Redstone Highlands Health Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Greensburg, Pennsylvania.
- Location
- 6 Garden Center Drive, Greensburg, Pennsylvania 15601
- CMS Provider Number
- 396021
- Inspections on file
- 27
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 18 (1 serious)
Citation history
Health deficiencies cited at Redstone Highlands Health Care during CMS and state inspections, most recent first.
Missing documentation for controlled medication administration: Controlled drug records showed signed-out doses of oxycodone for two residents and alprazolam for another resident, but the MAR/clinical records did not document that the doses were actually administered. The residents had diagnoses including cognitive impairment, Parkinson’s disease, arthritis, spinal fusion, heart failure, spinal stenosis, and rheumatoid arthritis, and the DON confirmed the missing documentation.
A resident with an indwelling urinary catheter was observed sitting in her wheelchair eating lunch while her catheter drainage bag was attached to the bed frame and visible from the doorway, with no privacy bag covering it and yellow urine visible in the bag. RN, NHA, and DON all confirmed the bag was not in a dignity/privacy bag, although it should have been.
The facility failed to ensure a resident’s psychotropic regimen was free from unnecessary medication and did not have informed consent before starting aripiprazole for confusion. The resident was cognitively impaired, needed help with daily care, and had diagnoses including anxiety and depression. The DON confirmed the lack of informed consent for the antipsychotic.
Baseline Care Plans Omitted Immediate Catheter and IV Therapy Needs: Two residents admitted for aftercare had immediate care needs that were not included in their baseline care plans. One resident had a foley catheter, and another had a midline catheter with daily IV ertapenem ordered for a UTI. The DON confirmed the baseline care plans did not include the needed care and treatment information.
The facility failed to develop individualized care plans for two residents with complex treatment needs. One resident had a wound VAC ordered for surgical wounds, and another resident had a midline catheter for IV antibiotics; in both cases, there was no documented care plan addressing the device-related care and treatment needs, and the DON confirmed the omissions.
Failure to notify the physician and obtain orders before giving G-tube water boluses. A resident with cognitive impairment, anxiety, depression, and gastrostomy status became suddenly tired after therapy, did not eat lunch, and was found diaphoretic with a BP of 61/43 mmHg. The RN gave two 500 cc water boluses via the G-tube before notifying the physician or obtaining an order, and the DON confirmed the omission.
A resident who was cognitively intact, needed extensive assistance with daily care, and had HF reported dizziness and a sensation that the room was spinning. An on-call practitioner and APN ordered orthostatic VS in the morning, but there was no documented evidence that staff obtained them, and the DON confirmed the order was not documented as completed.
Warfarin Administered Despite Hold Order: A cognitively impaired resident receiving warfarin for atrial fibrillation had a critical INR result, and the physician ordered the anticoagulant held for 3 days with daily INR checks. Review of the MAR showed the warfarin was still given on 2 nights after the hold order, and the DON confirmed it should have been held.
The facility failed to obtain an INR as ordered for a resident receiving warfarin for atrial fibrillation. The resident had a critical INR reported by the lab, and the physician ordered coumadin held and daily INR checks, but staff did not draw the INR as ordered. The DON confirmed the missed lab draw.
QAPI failed to correct repeated deficiencies cited in prior surveys and was found ineffective in maintaining compliance with baseline care plans, comprehensive care plans, professional standards of care, quality of care, pharmacy records, significant med errors, and infection prevention and control. Prior POCs said these areas would be monitored by QAPI, but the current survey again cited the facility for the same regulatory failures.
Failure to Use EBP for Resident With Wound VAC: A resident with a surgical wound and wound VAC had no documented EBP order, no signs indicating EBP, and no PPE available in the room despite facility policy and CDC/CMS guidance calling for targeted gown and glove use during high-contact care for residents with wounds or indwelling devices. The DON confirmed that EBP was not in place even though it should have been.
Failure to document pneumococcal vaccine offer and refusal. A resident’s MDS showed the pneumococcal vaccine was not up to date because it was reportedly offered and declined, but there was no charted evidence that the vaccine was ever offered or refused. The Infection Control Nurse confirmed there was no documented evidence the resident was offered the vaccine at admission or afterward.
A resident with dementia and significant mobility deficits, care planned for two-person assistance with transfers, was transferred by a CNA alone, who did not review the Kardex or care plan and believed the resident was a one-person assist. During the transfer the resident complained of leg pain, and later developed redness, warmth, swelling, and pain in the knee. Nursing and physician assessments documented these findings, and imaging confirmed a nondisplaced patella fracture. The facility’s investigation and staff interviews determined that the CNA routinely did not access Kardex information and failed to follow the resident’s transfer interventions, resulting in substantiated neglect.
A resident with dementia and decreased mobility, care-planned for 2-person assistance with bed-to-chair transfers, was transferred by a single CNA who did not review the Kardex or know how to access it, believing the resident was a 1-assist transfer. During and after the transfer, the resident complained of leg pain, and later exhibited redness, warmth, and swelling of the knee. Physician evaluations and imaging identified a nondisplaced patella fracture, and the facility’s investigation substantiated neglect related to failure to follow the care-planned transfer interventions.
A resident with dementia and a history of wandering was able to exit the facility unsupervised when the Wander Guard alarm system failed to function due to a low battery. Staff did not recognize the event as an elopement, did not notify administration promptly, and did not check or replace the device after the resident was returned by EMS, resulting in a deficiency related to inadequate supervision and accident hazard prevention.
A resident with moderate cognitive impairment and heart failure was given warfarin instead of rosuvastatin for several days due to a pharmacy labeling error. The error was discovered after the resident's INR was found to be critically high, and although the pharmacy was notified, there was no documentation that the facility checked for similar errors in other medication cards.
A resident with cognitive impairment and a history of atherosclerotic heart disease developed a pressure ulcer on the left heel. Although a wound care consultant recommended treatment with skin prep and a bordered foam dressing, the facility did not update the wound care orders to include the foam dressing. As a result, the recommended treatment was not provided, and the wound progressed to a Stage 3 pressure ulcer.
A resident with cognitive impairment and heart failure was administered coumadin instead of the prescribed rosuvastatin calcium for several days due to a pharmacy packaging error. The medication card was mislabeled, and the error was only discovered after the resident had already received the incorrect medication, resulting in abnormal lab findings and physician notification.
A resident with morbid obesity and a history of falls, who required two-person assistance for bed mobility, was being cared for by a single nurse aide during in-bed care. While being changed, the resident reached for an item and rolled out of bed, resulting in a hip fracture. The incident was determined to be neglect due to failure to follow the resident's care plan.
A resident with morbid obesity and decreased mobility, care planned for two-person assistance with bed mobility, was assisted by only one nurse aide during in-bed care. While being changed, the resident reached for an item and fell from bed, sustaining a right hip fracture. The aide did not follow the care plan, leading to the fall and injury.
A resident with morbid obesity and decreased mobility, who required two-person assistance for bed mobility, was assisted by only one nurse aide during in-bed care. While being repositioned, the resident reached for an item and fell from bed, sustaining a right hip fracture. The aide did not follow the care plan, leading to the incident.
The facility failed to follow physician's orders for medication administration and weight monitoring for three residents. A resident received Labetalol despite a low heart rate, and two residents experienced significant weight gains without physician notification.
The facility failed to maintain accountability for controlled medications for three residents. One resident's records lacked evidence of Fentanyl patch destruction, while two others had discrepancies between controlled drug records and medication administration records for Oxycodone/Tylenol and Percocet. The Nursing Home Administrator confirmed the documentation issues.
The facility did not maintain sanitary conditions in food service areas. Observations revealed several food items in the main kitchen were open to air and undated, contrary to facility policy. Additionally, a Nurse Aide entered the kitchenette without a hairnet, violating the requirement for hair restraints. These issues were confirmed by the Executive Chef and Nursing Home Administrator.
A facility failed to ensure that a designated interdisciplinary team member obtained required information from a hospice provider for a resident receiving hospice services. The resident had a Stage 3 pressure ulcer, and the care plan required weekly documentation of wound treatment and measurements. However, there was no evidence of these assessments being completed for several weeks. The DON confirmed that hospice was responsible for the wound care but did not provide documentation.
A resident with an ankle fracture did not receive a thorough investigation into the injury's cause, as required by facility policy. The DON concluded the investigation after the resident denied abuse, but there was no documentation ruling out neglect. This resulted in a deficiency for failing to meet regulatory requirements for investigating injuries of unknown origin.
The facility failed to accurately complete MDS assessments for three residents. One resident's assessment did not reflect the administration of prescribed medications, while two others had incorrect discharge statuses recorded. These discrepancies were confirmed through staff interviews and a review of clinical records.
The facility failed to develop baseline care plans for three residents, omitting necessary information regarding their immediate care needs. One resident required a feeding tube, another had a Foley catheter, and a third was on anticoagulant and diuretic medications. Interviews confirmed the absence of these care plans, which were supposed to include Enhanced Barrier Precautions (EBP) as per facility policy.
The facility failed to develop comprehensive care plans for two residents, one with a colostomy and another with diabetes requiring a continuous glucose monitoring system. The lack of documented care plans for these specific needs was confirmed by the Nursing Home Administrator.
A facility failed to update a resident's care plan after the completion of antibiotic therapy for pneumonia. The resident, who was cognitively intact and required assistance for daily care needs, had a care plan that was not revised to reflect the end of the antibiotic treatment. This was acknowledged by the Nursing Home Administrator, despite the facility's policy requiring care plans to be updated as needed.
A facility failed to clarify a provider's orders for a resident's wound care, resulting in a deficiency. The resident, with a history of hip fracture, diabetes, and dementia, had inconsistent orders for heel wound care. Verbal orders from the wound consultant differed from written assessments, leading to confusion in treatment frequency. This inconsistency violated professional standards of quality care.
The facility failed to securely store medications, with an unlocked medication cart accessible to unauthorized individuals and loose pills found in a drawer. An unopened insulin pen for a resident was improperly stored in the cart instead of the refrigerator. Additionally, a box containing controlled medication was not permanently affixed in the refrigerator, allowing it to be removed.
A facility failed to follow infection control practices during wound care for a resident with pressure ulcers. The resident, who required assistance for daily care, did not have enhanced barrier precautions (EBP) in place, and a nurse did not perform hand hygiene between glove changes or wear a gown as required. The Nursing Home Administrator confirmed these lapses in protocol.
The facility failed to provide written notification to residents and their responsible parties regarding the reasons for hospital transfers, affecting five residents. These residents, with various medical conditions, were transferred to the hospital without the required written notice, as confirmed by facility administrators.
The facility failed to serve food items at palatable temperatures. Residents reported that food served in their rooms was often cold, and a food committee meeting confirmed inconsistent food temperatures. A test tray revealed that iced tea was 49 degrees F, coffee was 138 degrees F, mixed vegetables were 119 degrees F, pork was 129 degrees F, and rice was 136.2 degrees F. The Dietary Director confirmed that the food was not at an appetizing temperature.
A resident, who was cognitively impaired and at risk for dehydration due to diuretic use, refused daily weights as ordered by the physician. Despite a communication form being sent, there was no documented response from the physician, and the Director of Nursing confirmed the lack of proper notification.
The facility failed to maintain comfortable air temperatures in the second-floor dining/activity room, with residents complaining of cold conditions. The Maintenance Director confirmed the air conditioner was on, and the heat was off, making the room temperature 67 degrees Fahrenheit. Unsealed windows contributed to the cold environment.
The facility failed to complete comprehensive annual MDS assessments within the required time frame for two residents. The assessments were 35 and 25 days late, respectively, as confirmed by the DON.
A facility failed to develop an individualized care plan for a resident with cognitive impairment and exit-seeking behavior. Despite an incident where the resident attempted to leave a locked unit, no care plan was documented. The DON confirmed that a care plan should have been created.
The facility failed to update care plans for two residents. One resident's care plan included outdated medication orders, and another resident's care plan did not include new interventions after an elopement incident. The Director of Nursing confirmed these deficiencies.
A facility failed to provide appropriate catheter care for a resident with an indwelling urinary catheter, as required by the care plan and facility policy. Documentation showed missed catheter care during several shifts in March and April, confirmed by the Assistant Director of Nursing.
A resident experienced significant weight loss, but the facility failed to ensure timely re-weighs, physician notification, and intervention as per their weight management policy. Despite dietary recommendations, there was no documentation of re-weighs or notifications to the family, physician, or nutrition services director, leading to a delay in addressing the resident's weight loss.
The facility failed to follow the physician's order for oxygen administration for a resident with pulmonary fibrosis and pneumonia. The resident's oxygen flow rate was set at 7 liters instead of the prescribed 0-6 liters, as confirmed by staff interviews.
The facility's QAPI committee failed to correct recurring deficiencies related to comprehensive care plans, care plan timing and revision, and respiratory care. Despite previous plans of correction, the current survey found repeated deficiencies, indicating the QAPI committee's ineffectiveness in maintaining compliance with these regulations.
Missing documentation for controlled medication administration
Penalty
Summary
The facility failed to maintain accountability for controlled medications for three residents. The facility policy dated July 11, 2025 stated that staff are to sign the MAR after a medication is administered and, if the medication is a controlled substance, to sign the narcotic book. For Resident 4, a quarterly MDS dated February 17, 2026 showed moderate cognitive impairment, need for staff assistance, and diagnoses of arthritis and Parkinson's disease. Physician orders dated February 10, 2026 included oxycodone 5 mg, two tablets every six hours as needed for severe pain, but controlled drug records showed two 5 mg oxycodone tablets were signed out on February 21, March 2, and April 9, 2026 without documented evidence in the clinical record that those doses were administered. For Resident 5, an admission MDS dated March 9, 2026 showed the resident was cognitively intact, needed staff assistance with daily care, had a spinal fusion diagnosis, and was receiving PRN pain medication. Physician orders dated February 12 and March 3, 2026 included oxycodone 5 mg, two tablets every six hours as needed for severe pain or pain, and controlled drug records showed two 5 mg oxycodone tablets were signed out on February 14 and April 2, 2026 without documentation that they were administered. For Resident 11, a quarterly MDS dated March 19, 2026 showed cognitive impairment, need for assistance with personal care, and diagnoses of heart failure, spinal stenosis, and rheumatoid arthritis. Physician orders dated January 16, 2026 included alprazolam 0.5 mg every twelve hours as needed for anxiety, and controlled drug records showed doses signed out on December 12, December 19, December 29, 2025, January 9, 2026, and February 28, 2026 without documented evidence of administration. The DON confirmed there was no documented evidence in the clinical records for Residents 4, 5, and 11 that the signed-out controlled medications were administered.
Visible urinary catheter drainage bag without privacy covering
Penalty
Summary
The facility failed to maintain the dignity of Resident 100, who was admitted with a diagnosis of aftercare following joint replacement surgery and had an indwelling urinary catheter. Observation of the resident while she was sitting in her wheelchair eating lunch showed that her urinary catheter drainage bag was attached to the bed frame on the left side of her bed, visible from the doorway, with no privacy bag covering it and yellow urine visible in the bag. RN 1 confirmed that there was no dignity or privacy bag on the resident’s urine drainage bag, and the NHA and DON both confirmed that urinary catheter drainage bags should have been kept in dignity/privacy bags.
Unnecessary Psychotropic Medication and Missing Informed Consent
Penalty
Summary
The facility failed to ensure one resident’s medication regimen was free from unnecessary psychotropic medications and failed to implement non-pharmacological interventions and informed consent before starting an antipsychotic medication. Resident 2 was cognitively impaired, required assistance with daily care needs, and had diagnoses including anxiety and depression. Physician orders included aripiprazole 2 mg daily for confusion, but the facility could not provide evidence of informed consent for the medication, and it was not available in the clinical record for review. During an interview, the DON confirmed that the facility failed to ensure the resident had informed consent prior to administering the antipsychotic medication.
Baseline Care Plans Omitted Immediate Catheter and IV Therapy Needs
Penalty
Summary
The facility failed to ensure that the baseline care plan included information about residents’ immediate care needs within 48 hours of admission for two residents. Facility policy dated July 11, 2025, stated that the licensed nurse would initiate a baseline care plan upon admission and complete it within 48 hours, with review and update on the first business day following admission. Review of admission records for one resident admitted on April 11, 2026, showed admission for aftercare following a joint replacement with a foley catheter in place. Observations on April 13 and April 15, 2026, showed the resident in bed and later in a wheelchair with the urinary drainage bag attached to the bed frame. The DON confirmed on April 16, 2026, that the resident’s baseline care plan did not include the care and treatment needs required for foley catheter use and should have. Review of admission records for another resident admitted on April 4, 2026, showed admission for aftercare following a UTI with a midline catheter in place. A nursing note documented that the resident arrived with a midline in the left upper arm, and physician orders included daily IV ertapenem sodium for the UTI. An observation on April 13, 2026, showed the resident sitting up in bed eating lunch with the midline catheter still in the left upper arm, and the resident’s daughter stated he was admitted for treatment of the UTI and needed long-term IV antibiotics for about four weeks. The DON confirmed on April 16, 2026, that this resident’s baseline care plan did not include the care and treatment needs required for IV antibiotic use and should have.
Failure to Develop Care Plans for Wound VAC and Midline Catheter Care
Penalty
Summary
The facility failed to develop comprehensive care plans with specific, individualized interventions for two residents. Resident 5 had an admission MDS dated March 9, 2026 showing the resident was cognitively intact, needed staff assistance with daily care needs, had diagnoses including fusion of the spine, and had surgical wounds. Physician orders dated March 17, 2026 directed staff to cleanse the mid back wound with NSS, pack the open wounds with black foam, and apply a wound VAC at -125 mmHg continuously, with changes three times a week and as needed for dislodgement; the wound VAC was to be removed if the resident left the facility. There was no documented evidence of a care plan addressing the resident’s wound VAC care and treatment needs, and the DON confirmed this during interview. Resident 42 had an annual MDS dated January 4, 2026 showing the resident was cognitively intact, needed staff assistance with daily care needs, and had paraplegia. Physician orders dated April 10, 2026 allowed placement of a midline catheter for IV antibiotics, and an observation on April 15, 2026 found the resident had a midline catheter in the right upper arm. There was no documented evidence of a care plan addressing the resident’s care and treatment related to the midline catheter, and the DON confirmed during interview that such a care plan had not been developed and should have been.
Failure to Notify Physician and Obtain Orders Before G-Tube Water Boluses
Penalty
Summary
The facility failed to notify the physician of a change in condition and failed to obtain physician orders before administering two 500 cc water boluses through a resident’s gastrostomy tube. Resident 2 had cognitive impairment, required assistance with daily care needs, and had diagnoses including anxiety, depression, and gastrostomy status. A quarterly MDS assessment dated February 6, 2026, documented these conditions. On April 13, 2026, after therapy staff reported that Resident 2 was suddenly very tired, the resident did not eat lunch and was brought to the nurse’s station with eyes closed and marked diaphoresis. At that time, blood sugar was 164 mg/dl, temperature 98.0 F, pulse 72 bpm, respirations 18, and blood pressure was 61/43 mmHg. The resident was placed back in bed, legs elevated, and given 500 cc water via gastrostomy tube. Blood pressure later improved to 92/54 mmHg, and a second 500 cc water bolus was given via gastrostomy tube before the physician was notified or an order was obtained. The DON confirmed that the RN did not notify or obtain a physician’s order before administering the two boluses.
Failure to Follow Ordered Orthostatic Vital Signs
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards of practice by not following a physician's order after a change in condition for Resident 54. The resident's quarterly MDS dated February 20, 2026, showed that she was cognitively intact, required extensive assistance with daily care needs, and had a diagnosis of heart failure. On March 10, 2026, nursing documentation noted that the resident said she felt as though she was falling out of bed and that everything was wrong, and an on-call practitioner was contacted with orders for orthostatic vital signs in the morning. An advanced practice nursing note from the same date documented that the resident complained of the room spinning while lying in bed and that staff were to perform orthostatic vital signs in the morning. There was no documented evidence in the clinical record that orthostatic blood pressures were obtained as ordered, and the DON confirmed that there was no documented evidence that the ordered orthostatic vital signs were completed after the resident's change in condition.
Warfarin Administered Despite Hold Order
Penalty
Summary
The facility failed to ensure that warfarin was held per physician orders for one resident who was cognitively impaired and receiving an anticoagulant for atrial fibrillation. The resident’s care plan directed that warfarin be administered as ordered, laboratory tests be obtained as ordered, and abnormal results be reported to the physician. A physician order dated April 6, 2026, directed warfarin 4 mg at bedtime and a PT/INR check on April 13, 2026. A laboratory report for the PT/INR on April 13, 2026 showed a critical INR of 5.7, and the result was called to the facility. The facsimile report included a physician order to hold warfarin for three days and check the INR daily for five days. Review of the MAR showed warfarin was still administered at bedtime on April 13 and April 14, 2026, despite the hold order. The DON confirmed that the warfarin should have been held on those dates and was not.
Missed INR Lab Draw for Resident on Warfarin
Penalty
Summary
The facility failed to ensure that laboratory specimens were obtained as ordered by the physician for Resident 3. Resident 3’s record showed cognitive impairment and anticoagulant use, with diagnoses including atrial fibrillation and a care plan directing that warfarin be administered as ordered, laboratory tests be completed as ordered, and abnormal results be reported to the physician. Physician orders included warfarin 4 mg at bedtime and a PT/INR check, and the laboratory later reported a critical INR of 5.7 to the facility with a read-back from nursing staff. A written physician order on the laboratory facsimile directed staff to hold coumadin for three days and check the INR daily for five days. A review of the clinical record showed that staff did not obtain the INR on April 14, 2026, as ordered. The Director of Nursing confirmed in interview that Resident 3 should have had an INR drawn on that date but did not.
QAPI Failed to Correct Repeated Deficiencies
Penalty
Summary
The facility’s QAPI committee failed to correct repeated quality deficiencies identified in prior surveys and did not ensure that plans to improve the delivery of care and services effectively addressed recurring problems. The report states that the facility had plans of correction for surveys ending March 20, 2025, April 8, 2025, and August 5, 2025, and those plans included monitoring by QAPI for baseline care plans, comprehensive care plans, services provided meeting professional standards, quality of care, pharmacy records, residents being free of significant medication errors, and infection prevention and control. The current survey ending April 16, 2026 found repeated deficiencies in those same areas, including baseline care plans (F655), develop/implement comprehensive care plan (F656), services provided meet professional standards (F658), quality of care (F684), pharmacy records (F755), residents are free of significant med error (F760), and infection prevention and control (F880). The report states that the QAPI committee was ineffective in maintaining compliance with these regulations despite the prior plans of correction and monitoring expectations.
Failure to Use EBP for Resident With Wound VAC
Penalty
Summary
The facility failed to follow infection control guidelines from CMS and CDC to reduce the spread of infections and prevent cross-contamination for one resident. CDC guidance cited in the report states that Enhanced Barrier Precautions (EBP) are used during high-contact resident care activities for residents with chronic wounds or indwelling medical devices, and the facility policy dated July 11, 2025, stated that an order for EBP would be obtained for residents with wounds and/or indwelling medical devices even if they were not known to be infected or colonized with an MDRO. Resident 5’s admission MDS dated March 9, 2026, indicated the resident was cognitively intact, needed staff assistance with daily care, had a diagnosis including fusion of the spine, and had surgical wounds. Physician orders dated March 17, 2026, directed staff to cleanse the mid back wound, pack the open wounds with black foam, and apply a wound VAC at -125 mmHg continuously, with changes three times a week and as needed for dislodgement. There was no documented evidence that orders were obtained for EBP related to the resident’s wound. On April 13, 2026, the resident was observed sitting in a wheelchair in her room with a wound VAC canister on the bedside table connected to tubing attached to her, with no signs indicating EBP and no PPE available in the room. The DON confirmed on April 14, 2026, that there were no orders for EBP and no EBP in place for the resident, although there should have been.
Failure to Document Pneumococcal Vaccine Offer and Refusal
Penalty
Summary
The facility failed to ensure that each resident received pneumococcal immunizations for one of 30 residents reviewed, Resident 16. The facility’s pneumococcal vaccine policy stated that residents were to be assessed prior to or upon admission for eligibility to receive the pneumococcal vaccine series and, when indicated, offered the vaccine within 30 days of admission unless medically contraindicated or already vaccinated, with refusals documented in the medical record. Resident 16’s annual MDS assessment indicated the resident’s pneumococcal vaccination was not up to date because the vaccine had been offered but declined; however, there was no documented evidence that the vaccine was actually offered or that the resident declined it. The Infection Control Nurse confirmed that there was no documented evidence that Resident 16 was offered the pneumococcal vaccine at admission or at any time afterward.
Neglect Due to Failure to Follow Two-Person Transfer Requirements
Penalty
Summary
The facility failed to protect a resident from neglect when staff did not follow the resident’s care plan and transfer requirements, resulting in a nondisplaced patella fracture. The resident had dementia, was cognitively impaired, and according to an annual MDS and care plan required substantial to maximum assistance and the assistance of two staff for transfers. Facility policy required use of the Kardex in the PCC system at the start of each shift to verify accurate information on transfer status and other care needs. Despite these requirements, a nurse aide transferred the resident alone from bed to wheelchair, believing the resident was a one-person assist and without checking the Kardex or care plan for the correct transfer status. During the transfer, the resident stated, “oh my leg,” but the aide did not observe obvious injury at that time. Later that day, the aide noticed the resident’s knee was red and reported this to the nurse. A nursing note documented that the resident complained of left knee pain with redness, warmth, and slight edema, and subsequent physician assessments noted ongoing swelling, erythema, warmth, and pain with weight-bearing. An X-ray ultimately revealed a nondisplaced patella fracture of unclear cause, as the resident reported no fall. The facility’s investigation, including interviews with the aide and leadership, confirmed that the aide had not accessed the Kardex, did not remember how to access it, and never looked at Kardexes for her residents, and that she failed to follow the resident’s care plan transfer interventions, leading to substantiated neglect associated with the injury.
Failure to Follow Care-Planned Transfer Status Resulting in Knee Fracture
Penalty
Summary
The facility failed to ensure a resident’s environment was free from accident hazards and that care-planned transfer interventions were followed. An annual MDS for Resident 3 showed cognitive impairment and a need for substantial to maximum assistance with bed-to-chair transfers. The resident’s care plan documented a self-care deficit related to decreased mobility and required assistance of two staff for transfers. Despite this, on the day in question, a nurse aide transferred the resident alone from bed to wheelchair without checking the resident’s Kardex for current transfer status, believing the resident was a one-person assist. The aide reported that she did not know how to access the Kardex on the kiosk and never looked at Kardexes for her residents. Following this transfer, the resident complained of left leg pain during the transfer and later that day had a red, warm, and slightly swollen left knee, which was reported to the nurse. Subsequent physician assessments documented ongoing left knee swelling, erythema, warmth, and pain with weight-bearing as reported by staff, although the resident denied pain at one point. An X-ray revealed a nondisplaced patella fracture of unclear cause, as the resident reported no fall. The facility’s internal accident/injury report concluded that the resident had an acute left knee fracture and that neglect was substantiated. The Nursing Home Administrator and DON confirmed that the nurse aide failed to follow the resident’s care plan transfer interventions, which resulted in the injury.
Failure to Prevent Elopement Due to Inadequate Supervision and Non-Functioning Wander Guard
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision and interventions to prevent elopement for a resident identified as being at risk. Facility policies required that an elopement risk observation be completed by a licensed nurse upon admission, re-admission, or significant change in status, and that interventions such as a Wander Guard device be implemented as needed. For one resident with dementia and a history of wandering, the care plan and physician orders specified the use of a Wander Guard, with function and placement to be checked every shift. However, documentation and interviews revealed that the resident was able to leave the facility unsupervised, and the Wander Guard system did not alarm as intended. On the day of the incident, the resident accessed the elevator, exited the building, and was later returned by EMS. Staff failed to recognize the event as an elopement, did not notify administrative staff until the following day, and did not perform a physical assessment or notify the resident's family upon return. The Wander Guard device was found to have a low battery, and system reports confirmed that the device's battery status had been low on the day of the elopement. Despite this, staff had charted that the Wander Guard was functioning for all shifts, and no immediate action was taken to check or replace the device after the resident was returned. Interviews with nursing staff and the administrator confirmed that the alarm system was not functioning properly prior to the elopement and that staff did not follow policy in responding to the incident. The administrator acknowledged that the Wander Guard should have been checked and replaced after the resident's return, and that no new interventions were implemented until the following day. The failure to ensure the proper functioning of the Wander Guard system and to respond appropriately to the elopement placed the resident in immediate jeopardy.
Removal Plan
- Resident 3's wander guard transmitter was replaced with a new transmitter and checked for function.
- A facility wide sweep was conducted on all in house wander guard transmitters to ensure proper function and battery life.
- Any transmitters with a low battery life or improper function were replaced.
- Disciplinary action was enforced with the staff member who failed to respond to the incident in a timely and appropriate manner.
- All licensed nursing staff were re-educated on the elopement policy and procedure.
- All licensed nursing staff were also re-educated on the wander guard system function and documentation.
- All new staff and agency staff will receive the education.
- The Director of Nursing or designee added checking the transmitter battery life to the weekly audit tool and the weekly audit tool would include wander guard placement and battery status.
- Any transmitters with a low battery status would be replaced at the time of discovery.
- The wander guard system check was completed daily and will continue to be checked for function daily.
- System check audits would be completed by the Building Services Director or designee daily for three months and transmitter audits would be completed weekly for four months, and then monthly for three months.
- Upon admission, all residents would receive an elopement assessment and the assessments would determine interventions as needed.
- Updates would be added to the resident care plan and discussed with the interdisciplinary team.
- Audit results would be reported to the Quality Assurance Performance Improvement committee to identify trends, further opportunities for quality improvement, and needs for additional education/re-education.
Significant Medication Error Due to Pharmacy Labeling
Penalty
Summary
A medication error occurred when a resident, who was moderately cognitively impaired and required staff assistance for daily care, was administered the wrong medication for several days. The resident was supposed to receive rosuvastatin calcium, but due to a pharmacy labeling error, was instead given warfarin tablets. The error was discovered when a medication nurse identified a discrepancy in the medication card, which was labeled as rosuvastatin calcium but contained warfarin. The resident's clinical records showed that she had diagnoses including heart failure and was discharged from the facility after the incident. Following the administration of the incorrect medication, the resident's blood work revealed a critically elevated INR of 7.0, indicating a significant alteration in blood clotting time. The facility notified the physician and family, and the pharmacy was contacted regarding the labeling error. However, there was no documented evidence that the facility investigated whether other medication cards in the facility were also mislabeled by the pharmacy. The facility later ended its contract with the pharmacy due to this breach in service.
Failure to Implement Wound Consultant Recommendations for Pressure Ulcer Care
Penalty
Summary
A facility failed to follow pressure ulcer treatment recommendations for a resident who was cognitively impaired, required assistance for care needs, and had a diagnosis of atherosclerotic heart disease. Upon admission, the resident had an order to apply skin prep to the heels every shift. On July 17, a nurse documented a blood-filled blister on the resident's left heel, and a wound consult was ordered. The following day, the wound care consultant assessed the resident and recommended applying skin prep to the base of the wound and securing it with a bordered foam dressing. However, no new orders were obtained to reflect this recommendation. Review of the resident's treatment administration records showed that the bordered foam dressing was not applied to the left heel from July 18 through July 25, despite the consultant's recommendation. By July 25, the resident's left heel wound had progressed to a Stage 3 pressure ulcer. An interview with the Assistant Nursing Home Administrator confirmed that the wound care orders, including the foam dressing, were not added to the resident's wound orders, resulting in the recommended wound care not being completed.
Medication Administration Error Due to Pharmacy Packaging
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the accurate receiving, dispensing, and administration of medication for a resident. According to facility policy, medications are to be administered as prescribed and in accordance with manufacturer specifications and good nursing practices. However, a medication card delivered from the pharmacy was labeled as rosuvastatin calcium but actually contained coumadin tablets. This error resulted in the resident, who was moderately cognitively impaired and had a diagnosis of heart failure, receiving coumadin instead of the prescribed rosuvastatin calcium for several days before the mistake was identified. Clinical documentation showed that the error was discovered when staff became aware that the medication card contained the wrong medication. The resident subsequently underwent lab work, which revealed an elevated INR, and the physician was notified. The incident was confirmed through interviews and review of records, which indicated that the pharmacy had packaged the medication incorrectly, leading to the administration error.
Failure to Follow Care Plan for ADL Assistance Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when staff failed to follow a resident's care plan for assistance with activities of daily living (ADLs) and fall prevention. The resident, who had a diagnosis of morbid obesity and was identified as being at risk for falls due to balance issues, required assistance from two staff members for bed mobility and transfers, as documented in the care plan. Despite this, a nurse aide provided in-bed care with only one staff member present. During the provision of care, the resident was rolled onto his left side to be changed after a bowel movement. While the nurse aide was cleaning the resident, he reached for an item on his nightstand and rolled out of bed, falling onto the floor and landing on his right hip. The resident reported hip pain, and subsequent assessment and x-ray revealed an intertrochanteric fracture of the right hip. The incident was confirmed by statements from both the nurse aide and the resident, as well as documentation in the clinical record. The facility's investigation determined that neglect had occurred because the nurse aide did not adhere to the care plan, which required two staff for bed mobility. The nurse aide had previously completed training on preventing, recognizing, and reporting abuse, but failed to follow the established protocol for this resident, resulting in the fall and injury.
Failure to Follow Care Plan for Fall-Risk Resident Results in Injury
Penalty
Summary
A deficiency occurred when staff failed to implement care-planned interventions for a resident identified as a fall risk. The resident had a history of morbid obesity, decreased mobility, and required assistance from two staff members for bed mobility and transfers, as documented in the care plan. Despite these documented needs, an agency nurse aide provided in-bed care with only one assist, contrary to the care plan requirements. During routine care, the nurse aide rolled the resident onto his left side to change him after a bowel movement. While being assisted, the resident reached for an item on his nightstand and rolled out of bed, falling onto the floor and landing on his right hip. The resident reported hip pain and was found to have small scratches on his right elbow. Subsequent x-rays revealed an intertrochanteric fracture of the right hip, which was determined to be likely acute in nature. The investigation confirmed that the nurse aide did not follow the resident's care plan, which specified the need for two-person assistance with bed mobility. The aide admitted to providing care alone and was unaware of the specific requirements at the time. This failure to follow the care plan directly resulted in the resident's fall and subsequent injury.
Failure to Follow Care Plan for Bed Mobility Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when a resident, who had a history of morbid obesity, decreased mobility, and was care planned to require assistance from two staff members for bed mobility and transfers, experienced a fall resulting in a right hip fracture. The resident's care plan specifically indicated the need for two-person assistance due to self-care deficits and balance issues. Despite these documented needs, a nurse aide provided in-bed care with only one assist during a routine care activity. During the incident, the nurse aide rolled the resident onto his left side to perform hygiene care after a bowel movement. While the resident was being repositioned, he reached for an item on his nightstand and rolled out of bed, landing on his right hip. The resident reported pain, and subsequent assessment and x-ray revealed an intertrochanteric fracture of the right hip. The nurse aide later acknowledged that she did not follow the care plan and believed she could manage the task alone. Investigation confirmed that the nurse aide failed to adhere to the resident's care plan, which required two staff for bed mobility. This failure to follow the established care plan and provide adequate supervision directly resulted in the resident's fall and injury. The deficiency was cited as past non-compliance after review of clinical records, staff statements, and investigation documents.
Failure to Follow Physician's Orders for Medication and Weight Monitoring
Penalty
Summary
The facility failed to ensure that residents received care and treatment in accordance with professional standards of practice. For Resident 15, who was cognitively impaired and diagnosed with hypertension, the facility did not adhere to the physician's orders regarding the administration of Labetalol. Despite the order to withhold the medication if the resident's heart rate was below 50 beats per minute, the medication was administered on two occasions when the heart rate was 44 bpm and 47 bpm, respectively. Additionally, the facility did not follow physician's orders for Residents 70 and 95 regarding weight monitoring and physician notification. Resident 70 experienced a 4.4-pound weight gain overnight, but there was no documented evidence that the physician was informed. Similarly, Resident 95 had a significant weight gain of 47.8 pounds over a few days, yet the physician was not notified. These failures were confirmed through staff interviews, indicating a lack of adherence to prescribed care protocols.
Plan Of Correction
Resident 15 had no adverse reactions to having an antihypertensive medication (a medication that treats hypertension) administered outside of heart rate parameters set forth by the physician. The physician was made aware of the medication administration outside of the parameters. Resident 70 had no adverse reactions to not having the medical doctor (MD) notified of a weight gain in one day. The resident is no longer in the facility. Resident 95 had no adverse reactions to not having the MD notified of a weight gain in one day. The resident is no longer in the facility. Facility-wide sweep for all residents who have heart rate parameters with antihypertensive medications to ensure that heart rate parameters were followed according to physician order was conducted. Facility-wide sweep for all residents with significant weight loss was conducted to ensure proper physician notification. Any issues identified were corrected at time of discovery. All licensed nursing staff was re-educated on heart rate parameters surrounding antihypertensive medications and notification of physician in addition to significant weight change education. The Assistant Nursing Home Administrator or designee will conduct audits to ensure that heart rate parameters with antihypertensive medications are followed and that all significant weight changes have physician notification, weekly for 4 weeks and then monthly for 2 months. Identified issues will be addressed at time of discovery. Audit results will be reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for quality improvement and needs for additional education.
Failure to Maintain Accountability of Controlled Medications
Penalty
Summary
The facility failed to ensure the accountability of controlled medications for three residents. For one resident, the records showed that a Fentanyl patch was applied on multiple dates, but there was no documented evidence that the old patches were destroyed as required. This lack of documentation was confirmed by the Nursing Home Administrator during an interview. Another resident had orders for Oxycodone/Tylenol to be administered as needed, but the medication administration record did not show evidence of administration on several dates when the controlled drug record indicated it was signed out. Similarly, a third resident had orders for Percocet, but the medication administration record did not reflect administration on dates when the controlled drug record showed it was signed out. The Nursing Home Administrator confirmed the absence of documentation for the administration of these medications. These findings indicate a failure in maintaining accurate records and accountability for controlled substances, as required by the regulations.
Plan Of Correction
Residents 28 and 36 were noted to not have any adverse effects from not having documented medication administration in the electronic medical record (EMR). Resident 4 was noted to not have any adverse effects from not having documentation of destroyed controlled substances. A facility-wide sweep of all residents in-house with the physician order of Percocet was conducted to ensure all administrations were documented in the narcotic book and matched the EMR. A facility-wide sweep of all residents with Fentanyl patches had documentation of medication destruction upon removal on the narcotic (NARC) signoff sheet. All licensed nurses were educated on medication administration and documentation in the EMR, as well as the destruction of controlled substances. The Director of Nursing or designee will conduct audits to ensure that all Percocet administrations are documented in the narcotic book and match the EMR, and that Fentanyl patches have documentation of medication destruction upon removal on the NARC sheet weekly for 4 weeks and monthly for 2 months. Identified issues are addressed at the time of discovery. Audit results are reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for quality improvement and needs for additional education/re-education.
Sanitary Conditions Not Maintained in Food Service
Penalty
Summary
The facility failed to ensure that food was prepared and served under sanitary conditions, as required by professional standards for food service safety. During an observation in the main kitchen, several food items, including American cheese, scones, Danish pastries, apple pie, blueberry pie, and a bag of brownie mix, were found open to air and undated. This was confirmed by an interview with the Executive Chef, who acknowledged that these items should have been covered and dated according to the facility's policy on food and nutrition services. Additionally, an observation in the kitchenette revealed that a Nurse Aide entered the area without wearing a hairnet, which is a violation of the facility's policy requiring employees to wear appropriate hair restraints. This was confirmed in an interview with the Nursing Home Administrator, who acknowledged that the Nurse Aide should have been wearing a hairnet while in the food preparation area. These findings indicate a failure to adhere to the facility's established protocols for maintaining sanitary conditions in food service areas.
Plan Of Correction
All food products identified as open to air and undated were immediately discarded. This includes one-quarter pound of American cheese, 15 scones, 6 Danishes, 1 apple pie, 1 blueberry container, and 1 brownie mix. Nurse Aide 3 has since been removed from duties and dismissed from Redstone. A facility-wide sweep of all food storage areas and pantries was conducted to ensure proper storage. All issues identified were corrected at the time of discovery. The System Food Service Director and dietary staff were re-educated on the proper storage of food products. The System Food Service Director, dietary and nursing staff was re-educated on proper food handling and PPE etiquette. The System Food Service Director or designee will conduct audits to ensure proper storage of all food products, weekly X4 weeks, monthly x2 months. The Director of Nursing Assistants (DNA) or designee will conduct spot-check compliance audits to ensure proper food handling and personal protective equipment (PPE) etiquette during meals weekly X4 weeks, monthly X2 months. Identified Issues are addressed at the time of discovery. Audit results are reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for quality improvement and needs for additional education/re-education.
Failure to Document Hospice Wound Assessments
Penalty
Summary
The facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for a resident who received hospice services. The agreement between the facility and the hospice provider, dated March 5, 2021, stipulated that hospice services should be provided at the same level as if the resident were in their own home. The facility's policy, dated September 27, 2024, required the hospice provider to document pertinent information relative to each visit throughout the course of care. The resident in question had a Stage 3 pressure ulcer and was receiving hospice care. The care plan required staff to document weekly the treatment and measurements of the wound. However, there was no documented evidence of the weekly wound assessments and measurements being completed for several weeks, specifically from September 8 through November 22, 2024. This lack of documentation indicated a failure to meet the requirements set forth in the hospice agreement and facility policy. An interview with the Director of Nursing confirmed that the hospice was responsible for following the resident's wounds during their visits. However, the hospice did not provide any documented evidence of their weekly wound assessments and measurements being completed on the specified dates. This oversight led to the deficiency cited in the report.
Plan Of Correction
A communication was made to the hospice team to ensure all documentation was made available in resident 35's electronic medical record (EMR) as it relates to weekly wound assessment/measurements for the weeks of September 8 through 14, 2024; September 15 through 21, 2024; September 22 through 28, 2024; September 29 through October 5, 2024; October 6 through 12, 2024; October 13 through 19, 2024; and November 17 through 22, 2024. A sweep of all hospice caseloads was conducted to ensure all wound records of hospice services were rendered into the patient's EMR. Any issues identified were corrected at the time of discovery. The skilled nursing interdisciplinary team (IDT) and hospice IDT members were re-educated on having all records of hospice services rendered to the patient available in the patient's electronic medical record. The risk management assistant or designee will conduct audits to ensure all wound documentation of hospice services rendered is made available in the hospice patient's electronic medical record weekly X4 weeks, monthly X2 months. Identified issues will be addressed at the time of discovery. Audit results are reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for quality improvement and needs for additional education/re-education.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for a resident, leading to a deficiency in compliance with regulatory requirements. The resident, who was cognitively intact and required assistance for daily care, suffered an ankle fracture. Despite the facility's policy mandating a thorough investigation for injuries of unknown origin, there was no documented evidence that such an investigation was conducted to rule out abuse or neglect as potential causes. The Director of Nursing interviewed the resident, who denied any abuse, and concluded the investigation without further action. However, there was no documentation to show that neglect was considered or ruled out as a cause for the fracture. This lack of a comprehensive investigation into the resident's injury of unknown origin resulted in a failure to meet the regulatory requirements for investigating and preventing potential abuse or neglect.
Plan Of Correction
I hereby acknowledged the CMS 2567-A, issued to Redstone Highlands Health Care Center for the survey ending March 20, 2025 and attest that all deficiencies listed on the form will be corrected in a timely manner. This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because Redstone Highlands Healthcare Center agrees with the allegations and citations listed on the statement of deficiencies. Redstone Highlands Healthcare Center maintains that the alleged deficiencies do not, individually and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as Redstone Highlands Healthcare Center's written credible allegation of compliance. By submitting this plan of correction, Redstone Highlands Healthcare Center does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Redstone Highlands Healthcare Center reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding. Resident 24 was assessed and noted to have no adverse effects related to the investigation of ruled-out neglect from the incident dated October 12, 2024. The resident is followed to ensure psycho-social needs are met. No new orders from the physician. The resident has had no adverse effects from the completed investigation of injury of unknown origin. A facility-wide sweep of all residents with pain scales presenting with unidentified pain source, if applicable. Any issues identified were corrected at the time of discovery, and an investigation will be initiated to rule out abuse/neglect and identify the cause, if applicable. The whole house staff was educated on the Abuse / Neglect Prohibition policy and procedure. The Director of nursing (DON) or designee will conduct audits to ensure all pain scales with unidentified sources are investigated to rule out abuse/ neglect to completion and documented weekly for 4 weeks, then monthly for 2 months. Identified issues will be addressed at the time of discovery. Audit results are reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for quality improvement and needs for additional education/re-education.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for three residents, leading to deficiencies in the documentation of their medical status. For one resident, the MDS assessment did not accurately reflect the administration of anticoagulant and diuretic medications, despite physician's orders and medication administration records indicating that these medications were given during the seven-day look-back period. This discrepancy was confirmed through an interview with the Registered Nurse Assessment Coordinator (RNAC). Additionally, the facility inaccurately coded the discharge status for two residents. One resident was discharged home with home health services, but the MDS assessment incorrectly indicated a discharge to a short-term general hospital. Another resident's death tracking MDS assessment inaccurately recorded the resident as deceased, while nursing notes confirmed the resident was sent to a hospital for further evaluation and treatment. These inaccuracies were confirmed through interviews with the Assistant Campus Director.
Plan Of Correction
Residents 69 and 96 have discharged from the facility. Resident 55 MDS was updated with appropriate coding. A facility-wide sweep of all residents meeting the requirements of anticoagulants and diuretic medications on admission assessments, discharge status in Section A2105 of discharge assessments, and accurate discharge to the hospital minimum data set (MDS) tracking's were opened were completed going back to February 1, 2025. Any issues identified were corrected at the time of discovery. The Registered Nurse Assessment Coordinators (RNAC) was re-educated regarding the resident assessment instrument (RAI) Manual for Section N: Medications and Section A: Identification Information. The Nursing home administrator (NHA) or designee will conduct audits to ensure that Admission MDS assessments with anticoagulant and diuretics coded were completed correctly per the RAI Manual, and discharge assessments will have accurate discharge tracks and locations completed correctly per the RAI Manual required schedule weekly X4 weeks, then monthly X2 months. Identified issues will be addressed at time of discovery. Audit results are reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for quality improvement and needs for additional education/re-education.
Failure to Develop Baseline Care Plans for Residents
Penalty
Summary
The facility failed to ensure that baseline care plans were developed for three residents, which included necessary information regarding their immediate care needs. The facility's policy required that a baseline care plan be initiated upon admission and completed within 48 hours, individualized to each resident. However, for Resident 89, who required a feeding tube for nutritional support, there was no documented evidence of a baseline care plan addressing the need for Enhanced Barrier Precautions (EBP) due to the feeding tube. Similarly, Resident 94, who had a Foley catheter for urinary retention, also lacked a baseline care plan addressing EBP needs. Additionally, Resident 95, who had a Foley catheter and was on anticoagulant and diuretic medications, did not have a baseline care plan that included EBP needs. Interviews with the Nursing Home Administrator and the Assistant Campus Director confirmed the absence of these baseline care plans for the residents' specific care and treatment needs. The facility's failure to develop these plans was identified during a review of facility policies, clinical records, and staff interviews.
Plan Of Correction
Resident 89, 94 and 95 had no adverse reactions related to not having a baseline care plan demonstrating the need for enhanced barrier precautions (EBP), anticoagulants or diuretics. Resident 89 is no longer in the facility. Resident 94 is no longer in the facility. Resident 95 is no longer in the facility. A facility-wide sweep of all foley catheters, feeding tubes, anticoagulants and diuretics was conducted to ensure that a baseline care plan was initiated with the related items in place. Any issues identified were corrected at time of discovery. The registered assessment coordinator (RNAC) and all licensed nursing staff were re-educated regarding updating the baseline care plan with enhanced barrier precautions (EBP) for foley catheters and feeding tubes as well as to demonstrate the use of anticoagulants and diuretics. The Assistant Nursing Home Administrator or designee will conduct audits to ensure that the baseline care plan is initiated and the proper related items are in place, weekly X4 weeks, and then monthly X2 months. Identified issues will be addressed at time of discovery. Audit results will be reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for quality improvement and needs for additional education.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, which led to deficiencies in addressing their specific care needs. For one resident, who was cognitively impaired and required assistance for daily care needs, there was no documented care plan to address the management of her colostomy. This oversight was confirmed by the Nursing Home Administrator during an interview, acknowledging that a care plan should have been in place for the resident's colostomy care. Another resident, who was cognitively intact and had a diagnosis of diabetes, did not have a care plan developed to address her diabetes management or the use of a continuous glucose monitoring system. Despite having physician orders for the use of a Freestyle Libre 3 sensor, there was no documentation of a care plan to support her treatment needs. This lack of documentation was also confirmed by the Nursing Home Administrator, indicating a failure to provide individualized care planning for the resident's diabetes management.
Plan Of Correction
Resident 40's care plan was updated to include the presence of an ostomy and interventions to address the care and maintenance. Resident 55's care plan was updated to include Diabetes Mellitus and the use of a continuous glucose monitor. Facility-wide sweep was conducted to capture other residents who have colostomies and diabetes and their care plans to ensure that colostomy status, diabetes mellitus and continuous glucose monitoring have been included with interventions in the care plans. Any issues identified were corrected at time of discovery. The registered nurse assessment coordinator (RNAC) and licensed nursing staff were re-educated on the need to update the comprehensive care plan accurately and timely when resident changes occur. The Assistant Nursing Home Administrator or designee will conduct audits to ensure that the care plan updates are completed timely weekly X4 weeks, then monthly fX2 months. Identified issues will be addressed at time of discovery. Audit results will be reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for quality improvement and needs for additional education.
Failure to Update Resident Care Plan Post-Antibiotic Therapy
Penalty
Summary
The facility failed to update and revise a resident's care plan to reflect specific care needs, as required by regulations. The deficiency was identified for one resident, who was cognitively intact and required assistance for daily care needs. The resident had been diagnosed with pneumonia and was on antibiotic therapy. The care plan, dated March 4, 2025, indicated that staff were to administer the antibiotic medication as ordered by the physician. However, the care plan was not updated when the resident's antibiotic therapy was completed. This oversight was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the care plan should have been updated. The facility's policy, dated September 27, 2025, stated that care plans should be individualized and updated by the licensed nurse and interdisciplinary team as needed with changes as applicable.
Plan Of Correction
Resident 73's care plan has been updated to demonstrate discontinued orders and interventions appropriate to identified needs. A facility-wide sweep of all discontinued antibiotic therapy was conducted. Any issues identified were corrected at the time of discovery. The registered nurse assessment coordinator (RNACs) and licensed nursing staff were re-educated regarding timely resident care plan revisions when resident changes occur. The Assistant Nursing Home Administrator or designee will conduct audits to ensure that care plan revisions are completed timely, weekly for 4 weeks, then monthly for 2 months. Identified issues will be addressed at the time of discovery. Audit results will be reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for quality improvement and needs for additional education.
Failure to Clarify Provider's Orders for Wound Care
Penalty
Summary
The facility failed to clarify a provider's orders for a resident, leading to a deficiency in meeting professional standards of quality care. The resident, who was cognitively intact and required assistance for daily care needs, had a history of a left hip fracture, diabetes, and dementia. The resident's care plan included orders for wound care on the heels due to deep tissue injury and pressure ulcers. However, discrepancies were found between the verbal orders given by the wound consultant and the written orders documented in the clinical records. The verbal orders instructed the wound nurse to change the dressings every other day, while the written assessments indicated daily changes. The inconsistency in the orders was further complicated by the wound consultant's process, where verbal orders were given to the wound nurse, but the consultant's assistant typed the assessments, leading to mismatched documentation. This lack of clarity and consistency in the orders resulted in the facility's failure to meet the professional standards of quality care as required by the Pennsylvania Nursing Practice Act and the comprehensive care plan regulations.
Plan Of Correction
Resident 48 had no adverse reactions to having wound care orders not matching the wound physician's orders from rounding notes. Physician's order has been updated and the electronic medical record (EMR) reflects update. Resident 48 has since been discharged from the facility. A facility-wide sweep on all in-house residents with active wound care orders was conducted to ensure all rounding wound care physician orders were correctly transcribed into the EMR. Any issues identified were corrected at time of discovery. The wound care coordinator and all licensed nursing staff was re-educated on transcription of wound care orders from the rounding wound physician into the EMR. The Assistant Nursing Home Administrator or designee will conduct audits to ensure that EMR orders for wound care match the MD rounding report from the rounding wound physician, weekly X4 weeks then monthly X2 months. Identified issues will be addressed at time of discovery. Audit results will be reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for quality improvement and needs for additional education.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to ensure the secure storage of medications, as evidenced by an unlocked and unsecured medication cart on the first floor, which was accessible to residents, family, and staff. This was observed while a registered nurse was attending to a resident in a room. Additionally, loose pills were found in the second drawer of the medication cart, not in their original pharmacy packaging, which was confirmed by an LPN to be inappropriate. Furthermore, the facility did not store unopened and unused multi-dose containers of insulin according to the manufacturer's instructions. An unopened Insulin Aspart Pen Injector for a resident was found in the medication cart instead of being refrigerated as required. The facility also failed to store refrigerated controlled medications in a separately locked, permanently affixed container. A red plastic box containing Ativan Intensol was not permanently affixed to the refrigerator, allowing it to be removed, which was confirmed by the Assistant Director of Nursing.
Plan Of Correction
All medication carts were rounded on and ensured to be locked. Any loose medication within the drawer of the medication cart was destroyed by nursing staff via drug buster. The insulin pen within the medication cart was immediately discarded. Controlled substance contents was moved to a permanently affixed box within the refrigerator that was preexisting. A Facility-wide sweep was conducted to include: all medication carts to ensure that they are locked when not in use; that there are no loose medications in the drawers; and that all insulin is dated once removed from the refrigerator. In addition, a facility-wide sweep of medication room refrigerators was conducted to ensure that all controlled substance boxes are permanently affixed to the refrigerator. Any issues identified were corrected at time of discovery. All licensed nursing staff was re-educated on the policies including but not limited to medication storage, disposition and labeling. The director of nursing (DON) or designee will conduct audits to ensure that all med carts are locked when not in use, no loose medications are left in the med cart, all insulin pens are dated when outside of the refrigerator and all controlled substance boxes in the medication room refrigerators are permanently affixed, weekly X4 weeks then monthly X2 months. Identified issues will be addressed at time of discovery. Audit results will be reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for quality improvement and needs for additional education.
Infection Control Deficiency in Wound Care
Penalty
Summary
The facility failed to adhere to proper infection control practices during the administration of treatment for a resident with pressure ulcers. The resident, who was cognitively intact and required assistance for daily care needs, had a diagnosis that included a left hip fracture, diabetes, and dementia. Physician's orders indicated that the resident's bilateral heels were to be cleansed and dressed every other day due to pressure ulcers. During an observation, a registered nurse provided wound care to the resident's heels without wearing a gown, which was against the facility's policy for enhanced barrier precautions (EBP). The nurse removed the soiled dressing from the resident's left foot, removed her gloves, and donned clean gloves without performing hand hygiene in between. This was confirmed by the nurse during an interview, acknowledging the lapse in hand hygiene. Further interviews revealed that the resident should have been on EBP due to having wounds, but there were no EBP supplies available in the resident's room. The Nursing Home Administrator confirmed that EBP was not in place for the resident and that the nurse should have washed her hands after glove removal and worn a gown during the treatment administration.
Plan Of Correction
Resident 48 had no adverse reactions from Registered Nurse 1's providing wound care without wearing a gown per enhanced barrier precautions (EBP) protocol. Resident 48 has since been discharged in good condition from the facility. Registered Nurse 1 was immediately re-educated on EBP precautions and proper hand hygiene. A facility-wide sweep was conducted of all in-house residents with wounds requiring EBP to ensure EBP is followed during wound/skin treatments. Any issues identified were corrected at the time of discovery. All licensed therapists and nursing staff were re-educated on EBP protocol and proper hand hygiene. The Infection Control Preventionist or Designee will conduct spot-check audits to ensure EBP protocol is being followed along with proper hand hygiene during wound/skin treatments for weekly X4 weeks and monthly X2 months. Identified issues will be addressed at the time of discovery. Audit results are reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for quality improvement and needs for additional education/re-education.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents and their responsible parties regarding the reasons for hospital transfers, as required by regulations. This deficiency was identified for five residents during a review of clinical records and staff interviews. The facility did not document the reasons for the transfers in writing, nor did they notify the residents' responsible parties, which is a violation of the notice requirements before transfer or discharge. Resident 28, who was cognitively intact and dependent on staff for daily care, was transferred to the hospital without written notification to the responsible party. Similarly, Resident 39 was admitted to the hospital with a urinary tract infection, and there was no documented evidence of written notice provided. Resident 40, who was cognitively impaired and required maximum assistance, was sent to the hospital following a fall, but again, no written notice was given to the responsible party. Resident 48, who had multiple diagnoses including a hip fracture and dementia, was transferred to the hospital twice due to worsening kidney function, yet no written notice was provided. Lastly, Resident 69, who had cancer and other conditions, was sent to the hospital due to ostomy issues, but there was no documented evidence of written notification to the resident or their responsible party. Interviews with facility administrators confirmed the lack of written notices for these transfers.
Plan Of Correction
Residents 69 and 48 have since been discharged from the facility. Residents 39, 28, and 40 have not been sent out of the facility since findings. A sweep of all resident transfers was conducted to ensure there was documentation evidence of written notice to the resident's responsible party regarding the reasoning for the transfer from the facility. All issues discovered were corrected at the time of discovery. The navigation team was re-educated on written notice to the resident's responsible party when a transfer is facility-initiated. The Nursing home administrator (NHA) or designee will conduct audits to ensure all facility-initiated transfers have documented written notice to the responsible party regarding the reason for transfer weekly X4 weeks, then monthly X2 month. Identified issues will be addressed at the time of discovery. Audit results are reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for quality improvement and needs for additional education/re-education.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
The facility failed to serve food items at palatable temperatures, as evidenced by resident interviews, observations, and staff interviews. The facility's policy required cold food to be served between 33 and 50 degrees Fahrenheit and hot food between 135 and 155 degrees Fahrenheit. However, residents reported that food served in their rooms was often cold, and a food committee meeting confirmed inconsistent food temperatures. During an observation of lunch meal service, a test tray revealed that iced tea was 49 degrees F, coffee was 138 degrees F, mixed vegetables were 119 degrees F, pork was 129 degrees F, and rice was 136.2 degrees F. The Dietary Director confirmed that the food was not at an appetizing temperature.
Failure to Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to ensure timely notification of a resident's physician regarding a change in condition. Resident 40, who was cognitively impaired and at risk for dehydration due to diuretic use, had physician's orders for daily weights with instructions to notify the physician if there was a significant weight change. The resident refused daily weights, and although a communication form was sent to the physician, there was no documented response as of two days later. The Director of Nursing confirmed the lack of documented evidence of physician notification about the refusals, which should have been done according to the facility's policies.
Failure to Maintain Comfortable Air Temperatures in Dining/Activity Room
Penalty
Summary
The facility failed to provide comfortable air temperatures in the second-floor dining/activity room. Observations revealed that residents were eating lunch with blankets and long sleeves on, and they verbalized that the room was cold. Interviews with a group of residents confirmed that the second-floor dining room was very cold, making them uncomfortable during activities and meals. An Activities Aide noted that the room thermometer was set at 70 degrees Fahrenheit, but residents still found the room too cold, affecting their participation in activities and meals. The Maintenance Director confirmed that the air conditioner was turned on throughout the facility, and the heat was turned off, making it impossible to run both simultaneously. He acknowledged residents' complaints about the cold and mentioned using portable heaters during the winter. Observations and interviews confirmed that the room temperature was 67 degrees Fahrenheit, and the room had many unsealed windows letting in cold air. The Director of Nursing confirmed that the room should be at a comfortable temperature for the residents.
Failure to Complete Annual MDS Assessments on Time
Penalty
Summary
The facility failed to ensure that a comprehensive annual Minimum Data Set (MDS) assessment was completed within the required time frame for two residents. According to the Resident Assessment Instrument (RAI) User's Manual, an annual MDS assessment must be completed no later than 366 days after the previous comprehensive assessment's Assessment Reference Date (ARD) and within 92 days since the ARD of the previous quarterly assessment. For Resident 11, the ARD of the next annual MDS was 35 days late, and for Resident 52, it was 25 days late. The Director of Nursing confirmed that the annual MDS assessments for these residents were completed late during an interview on April 25, 2024.
Failure to Develop Care Plan for Exit-Seeking Behavior
Penalty
Summary
The facility failed to develop an individualized care plan for a resident exhibiting exit-seeking behavior. A quarterly Minimum Data Set (MDS) assessment for the resident revealed cognitive impairment and behaviors such as hitting, kicking, yelling, screaming, and rummaging. A nursing note documented an incident where the resident attempted to leave a locked unit and was brought back by a nurse aide after a visitor mistakenly let her out. Despite this incident, there was no documented evidence of a care plan addressing the resident's exit-seeking behavior. The Director of Nursing confirmed that a care plan should have been developed but was not.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure that a resident's care plan was updated to reflect the resident's specific care needs for two residents. For Resident 8, the admission Minimum Data Set (MDS) assessment dated February 8, 2024, indicated cognitive impairment and extensive assistance with daily care needs. However, the care plan dated February 5, 2023, included the use of heparin and antibiotics, which the resident was not receiving as of April 22, 2024. The Director of Nursing confirmed on April 24, 2024, that the care plan was not updated to reflect the current medication orders for Resident 8. For Resident 20, the quarterly MDS assessment dated March 12, 2024, revealed severe cognitive impairment and extensive assistance with daily care needs. The care plan revised on March 5, 2024, indicated the use of a Wanderguard and identified the resident as an elopement risk. Despite a nursing note from October 2, 2023, documenting an elopement incident, the care plan was not updated to include new interventions to prevent further elopements. The Director of Nursing confirmed on April 25, 2024, that the care plan should have been updated to reflect these new interventions.
Failure to Provide Appropriate Catheter Care
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter. The facility's policy required catheter care to be performed at least twice daily and after bowel incontinence or when secretions accumulated around the urinary meatus. The care plan for the resident indicated that catheter care should be provided every shift. However, documentation revealed that catheter care was not completed during several evening and night shifts in March and April 2024. This was confirmed by the Assistant Director of Nursing.
Failure to Ensure Timely Re-Weighs and Notifications for Significant Weight Loss
Penalty
Summary
The facility failed to ensure timely re-weighs, physician notification, and intervention for a resident who experienced significant weight loss. According to the facility's weight management policy, a resident's weight should be retaken if there is a change of five percent or more since the last assessment, and if there is an actual five percent or more gain or loss in one month, the resident's family, physician, and the nutrition services director should be notified. Resident 320, who was cognitively intact and required extensive assistance for daily care needs, experienced a 10.4-pound weight loss in five days and a further drop in weight over the following week. Despite these significant changes, there was no documented evidence that the resident was re-weighed or that the necessary notifications were made according to the facility's policy. A dietary note indicated that the dietary department was aware of the resident's significant weight loss and had recommended supplements to address the issue. However, the resident continued to lose weight, and there was no documentation of re-weighs or notifications to the family, physician, or nutrition services director. The Director of Nursing confirmed that the weight loss was not noted until five days after it first occurred, indicating a failure to follow the facility's policy on weight management and timely intervention.
Failure to Follow Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to ensure the physician's order for oxygen was followed for one resident. The facility policy for oxygen administration indicated that oxygen should be started at the prescribed liter flow and may be titrated according to physician orders. Resident 10, who was cognitively intact and required assistance for daily care needs, had diagnoses of pulmonary fibrosis and pneumonia. The physician's orders and care plan for Resident 10 specified an oxygen flow rate of 0-6 liters. However, observations revealed that the resident was using oxygen at a flow rate of 7 liters. Interviews with a Licensed Practical Nurse and the Director of Nursing confirmed that the oxygen flow rate was set incorrectly and should have been within the prescribed range.
QAPI Committee Ineffectiveness in Addressing Recurring Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. The current survey identified repeated deficiencies related to the development and implementation of comprehensive care plans, care plan timing and revision, and respiratory care. These deficiencies were previously cited in a survey ending May 24, 2023, and the facility had developed plans of correction that included monitoring by the QAPI committee. However, the QAPI committee was ineffective in maintaining compliance with these regulations, as evidenced by the repeated deficiencies found in the current survey ending April 25, 2024. Specifically, the facility's plan of correction for the deficiency regarding the development and implementation of comprehensive care plans, cited under F656, was not effective. Similarly, the plan of correction for care plan timing and revision, cited under F657, and the plan for respiratory care, cited under F695, were also ineffective. The QAPI committee's failure to maintain compliance with these regulations indicates that the quality assurance systems in place were not sufficient to address and correct the recurring deficiencies.
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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