Roosevelt Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- 7800 Bustleton Avenue, Philadelphia, Pennsylvania 19152
- CMS Provider Number
- 395537
- Inspections on file
- 47
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Roosevelt Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
The facility failed to ensure that an LPN, another LPN, an RN, and a third LPN had competency validation for emergency trach tube change and decannulation. Facility policy outlined detailed steps for managing a blocked or failed trach tube, but review of competency records showed none of the four nursing employees had the required emergency trach competencies, and the DON confirmed the missing documentation.
The facility failed to make the most recent DOH survey results readily accessible to residents and visitors on three nursing floors. During a resident council meeting, residents said they were not aware of the survey binder, and a later tour confirmed the binder was behind the receptionist desk on the first floor and behind nursing stations on the other floors, where it was not readily accessible.
A resident’s code status was not documented in the EMR. The resident had Acute Renal Failure and Acute Respiratory Failure, and the DON confirmed the record did not accurately reflect the resident’s code status.
Failure to thoroughly investigate a resident-to-resident altercation during a smoke break. A resident reported that another resident hit him with a walker and knocked a cup from his hand, while the investigation lacked additional staff and resident interviews to determine who was supervising the patio area. The involved residents had multiple psychiatric, substance use, and orthopedic diagnoses, and one resident stated no staff were present during the incident.
Care plan not developed or implemented for repeated falls. A resident with dementia, prior hip fracture, gait and mobility problems, and high fall risk had multiple falls, including overnight events. The record showed no care plan goals or interventions after the initial fall, despite PT noting max assist needs and fall risk screenings identifying the resident as high risk.
A resident admitted with encephalopathy and a tracheostomy-related diagnosis had an Enhanced Barrier Precautions sign posted outside the room and PPE available, but the clinical record did not contain a comprehensive person-centered care plan for Enhanced Barrier Precautions. The facility policy required the care plan to be developed within 7 days of the required MDS assessment.
Failure to provide ADL grooming and nail care for two residents. One resident with frostbite, AKI, and hidradenitis had long nails and facial hair, while another resident with CVA, hemiplegia, and a preference for showers had facial hair and reported it had been a while since the last shower. Staff confirmed both residents had not received complete shaving or nail care, and a unit manager noted facial hair remained on the neck of one resident.
A resident with severe vascular dementia, pulmonary fibrosis, bilateral visual loss, glaucoma, and a history of falls was found in a room with three missing ceiling tiles exposing plenum space and electrical wires, along with a call bell system partially detached from the wall. Facility maintenance logs showed no work orders for the ceiling tile repairs, and an LPN confirmed the resident had been sleeping in that room for several days.
The facility failed to implement ordered catheter care for two residents. One resident was observed with a Foley catheter using a 16 Fr, 30 mL balloon instead of the ordered 16 Fr, 10 mL balloon, and another resident was observed with a suprapubic catheter using a 16 Fr, 30 mL balloon instead of the ordered 16 Fr, 10 mL balloon. Both findings were confirmed by the charge nurse.
Failure to provide ordered fortified foods for a resident with an unhealed pressure ulcer and weight loss. The resident required eating assistance, had a therapeutic diet, and the RD documented increased nutritional needs with recommendations for double portions and fortified foods to support wound healing. During meal observations, only standard items were served, and nurse aides confirmed no additional fortified foods were provided.
Delayed physician review of pharmacist MRRs affected two residents. One resident receiving Abilify had an overdue AIMS test recommendation that was signed by the physician without a review date, and the updated AIMS was not documented until later. Another resident had a pharmacist recommendation to reassess pantoprazole, but the physician did not acknowledge the MRR until weeks later.
A resident with encephalopathy and a tracheostomy order for daily inner cannula changes did not have EBP followed during trach care. An RN changed the disposable inner cannula without wearing the required PPE gown, even though the EBP sign was posted and PPE was available; the IP later confirmed the gown was required.
A resident with multiple chronic conditions, including low back pain, end stage renal disease, chronic pancreatitis, and osteoarthritis, had an active PRN order for oxycodone 5 mg by mouth every 4 hours for pain. A nurse documented in a nursing note that the resident had pain and received one PRN oxycodone dose with positive effect, and the narcotic reconciliation log showed the drug was signed out during the night. However, the corresponding dose was not documented on the MAR. In an interview, the NHA and DON confirmed the missing MAR entry and stated that all narcotics are expected to be documented both in the narcotic log and on the MAR.
A resident with dementia and severe cognitive impairment, as shown by a low BIMS score, was able to leave a resident floor in the evening and enter the main kitchen unsupervised after kitchen staff had left. The kitchen had not been locked, contrary to the Administrator’s stated expectation, allowing the resident to access the area where a fire alarm pull switch was located beyond stoves and other kitchen equipment. Staff later found the resident in the kitchen in a wheelchair after a fire alarm was activated, and the resident reported looking for a snack and pulling something without knowing what it was.
A resident with an active PRN order for Cyclobenzaprine HCl 10 mg for muscle spasms did not receive the medication for several weeks because it was not available in the med cart, despite having previously received it routinely at bedtime. The resident reported not getting the muscle relaxant and being told by staff that the pharmacy did not have it, and staff confirmed the drug was unavailable for administration. Review of the MARs showed the last dose was given at the end of one month, with no further doses documented the following month, resulting in a deficiency related to pharmacy services and failure to provide necessary pharmaceutical care.
A resident with an elevated potassium level had physician orders for repeat lab tests, but staff failed to obtain the required laboratory studies on the specified dates. The DON confirmed that the ordered lab work was not completed, and clinical records lacked evidence of the tests being performed.
A resident with lower extremity wounds and a history of cellulitis did not receive timely podiatry follow-up as ordered after admission. The facility missed two scheduled appointments, failed to arrange transportation as promised, and did not document reasons for the missed services. Staff interviews confirmed the missed appointments and lack of explanation.
A resident with chronic kidney disease, urinary tract infection, and urinary retention had a new Foley catheter placed, but the facility did not develop a comprehensive, person-centered care plan for catheter care as required. This omission was confirmed by the ADON after review of the resident's records.
A resident with multiple urinary diagnoses had a Foley catheter placed without a corresponding physician order documented in the clinical record, despite facility policy requiring such documentation. Additionally, the same resident, who had an order for 1:1 supervision for safety, was left unsupervised when the assigned staff stepped away from the room, and this lapse was confirmed by facility leadership.
The facility did not display the required State Survey Agency contact information, including the Department of Health Hotline number, in the lobby or on any nursing floors. During a group interview, several alert and oriented residents reported not knowing how to contact the Department of Health, and observations with the Administrator confirmed the absence of the postings.
Pharmacist recommendations from monthly medication regimen reviews were not consistently reviewed or acted upon by physicians in a timely manner for three residents. In several cases, recommendations regarding medication timing, laboratory monitoring, and vital sign checks were either not implemented, not documented, or lacked proper physician signatures, despite facility policy requiring such actions.
Multiple residents reported that meals were consistently served cold, with specific complaints about cold pancakes, dry eggs, missing meal items, and insufficient accompaniments for beverages. Direct observation of a test tray with the Food Service Director confirmed that food and drink items were below the expected temperature for palatability and safety, and the Food Service Director acknowledged the deficiency.
Staff failed to consistently use required PPE and post enhanced barrier precaution signage for residents with indwelling devices or wounds, resulting in care being provided without gowns or gloves. Additionally, nurses used a blood pressure cuff on multiple residents without disinfecting it between uses. Staff interviews revealed confusion about PPE requirements and reliance on signage that was not always posted or accessible.
A resident with an indwelling urinary catheter was found to have a urine bag containing cloudy urine with sediment, and the bag was not dated. Nursing staff confirmed inconsistent bag changes and lack of adherence to facility policy. There was no documentation of urine output monitoring, physician notification, or follow-up after the cloudy urine was observed.
A resident with severe malnutrition and cognitive impairment did not receive a physician-ordered nutritional supplement, as confirmed by record review, meal observations, and staff interviews. The supplement was not documented as administered and was absent from the resident's meal trays, despite care plan and physician orders.
A resident with COPD and acute respiratory failure was observed receiving oxygen at a rate higher than the physician-ordered 2 liters per minute via nasal cannula. The nurse confirmed the administration of 5 liters per minute, which did not follow the documented order for respiratory care.
Two residents receiving hemodialysis had incomplete Hemodialysis Communication Records, with missing documentation such as new orders, shunt site observations, pain reports, lab values, and staff signatures on multiple occasions, as confirmed by an LPN.
A resident with acute congestive heart failure did not receive prescribed cardiac medications, including Carvedilol, Entresto, Rivaroxaban, and Spironolactone, in a timely manner after admission. The medications were not available as ordered, and administration was delayed until the following evening, with medication records inaccurately coded as 'held' without physician parameters.
Surveyors identified that the facility exceeded the acceptable medication error rate, with errors including a resident not rinsing after inhaled corticosteroid administration, another resident missing a scheduled inhalation medication due to unavailability, and a third resident receiving the wrong formulation of aspirin. These errors resulted in a medication error rate of 10.34%.
Surveyors found that several residents did not receive the food items they requested, with some reporting this happened multiple times a week. Residents and staff confirmed ongoing issues with meal accuracy, including a resident being served pasta despite a 'no pasta' order and another dependent resident not receiving a preferred sandwich provided by family. These incidents show the facility did not consistently accommodate resident dietary preferences.
Surveyors identified deficiencies in food storage and sanitation, including a foul odor and dirty walls in the dishwasher area, as well as improperly labeled food items in the walk-in cooler. Several meats were marked only with received dates and lacked required use-by or defrost dates, contrary to facility policy.
A resident at Roosevelt Rehabilitation and Healthcare did not receive a breakfast meal due to miscommunication among nurse aides. The resident had previously reported a nurse aide for refusing to change bed linens, which he believed led to retaliation. On the morning in question, the resident was asleep when the breakfast tray was delivered, and it was left because he did not like to be woken up. The facility's policy to deliver food trays to each resident's room was not followed, resulting in the resident missing his meal.
The facility failed to provide timely incontinence care for several residents, including one with chronic obstructive pulmonary disease and another with hypertension and diabetes. Residents reported being left soiled for extended periods, with call bells either unreachable or unanswered. This deficiency highlights a systemic issue in the facility's response to residents' toileting needs.
The facility failed to maintain sanitary conditions in food preparation and service, with observations of improper food storage, lack of labeling, and inadequate hand hygiene practices. A dietary aide was seen without proper hair restraints, and nursing aides did not perform hand hygiene after assisting residents, violating the facility's policies.
The facility failed to maintain an effective antibiotic stewardship program, as it did not consistently document necessary information such as symptoms, stop dates, total days of therapy, outcomes, and adverse events for antibiotic orders over a six-month period. Additionally, an Infection Report tool was not utilized after April 2024, as confirmed by the DON.
The facility failed to provide meals that were palatable, attractive, and served at safe temperatures during lunch observations. Meals were served at incorrect temperatures, lacked color, and were unappealing, leading to resident dissatisfaction and refusal to eat. The Regional Dietary Director and a unit manager confirmed these issues, and management acknowledged the problem.
The facility failed to implement enhanced barrier precautions and proper infection control practices for four residents. A resident with a feeding tube was cared for without the required gown, and two residents with feeding tubes lacked precaution signs outside their rooms. Additionally, a nurse aide did not follow hand hygiene protocols while preparing and feeding a resident.
The facility failed to maintain a clean and homelike environment on two nursing units. Issues included water leaks from the ceiling, missing ceiling tiles, sticky floors, missing baseboard molding, a hole in the wall, and a strong urine odor in a room and hallway. A resident reported the water leak had been ongoing for weeks without proper resolution, and these observations were confirmed by the facility administrator.
A facility failed to create a baseline care plan within 48 hours for a resident with a laryngectomy tube, who managed her own care. Despite the resident's preference for self-care, the facility did not develop a plan addressing her respiratory and communication needs, as confirmed by the DON.
A facility failed to create a smoking-related care plan for a resident with COPD and end-stage renal disease, despite identifying them as a smoker. The resident's MDS inaccurately reported no tobacco use, and no further assessment or care plan was developed. The DON confirmed the absence of a care plan, indicating a deficiency in policy adherence.
A resident with contractures due to a stroke did not receive necessary services to prevent further decline in range of motion. Observations showed the resident without positioning devices or splints, and clinical records indicated no restorative program was established. The Rehab Director confirmed the lack of services for the resident's condition.
A resident experienced significant weight loss, losing over 15 pounds in one month, which was not addressed by the facility until eight days later. The facility failed to adhere to its policy of reweighing residents with significant weight changes and did not evaluate the resident in a timely manner. The resident, who was on enteral nutrition and NPO, was found to have severe protein-calorie malnutrition with a BMI of 17.4.
A facility failed to maintain complete records of communication between the facility and a dialysis center for a resident with ESRD. The resident's dialysis binder lacked documentation on several occasions, indicating a failure to assess and monitor the resident after dialysis. A nurse confirmed the incomplete records and acknowledged the nursing staff's responsibility to complete the documentation.
A resident experienced a significant weight loss of over 26% without documented physician assessment or intervention, despite facility policy requiring such actions for significant weight changes. The resident's weight dropped from 178.2 lbs to 131.8 lbs, and although the dietitian was involved, the clinical record lacked evidence of a physician's assessment addressing the weight loss.
A facility failed to ensure a physician documented the rationale for rejecting pharmacist recommendations for a resident's medication regimen. The pharmacist suggested a dose reduction for Aripiprazole and a dosing schedule change for Midodrine, but the physician disagreed without providing a rationale. The Director of Nursing confirmed the documentation was incomplete, violating facility policy.
The facility failed to ensure proper labeling and storage of medications, as observed in four medication carts across different floors. Issues included missing opening dates on over-the-counter medications and eye drops, unidentifiable insulin pens, and loose pills in cart drawers. These deficiencies were confirmed by interviews with LPNs during observations.
The facility failed to maintain an effective pest control program, as evidenced by observations of fly traps with dead flies and reports of mice, rats, flies, and roaches in resident rooms. These issues were confirmed by the Administrator.
The facility failed to adequately train staff on Enhanced Barrier Precautions (EBPs), leading to inconsistent implementation of infection control measures. Observations and interviews revealed that staff misunderstood EBP requirements, with some equating them to isolation precautions. A nursing assistant was observed providing care to a resident with a feeding tube without wearing a gown, contrary to the facility's policy.
The facility failed to provide meals according to residents' dietary preferences, affecting four residents. Observations revealed discrepancies such as serving incorrect food items and undercooked meals. A resident received mashed potatoes instead of sweet potatoes, another was served a white bread sandwich despite a preference for wheat, and two residents received hard tortellini. Additionally, a resident with a colostomy bag was served pasta, which they avoid. These issues were confirmed by staff and resident interviews.
The facility failed to provide timely incontinence care for two residents, as evidenced by one resident reporting being wet from 5:00 a.m. to 11:00 a.m. and another resident experiencing delays during the night shift. Both residents have intact cognition and require two-person assistance for ADLs.
Missing Tracheostomy Emergency Competencies for Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skill sets for the emergency care of residents with tracheostomy tubes. Review of the facility policy titled Emergency Tracheostomy Tube Change and Decannulation showed detailed steps for removing and replacing a blocked or failed tracheostomy tube, including deflating the cuff, using a resuscitation bag and mask, inserting a backup tube, and completing the procedure within 30 seconds if possible. However, review of staff competency records showed that Employee E8, an LPN; Employee E9, an LPN; Employee E10, an RN; and Employee E11, an LPN did not have competencies related to Emergency Tracheostomy Tube Change and Decannulation. Interview with the DON confirmed that no Emergency Tracheostomy Tube Change and Decannulation competencies were provided for those four nursing employees. The report identifies four of four employee records reviewed as lacking the required competency documentation for tracheostomy emergency care, despite the facility policy describing the procedure and the need for experienced clinicians to perform it.
Survey Results Not Readily Accessible to Residents
Penalty
Summary
The facility failed to ensure that the most recent Department of Health survey results were readily accessible to residents and visitors on three of three nursing floors. During a Resident Council meeting with thirteen alert and oriented residents, residents reported that they were not aware of the survey binder. A subsequent facility tour with the Administrator confirmed that the Department of Health survey binder was placed on the first floor behind the receptionist desk, and copies on the 2nd, 3rd, and 4th floors were located behind the nursing stations and were not readily accessible to residents. The survey results in the binders on the 2nd, 3rd, and 4th nursing units were last dated April 29, 2025.
Missing Code Status Documentation
Penalty
Summary
The facility failed to document the code status for one of 35 residents reviewed, Resident R4. Facility policy on Advance Directives stated that nursing staff will document whether a resident has executed an Advance Directive in a section of the medical record that is retrievable by staff, and that the attending physician provides information to the resident and legal representative regarding health status, treatment options, and expected outcomes during the initial comprehensive assessment and care plan development. Resident R4 was admitted to the facility with diagnoses of Acute Renal Failure and Acute Respiratory Failure. Review of the resident’s electronic medical record revealed no information on R4’s code status. The DON confirmed in interview that the electronic medical record did not accurately reflect the resident’s code status.
Failure to Thoroughly Investigate Resident-to-Resident Altercation
Penalty
Summary
The facility did not ensure that an alleged resident-to-resident altercation during a smoke break was thoroughly investigated. The incident involved Resident R53 and Resident R232, and the facility’s investigation report stated that during the 1:00 p.m. smoke break there was an altercation in which Resident R53 reported that Resident R232 hit him with a walker and knocked a cup out of his hand. Resident R53’s clinical record showed a history of low back pain, anxiety disorder, major depressive disorder, right artificial hip joint, osteoarthritis of the right knee and hip, nicotine dependence, and psychoactive substance use. Resident R232’s clinical record showed bipolar disorder, joint replacement surgery, osteoarthritis, antisocial personality disorder, schizoaffective disorder, tobacco use, and psychoactive substance use. The investigation report indicated that Resident R232 was placed on one-hour safety checks for 12 hours, and it included an in-service on abuse and zero tolerance. However, the report did not contain evidence of additional interviews of residents or staff to determine which employee and how many employees were supervising residents during the 1:00 p.m. smoke break. Resident R53 stated in interview that no staff were present on the patio at the time of the altercation, while a recreation aide stated that he was on the smoke break and walking around the patio area and did not witness any verbal confrontation. The cited deficiency was 28 Pa Code 201.18(b)(1) management.
Care Plan Not Developed or Implemented for Repeated Falls
Penalty
Summary
Facility did not ensure a resident-centered care plan was developed and implemented for Resident R144, resulting in repeated falls. Resident R144 had a medical history that included a displaced intertrochanteric fracture of the right femur, dementia with agitation, dizziness and giddiness, a benign neoplasm of the cerebral meninges, anxiety disorder, osteoarthritis, falls, gait and mobility abnormalities, and cerebral infarction. Her MDS completed on March 18, 2026 showed a BIMS score of 6, and the record described her as awake, alert, oriented x2, and forgetful. She had three falls since admission, including falls on March 12, March 30, and April 9, 2026. The record showed that after the initial fall on March 12, 2026, there was no evidence of goals or interventions added to the care plan. Interim fall risk evaluations completed on March 30, 2026 and April 8, 2026 identified her as high risk for falls, with scores of 16 and 20. PT evaluation on March 12, 2026 found she required maximum assistance with transfers and bed mobility. On April 9, 2026, she was found lying on her right side next to her low bed, and observation indicated it appeared she had used the trash can as a toilet and fell. During interview, she stated she attempted to use the restroom during the overnight shift, and the care plan contained no evidence of implemented interventions related to the repeated overnight falls.
Failure to Develop Comprehensive Care Plan for Enhanced Barrier Precautions
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan within 7 days of the comprehensive assessment for one resident, R250. The resident was admitted with diagnoses of encephalopathy and encounter for attention to tracheostomy. Review of the facility policy on comprehensive person-centered care plans stated that such a plan must include measurable objectives and timetables and be developed within 7 days of completion of the required MDS assessment and no more than 21 days after admission. On April 7, 2026, observation confirmed that an Enhanced Barrier Precautions sign was posted outside R250's door and PPE was available. On April 8, 2026, the Infection Preventionist confirmed that the clinical record did not contain a comprehensive care plan developed for Enhanced Barrier Precautions.
Failure to Provide ADL Grooming and Nail Care
Penalty
Summary
The facility failed to provide care and services to maintain activities of daily living for two residents by not ensuring shaving and nail care were completed. Facility policies for shaving and fingernail/toenail care stated these procedures were intended to promote cleanliness, provide skin care, keep nails trimmed, and prevent infections. Resident R246 was admitted with frostbite with tissue necrosis of both feet, acute kidney failure, a phosphorus metabolism disorder, and hidradenitis suppurativa, and the care plan identified an ADL self-care deficit related to deconditioning and frostbite with interventions for supervision/setup with grooming and personal hygiene and one staff assist with bathing. Resident R155 was admitted after a cerebral infarction with left-sided hemiplegia and hemiparesis, and the care plan identified an ADL self-care deficit related to CVA with an intervention for one staff assist with bathing; the resident also preferred showers. On April 6, 2026, observations showed R246 had long nails on both hands and facial hair, and R246 stated the nails could be cut and the facial hair could be shaved. At the same time, R155 was observed with facial hair and stated it had been a while since the last shower and that a shower was preferred over a bed bath. Staff later confirmed that R155 had facial hair and had not received a shave, and that R246 had long nails and facial hair that had not been shaved. A unit manager later observed that R155 had been shaved on the cheeks but still had long facial hair on the neck, and reported that R246 still had facial hair and would be set up for a shave that day; the manager also stated that nail care and shaving of facial hair were part of the nursing assistants' morning ADL care tasks. R155 later confirmed that facial hair remained on the neck.
Unsafe Resident Room Conditions
Penalty
Summary
The facility did not ensure Resident R15’s environment was free from accident hazards. Resident R15 had a history of vascular dementia, progressive pulmonary fibrosis, immunodeficiency, unqualified visual loss of both eyes, glaucoma, a history of falling, acquired absence of the left toe, mononeuropathy, and schizoaffective disorder/bipolar type. While the resident was in bed in room [ROOM NUMBER]-A on the 3 North unit, surveyors observed three missing ceiling tiles above the bed, exposing plenum space and electrical wires. Surveyors also observed that the call bell system in room [ROOM NUMBER]-A was partially detached from the wall. Review of the facility’s maintenance logs for March 2026 and April 2026 showed no evidence of TELS work orders to repair the ceiling tiles. A licensed nurse confirmed that Resident R15 had been sleeping and residing in the room for the past three or four days, and the facility administrator confirmed the findings.
Failure to Follow Ordered Catheter Specifications
Penalty
Summary
The facility failed to implement ordered treatment and services related to incontinence management for two residents. Review of the physician’s order for one resident showed an order to maintain a Foley catheter with a 16 Fr, 10 mL balloon size, but on observation the resident had a Foley catheter with a 16 Fr, 30 mL balloon size, which was confirmed by the charge nurse. Review of the physician’s order for a second resident showed an order for a suprapubic catheter #16 with 10 mL balloon inflation to a urinary drainage bag, to be changed monthly and as needed and monitored for signs and symptoms of infection or obstruction. On observation, the second resident had a suprapubic catheter with a 16 Fr, 30 mL balloon size, which was also confirmed by the charge nurse. The report states that the facility failed to implement the ordered catheter and balloon sizes for both residents.
Failure to Provide Ordered Fortified Foods
Penalty
Summary
The facility failed to implement nutrition interventions consistent with Resident R3’s assessed needs. Resident R3 was cognitively intact and had diagnoses of muscle weakness and dementia, along with an unhealed pressure ulcer. The resident’s MDS also showed the resident required setup or clean-up assistance with eating, had unplanned weight loss, and was prescribed a therapeutic diet. The care plan identified the resident as having a pressure ulcer and/or being at risk for pressure ulcer development, with interventions to consult the RD as needed, monitor nutritional status, and serve the diet as ordered. A nutrition note by the RD documented that Resident R3’s sacral wound had worsened and that baseline nutritional needs had increased to support wound healing, with recommendations to add double portions at mealtimes and fortified foods. However, during observations of lunch meals, the resident was served cottage cheese with diced peaches and later rice with gravy and a side toss salad, and there was no evidence of additional fortified food items on either tray. Nurse aides confirmed that no additional fortified foods were served. The RD identified fortified food items as mashed potatoes, cereal, or pudding.
Delayed Physician Review of Pharmacist Medication Regimen Recommendations
Penalty
Summary
The facility failed to ensure medication regimen reviews were timely addressed by the physician for two residents reviewed, R3 and R5. Facility policy stated that a licensed pharmacist conducts monthly medication regimen reviews and reviews the resident's medical record to identify and resolve medication-related problems and irregularities. For R3, the pharmacist's recommendation to the prescriber dated December 22, 2025 noted that the resident was receiving Abilify and needed an AIMS test every 6 months to assess for side effects of neuroleptic medication; the last documented AIMS test was in May 2025 and was due at that time. The physician signed agreement with the recommendation but did not date when the review was completed, and the resident did not receive an updated AIMS test until February 3, 2026. For R5, the pharmacist's recommendation to the prescriber dated February 23, 2026 asked the physician to reassess the need for pantoprazole, but the physician did not review and acknowledge the medication regimen review until April 1, 2026.
Failure to Use Enhanced Barrier Precautions During Tracheostomy Care
Penalty
Summary
Enhanced Barrier Precautions were not implemented for Resident R250 during tracheostomy care. The resident was admitted with diagnoses of encephalopathy and encounter for attention to tracheostomy, and had a physician order for daily change of the disposable inner cannula on the day shift. Facility policy stated that Enhanced Barrier Precautions apply in specified MDRO-related situations and that standard precautions apply to all residents regardless of infection or colonization status. During observation of tracheostomy care, Registered Nurse Employee E3 changed the resident’s disposable inner cannula without wearing an Enhanced Barrier Precautions gown, even though the EBP sign was posted outside the resident’s door and PPE was available. The Infection Preventionist later confirmed that staff are required to follow Enhanced Barrier Precautions when providing tracheostomy care and changing the inner cannula, and that Employee E3 should have been wearing a PPE gown.
Failure to Accurately Document PRN Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident when documentation of a PRN narcotic dose was inconsistent across required records. The resident, who had diagnoses including low back pain, end stage renal disease, chronic pancreatitis, and osteoarthritis, had an active physician order for oxycodone 5 mg by mouth every 4 hours as needed for pain until it was discontinued following the resident’s death. A nursing note signed by employee E3 at 3:09 a.m. documented that the resident exhibited signs and symptoms of pain and that one PRN dose of oxycodone was given with a positive effect. The narcotic reconciliation log showed that an oxycodone dose was signed out at 1:38 a.m. the same date. However, review of the MAR revealed that this oxycodone dose was not documented there. In an interview, the Nursing Home Administrator and the Director of Nursing confirmed that the oxycodone dose was not signed out on the MAR and that facility expectations require all narcotics to be documented both in the narcotics log and on the MAR.
Failure to Secure Kitchen Allows Cognitively Impaired Resident Unsupervised Access
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and to provide adequate supervision when a resident with severe cognitive impairment accessed the main kitchen unattended during nighttime hours. The resident had diagnoses including dementia and anxiety, and an MDS dated August 22, 2025, documented a BIMS score of 3, indicating severely impaired cognition. On the evening of August 27, 2025, the resident, who was on the third floor at 8:30 p.m., was later found missing at 8:45 p.m. when staff could not locate her and a fire alarm sounded. According to the facility’s investigation, staff responding to the fire alarm found the resident in the first-floor kitchen, seated in her wheelchair, stating she had been looking for a snack and that she had pulled something without knowing what it was. The investigation determined that the resident had accessed the kitchen after hours when kitchen staff had left but failed to lock the kitchen. Observation of the first-floor kitchen showed that the fire alarm pull switch was located in the middle of the kitchen, beyond the stove and other kitchen equipment, with two fire doors and one regular door next to the switch leading to the exterior of the building. The Administrator confirmed that the kitchen should have been locked after kitchen staff left and that it was not locked on the night of the incident, allowing the resident to enter the kitchen and activate the fire alarm pull switch.
Failure to Provide Ordered PRN Muscle Relaxant Due to Medication Unavailability
Penalty
Summary
Surveyors determined that the facility failed to provide necessary pharmaceutical services when a resident did not receive a prescribed PRN muscle relaxant for an extended period. The resident reported during an interview that she had routinely taken Cyclobenzaprine HCl 10 mg at bedtime to relieve muscle spasms but had not received it for the past two weeks, and staff told her the medication was not available from the pharmacy. A staff member confirmed that the medication was not available in the medication cart to administer to the resident. Review of the physician’s order dated November 10, 2025, showed an active order for Cyclobenzaprine HCl 10 mg, 1 tablet by mouth every 8 hours as needed for muscle spasms. Review of the December 2025 MAR showed the medication was administered 15 times, with 11 of those doses given at bedtime between 8 p.m. and 10 p.m., and the last recorded administration on December 28, 2025. Further review of the January 2026 MAR through January 26, 2026, revealed that the resident did not receive any doses of Cyclobenzaprine HCl for the entire month, indicating that the ordered PRN medication was not provided after December 28, 2025. This lack of availability and administration of the ordered medication, despite an ongoing physician order and prior routine use by the resident, formed the basis of the cited deficiency under 28 Pa. Code 201.14(a) and 211.9(a)(1)(f)(2)(4)(k) related to pharmacy services.
Failure to Obtain Physician-Ordered Laboratory Studies
Penalty
Summary
The facility failed to ensure that laboratory studies were promptly obtained as ordered by the physician for one resident. Clinical record review showed that a resident had an elevated potassium level, and the physician ordered a repeat Basic Metabolic Panel (BMP) to be done on a specific date. However, documentation revealed that the repeat BMP was not completed as ordered, and a subsequent order for a Comprehensive Metabolic Panel (CMP) was also not carried out. An interview with the Director of Nursing confirmed that staff did not obtain the required lab work on the dates specified by the medical practitioner. There was no evidence in the clinical records that the laboratory tests ordered by the physician were completed as required.
Failure to Arrange Timely Outside Professional Services for Wound Care
Penalty
Summary
The facility failed to provide timely access to outside professional services for a resident who required follow-up care for wounds on the lower extremity. The resident, who had a history of cellulitis and a chronic venous hypertension ulcer of the right lower extremity, was admitted with a hospital discharge order for a podiatry follow-up. Clinical record review showed that the resident was not seen by podiatry as ordered on two separate occasions, and there was no documentation explaining the missed appointments or cancellations. The resident reported that staff had informed him transportation was arranged for his appointments, but at the time of the scheduled visits, he was told there was no transportation and the appointments were not completed. Interviews with staff, including the DON, confirmed that the facility missed both scheduled podiatry appointments and could not provide a reason for the failure to send the resident. There was no evidence in the clinical record that the required services were furnished or that the missed appointments were documented.
Failure to Develop Comprehensive Care Plan for Catheter Care
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan addressing urinary catheter care for a resident with multiple urinary diagnoses, including chronic kidney disease, urinary tract infection, prostatic hyperplasia with lower urinary tract symptoms, urinary urgency, and urinary retention. The resident was admitted with these conditions and had a new Foley catheter placed at a recent urology appointment. Review of the resident's clinical record and care plan revealed that, despite the presence of the catheter and related diagnoses, no care plan for catheter care was documented. This deficiency was confirmed during an interview with the Assistant Director of Nursing, who acknowledged the absence of a comprehensive care plan for the urinary catheter.
Failure to Follow Physician Orders for Catheter Care and 1:1 Supervision
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice by not following physician's orders for urinary catheter care and for required 1:1 staff supervision. For one resident with chronic kidney disease, urinary tract infection, prostatic hyperplasia, urinary urgency, and urinary retention, a Foley catheter was placed at a urology appointment. However, there was no physician order for the urinary Foley catheter documented in the resident's clinical record since the date of placement, despite the presence of a hard copy urology consultation indicating the catheter. The facility's policy required specific documentation for catheter care, but the necessary physician order was missing. Additionally, the same resident had a physician order for 1:1 supervision every shift for safety, but this was not consistently implemented. During an observation, the resident was found in their room without 1:1 staff present, and the assigned nurse aide confirmed she had stepped away from the resident's room for approximately five minutes. Interviews with facility leadership confirmed the lack of a physician order for the Foley catheter and the lapse in required supervision.
Failure to Post State Survey Agency Contact Information
Penalty
Summary
The facility failed to display the required contact information for the State Survey Agency, including the Department of Health (DOH) Hotline number, in the lobby and on all three nursing floors. During a resident council interview with nine alert and oriented residents, none of the residents knew how to contact the DOH with a complaint, and all confirmed they had not seen the contact information posted. One resident specifically stated that the number was not posted and suggested that pamphlets should be distributed. Observations conducted with the Administrator confirmed that the required contact information was not posted in the designated areas. The Administrator acknowledged this omission during an interview.
Failure to Ensure Timely Physician Review of Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that pharmacist recommendations from monthly medication regimen reviews were reviewed and acted upon by physicians in a timely manner for three of five residents reviewed. For one resident, the pharmacist recommended adjusting the timing of insulin lispro administration to align with meal times, and although the physician indicated agreement and signed the recommendation, the clinical record and medication administration record did not reflect any change to the order. For another resident, the pharmacist recommended ordering specific laboratory tests to monitor medication safety and efficacy, and while the physician wrote that the labs were ordered and signed the document, there was no corresponding physician order for the labs in the clinical record. Additionally, the pharmacist suggested changing the administration time of tamsulosin to after dinner for better absorption, but the physician disagreed with the recommendation, and the document was not signed or dated by the physician. For a third resident, the pharmacist recommended adding weekly blood pressure and pulse monitoring due to ongoing antihypertensive therapy. The document had an "OK" written on it, but lacked a physician signature or date, and there was no evidence in the clinical record that the recommendation was reviewed or acted upon. An interview with the Director of Nursing confirmed that there was no documentation showing that these recommendations were noted and completed. These findings indicate a failure to follow facility policy and regulatory requirements for timely physician review and documentation of pharmacist recommendations.
Failure to Serve Palatable Food at Safe Temperatures
Penalty
Summary
Surveyors identified that the facility failed to provide food and drink that was palatable and served at the proper temperature for all six residents interviewed. Multiple residents reported that their food was consistently cold, with specific complaints about cold pancakes, lack of cold cereal, dry eggs, missing meal items, and insufficient accompaniments for beverages. One resident noted that a rib sandwich was served cold, and another stated that the food was always cold and unappetizing. These concerns were echoed during a group interview, where all participating residents agreed there were ongoing problems with the food. Direct observation of a test tray with the Food Service Director confirmed these complaints, as food and drink items were measured at temperatures below the expected standard for palatability and safety. For example, apple juice was 46.5°F, canned pineapple was 65°F, mashed potatoes were 126°F, and a pork riblet was 111°F. The Food Service Director acknowledged that foods should reach 140°F and confirmed that the tested items were too cool to be considered palatable. These findings were supported by facility documentation, resident interviews, and direct observation.
Failure to Implement Enhanced Barrier Precautions and Equipment Disinfection
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically regarding the use of enhanced barrier precautions (EBP) and proper cleaning of medical equipment. Observations revealed that staff did not consistently use required personal protective equipment (PPE), such as gowns and gloves, during high-contact care activities for residents with indwelling medical devices or wounds. For example, nurse aides provided bathing and incontinence care to a resident dependent on tube feeding without wearing gowns, despite care plan interventions specifying EBP. Additionally, there was no signage indicating EBP outside the rooms of residents requiring such precautions, and staff reported relying on signage to know when PPE was necessary. Further deficiencies were observed in the cleaning and disinfection of medical equipment. Multiple licensed nurses and registered nurses used a sphygmomanometer to check blood pressure on several residents without disinfecting the device between uses. This occurred even for residents on EBP, and staff confirmed at the time of observation that the equipment was not cleaned as required. The lack of proper disinfection was noted during medication administration and routine care activities. Interviews with staff, including nurse aides, licensed nurses, and the Assistant Director of Nursing (ADON), revealed gaps in knowledge and adherence to infection control protocols. Some staff were unaware of the need for PPE in the absence of signage, and EBP signage was found to be inaccessible, locked in the ADON's office. The infection preventionist indicated that unit managers were responsible for posting EBP signage, but this was not consistently done, leading to staff not following established infection control procedures.
Failure to Monitor Catheter Care and Urine Output
Penalty
Summary
A deficiency was identified regarding the care of a resident with an indwelling urinary catheter. The resident, who had diagnoses including Multiple Sclerosis, Spastic Hemiplegia, and the presence of urogenital implants, had a physician's order for a urinary catheter with a drainage bag. During observation, the urine bag was found to contain 50 cc of very cloudy liquid with sediment, and neither the bag nor the tubing was dated. The nurse interviewed confirmed the cloudiness of the urine and stated that the bag is sometimes changed only once a week, and that PRN staff do not always change the bags as required by facility policy. The nurse was unable to state when the urine bag was last replaced. Review of the clinical record revealed no documentation that the resident's urine output was being monitored, nor was there evidence that the physician had been notified about the cloudy urine. Additionally, there was no documentation of any monitoring or observation of the resident's status after the cloudy urine was observed. These findings indicate a failure to provide appropriate catheter care and monitoring as required.
Failure to Provide Ordered Nutritional Supplement to Resident with Malnutrition
Penalty
Summary
A resident with diagnoses including malnutrition, metabolic encephalopathy, muscle weakness, and cachexia was admitted to the facility with a BMI of 13, indicating extreme underweight status. The resident's care plan, initiated in early March, specified that nutritional supplements should be provided during meals according to the resident's preference. A physician order was in place for Ensure Plus to be administered three times daily as a supplement. Clinical record reviews, medication administration documentation, and direct meal observations revealed that the ordered supplement was not provided to the resident as prescribed. Specifically, there was no documented evidence that Ensure Plus was given from the date of the physician order through subsequent days, and the supplement was not present on the resident's meal trays during observed lunches. These findings were confirmed by staff interviews, including the nurse manager, registered dietitian, and director of nursing, all of whom acknowledged the lack of documentation and administration of the supplement as ordered.
Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
A deficiency occurred when a resident with diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and Acute Respiratory Failure was not provided respiratory care in accordance with physician orders. The resident had a documented order for oxygen administration at 2 liters per minute via nasal cannula to maintain a pulse oximetry reading above 92%. However, during an observation, the resident was found to be receiving oxygen at 5 liters per minute via nasal cannula, which was not consistent with the physician's order. This discrepancy was confirmed by a licensed nurse at the time of the observation. The facility's policy requires nurses to follow physician orders when administering oxygen, but this was not adhered to in this instance.
Incomplete Dialysis Communication Records for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate records related to dialysis communication for two residents who required hemodialysis. For one resident, physician orders indicated scheduled dialysis treatments three times per week. However, review of the Hemodialysis Communication Record revealed missing required information on multiple dates, including documentation of new orders received and sent with the patient, comments, shunt site observation, whether ports were capped and completed, whether the patient reported pain, lab values, pertinent observations, staff signature and title, and time. A licensed nurse confirmed the lack of this information in the resident's record. Similarly, another resident with physician orders for dialysis on the same schedule had incomplete documentation in the Hemodialysis Communication Record on at least one occasion. The missing information included the same required elements as above. This deficiency was confirmed through staff interview, indicating a pattern of incomplete record-keeping for residents receiving dialysis services.
Failure to Timely Provide and Administer Cardiac Medications for New Admission
Penalty
Summary
The facility failed to ensure the timely acquisition and administration of essential cardiac medications for a newly admitted resident diagnosed with acute congestive heart failure. Upon admission, the resident had physician orders for Carvedilol and Entresto to be administered starting the evening of admission, but these medications were not available and were not given as scheduled. The medication administration record showed that both medications were not administered at the prescribed times, and the first doses were delayed until the following evening. Additionally, Rivaroxaban and Spironolactone, which were part of the resident's hospital regimen and recommended for continued use, were not ordered until the day after admission, further delaying their administration. Interviews with the resident, the resident's wife, the DON, and the Administrator confirmed that the medications were not available on the day of admission and that the medication administration record was inaccurately coded as 'held' without physician parameters for holding the medications. The facility's policy required medications to be administered in a safe and timely manner as prescribed, but this was not followed, resulting in the resident not receiving critical heart medications as ordered.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by errors observed during medication administration for three of seven residents. One resident was administered Breo Ellipta Aerosol Powder by a licensed nurse, but the nurse did not ensure the resident rinsed and spit after inhalation, contrary to the physician's order. This step is necessary to comply with the prescribed administration method. The nurse confirmed the omission during an interview at the time of the finding. Another resident did not receive a scheduled dose of Ipratropium-Albuterol Inhalation Solution because the medication was not available in the facility, and the nurse was waiting for it to arrive from the pharmacy. Additionally, a third resident was given Aspirin Tablet Enteric Coated 81 mg instead of the prescribed Aspirin Tablet Chewable 81 mg, as per the physician's order. The nurse administering the medication confirmed this discrepancy during the observation. These incidents resulted in a calculated medication error rate of 10.34%.
Failure to Honor Resident Food Preferences and Requests
Penalty
Summary
Surveyors identified that the facility failed to honor resident food and drink preferences for six residents. Multiple residents reported not receiving the food items they selected on their menus, with some stating this occurred several times a week. During a group interview, all residents present agreed there were ongoing problems with the kitchen, and several residents specifically mentioned not receiving their requested meals or having items missing from their trays. One resident's lunch ticket specifically stated 'no pasta,' yet the resident was served spaghetti and meatballs, a fact confirmed by both the resident and a nursing aide who reviewed the ticket. Another resident, who is dependent on staff for all activities of daily living and is on a mechanically altered and therapeutic diet due to multiple sclerosis, did not receive the specific sandwich requested by her family. The family had provided bologna, apple sauce, and cranberry juice to ensure the resident received preferred items, but the resident was served a turkey sandwich instead of the requested bologna. A licensed nurse confirmed awareness of the resident's dietary preferences but was unable to explain why the correct item was not provided. These findings demonstrate that the facility did not consistently provide food that accommodated resident preferences and requests as required.
Deficient Food Storage and Sanitation Practices Identified
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During a tour of the Food Service Department, surveyors observed a foul smell caused by food debris in the dishwasher area and noted that the walls in this area had streaks of black dirt. In the walk-in cooler, several food items, including a 10-pound turkey, beef bologna, and two 10-pound ground beef packages, were labeled only with the received date and not with use-by or discard dates as required by facility policy. Additionally, a top round of meat was found with only a received date and no indication of when it was removed from the freezer to defrost, contrary to policy requirements for labeling and dating refrigerated foods.
Miscommunication Leads to Missed Meal for Resident
Penalty
Summary
Roosevelt Rehabilitation and Healthcare was found to be non-compliant with the requirement to provide meals at regular times, as evidenced by an incident involving Resident R3. On January 8, 2025, Resident R3 did not receive his breakfast meal due to a miscommunication among nurse aides. The facility's policy requires nursing staff to deliver food trays to each resident's room, but this was not followed for Resident R3. The resident had previously reported his assigned nurse aide, Employee E3, for refusing to change his bed linens, which he believed led to retaliation when he did not receive his breakfast. Further investigation revealed that Employee E3 was reassigned on the morning of January 8, 2025, and was not responsible for Resident R3's care at that time. However, a grievance report indicated that the meal was offered, but Resident R3 declined it, stating he was heading to lunch. The unit manager confirmed the miscommunication among staff, which resulted in the resident not receiving his breakfast tray. The facility's grievance investigation included a statement from Employee E3, noting that Resident R3 was asleep when the breakfast tray was delivered, and the tray was left because the resident did not like to be woken up.
Plan Of Correction
1. Facility cannot retroactively provide resident 3 with a missed meal. 2. Facility conducted full house audit on each meal to ensure every resident received a meal tray. Facility conducted full house audit to ensure all residents had meal tickets. 3. NHA/designee will re-educate all nursing department to ensure staff will remove food trays from the food cart and deliver the trays to each resident room when eating meals on the unit. 4. NHA/designee will conduct random audits on one cart to ensure all residents receive a meal daily x4 weeks, weekly x4 and monthly x2. Facility will conduct audits to ensure all residents have a meal ticket 3x a week for 4 weeks, weekly x4 and monthly x2. Results will be submitted to QAPI for review and recommendations as needed.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for four out of six residents reviewed, leading to a deficiency in nursing services. Resident R1, who was admitted with chronic obstructive pulmonary disease, anemia, and coronary artery disease, was found soiled and unable to reach the call bell, which was wrapped around the back of the bed. Despite having an intact cognition as indicated by a BIMS score of 14, Resident R1 reported being left soiled for an hour without assistance. This was corroborated by Resident R1's roommate, who confirmed that staff frequently did not assist Resident R1 in a timely manner. Similarly, Resident R2, with diagnoses of hypertension, diabetes mellitus, and arthritis, reported pressing the call bell overnight for toileting assistance but remained soiled for several hours as staff did not respond. Residents R3 and R4, who require extensive assistance with toileting hygiene, also reported not being changed in a timely manner. Resident R3's family further confirmed that Resident R3 was often found soiled during visits. These findings indicate a systemic issue in the facility's response to residents' incontinence care needs.
Sanitation and Hand Hygiene Deficiencies 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. Observations during a kitchen tour revealed several violations of the facility's food storage and handling policies. These included a broom and dustpan left on the kitchen floor, improperly stored cleaning equipment, and trash containers with dirty gloves in the dock area. In the dry storage area, several food items such as dressings, bread, sesame seeds, and brown sugar were found without proper labeling or expiration dates. The main refrigerator contained prepared yellow cakes without preparation or expiration dates, and the main freezer had open chicken fingers and frozen meatballs without labels indicating when they were opened or their expiration dates. Additionally, a dietary aide was observed handling food without a beard covering or hair net, contrary to the facility's policy. Further observations in the dining area revealed that nursing aides failed to perform hand hygiene after assisting residents with their meals. Specifically, two nursing aides were seen delivering food and assisting residents without washing their hands after touching potentially contaminated surfaces. One aide was observed touching a resident's wheelchair footrest and picking up an item from the floor with a napkin before directly assisting a resident with their meal. These actions were confirmed by the unit manager, indicating a breach in the facility's hand hygiene policy, which is intended to prevent the spread of healthcare-associated infections.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program over a six-month period, as evidenced by a lack of adherence to its own policies and procedures. The facility's policy, dated December 2016, required the collection and documentation of antibiotic usage and outcomes using a facility-approved tracking form. However, the review of facility documentation revealed that the facility did not consistently document necessary information such as symptoms, stop dates, total days of therapy, outcomes, and adverse events for antibiotic orders. Specifically, in April, May, and June 2024, numerous infections were recorded without symptoms documented, and most antibiotic orders lacked critical information as per the facility's policy. Additionally, the facility's antibiotic stewardship data indicated that an Infection Report tool, which was supposed to be completed by a licensed nurse at the onset of infection symptoms, was not utilized after April 2024. This tool was intended to determine if infections met the criteria for reporting. The Director of Nursing confirmed these findings during an interview on July 2, 2024. The facility's failure to adhere to its antibiotic stewardship program and documentation requirements resulted in a deficiency under 28 Pa. Code 211.10(d) and 28 Pa. Code 211.12(d)(1)(5).
Deficiency in Meal Quality and Temperature
Penalty
Summary
The facility failed to provide meals that were palatable, attractive, and served at safe and appetizing temperatures during lunch observations on two consecutive days. On June 30, 2024, a test tray revealed that the hot meal items, including glazed pork loin, steamed cauliflower, and sweet potatoes, were served at temperatures below the safe threshold, while apple juice was served above the recommended cold temperature. Residents reported the food as unappealing, cold, and difficult to eat, with some refusing to eat their meals. The Regional Dietary Director confirmed the lack of color and attractiveness of the meals served. On July 1, 2024, further issues were observed with the lunch service. A resident received a lunch tray with hard tortellini pasta and burned garlic bread, which was confirmed by a unit manager to be unpalatable. The resident's meal preferences were not met, and the food was described as having no flavor or appearance. A group interview with residents revealed dissatisfaction with the taste and temperature of the food, with reports of it being undercooked or overcooked and not seasoned. The facility's management acknowledged the issues with the lunch service during a meeting.
Failure to Implement Enhanced Barrier Precautions and Infection Control
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBPs) and proper infection control practices for four residents. Resident R52, who has a feeding tube due to conditions such as a stroke and dementia, was observed receiving care from a nursing assistant without the required gown, despite a sign indicating the need for EBPs. The nursing assistant misunderstood the EBP requirements, thinking they pertained to skin care rather than infection control. Additionally, residents R101 and R194, both with feeding tubes, did not have signs outside their rooms to alert staff and visitors about the need for EBPs, despite physician orders indicating such precautions every shift. In the dining room, infection control practices were not followed as a nurse aide was observed preparing and feeding a resident without washing or sanitizing her hands. This lack of adherence to hand hygiene protocols, as outlined in the facility's policy, further contributed to the deficiency. These observations indicate a failure in the facility's implementation of its infection prevention and control program, particularly in the use of EBPs and hand hygiene practices.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to ensure a clean and homelike environment in two of its three nursing units, specifically on the third and fourth floors. Observations revealed several issues, including water dripping from the ceiling in one room, with a missing ceiling tile and water being collected in a nearly full trash can. A resident reported that the leak had been ongoing for weeks since the air conditioner was turned on, and despite staff being aware, the issue was not resolved. The resident further stated that a ceiling tile was replaced without properly fixing the leak, leading to its collapse. Another room had water on the floor, making it sticky, and a different room had missing baseboard molding and a hole in the wall. Additionally, a strong odor consistent with urine was detected in a room and the hallway outside it. These observations were confirmed by the facility administrator.
Failure to Develop Baseline Care Plan for Resident with Laryngectomy
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident with specific respiratory care needs. The resident, identified as having a laryngectomy tube due to the surgical removal of the larynx, expressed that nursing staff did not consistently offer assistance with the care of her laryngectomy tube, which she managed herself. Despite the resident's ability to care for her tube, the facility's policy required a baseline care plan to be developed to address immediate health and safety needs, which was not done in this case. Interviews and record reviews revealed that the respiratory therapist assessed the resident upon admission and noted her preference for self-care. However, no baseline care plan was created to address the resident's laryngectomy tube care, impaired communication, or respiratory needs, including suctioning and assessment. The Director of Nursing confirmed the absence of a baseline care plan for these needs, indicating a lapse in adhering to the facility's care policies and state regulations.
Failure to Develop Smoking-Related Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan related to smoking for a resident identified as a smoker. The facility's policy requires that a comprehensive care plan with measurable objectives and timetables be developed for each resident, including those who smoke. However, despite the resident being identified as a smoker in the facility's documentation, no care plan was developed to address the resident's smoking habits and ensure their safety. The resident, who has chronic obstructive pulmonary disease and end-stage renal disease, was observed smoking in the designated area, yet their Minimum Data Set assessment inaccurately indicated that they did not use tobacco. The facility's smoking policy mandates that residents' smoking status be evaluated upon admission and re-evaluated quarterly or upon significant changes. Despite this, the resident's smoking evaluation conducted by a licensed nurse inaccurately reported that the resident did not smoke, leading to a lack of further assessment or care planning. The Director of Nursing confirmed the absence of a smoking-related care plan for the resident, highlighting a deficiency in adhering to the facility's policies and ensuring resident safety.
Failure to Provide ROM Services for Resident with Contractures
Penalty
Summary
The facility failed to provide appropriate care for a resident with limited range of motion, resulting in a deficiency. The resident, who had contractures in his hands due to a stroke, reported not receiving any services such as exercise or splinting to prevent further worsening of the contracture. Observations confirmed that the resident was lying in bed without any positioning devices or splints, and both hands appeared contracted. Clinical records revealed that the resident had hemiplegia and hemiparesis, with impaired range of motion in the upper extremities. An occupational therapy evaluation noted limited range of motion and decreased strength, but no restorative or functional maintenance program was established. The active care plan and physician orders did not include a restorative nursing program or services for the resident's limited range of motion. The Rehab Director confirmed that the resident was not receiving any services for his condition.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to provide acceptable nutritional parameters for a resident, identified as R194, who experienced significant weight loss. According to the facility's Weight Policy, residents should be weighed on admission, weekly for four weeks, and then monthly unless otherwise ordered. Any significant weight change, defined as a 5% gain or loss in one month, should be reported to the Registered Dietitian and reweighed. However, the facility did not adhere to this policy. Resident R194 lost over 15 pounds in one month, with a total weight loss of 26.04% from January to June 2024. Despite this significant weight loss, the staff did not address the issue until June 18, 2024, and no reweight was completed as per the policy. The resident was on enteral nutrition and NPO (Nothing by Mouth), and the weight loss was attributed to severe protein-calorie malnutrition, with a BMI of 17.4 indicating underweight status. The dietician confirmed that a reweight was not obtained after the significant weight loss was noted on June 10, 2024, and the resident was not evaluated until June 18, 2024. The delay in addressing the weight loss and the lack of adherence to the facility's policy contributed to the deficiency identified in the report.
Incomplete Dialysis Communication for Resident with ESRD
Penalty
Summary
The facility failed to ensure ongoing records of communication between the facility and the dialysis center for a resident with end-stage renal disease (ESRD) who required dialysis services. The facility's policy, revised in September 2010, mandates that residents with ESRD be cared for according to recognized standards, and that staff be trained in the care and special needs of these residents. However, a review of Resident R58's dialysis communication binder revealed incomplete documentation on several dates, indicating a lack of assessment and monitoring after the resident returned from dialysis. Resident R58, who was admitted with a diagnosis of ESRD and dependence on renal dialysis, had missing documentation in their dialysis binder on multiple occasions. The binder is supposed to include vital information such as vitals, weight, vascular access, and any new acute problems since the last treatment. An interview with a licensed nurse confirmed the incomplete documentation and acknowledged that it is the nursing staff's responsibility to complete the dialysis communication pages for all residents receiving dialysis.
Failure to Document Physician Assessment for Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a physician assessment was completed for a resident experiencing significant unplanned weight loss. According to the facility's Weight Policy, residents should be weighed upon admission, weekly for four weeks, and monthly thereafter unless otherwise ordered. Any significant weight change, defined as a 5% gain or loss in one month, should be reported to the Registered Dietitian and the physician. The policy also requires that interventions be documented in the care plan and discussed in the interdisciplinary team meeting. However, for Resident R194, who experienced a weight loss of over 15 pounds in one month, there was no documented evidence of a physician assessment addressing this significant weight change. Resident R194's weight records showed a decrease from 178.2 pounds to 131.8 pounds, a 26.04% loss, between January and June 2024. Despite the resident appearing cachectic and the dietitian being involved, the clinical record lacked documentation of a physician's assessment or intervention regarding the weight loss noted on June 10, 2024. This deficiency was confirmed during an interview with the Director of Nursing. The failure to document a physician's assessment and address the nutritional and medical issues related to the resident's weight change constitutes a violation of the facility's policies and state regulations.
Physician Fails to Document Rationale for Rejecting Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that the physician documented the review of pharmacy recommendations and provided a rationale for rejecting these recommendations for a resident. The consultant pharmacist conducted a medication regimen review for a resident, who had been prescribed Aripiprazole and Midodrine. The pharmacist recommended a gradual dose reduction for Aripiprazole and suggested that Midodrine should not be dosed after 5:00 p.m. However, the physician disagreed with both recommendations without documenting any rationale for the rejection. The deficiency was identified through a review of the clinical records, interviews with staff, and examination of the facility's policy on medication regimen reviews. The Director of Nursing confirmed that the medication regimen review documents for the resident were inadequately completed, as the physician failed to provide documentation for the rejection of the pharmacist's recommendations. This lack of documentation is inconsistent with the facility's policy, which requires the attending physician to document the review of any irregularities and the actions taken to address them.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were labeled and stored according to professional standards of practice. This deficiency was observed in four out of six medication carts across different floors. The facility's policy on medication storage and labeling, revised in February 2023, requires that medications be labeled with specific information, including the medication name, prescribed dose, strength, expiration date, resident's name, route of administration, and appropriate instructions. However, during observations, it was found that multiple bottles of over-the-counter medications and eye drops lacked a marked date of opening, and there were loose pills and capsules in the drawers of the medication carts. On the Third-floor center's medication cart, multiple bottles of over-the-counter medications and eye drops were found without a marked date of opening. Similarly, the Second-floor center's medication cart had an unidentifiable insulin pen and multiple bottles of eye drops without a marked date of opening. The Third-floor south's medication cart contained a substantial number of loose pills and capsules, along with over-the-counter medication bottles not dated for opening. Lastly, the Fourth-floor center's medication cart also had loose pills in the drawers. These findings were confirmed by interviews with licensed nurses present during the observations.
Pest Control Deficiency in Resident Care Areas
Penalty
Summary
The facility failed to maintain an effective pest control program in the resident care areas, as evidenced by observations and resident interviews. In Resident room [ROOM NUMBER], a sticky fly trap with dead flies was observed hanging from the ceiling. A resident in this room reported the presence of flies and mentioned using the trap for some time. Another resident in a different room reported the presence of mice, rats, flies, and roaches, pointing out roaches behind the door and inside the bathroom. These observations were confirmed by the Administrator.
Inadequate Training on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to provide adequate training on infection control procedures related to Enhanced Barrier Precautions (EBPs) for seven out of eight employees interviewed. The facility's policy on EBPs, dated August 2022, requires the use of gowns and gloves during high-contact resident care activities to prevent the spread of multi-drug resistant organisms (MDROs). Despite a documented in-service training session held in May and June 2024, observations and interviews revealed that staff members were not properly implementing these precautions. For instance, a nursing assistant was observed providing care to a resident with a feeding tube without wearing a gown, contrary to the facility's EBP policy. Interviews with various staff members, including nursing assistants and licensed nurses, indicated a lack of understanding and inconsistent interpretations of the EBP requirements. Some staff equated EBPs with isolation precautions, while others misunderstood the purpose of the barrier precaution signs posted on residents' doors. This confusion among staff members highlights a significant gap in the facility's training and communication regarding infection control measures, particularly in the context of EBPs.
Failure to Adhere to Residents' Dietary Preferences
Penalty
Summary
The facility failed to provide food products based on the residents' food preferences for four out of 36 residents. The facility's policy, last revised in July 2017, requires that individual food preferences be assessed upon admission and communicated to the interdisciplinary team. However, observations and staff interviews revealed discrepancies in meal preparation and delivery. Resident R22 received mashed potatoes instead of the preferred mashed sweet potatoes and was missing bread or a roll with butter. Resident R23 was served a white bread sandwich despite a preference for wheat bread and received no tea or substitute vegetable, even though they disliked cauliflower. Further issues were observed on the third floor, where Resident R155 and Resident R98 received undercooked tortellini, which was too hard to chew. Resident R98's meal did not match their preference ticket, which included baked ziti with cheese and marinara sauce, Italian blend vegetables, and a sandwich. Additionally, Resident R57, who does not eat pasta due to having a colostomy bag, was served tortellini instead of the requested sandwich. These incidents indicate a failure to adhere to residents' dietary preferences and needs, as confirmed by staff and resident interviews.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for two residents, R1 and R2, as determined through clinical record review, observations, and staff interviews. Resident R1, who has a diagnosis of a disorder of the skin and subcutaneous tissue, rash, and other nonspecific skin eruptions, is care planned to be checked approximately every 2 hours and provided incontinence care as needed. Despite this, Resident R1 reported being wet and not changed from 5:00 a.m. until 11:00 a.m. on the day of the interview. The resident's call bell request for assistance was also ignored, and a nursing assistant suggested delaying the change until after lunch, which the resident declined due to the prolonged wait time. Resident R1's MDS indicated a BIMS score of 15, showing intact cognition, and required two-person assistance for ADLs. Similarly, Resident R2, who also has a BIMS score of 15 and requires two-person assistance for ADLs, reported experiencing delays in being changed, particularly during the 11-7 shift the previous night. The deficiency was observed during an interview with Resident R1, who expressed frustration over the lack of timely incontinence care. The resident's roommate, Resident R2, corroborated these concerns, indicating that staff sometimes failed to change her in a timely manner. The failure to provide timely incontinence care for these residents violates their rights and the facility's nursing services regulations, as outlined in 28 Pa Code 201.29(j) and 28 Pa Code 211.11(d)(1)(5).
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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