Providence Rehab And Hlthcare Ctratmercyfitzgerald
Inspection history, citations, penalties and survey trends for this long-term care facility in Yeadon, Pennsylvania.
- Location
- 600 South Wycombe Ave, Yeadon, Pennsylvania 19050
- CMS Provider Number
- 395989
- Inspections on file
- 33
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Providence Rehab And Hlthcare Ctratmercyfitzgerald during CMS and state inspections, most recent first.
Three residents with significant medical conditions experienced misappropriation of their personal property by a facility employee, including unauthorized use of financial cards and possession of fare cards. The incidents were discovered following a family report and a police investigation, with no additional residents reporting missing property or finances.
A resident with cerebral palsy and mobility impairments was left unattended on a bed that was not in the lowest position during a bathing routine. The staff member stepped away to request cream, and the resident subsequently slid off the bed and hit her head on a nightstand. Staff interviews confirmed that the bed was not lowered as required by the care plan, leading to the fall.
A facility did not conduct a thorough investigation after a resident, who required assistance with personal hygiene due to physical limitations, alleged neglect when a nurse aide refused to help with toileting hygiene. Although policy required statements from all involved staff, the facility failed to obtain written statements from several key staff members who were present or involved in the incident, resulting in an incomplete investigation.
A resident admitted with a PICC line did not have required baseline and ongoing measurements documented, including catheter length and arm circumference, as ordered by the physician and facility policy. The PICC line dressing was not changed as required, and observations confirmed the dressing was peeling and dated prior to admission. No documentation of necessary assessments or dressing changes was found in the resident's records.
Staff did not follow infection control protocols for two residents: one with a multi-drug resistant organism was transferred by staff wearing only gloves instead of full PPE as required, and an air mattress for another resident with pressure wounds was left uncovered on the floor while being prepared for use.
Two residents were found living in unsanitary and cluttered conditions, with one requiring total assistance and the other exhibiting ongoing behaviors that contributed to a dirty environment. Staff and management confirmed repeated challenges in maintaining cleanliness due to resident refusals and behaviors, resulting in persistent foul odors, soiled linens, and cluttered rooms.
The facility did not maintain and inspect its fire alarm system according to NFPA standards. A document review revealed the absence of documentation for a required semi-annual visual fire alarm inspection. This deficiency impacts the entire facility, as confirmed by the Administrator and Maintenance Director.
The facility failed to maintain the sprinkler system, with storage found within 18 inches of sprinklers in multiple locations, including storage rooms on the first floor. This issue was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility failed to maintain and inspect the emergency generator, affecting the entire facility. Documentation for weekly battery voltage and monthly battery conductance testing was missing. Additionally, a Low Fuel alarm was observed on the generator annunciator panel at the Nurses' Station. These issues were confirmed during an exit interview with the Administrator and Maintenance Director.
The facility did not maintain egress doors free from obstructions, as the emergency magnetic door release mechanisms were non-functional at three locations on the first floor. This issue was observed and confirmed during an exit interview with the Administrator and Maintenance Director.
A delayed egress door on the first floor of the facility, across from a resident room, failed to alarm and open as required by NFPA 101 standards. This deficiency was confirmed by the Administrator and Maintenance Director during an exit interview, affecting one of two floors in the facility.
The facility did not maintain portable fire extinguishers as required by NFPA 10 standards. An observation revealed that the fire extinguisher in the Elevator Machine Room on the first floor was blocked by storage. This was confirmed in an interview with the Administrator and Maintenance Director.
The facility did not comply with NFPA 70, as storage was found within three feet of electrical panels on the first floor, violating the required clearance. This was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility's emergency preparedness plan lacked documentation on the role of the Ambulatory Surgical Center under a waiver declared by the Secretary, affecting the entire facility. This was confirmed during a document review and an exit interview with the Administrator and Maintenance Director.
A facility failed to maintain a clean and odor-free environment for a resident with severe cognitive impairment and multiple medical conditions. Observations revealed persistent offensive odors and unclean conditions, including a strong odor of urine and bowel movement, a foul sour odor near the resident's bed, and dried spillage on medical equipment. Despite initial cleaning efforts, the odors and unclean conditions persisted, as confirmed by staff interviews.
The facility failed to protect residents from the misappropriation of narcotic medications, as discrepancies in narcotic counts were discovered for two residents. The facility's policy on controlled substances was not followed, leading to missing medications and documentation. Interviews revealed that staff did not reference the narcotic index during counts, resulting in oversight of missing narcotics.
A facility failed to develop a comprehensive care plan for a resident with diabetes, despite the resident's need for insulin injections and blood sugar monitoring. The deficiency was confirmed by a nurse, who acknowledged the absence of a care plan addressing the resident's diabetes management.
A resident's medication was left unattended on their over-bed table on two occasions, despite the resident's refusal to take it due to concerns about increased urination. The unattended medication, which included potassium chloride and a diuretic, posed a safety risk as it could have been taken by another resident. The facility acknowledged the lapse in maintaining a safe environment.
A medication labeling error occurred when a nurse administered a nasal spray to a resident using a bottle labeled with another resident's name. The facility's policy requires verification of the resident's identity and medication label checks, which were not properly followed, leading to this deficiency.
A medication labeling deficiency occurred when a nurse administered a nasal spray to a resident using a bottle labeled with another resident's name. The facility's policy requires verification of the resident's identity and medication label checks, which were not followed, leading to the administration of medication with incorrect labeling.
The facility did not adhere to professional standards for food service safety. Observations revealed bread stored on the floor in the freezer, standing water in the dish room due to a clogged drain, and visible dirt and crumbs in the prep area. The convection oven had burned-on food, and the plate heater was dirty. These issues were confirmed by the Food Service Director.
A resident receiving enteral nutrition had their feeding bag improperly labeled, missing critical information such as the resident's name, formula, infusion rate, and preparer's initials. This was confirmed by an LPN during an observation, indicating a failure to adhere to facility policy and physician orders.
The facility failed to ensure that three residents, who were severely cognitively impaired, had the capacity to understand and sign binding arbitration agreements. Despite facility policy requiring informed consent, a concierge relied on personal judgment rather than reviewing clinical records, leading to the signing of agreements by residents unable to make informed decisions.
A facility failed to follow its infection control policy by not using gowns during wound care for a resident with a stage four pressure ulcer. Despite the care plan requiring enhanced barrier precautions, two staff members only wore gloves, neglecting the use of gowns, which was confirmed by a nurse after the observation.
The facility failed to notify the Ombudsman of emergency transfers and discharges for four residents. These residents experienced various medical emergencies, including changes in mental status, elevated blood pressure, low blood sugar, and breathing difficulties, leading to hospital transfers. Documentation confirming notification to the Ombudsman was absent, as confirmed by the DON.
The facility failed to ensure that call bells were within reach for four residents, with some call bells being non-functional or incorrectly placed. Staff confirmed these issues, which violated the facility's policy on call light accessibility.
The facility failed to ensure complete and accurate documentation of wound care treatments for a resident. Missing entries on the Treatment Administration Record for specific dates indicated that the treatments were not completed or documented as required, despite physician's orders for detailed wound care procedures.
Failure to Prevent Misappropriation of Resident Property
Penalty
Summary
The facility failed to ensure that residents were free from misappropriation of their property for three residents. One resident, who had diagnoses including hemiplegia, hemiparesis, and dementia, was found to have missing access, debit, and credit cards, with unauthorized purchases made using these cards. The incident was brought to the facility's attention by the resident's family. During the subsequent police investigation, an employee was identified as the perpetrator and was found in possession of fare cards belonging to two additional residents, both of whom had medical conditions such as muscle wasting, systemic lupus erythematosus, anemia, and lymphedema. These two residents were unaware that their cards were missing. Facility documentation and interviews confirmed that no other residents reported missing property or finances, and all interviewed residents stated they felt safe. The affected residents no longer resided at the facility at the time of the investigation. No further incidents or perpetrators were identified through facility or police investigation.
Failure to Implement Fall Prevention Interventions During Resident Care
Penalty
Summary
A deficiency occurred when staff failed to implement fall prevention interventions for a resident with cerebral palsy, muscle weakness, and significant mobility impairments. The resident, who required extensive assistance with bed mobility and used a wheelchair, had a care plan in place specifying that the bed should be kept in the lowest position at all times except during care. Despite this, during a bathing routine, the nurse assistant left the resident unattended on the bed, which was not in the lowest position, while stepping away to request cream for skin care. As a result, the resident slid off the bed and struck her head on the nightstand, sustaining pain and injury. Interviews with staff confirmed that the bed was not lowered before the nurse assistant left the resident, contrary to the care plan and facility policy. The Director of Nursing acknowledged that the bed should have been lowered before the staff member left the resident unattended, as direct care was no longer being provided at that moment.
Failure to Conduct Thorough Investigation of Neglect Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of neglect involving a resident who required staff assistance with personal hygiene and toileting due to orthopedic aftercare, muscle weakness, and an ADL self-care performance deficit. The incident occurred when a nurse aide refused to assist the resident with hygiene after toileting, despite the resident's inability to clean herself properly due to swollen legs. The resident, her roommate, and several staff members confirmed that the aide told the resident to clean herself and subsequently left the room, after which another aide was assigned to provide care. Following the incident, the facility initiated an investigation as required by policy, which mandates obtaining statements from all staff members who had contact with the resident during the period of the alleged incident. However, the investigation was incomplete, as written statements were not obtained from all relevant staff, including the social services assistant, a licensed nurse who interacted with the resident immediately after the incident, and the nurse aide who provided care following the event. The nursing supervisor and the Director of Nursing both confirmed that these statements were not collected, despite their involvement or presence during the incident. The deficiency was identified through review of facility policies, documentation, clinical records, and interviews with residents and staff. The failure to obtain comprehensive witness statements from all involved parties resulted in an incomplete investigation of the neglect allegation, contrary to the facility's own policies and regulatory requirements.
Failure to Maintain and Document PICC Line Care per Standards
Penalty
Summary
The facility failed to maintain intravenous (IV) devices in accordance with professional standards of practice for one resident who was admitted with a peripherally inserted central catheter (PICC) line. Upon admission, the resident's assessment did not include required measurements such as the total catheter length, external catheter length, or arm circumference, despite facility policy and physician orders mandating these assessments. The resident received antibiotic medication through the PICC line, and the dressing was observed to be peeling and dated prior to admission, indicating it had not been changed as required. Further review of the resident's clinical records, including medication administration records, progress notes, evaluations, and care plan, revealed no documentation of the PICC line external catheter length, total catheter length, or arm circumference at any time since admission. Physician orders specifically required documentation of these measurements and regular dressing changes, but these were not completed or recorded. Observations with the Director of Nursing confirmed that the PICC line dressing had not been changed since admission, and the required assessments and documentation were not performed.
Failure to Follow Infection Control Protocols for Precautions and Equipment
Penalty
Summary
Facility staff failed to adhere to established infection prevention and control protocols for two residents. For one resident colonized with a multi-drug resistant organism (CRE), both Enhanced Barrier Precautions and Contact Precautions were ordered and signage indicated the need for surgical masks, eye protection, gowns, and gloves during care. However, during a transfer using a hoyer lift, two staff members were observed wearing only gloves, despite acknowledging that gowns were also required. This was confirmed in interviews, where staff admitted to not following the full PPE requirements as outlined in facility policy and physician orders. In a separate incident, another resident with multiple pressure wounds and a physician order for a pressure-reducing air mattress was observed to have an air mattress placed directly on the floor without any protective covering. The mattress was being inflated in preparation for use, but was left exposed to potential contamination from dirt and debris. A licensed nurse confirmed the mattress was on the floor and uncovered at the time of observation.
Failure to Maintain Safe, Clean, and Homelike Environment for Two Residents
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for two residents. One resident, who required total assistance for activities of daily living, enteral feeding, and used a urinary catheter, was observed in a room with a foul odor, two large bags of laundry at the door, and a floor soiled with food, crumbs, papers, and other personal items scattered around. The resident's roommate was observed lying on a bed with no sheets, and the room was cluttered and unsanitary. Staff interviews confirmed ongoing challenges in maintaining cleanliness due to the roommate's behaviors, including refusal of care and not allowing staff to touch his belongings. The second resident, who had intact cognition and a diagnosis of diabetes, exhibited ongoing behavior concerns related to cleanliness and unsanitary conditions. Nursing notes documented repeated incidents of the resident refusing personal care, using linen to clean himself after defecating, and keeping his environment cluttered with clothes, trash, and feces. Staff reported that despite multiple daily attempts to clean the room, the resident often refused assistance and quickly returned the room to an unsanitary state. Facility leadership confirmed the first resident's high risk for infection and the ongoing behavioral issues of the second resident.
Failure to Maintain Fire Alarm System
Penalty
Summary
The facility failed to maintain and inspect its fire alarm system as required by NFPA 101, NFPA 70, and NFPA 72 standards. During a document review on January 21, 2025, it was discovered that the facility could not provide documentation of a semi-annual visual fire alarm inspection within six months of December 12, 2024. This deficiency affects the entire facility, as confirmed during an exit interview with the Administrator and the Maintenance Director.
Plan Of Correction
The documentation of the semiannual visual fire alarm inspection was missed. Annual was performed and semi-annual is scheduled. The Maintenance Director was in-serviced on ensuring that the semi-annual visual fire alarm inspection takes place every 6 months. The Maintenance Director has scheduled in TELs, our work order system, the testing of the semi-annual visual fire alarm inspection. The Maintenance Director will review this plan of correction at the monthly Quality Assurance Performance Improvement meeting to ensure compliance is maintained.
Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the sprinkler system as required, affecting the entire facility. During observations on January 21, 2025, between 9:38 a.m. and 9:42 a.m., it was noted that there was storage within 18 inches of a sprinkler in multiple locations. Specifically, at 9:38 a.m., storage was observed on the first floor in the storage room across from Occupational Therapy, and at 9:42 a.m., in the storage room across from the Elevator Machine Room. This condition was observed throughout the facility. An exit interview with the Administrator and the Maintenance Director confirmed the presence of storage within 18 inches of a sprinkler.
Plan Of Correction
The items in the storage room across from the occupational therapy gym and the elevator machine room that was within 18" of the ceiling has been removed. The facility has determined that storage in the facility have the potential to be affected. The Maintenance Director in-serviced staff on ensuring that nothing gets stored within 18" from the ceiling throughout the building. The Maintenance Director will conduct weekly audits of throughout the building weekly. This audit will be completed weekly for four weeks and then monthly for three months. This plan of correction will be monitored at the monthly Quality Assurance Performance Improvement meeting until such time consistent substantial compliance has been met.
Failure to Maintain Emergency Generator and Inspect Electrical Systems
Penalty
Summary
The facility failed to maintain and inspect the emergency generator, which affected the entire facility. During a document review, it was found that the facility could not provide documentation for weekly battery voltage testing and monthly battery conductance testing. This lack of documentation was confirmed during an exit interview with the Administrator and the Maintenance Director. Additionally, an observation revealed that the remote generator annunciator panel at the Nurses' Station on the first floor had a Low Fuel alarm. This issue was also confirmed during the exit interview with the Administrator and the Maintenance Director. These deficiencies indicate a failure in maintaining the essential electrical systems as required by NFPA standards.
Plan Of Correction
The weekly battery voltage tests and monthly battery conductance testing were completed. The Maintenance Director was in-serviced on ensuring that the weekly battery voltage testing and the monthly battery conductance testing are completed accurately. The Maintenance Director will audit the accuracy and completion of the voltage testing. This plan of correction will be monitored at the monthly Quality Assurance Performance Improvement meeting until such time consistent substantial compliance has been met.
Failure to Maintain Egress Doors Free from Obstructions
Penalty
Summary
The facility failed to maintain egress doors free from obstructions, affecting one of two floors. During observations conducted on January 21, 2025, between 9:54 a.m. and 10:05 a.m., it was noted that the emergency magnetic door release mechanisms were not functioning at three specific locations on the first floor. These locations included the stairwell doors across from resident rooms 131, 121, and 114. This deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director at 10:15 a.m. on the same day.
Plan Of Correction
The emergency magnetic door release at the stairwell door across from resident room 131, 121, and 114 are now fully functioning. The facility has determined that all emergency magnetic doors have the potential to be affected. The Maintenance Director was in-serviced on ensuring that the emergency magnetic doors are fully functioning. The Maintenance Director will monitor the emergency magnetic doors weekly. The Maintenance Director will review this plan of correction at the monthly Quality Assurance Performance Improvement meeting to ensure compliance is maintained.
Delayed Egress Door Malfunction
Penalty
Summary
The facility failed to maintain the functionality of delayed egress doors, which is a requirement for ensuring safe evacuation in case of emergencies. During an observation on January 21, 2025, it was noted that the delayed egress door located on the first floor, across from resident room 231, did not alarm or open as it should have. This deficiency was identified during a survey, indicating a lapse in the facility's adherence to the National Fire Protection Association (NFPA) 101 standards for egress doors. The issue was confirmed during an exit interview with the Administrator and the Maintenance Director, who acknowledged that the door failed to perform its intended function. This deficiency affects one of the two floors in the facility, potentially compromising the safety of residents and staff in the event of an emergency. The report does not provide details on any specific residents affected or any immediate consequences resulting from this deficiency.
Plan Of Correction
The delay egress door across from room 231 was fixed and is now functioning. The facility has determined that all egress doors have the potential to be affected. The Maintenance Director was in-serviced on ensuring that the egress doors alarm and open. The Maintenance Director will monitor the functioning of the egress doors weekly. The Maintenance Director will review this plan of correction at the monthly Quality Assurance Performance Improvement meeting to ensure compliance is maintained.
Obstructed Fire Extinguisher in Elevator Machine Room
Penalty
Summary
The facility failed to maintain portable fire extinguishers in accordance with NFPA 10 standards. During an observation on January 21, 2025, at 9:40 a.m., it was noted that the portable fire extinguisher in the Elevator Machine Room on the first floor was obstructed by storage items. This deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director at 10:15 a.m. on the same day.
Plan Of Correction
The portable fire extinguisher in the elevator room was unblock. The facility has determined that all fire extinguishers have the potential to be affected. The Maintenance Director in-serviced staff to ensure that the fire extinguishers in the building do not get blocked. The Maintenance Director will randomly audit the fire extinguishers throughout the building. This plan of correction will be monitored at the monthly Quality Assurance Performance Improvement meeting until such time consistent substantial compliance has been met.
Non-compliance with NFPA 70 Due to Inadequate Clearance
Penalty
Summary
The facility failed to comply with NFPA 70, National Electric Code, regarding electrical wiring and equipment. During an observation on January 21, 2025, it was noted that there was storage within three feet of electrical panels in two locations on the first floor. Specifically, the storage was found in the storage room across from Occupational Therapy and in the Laundry Dryer Room. According to NFPA 70 110.26(A)(1), a clearance of three feet is required in front of electrical equipment with a nominal voltage to ground of 0 to 150 volts. This deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director.
Plan Of Correction
The storage within three feet of the electrical panels across from the Occupational Therapy room and the laundry dryer room have been removed. The facility has determined that all electrical panels in the building have the potential to be affected. The Maintenance Director has in-serviced the staff to ensure that storage remains three feet from the electrical panels throughout the building. The Maintenance Director will randomly audit electrical panels throughout the building weekly. This plan of correction will be monitored at the monthly Quality Assurance Performance Improvement meeting until such time consistent substantial compliance has been met.
Deficiency in Emergency Preparedness Plan Documentation
Penalty
Summary
The facility was found to be deficient in its emergency preparedness plan, specifically lacking policy and procedure documentation regarding the role of the Ambulatory Surgical Center under a waiver declared by the Secretary, in accordance with section 1135 of the Act. This deficiency affects the entire facility as it pertains to the provision of care and treatment at an alternate care site identified by emergency management officials. During a document review on January 21, 2025, it was revealed that the facility could not provide the necessary documentation for their Emergency Preparedness Plan concerning the roles under a waiver declared by the Secretary. An exit interview with the Administrator and the Maintenance Director confirmed the absence of this critical documentation.
Plan Of Correction
The statements made in this Plan of Correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein. To maintain compliance with all federal and state regulation, the facility has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the facilities allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. The Emergency Prepared Plan policy and procedure documentation concerning the Roles under a Waiver Declared by Secretary was located and placed in the Emergency Prepared Plan. The Maintenance Director was in-serviced on ensuring that the Emergency Prepared Plan is complete and updated. The Maintenance Director will monitor and review this plan of correction at the monthly Quality Assurance Performance Improvement meeting to ensure compliance is maintained.
Failure to Maintain Clean and Odor-Free Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for Resident R79, as evidenced by persistent offensive odors and unclean conditions in the resident's room. Resident R79, who was admitted to the facility with severe cognitive impairment and multiple medical conditions including anoxic brain damage, pressure ulcers, heart failure, and respiratory failure, was dependent on a feeding tube and required assistance with all activities of daily living. Observations revealed a strong odor of urine and bowel movement emanating from the resident's room, along with a foul sour odor near the resident's bed. Additionally, there was a large puddle of tube feeding formula on the floor and dried spillage on the feeding pole and oxygen concentrator. Despite initial cleaning efforts, the dried spillage on the medical equipment remained, and the foul odor persisted. Subsequent observations confirmed that the strong odors continued to be present in the hallway and the resident's room over several days. Interviews with the Director of Nursing and the Regional Director of Environmental Services corroborated the presence of the odors and the unclean state of the medical equipment. The facility's failure to address these issues resulted in a deficiency related to maintaining a clean and comfortable environment for the resident.
Plan Of Correction
The statements made in this Plan of Correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein. To maintain compliance with all federal and state regulation, the facility has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the facilities allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. Resident R79's room was thoroughly cleaned and disinfected. The room is free from offensive odor. A house-wide audit was performed of all resident rooms to ensure that rooms were free from offensive odors. Housekeeping staff will be in-serviced on ensuring that resident rooms are free from offensive odors. The Director of Nursing/Designee will conduct a random audit of five resident rooms weekly for four weeks and then monthly for three months. The audits will ensure that resident rooms are free from offensive odors. This plan of correction will be monitored at the monthly Quality Assurance Performance Improvement meeting until such time consistent substantial compliance has been met.
Failure to Protect Residents from Narcotic Diversion
Penalty
Summary
The facility failed to protect residents from the misappropriation of their property, specifically involving the diversion of narcotic medications for two residents. The facility's policy on controlled substances, which mandates strict procedures for handling, storing, and documenting narcotic medications, was not adhered to. The policy requires that only authorized personnel handle these substances, and that they be counted and documented accurately at each shift change. However, discrepancies in the narcotic count were discovered, indicating a failure to follow these procedures. For one resident, a physician's order for Oxycodone was not properly managed, as the narcotic count was correct during several shift changes, but later the medication and its documentation were found missing. The investigation revealed that a page from the narcotic book had been ripped out, and the medication was unaccounted for. Similarly, for another resident, 30 tablets of Oxycodone were delivered and counted correctly initially, but were later found missing during a shift change. Interviews with the Director of Nursing revealed that the staff did not follow the facility's policy on counting controlled substances, as they failed to reference the narcotic index during counts, leading to the oversight of missing narcotics. This deficiency was identified as past non-compliance, indicating that the facility had not ensured residents were free from misappropriation of their property, specifically regarding the handling of controlled substances.
Failure to Develop Diabetes Management Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with diabetes, which is a requirement according to their policy on Comprehensive Person-Centered Care Plans. The resident, who was admitted in February 2024, had a diagnosis of diabetes and required insulin injections. Despite having active physician orders for blood sugar monitoring and insulin administration, the facility did not create a care plan addressing the resident's diabetes management or their dependence on insulin medications. The deficiency was confirmed during an interview with a licensed nurse, who acknowledged that no care plan was developed for the resident's diabetes and insulin needs. This oversight was identified during a review of the resident's care plan, which lacked any mention of diabetes management, despite the resident's medical condition and treatment requirements.
Plan Of Correction
Residents R80's care plan was updated to reflect diabetes management. A house-wide audit was completed of all diabetic residents to ensure that they have a diabetic care plan in place. Licensed staff will be in-serviced on ensuring that residents have a comprehensive care plan related to diabetes management. The Director of Nursing/Designee will conduct a random audit of 5 residents with diabetes to ensure that a comprehensive care plan related to diabetes management has been developed. This audit will be completed weekly for four weeks and then monthly for three months. This plan of correction will be monitored at the monthly Quality Assurance Performance Improvement meeting until such time consistent substantial compliance has been met.
Medication Safety Lapse for Resident
Penalty
Summary
The facility failed to maintain a safe environment for Resident R213 by leaving medication unattended on the resident's over-bed table on two separate occasions. During an initial tour, a pill was observed in a dose cup on the resident's table, which the resident refused to take due to concerns about increased urination. The following day, the same situation was observed, and the nurse, Employee E7, discarded the pill after the resident again refused it, citing the same reason. The nurse reported to the unit manager that the resident must have spit the pill out after initially taking it. Resident R213 was admitted with a diagnosis of non-ST-elevation myocardial infarction and was prescribed a regimen that included potassium chloride and a diuretic, among other medications. The unattended medication posed a risk as it could have been ingested by another resident, compromising the safety of the environment. The facility's administration confirmed that the medication should not have been left on the over-bed table, acknowledging the lapse in providing a safe environment for residents.
Plan Of Correction
The medication left on resident R213's over bed table was removed. A house-wide audit was completed to ensure that each resident's environment was safe related to medication being left on the residents' over bed table. Licensed staff will be in-serviced on ensuring that a safe environment is maintained related to medication being left on residents' over bed tables. The Director of Nursing/Designee will conduct a random audit of 5 residents' environments to ensure that a safe environment is maintained related to medication being left on an over bed table. This audit will be completed weekly for four weeks and then monthly for three months. This plan of correction will be monitored at the monthly Quality Assurance Performance Improvement meeting until such time consistent substantial compliance has been met.
Medication Labeling Error During Administration
Penalty
Summary
The facility failed to ensure that medications were properly and accurately labeled in accordance with currently accepted professional principles. This deficiency was identified during an observation of medication administration for a resident, where a licensed nurse administered a nasal spray labeled with another resident's name. The facility's policy on medication administration requires that medications be administered safely and as prescribed, with the individual administering the medication verifying the resident's identity and checking the label three times to ensure the right resident, medication, dosage, time, and method of administration. In this case, the nurse picked up a box labeled with the current resident's name and room number but administered a nasal spray bottle that had a typewritten label with a different resident's name. The nurse confirmed that the bottle used was incorrectly labeled with another resident's name. This incident involved a resident who was admitted with a diagnosis of Acute Sinusitis and had a physician's order for Fluticasone Propionate Nasal Suspension. The error was discovered during a medication administration observation, highlighting a failure in the facility's medication labeling and administration process.
Plan Of Correction
Resident R42's fluticasone propionate was placed in the correct box. House wide audit completed to ensure that medication were properly and accurately labeled in accordance with currently accepted professional principles. Licensed staff will be in-serviced to ensure that medications are properly and accurately labeled in accordance with currently accepted professional principles. The Director of Nursing/Designee will conduct a random audit of 5 residents' medications to ensure that they are properly and accurately labeled in accordance with currently accepted professional principles. This audit will be completed weekly for four weeks and then monthly for three months. This plan of correction will be monitored at the monthly Quality Assurance Performance Improvement meeting until such time consistent substantial compliance has been met.
Medication Labeling Deficiency
Penalty
Summary
The facility failed to ensure that medications were properly and accurately labeled in accordance with currently accepted professional principles. During an observation of medication administration, it was found that a nurse administered a nasal spray to a resident using a bottle labeled with another resident's name. Specifically, the bottle of Fluticasone nasal spray used for Resident R42 was labeled with Resident R78's name, despite being administered to Resident R42. This discrepancy was confirmed during an interview with the nurse at the time of the observation. Resident R42 was admitted to the facility with a diagnosis of acute sinusitis and had a physician's order for Fluticasone Propionate Nasal Suspension for allergy relief. Resident R78, who had been discharged from the facility, had a similar order for the same medication, which was discontinued upon discharge. The facility's policy requires that medications be administered safely and as prescribed, with verification of the resident's identity and medication label checks. However, these procedures were not followed, leading to the administration of medication with incorrect labeling.
Plan Of Correction
Resident R42's fluticasone propionate was placed in the correct box. A house-wide audit was completed to ensure that medications were properly and accurately labeled in accordance with currently accepted professional standards. Licensed staff will be in-serviced to ensure that medications are properly and accurately labeled in accordance with currently accepted professional principles. The Director of Nursing/Designee will conduct a random audit of 5 residents' medications to ensure that they are properly and accurately labeled in accordance with currently accepted professional principles. This audit will be completed weekly for four weeks and then monthly for three months. This plan of correction will be monitored at the monthly Quality Assurance Performance Improvement meeting until such time consistent substantial compliance has been met.
Food Service Safety Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During an initial tour of the Food Service Department, several deficiencies were observed. In the walk-in freezer, two cardboard boxes of bread were found sitting directly on the floor. In the dish room area, there was standing water on the floor due to a clogged floor drain, and dietary staff were using a shop vacuum to collect the water. The under-table shelves in the prep and cooks area were visibly dirty with dust and crumbs, and the tray slides under the coffee urn were stained with dark brown liquid. The inside of the convection oven had dark black burned-on food substances on all surfaces, and the plate heater had dirt and crumbs on the inside surfaces where clean plates are stacked. These findings were confirmed by the Food Service Director during an interview.
Plan Of Correction
The two cardboard boxes of bread were removed from the floor. The standing water from the dish room area was removed and a plan has been put into place to fix the floor drain. The under-table shelves and floors in the prep area and cooks' area was cleaned and disinfected. The tray slides under the coffee urn were cleaned and disinfected. The surfaces on the inside of the convection oven were cleaned. The inside surfaces of the plate heater was cleaned. Full audit of the kitchen was completed. Variances addressed as needed. Dietary staff will be in-serviced on ensuring that food is stored, prepared, distributed, and served in accordance with professional standards for food service safety. The Director of Nursing/Designee will conduct five random audits of the walk-in freezer, dish room area, under-table shelves, floor, tray slides, convection oven, and plate heater to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This audit will be completed weekly for four weeks and then monthly for three months. This plan of correction will be monitored at the monthly Quality Assurance Performance Improvement meeting until such time consistent substantial compliance has been met.
Improper Labeling of Tube Feeding Bags
Penalty
Summary
The facility failed to ensure proper labeling of tube feeding bags for a resident, identified as Resident R79, who was receiving enteral nutrition. The resident, admitted to the facility in September 2023, had significant medical conditions including anoxic brain damage and dysphagia, necessitating the use of a feeding tube. According to the physician's orders, the resident was to receive Peptamen AF formula in 375 mL boluses four times daily, with specific instructions to change and label the feeding bag and administration set daily with the resident's name, date, time, and initials of the person preparing the feeding. During an observation on January 12, 2025, it was noted that the tube feeding bag in use for Resident R79 was only labeled with the date, lacking the resident's name, formula, infusion rate, and the preparer's initials. Employee E8, a licensed nurse, confirmed that the bag was not properly labeled according to the facility's policy and the physician's orders. This oversight in labeling could potentially lead to errors in the administration of the resident's nutritional support.
Plan Of Correction
Resident R79's tube feed label was updated. A house-wide audit of residents with tube feedings was completed to ensure that tube feedings were labeled properly. Licensed staff will be in-serviced to ensure that tube feedings are properly labeled. The Director of Nursing/Designee will conduct a random audit of five residents to ensure that tube feedings are properly labeled. This audit will be completed weekly for four weeks and then monthly for three months. This plan of correction will be monitored at the monthly Quality Assurance Performance Improvement meeting until such time consistent substantial compliance has been met.
Failure to Ensure Residents' Capacity to Sign Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents had the capacity to understand the terms of a binding arbitration agreement for three residents. The facility's policy requires that residents or their representatives be informed of the nature and implications of binding arbitration agreements to make informed decisions. However, the facility did not adhere to this policy, as evidenced by the cases of three residents who were severely cognitively impaired and yet were noted to have verbally signed the agreements. These residents had diagnoses such as dementia, Alzheimer's Disease, and cognitive communication deficits, with BIMS scores indicating severe cognitive impairment. Employee E11, a concierge responsible for obtaining signatures on the arbitration agreements, did not review the residents' clinical records to assess their cognitive status. Instead, she relied on her personal judgment to determine if residents were capable of signing the agreements. This resulted in the signing of agreements by residents who were not capable of understanding them, as they were severely cognitively impaired and unable to make informed decisions. The facility's failure to ensure proper understanding and capacity before signing the agreements led to this deficiency.
Plan Of Correction
Resident R44, R41, and R72's binding arbitration agreements have been removed. A house-wide audit was completed to ensure that the residents who signed a binding arbitration agreement have the capacity to understand the terms of the agreement. The admission director and concierge will be in-serviced to ensure that residents have the capacity to understand the terms of a binding arbitration agreement before signing them. The Director of Nursing/Designee will conduct a random audit of five residents to ensure that they have the capacity to understand the terms of a binding arbitration agreement before signing them. This audit will be completed weekly for four weeks and then monthly for three months. This plan of correction will be monitored at the monthly Quality Assurance Performance Improvement meeting until such time consistent substantial compliance has been met.
Failure to Implement Enhanced Barrier Precautions for Wound Care
Penalty
Summary
The facility failed to maintain effective infection control practices related to enhanced barrier precautions for a resident with a stage four pressure ulcer. The facility's policy on Enhanced Barrier Precautions, dated March 2024, requires the use of gowns and gloves during high-contact care activities, such as wound care, to prevent the transmission of multi-drug resistant organisms. However, during an observation on January 12, 2025, it was noted that two employees, a licensed nurse and a nurse aide, provided wound care to the resident's sacral wound while only wearing gloves, neglecting to wear gowns as required by the policy. The resident in question was admitted to the facility in September 2023 and had a diagnosis of a stage four pressure ulcer in the sacral region, which is the most severe stage of a pressure sore and has a high risk of infection. The resident's care plan, dated April 29, 2024, specified the need for enhanced barrier precautions, including the use of gloves and gowns during wound care. Despite this, the employees did not adhere to the required precautions, as confirmed by the licensed nurse during an interview following the observation.
Plan Of Correction
Employee E8 and E9 were rein-serviced on maintaining effective infection control practices related to enhanced barrier precautions. A house-wide audit was completed of residents with enhanced barrier precautions to ensure that staff were maintaining effective infection control practices related to enhanced barrier precautions. Staff members will be in-serviced to ensure that the facility maintains effective infection control practices related to enhanced barrier precautions. The Director of Nursing/Designee will conduct a random audit of five residents to ensure that staff are maintaining effective control practices related to enhanced barrier precautions. This audit will be completed weekly for four weeks and then monthly for three months. This plan of correction will be monitored at the monthly Quality Assurance Performance Improvement meeting until such time consistent substantial compliance has been met.
Failure to Notify Ombudsman of Emergency Transfers and Discharges
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers and discharges for four residents. Clinical record reviews revealed that Resident R2 experienced a change in mental status and was transferred to a hospital following a cardiologist's consultation. Resident R3 had elevated blood pressure and was unresponsive, leading to a hospital transfer. Resident R4 had low blood sugar, facial swelling, and difficulty swallowing, prompting a physician-ordered hospital transfer. Resident R6 experienced breathing difficulties and low oxygen levels, resulting in a hospital transfer. Both Residents R2 and R6 did not return and were discharged from the facility. Further investigation showed that there was no documentation available to confirm that the Ombudsman was notified of these emergency transfers and discharges. An interview with the Director of Nursing confirmed the absence of such documentation for the residents involved. This lack of notification is a violation of the facility's responsibility to inform the Ombudsman of such significant events, as required by the relevant state codes.
Call Bell Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that residents' call bells were within reach, affecting four out of 25 residents observed. During an observation of the first and second-floor units, it was noted that a resident's call bell was hanging over her bedside table, making it inaccessible. Interviews with staff confirmed the observation. Another resident's call bell was found clipped to a bed but plugged into the wrong socket, and the call button was missing, rendering it non-functional. This issue was confirmed by both the resident and the unit manager, who acknowledged that the call bells for two residents were switched and that one was broken. Further observations revealed that another resident's call bell was also hanging over her bedside table and was not within reach. The unit manager confirmed this observation. The facility's policy on answering call lights emphasizes the importance of ensuring that call lights are plugged in and functioning at all times, which was not adhered to in these instances. The deficiencies were noted under the Pennsylvania Code for nursing services.
Incomplete Documentation of Wound Care Treatments
Penalty
Summary
The facility failed to ensure that Resident R1's medical records were complete and accurately documented regarding wound care treatments. The facility's policy on wound care documentation requires detailed recording of the type of wound care given, date and time, resident's position, name and title of the individual performing the care, changes in the resident's condition, assessment data, resident's tolerance, any complaints, refusal of treatment, and the signature and title of the person recording the data. However, the review of Resident R1's clinical records revealed missing documentation for wound care treatments on specific dates. Specifically, there were no nurse's initials entered on the Treatment Administration Record (TAR) for the evening shifts of December 15, 2023, December 22, 2023, and December 28, 2023, indicating that the treatments were not completed or documented as required. Resident R1 was admitted to the facility with diagnoses including Adult Failure to Thrive, Chronic Kidney Disease stage IV, Essential Hypertension, muscle wasting, and muscle weakness. The physician's orders for wound care included cleansing the sacrum with normal saline solution, applying Desitin and foam dressing, and using Dakins solution for wound care. Despite these orders, the facility's failure to document the wound care treatments accurately and completely on the specified dates constitutes a deficiency in maintaining proper medical records and safeguarding resident-identifiable information as per accepted professional standards.
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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