Rehab & Nursing Ctr Greater Pittsburgh
Inspection history, citations, penalties and survey trends for this long-term care facility in Greensburg, Pennsylvania.
- Location
- 890 Weatherwood Lane, Greensburg, Pennsylvania 15601
- CMS Provider Number
- 395851
- Inspections on file
- 38
- Latest survey
- March 2, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Rehab & Nursing Ctr Greater Pittsburgh during CMS and state inspections, most recent first.
A resident with dementia, psychotic disorder with delusions, and a known history of wandering and wanting to leave, had been identified as an elopement risk and was documented as testing door handles and keypads and running toward open lobby doors. One evening, the resident was last observed in a wheelchair at the nurse’s station before EMS arrived and was granted entry through a remotely opened coded mag lock door. The resident, positioned close enough to the door, prevented it from closing, then moved through the corridor to an unalarmed exterior door, exited undetected, and was later found outside in a wheelchair by EMS attempting to approach the ambulance. Facility leadership acknowledged that adequate supervision to prevent elopement was not provided.
Surveyors observed that food products in the main kitchen's walk-in cooler and freezer were not stored according to facility policy, including an undated opened jar of grape jelly and boxes of food stacked to the ceiling and under fans. The Dietary Manager confirmed these improper storage practices and the failure to maintain sanitary conditions.
Three residents with diabetes experienced low blood glucose levels, but staff did not assess for hypoglycemia, monitor the effectiveness of treatment, or notify the physician as required by facility policy and physician orders. Care plans lacked appropriate interventions, and the DON confirmed these failures in documentation and protocol adherence.
Four residents with various medical conditions requiring oxygen therapy were found using oxygen equipment that was not labeled with the required date, contrary to facility policy and physician orders. Observations and staff interviews confirmed that proper labeling and maintenance procedures for oxygen tubing were not followed.
Grievance boxes in three facility locations were mounted above ADA-recommended heights and were sometimes blocked by furniture, making them inaccessible to residents, especially those using wheelchairs. Residents reported being unable to file grievances anonymously and often had to ask staff for assistance, which compromised their privacy. The NHA confirmed the lack of accessibility for these grievance boxes.
A resident who was cognitively intact and required moderate assistance for mobility was subjected to neglect and verbal abuse when a nurse aide failed to respond promptly to a call bell, made dismissive remarks, and exhibited a pattern of negative behavior including swearing and refusing assistance. The DON did not recognize these incidents as potential neglect or abuse and did not investigate further.
A resident with multiple medical conditions reported delayed response to a call bell and dismissive behavior from a nurse aide. Staff statements described the aide as having a negative attitude, swearing, and being unhelpful to residents. The DON did not recognize these incidents as potential abuse or neglect, failed to conduct a thorough investigation, and did not report findings to the State Survey Agency as required.
The facility did not post up-to-date nurse staffing information, as required, with the displayed information being outdated and not reflecting the current census or staffing hours. Both the receptionist and the NHA confirmed the posting was not current.
Surveyors found that the facility did not post required contact information for APS, the Medicaid Fraud Control Unit, or a statement about filing complaints with the State Survey Agency. The Nursing Home Administrator confirmed the absence of this information during an interview.
A resident with multiple medical conditions and a high risk for falls was not provided with adequate assistance or bedrails during incontinence care. A nurse aide turned the resident away and left her unsupervised while retrieving supplies, resulting in the resident falling from bed and sustaining a head injury and cervical fracture. Staff and leadership confirmed that proper supervision and interventions were not provided, constituting neglect.
A resident with multiple medical conditions and a high risk for falls was left unattended during incontinence care when a nurse aide turned away to retrieve supplies, resulting in the resident rolling out of bed. Bedrails, which were part of the care plan, were not in place at the time, leading to the resident sustaining a subarachnoid hemorrhage, scalp laceration, and C4 fracture. Staff and leadership confirmed that proper supervision and interventions were not provided.
The facility failed to offer four residents the opportunity to formulate advance directives, as required by policy. Despite having significant medical conditions, their records lacked documentation of being informed about their rights to accept or refuse treatment and to create an advance directive. This was confirmed by the Social Worker and DON.
The facility failed to secure medications in the B cart on the 300 hall, leaving it unattended and accessible to passersby. This was against the facility's policy, which requires medications to be stored in locked compartments with access limited to authorized personnel. The issue was confirmed by the DON.
A resident suffered a superficial frostbite burn due to improper supervision of cold pack use. The resident, with a history of sciatica and other conditions, reported that the ice pack was left on direct skin for too long, causing redness and blistering. The facility's policy required toweling and regular checks, but these were not effectively implemented, leading to harm.
Failure to Supervise High-Risk Resident Resulting in Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent elopement for a resident who had documented dementia, a psychotic disorder with delusions, and a known history of wandering and expressing a desire to leave the facility. An Elopement Risk Evaluation completed months earlier identified the resident as being at risk for elopement, and the care plan reflected this risk due to wandering and verbalizations about wanting to leave. A progress note documented that the resident had been testing door handles and keypads and would run toward the lobby door when it was open, indicating ongoing elopement-seeking behavior. On the night of the elopement event, the resident was last seen by an LPN sitting in a wheelchair at the nurse’s station. When EMS arrived and rang the buzzer for entry, staff remotely opened the coded mag lock door after visually confirming who was entering. Based on the facility’s reenactment, the resident was close enough to the door to keep it from closing and then propelled through the door and down a 25-foot corridor to an outside door that was not alarmed. The resident pushed this outside door open and went outside undetected by staff. EMS later found the resident outside in a wheelchair attempting to go toward the ambulance, and nursing staff then brought the resident back inside. The Nursing Home Administrator and Director of Nursing confirmed that the facility failed to provide adequate supervision to prevent this elopement.
Improper Food Storage in Main Kitchen
Penalty
Summary
The facility failed to properly store food products in the main kitchen's walk-in cooler and freezer, as observed during a survey. Specifically, an opened jar of grape jelly was found undated in the walk-in cooler, and multiple boxes of food items were stored up to the ceiling on top shelves and under fans in the freezer. These practices did not comply with the facility's policy, which requires all refrigerated and frozen foods to be covered, labeled, dated, and stored to allow adequate air circulation. The Dietary Manager confirmed these storage issues and acknowledged that the facility did not maintain sanitary conditions in the main kitchen.
Failure to Assess, Document, and Notify Physician of Hypoglycemia
Penalty
Summary
The facility failed to assess, document, and notify physicians of decreased capillary blood glucose (CBG) levels for three residents with diabetes. Facility policy required specific actions for hypoglycemia, including immediate notification of the provider, administration of glucose, monitoring, and documentation. However, clinical records and electronic medication administration records (eMAR) showed that when residents experienced low blood glucose readings, these protocols were not followed. For one resident with diagnoses including congestive heart failure and diabetes, multiple CBG readings below 70 mg/dL were recorded, but there was no evidence of assessment for hypoglycemia, monitoring for effectiveness of treatment, or physician notification as required by both physician orders and facility policy. The resident's care plan also lacked interventions for diabetes management, including hypo- or hyperglycemia. Another resident with diabetes had a CBG reading of 58 mg/dL, but again, there was no assessment, monitoring, or physician notification documented, despite care plan interventions instructing staff to report symptoms of hypo- and hyperglycemia. A third resident with diabetes had several CBG readings below 70 mg/dL, but the clinical record and eMAR did not show that the resident was assessed for hypoglycemia, that blood glucose was monitored for effectiveness of treatment, or that the physician was notified of abnormal results. The Director of Nursing confirmed that the facility failed to notify the doctor of a change in condition, failed to document assessments or interventions related to blood glucose, and failed to follow physician orders for these residents.
Failure to Maintain and Label Oxygen Equipment for Residents Receiving Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care and maintain oxygen equipment for four out of five sampled residents. According to facility policy, oxygen cannulas and tubing should be changed every seven days or as needed, and both oxygen and nebulizer equipment should be labeled with the date and stored properly between uses. During observations and interviews, it was found that residents with diagnoses such as pneumonia, coronary artery disease, heart failure, anemia, hypertension, respiratory failure, chronic obstructive pulmonary disease, bipolar disorder, and diabetes mellitus were receiving oxygen therapy, but the tubing in use was not labeled with an identifiable date as required by policy and physician orders. Specifically, residents were observed either in bed or sitting in a chair while using oxygen, and in each case, the oxygen tubing lacked proper labeling. Staff interviews confirmed that the required labeling and maintenance procedures were not followed for these residents. The Nursing Home Administrator acknowledged that the facility did not meet the standards for respiratory care and equipment maintenance for these residents, as outlined in both facility policy and physician orders.
Inaccessible Grievance Boxes Limit Resident Access
Penalty
Summary
The facility failed to provide accessible grievance boxes to residents in three locations: the 300-lounge, main dining room, and front lobby. According to the facility's own grievance policy, grievances may be submitted orally or in writing and may be filed anonymously. However, observations and interviews revealed that the grievance boxes were mounted at heights of 53, 52, and 51 inches, respectively, which exceeds the ADA-recommended maximum height of 48 inches for operable parts to ensure accessibility for individuals using wheelchairs. Additionally, access to the boxes in the 300-lounge and front lobby was obstructed by tables. During a resident group interview, residents reported that they could not anonymously file grievances because the boxes were too high to reach, not designed for people in wheelchairs, and required assistance from staff, which compromised anonymity. The Nursing Home Administrator confirmed these findings during an interview, acknowledging that the facility did not make the grievance boxes accessible in the identified locations.
Failure to Protect Resident from Neglect and Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from neglect and verbal abuse. The resident, who was cognitively intact and required moderate assistance for mobility, reported that her call bell was not answered in a timely manner when she requested help to use the bathroom. As a result, she had to take herself to the bathroom, and when the nurse aide eventually responded, the aide made a dismissive comment and left the room in a huff. Facility grievance documentation and staff statements indicated that the nurse aide in question had a pattern of negative behavior, including slamming doors, bullying residents, swearing, and refusing to assist with resident needs such as answering call bells and helping with meal trays. Despite these reports and statements from multiple staff members, the Director of Nursing did not identify the incidents as potential neglect or abuse and did not conduct a further investigation. The facility's failure to recognize and address these behaviors resulted in a lack of protection for the resident from neglect and verbal abuse, in violation of facility policy and state regulations.
Failure to Investigate and Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to promptly conduct a thorough investigation into allegations of potential abuse and neglect involving a resident. According to the report, a resident with diagnoses including kidney disease, Crohn's disease, and diabetes, who was cognitively intact and required moderate assistance with mobility, reported that her call bell was not answered in a timely manner when she needed help to go to the bathroom. The nurse aide responded dismissively, and additional staff statements described the same aide as having a negative attitude, swearing, and being unhelpful to residents, including leaving call bells unanswered and making inappropriate comments to residents. Despite these grievances and staff statements indicating possible abuse and neglect, the Director of Nursing confirmed that she did not identify these as potential abuse or neglect incidents and did not conduct a thorough investigation or implement corrective actions. Furthermore, the facility did not submit the results of a completed investigation to the State Survey Agency within the required five working days, as mandated by facility policy and federal requirements.
Failure to Post Current Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that current and accurate nurse staffing information was posted at the beginning of each shift. During an observation, it was found that the nurse staffing information displayed in the main lobby was outdated, showing a date from over two weeks prior and not reflecting the current resident census or the actual staffing hours for licensed and unlicensed nursing staff responsible for resident care. Interviews with the receptionist and the Nursing Home Administrator confirmed that the posted staffing information was not up to date and did not meet the required standards for accuracy and timeliness.
Failure to Post Required State Agency and Advocacy Contact Information
Penalty
Summary
Surveyors observed that the facility failed to post the required contact information for Adult Protective Services (APS), the Medicaid Fraud Control Unit, and a statement informing residents that they may file a complaint with the State Survey Agency. During observations on the nursing units, it was noted that the necessary elements, including agency names, addresses (mailing and email), and telephone numbers, were not accessible or visible to residents or their representatives. In an interview, the Nursing Home Administrator confirmed that this information was not posted as required by regulations. The deficiency was identified based on these observations and staff confirmation.
Failure to Prevent Resident Fall Due to Inadequate Supervision and Assistance
Penalty
Summary
The facility failed to protect a resident from neglect by not providing adequate assistance and interventions to prevent a fall with injury. The resident, who had multiple diagnoses including anemia, gastrointestinal bleed, diabetes, stroke, sacroilitis, anxiety, difficulty walking, abnormal posture, and Stage 5 kidney disease, was assessed as having intact cognition and required moderate assistance for bed mobility. The resident's care plan identified her as being at risk for falls due to impaired balance and poor coordination, and specified that staff should provide necessary assistance during transfers and ambulation, as well as use bedrails as needed. On the day of the incident, the resident had recently returned from the hospital after a blood transfusion and required incontinence care. During care, a nurse aide turned the resident away from herself and then turned away to retrieve supplies, leaving the resident unsupervised. At this time, the resident rolled out of bed, resulting in a head laceration, subarachnoid hemorrhage, and a C4 cervical fracture. Bedrails were not present on the bed at the time, despite the resident's care plan indicating their use. Staff interviews confirmed that proper technique would have involved either using bedrails or turning the resident toward the caregiver, or obtaining a second staff member for assistance. The Director of Nursing and the Nursing Home Administrator confirmed that the nurse aide's actions constituted neglect, as the resident was not adequately supervised or assisted during care, directly leading to the fall and resulting injuries. Facility policies reviewed emphasized the importance of safe resident handling, use of bedrails when indicated, and the need to prevent neglect by providing necessary goods and services to avoid physical harm.
Failure to Provide Adequate Supervision and Assistance During Incontinence Care Results in Resident Injury
Penalty
Summary
The facility failed to provide adequate assistance and interventions to prevent a fall with injury for a resident who had multiple medical conditions, including anemia, diabetes, stroke, sacroiliitis, difficulty walking, abnormal posture, and advanced kidney disease. The resident was identified as being at risk for falls and required partial to moderate assistance for bed mobility, with care plans specifying the use of bedrails and staff assistance during transfers and ambulation. Despite these documented needs, during incontinence care, a nurse aide turned the resident away from her and left the resident unattended on the bed while reaching for supplies, resulting in the resident rolling out of bed. At the time of the incident, bedrails were not in place, contrary to the resident's care plan and facility policy. As a result of this lapse in supervision and failure to follow established protocols, the resident sustained significant injuries, including a subarachnoid hemorrhage, a scalp laceration requiring six sutures, and a C4 vertebrae fracture. Staff interviews confirmed that proper procedures, such as using bedrails or turning the resident toward the caregiver, were not followed. Facility leadership acknowledged that adequate assistance and interventions were not provided to prevent the fall and resulting harm.
Failure to Provide Opportunity for Advance Directives
Penalty
Summary
The facility failed to provide the opportunity for four residents to formulate an advance directive, as required by their policy and regulatory standards. The facility's policy on Advance Directives, last reviewed on January 18, 2024, mandates that all adult residents be informed and provided with written information regarding their right to accept or refuse medical or surgical treatment and to formulate an advance directive. However, upon review of the clinical records for Residents R24, R29, R57, and R71, there was no documentation indicating that these residents were given the opportunity to formulate an advance directive. Resident R24 was admitted with diagnoses including type II diabetes, dysphagia, muscle weakness, and a left below-knee amputation. Resident R29 had type II diabetes, dysphagia, high blood pressure, and difficulty walking. Resident R57 was diagnosed with high blood pressure, a history of falling, and stage III chronic kidney disease. Resident R71 had multiple sclerosis, dysphagia, and stage III chronic kidney disease. Despite these significant medical conditions, the clinical records for these residents did not contain any advance directives or documentation of being offered the opportunity to create one. This deficiency was confirmed during an interview with the Social Worker and the Director of Nursing.
Medication Cart Left Unsecured on 300 Hall
Penalty
Summary
The facility failed to properly secure medications in one of the two medication carts on the 300 hall nursing unit, specifically the B cart. According to the facility's policy on Medication Labeling and Storage, medications should be stored in locked compartments with access restricted to authorized personnel. However, during an observation, the B medication cart was found unsecured and unattended, making it accessible to any passerby. This was confirmed by the Director of Nursing during an interview, indicating a breach in the facility's protocol for securing medications.
Failure to Supervise Cold Pack Use Results in Resident Harm
Penalty
Summary
The facility failed to implement effective safety measures by not supervising the use of a cold pack, resulting in actual harm to a resident. The resident, who was cognitively intact and had a history of sciatica, hyperlipidemia, polyneuropathy, and hypertension, suffered a superficial frostbite burn on the right knee. The facility's policy required appropriate toweling between the ice pack and the skin, with treatment times of 10-20 minutes and checks every 10 minutes. However, the resident reported that the ice pack was left on direct skin for too long, leading to redness and blistering. The incident occurred after the resident refused physical therapy due to pain and requested pain medication and an ice pack. A PT employee provided the ice pack, allegedly with proper toweling, but the resident later admitted to removing the cloth and placing the ice pack directly on the skin. The care plan did not include the use of cold packs as an intervention, and there was a lack of clear communication and supervision between the PT employee and the nursing staff. Interviews with staff revealed inconsistencies in the handling of the ice pack, and the facility acknowledged the failure to provide adequate education and supervision, resulting in harm to the resident.
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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