Conduct Ongoing Bedrail Assessments
Penalty
Summary
The facility failed to conduct ongoing accurate assessments for the use of bedrails for four residents, leading to a deficiency in ensuring that bedrails were used to meet residents' needs and address the risks associated with their usage. The facility's policy on the proper use of side rails, dated 8/24/23, requires an assessment to determine the resident's symptoms, risk of entrapment, and reason for using side rails. However, the clinical records for Residents R7, R21, R37, and R79 did not reveal ongoing assessments for side rail usage, despite observations confirming the presence of side rails on their beds. Resident R7, diagnosed with high blood pressure, dementia, and depression, had a physician order for quarter side rails to promote mobility, but no ongoing assessment was documented. Similarly, Resident R21, with high blood pressure, dementia, and anxiety, and Resident R37, with high blood pressure, muscle weakness, and hyperlipidemia, also had orders for side rails without documented ongoing assessments. Resident R79, with high blood pressure, dementia, and Parkinson's disease, had no documented order or care plan for bed rail usage, yet side rails were observed on their bed. Interviews with the Infection Preventionist confirmed the lack of ongoing assessments, which should have been completed on admission, quarterly, and annually.
Failure in Medication Administration via Feeding Tube
Penalty
Summary
The facility failed to provide appropriate care and services to residents receiving medications via feeding tube, specifically for two residents. Resident R23, who was admitted with diagnoses including metabolic encephalopathy and dysphagia, had physician orders to flush the G-Tube with specific amounts of water before, between, and after medication administration. The orders also allowed for medications to be crushed and mixed unless contraindicated. However, during an interview, the Director of Nursing confirmed that residents whose medications are administered via a feeding tube should not have an order to crush and mix medications together, indicating a failure in following proper medication administration protocols. Similarly, Resident R29, admitted with quadriplegia and dysphagia, had physician orders to flush the G-Tube with water before and after medications and to mix all allowable medications for administration via the G-tube. The Director of Nursing acknowledged that the facility did not provide appropriate care and services for residents receiving tube feedings, as the practice of crushing and mixing medications was not in line with the facility's policy. This deficiency was identified through clinical record reviews, observations, and staff interviews, highlighting a significant medication error in the care of these residents.
Inadequate In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to provide the required 12 hours of in-service education within 12 months of the hire date anniversary for five nurse aides. The facility's policy, dated 8/24/23, mandates that all nurse aide personnel participate in regularly scheduled in-service training, including no less than 12 hours per employment year. However, upon review, it was found that NA Employees E4, E21, E22, E23, and E24 did not meet this requirement, with each receiving only between 9.5 to 10 hours of training within their respective employment years. The deficiency was confirmed during an interview with the Director of Nursing on 8/7/24, who acknowledged the shortfall in meeting the in-service education requirements. This failure to comply with the mandated training hours is a violation of the facility's policy and the Pennsylvania Code, specifically 28 Pa. Code: 201.14(a) and 28 Pa. Code: 201.20(c), which pertain to the responsibility of the licensee and staff development, respectively.
Failure to Provide Behavioral Health Training to Staff
Penalty
Summary
The facility failed to provide required behavioral health training to five nurse aides, as determined by a facility assessment. The assessment indicated that all nursing staff should complete ongoing annual training, including behavioral health education. However, a review of the training records for Nurse Aides E4, E21, E22, E23, and E24 revealed that none of them received this training within their respective annual periods. The facility's policy on in-service training, dated August 24, 2023, mandates that all personnel attend regularly scheduled training sessions, with records maintained in personnel files or by department supervisors. Despite this policy, the training records for the five nurse aides did not include any documentation of behavioral health training. The Director of Nursing confirmed this deficiency during an interview, acknowledging the facility's failure to provide the necessary training.
Failure to Accommodate Visually Impaired Resident's Needs
Penalty
Summary
The facility failed to accommodate the needs of a resident with a visual impairment, specifically for Resident R32, who was admitted with diagnoses of anxiety, depression, and muscle weakness. The Minimum Data Set indicated that Resident R32 required assistance with eating, and the care plan noted impaired visual function due to macular degeneration. During an interview, Resident R32 reported that staff often left meal trays without describing the contents, which was confirmed during an observation where an LPN assisted the resident without describing the tray's items. The LPN acknowledged awareness of the resident's visual impairment and confirmed the failure to accommodate the resident's needs.
Neglect in Wound Care for Resident with Quadriplegia
Penalty
Summary
The facility failed to provide an environment free from neglect for a resident identified as R29, who was diagnosed with quadriplegia, anxiety, and depression. The resident's care plan indicated a need for wound care due to a pressure injury on the left distal index finger, with specific physician orders to cleanse the wound and apply Medihoney and a gauze dressing daily. However, during an observation, it was noted that the wound dressing was dated three days prior, indicating that the prescribed wound care was not administered as ordered. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed the failure to follow the physician's wound care orders. The LPN acknowledged the outdated dressing, and the RN Supervisor explained the protocol for documenting treatment orders and the necessary steps if a dressing is not completed. The Director of Nursing confirmed the facility's failure to provide the required care, which constitutes neglect under the facility's policies and state regulations.
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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