Sayre Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sayre, Pennsylvania.
- Location
- 151 Keefer Lane, Sayre, Pennsylvania 18840
- CMS Provider Number
- 395101
- Inspections on file
- 27
- Latest survey
- April 3, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Sayre Health Care Center during CMS and state inspections, most recent first.
A resident with dementia was transferred to another facility due to behavioral issues and unmet needs, but the required physician documentation detailing the necessity of the transfer, unmet needs, attempts to address those needs, and services at the receiving facility was not present in the clinical record.
A resident with a history of elopement attempts, falls, and behavioral issues was transferred to another SNF after the facility determined it could not meet their needs. The facility did not provide the required written notice of transfer to the responsible party prior to discharge, omitting information on the reason for discharge, effective date, discharge location, appeal rights, and Ombudsman contact details.
The facility was found non-compliant with NFPA 101 standards as a door in the Dietary Dry storage area was held open by a rubber wedge, affecting one of eight smoke compartments. This was confirmed during an exit interview with the Facility Administrator and Maintenance.
The facility did not comply with NFPA 101 standards as the Dietary Dry storage door was held open, blocking the manual pull station for the ansul system. This issue was confirmed during an interview with the Facility Administrator and Maintenance.
The facility failed to maintain automatic sprinkler systems, with dust-loaded sprinkler heads found in three locations affecting three of eight smoke compartments. Observations revealed dust on sprinkler heads near resident rooms in the 200, 300, and 400 Hall corridors. This was confirmed during an exit interview with the Facility Administrator and Facility Maintenance.
The facility failed to maintain smoke barrier doors between 300 Hall and 500 Hall, affecting two smoke compartments. The doors required adjustment to latch properly into the frame, as observed and confirmed by facility staff.
The facility did not maintain monthly inspections for a fire extinguisher in the Mechanical Room on 300 Hall, as required by NFPA 10. The last inspection was conducted during the annual maintenance in November 2024. This was confirmed during an exit interview with the Facility Administrator and Facility Maintenance.
The facility failed to properly cool beef rounds according to HACCP guidelines, leading to potential foodborne illness risks. The beef rounds were not cooled to a safe temperature before being served to residents. Additionally, the Unit 1 Nursing pantry had unsanitary conditions and expired food supplements available for use.
A facility failed to honor a resident's advance directive choices by not updating the resident's code status from full code to DNR in a timely manner. Despite the responsible party completing and the physician signing the necessary forms on February 27, 2025, the change was not documented until March 6, 2025.
A facility failed to provide a CMS-10055 form to a resident after Medicare payment ended, leaving the resident uninformed about potential liability for non-covered care. The resident remained in the facility without receiving the necessary notification, as confirmed by a review of records and an interview with the Nursing Home Administrator.
The facility failed to maintain a clean and homelike environment in Nursing Unit 2, with issues such as stained walls in a resident's room, cigarette butts in a non-smoking area, marred drywall, and peeling furniture. These deficiencies were observed and confirmed with the NHA.
The facility failed to conduct an FBI background check for a newly hired cook who had not lived in the state for more than two years, as required by their abuse prohibition policy. Despite this oversight, the employee had been providing services and had access to residents. Interviews with HR and the Nursing Home Administrator confirmed the lapse in completing the background check within the required timeframe.
The facility failed to implement comprehensive care plans for two residents, leading to inadequate care. One resident experienced agitation during a shower due to staff not following care plan interventions, while another resident lacked a care plan for their pacemaker and anticoagulation therapy. These deficiencies were identified through clinical record reviews and staff interviews.
A resident discharged to home with home health services had an incomplete discharge summary that failed to document a Stage 3 Pressure Ulcer and related treatment. The summary inaccurately noted no wound care, despite previous records indicating otherwise. This deficiency was identified through a closed clinical record review and staff interview.
The facility failed to implement restorative nursing programs for two residents following their discharge from skilled therapy services. One resident did not start the recommended exercises until over a month after discharge, while another had no evidence of an active program until questioned by a surveyor. This resulted in a lack of necessary care to maintain or improve their abilities in activities of daily living.
The facility failed to follow physician orders for two residents. One resident was not given prescribed artificial tears for dry eye syndrome, and another resident's daily weights were not consistently documented as ordered. These deficiencies were confirmed by the Nursing Home Administrator.
A facility failed to timely implement wound care recommendations for a resident with a sacral pressure ulcer. Despite wound care service recommendations, the care plan and physician orders were initiated after the resident's discharge, and there was no evidence of treatment completion. The facility lacked documentation of staff awareness or implementation of the recommendations.
The facility failed to provide appropriate respiratory care for two residents. One resident's oxygen concentrator was set incorrectly, and their nebulizer equipment was not bagged or changed as required. Another resident's nebulizer equipment was also not bagged or changed, despite available supplies. These deficiencies were confirmed through observations and resident interviews.
A facility failed to provide appropriate behavioral health interventions for a resident with known behavioral symptoms, leading to a deficiency. The resident, who exhibited behaviors such as false accusations, was not provided with a care plan that included necessary interventions like having two staff present during care. During a shower incident, the resident became agitated and falsely accused staff of harm, highlighting the facility's failure to implement existing care plan instructions to manage agitation.
The facility failed to securely store medications and ensure proper labeling, leading to deficiencies. An LPN crushed a Rosuvastatin tablet for a resident, despite resources indicating it should be swallowed whole, due to a lack of precautionary instructions on the label. Additionally, a pill was found on the floor in a common area, indicating a lapse in medication storage protocols.
A resident with dental concerns did not receive timely dental services, despite experiencing dental pain and infection. The facility delayed obtaining consent for dental services and failed to provide professional dental care for nearly a year, leading to a deficiency.
A facility failed to implement enhanced barrier precautions for a resident with a tunneled dialysis catheter, as required by their infection prevention and control program. Despite having a medical device that necessitates such precautions, there was no evidence of EBP being used, such as signs, PPE, or instructions for staff. The Nursing Home Administrator confirmed the oversight, which was contrary to the facility's policy and previously cited in an earlier survey.
The facility did not follow its procedures for rotating emergency water supplies, resulting in expired water being stored in essential areas. Observations revealed that multiple boxes of water on Nursing Unit 1 and in the main kitchen were past their best by dates, with no evidence of regular rotation as per policy. Staff interviews indicated a lack of clarity on managing expired supplies.
The facility did not meet the required minimum staffing levels for nurse aides across multiple shifts, failing to ensure the mandated nurse aide-to-resident ratios. Specific instances of insufficient staffing were noted during various periods, indicating a consistent failure to comply with regulations.
The facility failed to meet the required LPN staffing levels across multiple shifts, as evidenced by a review of nursing staffing hours. The facility did not ensure a minimum of one LPN per 25 residents on eight of 21 day shifts, one LPN per 30 residents on eight of 21 evening shifts, and one LPN per 40 residents on three of 21 overnight shifts. This deficiency was identified during specific periods, including October 2024, December 2024, and February 2025.
The facility did not meet the required 3.2 hours of direct nursing care per resident per day for eight days, with hours ranging from 2.74 to 3.19. This deficiency was confirmed through a review of staffing hours and an interview with the Nursing Home Administrator.
The facility failed to provide timely Notice of Medicare Non-Coverage (NOMNC) to two residents, as required by Medicare regulations. The notices were not delivered at least two calendar days before the end of Medicare-covered services, impacting the residents' ability to appeal the termination of services.
The facility failed to maintain a safe environment in the beauty shop, leaving it unattended with hazardous items and high water temperature. The beautician was unaware of the need to secure the area when not present.
The facility failed to maintain food service equipment in a sanitary manner and proper working order. Observations revealed thick dust buildup on the hood system and a dishwasher running at insufficient temperatures without a sanitizing agent. The issue persisted despite being logged and reported.
The facility failed to implement enhanced barrier precautions for three residents with indwelling devices and did not ensure hygienically clean laundry processing. Staff were unaware of the need for these precautions, and the facility lacked mechanisms to monitor laundry water temperatures and chemical sanitization.
The facility failed to provide adequate care for a resident with a PICC line, including the absence of a comprehensive care plan, emergency procedures, and documentation of required treatments and medications. Interviews and observations confirmed these deficiencies.
The facility failed to identify and care plan triggers for a resident with Chronic PTSD. The resident disclosed that loud noises and bright lights were triggers due to his combat experience, but these were not documented in the care plan. This deficiency was confirmed by the Nursing Home Administrator and DON.
The facility failed to develop and implement an individualized person-centered care plan for a resident diagnosed with dementia. Despite the admission MDS indicating the need for such a plan, a review of the resident's current care plan showed no indication that it had been created or implemented. This deficiency was confirmed during an interview with the Administrator and DON.
The facility failed to ensure that the consultant pharmacist reviewed the drug regimen of each resident and reported any irregularities to the attending physician monthly. For one resident, there was a delay and lack of evidence in reporting medication irregularities, and for another resident, there was no monthly review completed for a specific month. These findings were confirmed by the Nursing Home Administrator and the Director of Nursing.
The facility's medication error rate was 7.69 percent due to an LPN not following proper procedures for insulin administration for two residents. The LPN did not verify the correct attachment of the safety pen needle or ensure the presence of liquid before administering insulin.
The facility failed to ensure a resident received a COVID-19 vaccine despite signed consents and conflicting documentation about vaccine refusal. Staff interviews confirmed the absence of proper documentation and adherence to the facility's vaccination policy.
A facility failed to accurately assess the entrapment risk for a resident with dementia using a specialized mattress and side rails. The mattress was observed to shift, creating a gap, but the assessment inaccurately indicated it fit securely. The occupational therapist confirmed the mattress was not secured and the assessment was based on typical equipment without physical measurement.
Lack of Physician Documentation for Facility-Initiated Transfer
Penalty
Summary
The facility failed to ensure that the necessary resident information was documented by the physician to facilitate a facility-initiated transfer of a resident with dementia. The resident was admitted with a diagnosis of dementia and was later discharged to another skilled nursing facility because the facility determined it could not meet the resident's needs. Documentation from the Director of Nursing indicated that the resident exhibited behaviors such as attempting to elope, pulling fire alarms, threatening to let other residents out, inappropriate touching, entering other residents' rooms and taking items, and frequent falls despite interventions. Meetings were held with the resident's responsible party and the interdisciplinary team to discuss the need for transfer, and arrangements were made with the receiving facility, which had a secured unit. However, there was no evidence in the resident's clinical record of physician documentation prior to discharge that specified the necessity of the transfer for the resident's welfare, the specific needs that could not be met, the facility's attempts to meet those needs, or the services available at the receiving facility to address those needs. This lack of required physician documentation was confirmed during a telephone interview with the Nursing Home Administrator and Director of Nursing.
Failure to Provide Required Written Notice Prior to Facility-Initiated Discharge
Penalty
Summary
A facility-initiated discharge occurred for a resident who had a history of multiple elopement attempts, falls, wandering into other resident rooms, inappropriate touching of staff and other residents, removing clothing in common areas, and a sexual incident with another resident. The facility determined it could not meet the resident's needs and planned a transfer to another skilled nursing facility, with meetings held with the resident's responsible party to discuss these behaviors and the recommendation for transfer. Despite knowing about the planned transfer four days in advance, the facility failed to provide the resident's responsible party with a written notice of transfer prior to discharge. There was no documentation that the required notice, which should have included the reason for discharge, effective date, discharge location, information on appeal rights, and contact information for the State Long-Term Care Ombudsman, was given as mandated by regulations.
Non-compliance with Self-Closing Door Requirements
Penalty
Summary
The facility failed to maintain compliance with NFPA 101 standards regarding doors with self-closing devices. During an observation on March 19, 2025, at 10:48 a.m., it was noted that the door to the Dietary Dry storage area was being held open by an unapproved means, specifically a rubber wedge. This deficiency affected one of the eight smoke compartments within the facility. The issue was confirmed during an exit interview with the Facility Administrator and Facility Maintenance on the same day at 11:45 a.m.
Plan Of Correction
The Maintenance Director promptly took out the rubber wedge and closed the door to the dry food storage room. The facility Administrator educated both the Maintenance Director and the Food Service Director that, in accordance with life safety regulations, this door must never be propped open. To ensure compliance, the Maintenance Director will conduct weekly audits for a duration of four weeks, followed by monthly audits for three months, to verify that the dry food storage room door remains closed. The findings from these audits will be presented at the monthly Quality Assurance meeting for evaluation.
Obstruction of Ansul System Pull Station in Dietary Area
Penalty
Summary
The facility failed to protect cooking facilities in accordance with NFPA 101 standards. During an observation on March 19, 2025, it was noted that the door to the Dietary Dry storage area was held open, which obstructed access to the manual pull station for the ansul system. This deficiency was confirmed during an exit interview with the Facility Administrator and Facility Maintenance on the same day.
Plan Of Correction
- The Maintenance Director closed the door to the dry food storage area to ensure the ansul system was unobstructed without delay. - Both the Maintenance Director and the Food Services Director received training on the importance of keeping the ansul system clear in accordance with life safety regulations and compliance standards. - The Maintenance Director will conduct weekly audits for a duration of four weeks, followed by monthly audits for an additional three months, to verify that the ansul system remains unblocked. These audit results will be presented at the QA meeting for evaluation.
Failure to Maintain Sprinkler Systems
Penalty
Summary
The facility failed to maintain automatic sprinkler systems in three locations, affecting three of eight smoke compartments. During an observation on March 19, 2025, between 10:58 a.m. and 11:25 a.m., it was found that several sprinkler heads were loaded with dust. Specifically, the sprinkler head in the 200 Hall corridor near Resident Room 201 was observed at 10:58 a.m., the sprinkler head in the 300 Hall corridor near Resident Room 303 was observed at 11:02 a.m., and the sprinkler head in the 400 Hall corridor near Resident Room 407 was observed at 11:25 a.m. An exit interview with the Facility Administrator and Facility Maintenance confirmed the presence of dust on the sprinkler heads.
Plan Of Correction
- The Maintenance Director has cleaned the dust from the sprinkler heads situated in the 200 hallway by resident room 201, the 300 hallway by resident room 303, and the 400 hallway by resident room 407. - The facility Administrator provided training to both the Maintenance Director and the Environmental Services Director on the importance of keeping these sprinkler heads dust-free at all times. - The Maintenance Director will conduct weekly audits for a duration of four weeks, followed by monthly audits for four months, and will present the findings at the monthly Quality Assurance meeting for evaluation.
Failure to Maintain Smoke Barrier Doors
Penalty
Summary
The facility failed to maintain one set of smoke barrier doors, which affected two of the eight smoke compartments. During an observation on March 19, 2025, at 11:05 a.m., it was noted that the smoke barrier doors leading from 300 Hall into 500 Hall required adjustment to positively latch into the corresponding frame, specifically the left leaf of the doors. This deficiency was confirmed during an exit interview with the Facility Administrator and Facility Maintenance on the same day at 11:45 a.m., where it was acknowledged that the doors failed to latch into the frame.
Plan Of Correction
The Maintenance Director promptly modified the fire barrier door situated between the 300 and 500 areas to guarantee it latches correctly. The Maintenance Director received education from the facility administrator regarding the inspection of all smoke barrier doors to confirm their proper latching. The Maintenance Director will conduct weekly random audits of the smoke barrier doors for a duration of four weeks, followed by monthly audits for three months, and will present the findings at the monthly Quality Assurance meeting for evaluation.
Failure to Maintain Monthly Fire Extinguisher Inspections
Penalty
Summary
The facility failed to maintain portable fire extinguishers as required by NFPA 10, Standard for Portable Fire Extinguishers. During an observation on March 19, 2025, at 11:22 a.m., it was noted that the fire extinguisher located in the Mechanical Room on 300 Hall had not undergone monthly inspections since its last annual maintenance in November 2024. This deficiency was confirmed during an exit interview with the Facility Administrator and Facility Maintenance on the same day at 11:45 a.m.
Plan Of Correction
The Maintenance Director conducted an inspection of the fire extinguisher situated in the mechanical room along the 300 hallway. The Facility Administrator provided guidance to the Maintenance Director regarding the necessity of verifying that each fire extinguisher is inspected and documented on a monthly basis. The Maintenance Director is responsible for performing monthly audits and presenting the findings at the Quality Assurance meeting monthly for four months.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, and serve food in a manner that prevents the potential spread of foodborne illness. During an observation and review of the facility's cool down logs, it was found that the staff did not properly cool down four beef rounds according to the Hazard Analysis and Critical Control Points (HACCP) guidelines. The beef rounds were cooked and initiated for cooling, but the temperatures recorded did not meet the required cooling standards. The beef rounds did not reach the safe holding temperature of 40 degrees Fahrenheit within the specified time frame, and there was no documentation indicating further temperature checks. Despite this, the beef rounds were served to residents as roast beef. Additionally, an observation of the Unit 1 Nursing pantry revealed unsanitary conditions, including a microwave with dried, stuck-on food and expired food supplements available for resident use. The pantry contained 12 cartons of vanilla Glucerna with a use-by date that had already passed. These findings were confirmed through interviews and observations with the certified dietary manager and were reviewed with the Nursing Home Administrator.
Plan Of Correction
1. No residents were harmed. 2. The dietary manager reviewed temp logs, immediately had housekeeping thoroughly clean the microwave and removed the expired Glucerna from the cabinet. 3. The Dietary Manager educated dietary staff on the importance of food temps, thoroughly cleaning the microwaves and discarding expired food/drinks. 4. The Dietary Manager or designee will audit these areas of concern. These audits will be completed weekly for four weeks then monthly for four and brought to the monthly QA meeting for review.
Failure to Honor Advance Directive Choices
Penalty
Summary
The facility failed to honor the advance directive choices for a resident, identified as Resident 175. The clinical record review revealed that on August 1, 2024, the resident's responsible party indicated that the resident was a full code, meaning staff was to start CPR if necessary. However, on February 27, 2025, the responsible party completed a POLST form and a facility code status form, both indicating a Do Not Resuscitate (DNR) status for the resident. These forms were also signed by the physician on the same day, February 27, 2025. Despite the completion and signing of the DNR forms, there was no documentation that the facility changed Resident 175's code status order from full code to DNR until March 6, 2025. This oversight was identified during an interview with the Nursing Home Administrator on March 6, 2025, at 3:39 PM. The failure to update the resident's code status in a timely manner represents a deficiency in the facility's compliance with the requirements for honoring advance directives.
Plan Of Correction
1. All residents were unharmed, including Resident 175. Resident 175 Advanced Directive was reconciled and corrected immediately. 2. The Facility Administrator and the Interdisciplinary Team promptly assessed all existing residents to verify that their advanced directive and code status were accurate, up-to-date, and readily available to staff in the event of an occurrence. 3. All staff members received training on how to find the code status in the event of an occurrence. Additionally, all nurses were instructed and educated on the significance of updating residents upon their return from the hospital to ensure that the advance directives are accurate and up-to-date in case of an incident. 4. The Director of Nursing or designee will conduct weekly audits for a duration of four weeks, followed by monthly audits for three months. Physician Orders, Care Plan and spine of hard chart will be reviewed to verify accuracy and currency of each residents advance directive. The findings will be presented at the monthly Quality Assurance meeting for review.
Failure to Provide Required Payment Coverage Notification
Penalty
Summary
The facility failed to provide the required notification to a resident whose payment coverage changed. Specifically, for one of the three residents reviewed, identified as Resident 2, the facility did not issue the necessary CMS-10055 form after Medicare payment for the resident's care ended. The clinical record review indicated that Medicare payment for Resident 2's care ended on July 26, 2024, yet the resident remained in the facility without receiving the appropriate notification of potential liability for the non-covered stay. The review of the CMS-10123 form confirmed that the last covered day of Medicare payment was July 26, 2024, but there was no evidence that the CMS-10055 form was provided to Resident 2. An interview with the Nursing Home Administrator confirmed the absence of this documentation, indicating a lapse in the facility's compliance with the notification requirements for changes in payment coverage.
Plan Of Correction
1. No residents were harmed. Resident 2 expired so the facility was unable to provide the notice to the resident. 2. The social services department evaluated the accuracy of residents requiring a CMS-10055 form to verify that they had been notified timely regarding the termination of their Medicare coverage. 3. The facility administrator educated the social services department about the necessity of promptly notifying residents when their Medicare coverage has concluded, emphasizing that the resident must sign a CMS-10055 form as part of this notification process. 4. The facility administrator or designee will conduct weekly audits for a duration of four weeks, followed by monthly audits for three months. This process aims to confirm that residents are informed about the Medicare cut-off date and are signing the CMS-10055 form. The results of these audits will be presented at the monthly Quality Assurance meeting for evaluation.
Deficiencies in Maintaining a Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment on one of its nursing units, specifically Nursing Unit 2. Observations revealed several deficiencies, including a six-foot section of wall in a resident's room with a large, black linear stain and marring. Additionally, the egress area leading to the laundry building was littered with partially smoked cigarette butts, despite the facility being non-smoking. These observations were confirmed during a meeting with the Nursing Home Administrator. Further observations on Nursing Unit 2 included marred and gouged drywall near the bathrooms of two residents, as well as significantly peeling fake leather on love seats in the lounge area. The dining room walls near the hallway and courtyard door were also gouged at both foot and table height. These findings were discussed with the Nursing Home Administrator, highlighting the facility's failure to maintain a safe, clean, and homelike environment as required by regulations.
Plan Of Correction
1. No residents were harmed. Resident 24's room under the window was repaired and painted. The noted cigarette butts by the egress leading to the laundry facility were immediately cleaned up by the housekeeping staff. Resident 50's bathroom wall was patched and painted. Resident 54's bathroom was patched and painted. The furniture in the Unit 2 lounge was immediately disposed of and replenished with a love seat and chairs collected throughout the facility. The Unit 2 dining room was also patched and painted. 2. The Facility Administrator, Maintenance Supervisor, and Housekeeping Supervisor conducted a visual inspection of the facility and its grounds to pinpoint any areas requiring repair or furniture that might need to be replaced. 3. The Facility Administrator educated the Maintenance and Housekeeping departments to maintain a consistently safe, comfortable, and clean environment for the residents at all times. Maintenance and the Housekeeping Supervisor will complete weekly rounds of the facility and present any noted issues or repairs in the morning meeting. 4. The Facility Administrator and/or designee will conduct random audits on a weekly basis for a duration of four weeks, followed by monthly audits for three months. This process aims to ensure that all residents are provided with a clean and comfortable environment. All completed audits will be presented at the monthly Quality Assurance meeting for evaluation.
Failure to Conduct Required FBI Background Check for New Employee
Penalty
Summary
The facility failed to develop and implement an abuse prohibition policy that required a thorough investigation of prospective employees' employment history. Specifically, the facility did not conduct an FBI background check for Employee 7, a cook, who had not lived in the state where the facility is located for more than two consecutive years. This oversight was identified during a review of Employee 7's personnel record, which showed that the employee was hired 129 days prior to the review without the necessary FBI background check being completed. Interviews with Employee 8 from human resources and the Nursing Home Administrator confirmed that the facility did not complete the FBI background check within the required 90 days of employment. Despite this, Employee 7 had been providing services and had access to residents since being hired. This failure to adhere to the facility's policy on background checks represents a deficiency in ensuring the safety and protection of residents from potential abuse, neglect, or exploitation.
Plan Of Correction
1. No residents were harmed. Employee 7, who served as a dietary cook, was promptly removed from the schedule and will not be permitted to return until fingerprints are collected for the personnel record. 2. The human resources department conducted an audit of employee files to verify that all "out of state" employees had successfully undergone FBI fingerprint background checks. 3. The facility administrator educated the HR department of the essential requirements to ensure that "out of state" employees are completing the required fingerprint background checks. The HR Director will complete a new hire checklist sheet to ensure all FBI/fingerprint background checks are completed within 90 days of hire. 4. The Facility Administrator or designee will conduct weekly audits for a duration of four weeks, followed by monthly audits for an additional three months, to verify that fingerprint background checks are being performed on "out of state" new hires in a timely manner. All audit findings will be presented at the monthly Quality Assurance meeting for evaluation.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents, leading to deficiencies in their care. Resident 44 experienced an incident during a shower where staff did not follow the care plan interventions for her known behavior of making false accusations. Despite being agitated and expressing discomfort, the staff continued with the shower instead of stopping and reapproaching later, as outlined in her care plan. The care plan also lacked an intervention for two staff to provide care due to her behavior, which contributed to the incident. Resident 5, who has an implanted pacemaker, did not have a care plan addressing the care or precautions related to the pacemaker or its associated transmitting device. The resident's medical records lacked information about the device, and staff were not adequately informed about its operation or troubleshooting. Additionally, there was no care plan related to the resident's anticoagulation therapy with Eliquis, nor was there evidence of monitoring for side effects such as bleeding, which was only addressed after surveyor questioning. These deficiencies were identified through clinical record reviews and interviews with residents and staff. The facility's failure to develop and implement appropriate care plans for these residents resulted in inadequate care and monitoring, as evidenced by the surveyor's findings and subsequent discussions with the Nursing Home Administrator and other staff members.
Plan Of Correction
1. No residents were harmed. Employee 3 and 6 were educated to reapproach residents when they show signs of agitation. Resident 44 care plan was updated to reflect her plan of care. Resident 5 care plan was updated and reviewed to reflect the plan of care. 2. The Director of Nursing reviewed residents care plans to ensure they reflect their current plan of care. 3. The Director of Nursing provided education to the RNAC and nursing staff regarding the significance of revising care plans to align with the individualized needs of the residents. All updated care plans or resident information will be found on PCC in the Kardex section of the EMR. 4. The Director of Nursing or designee will perform care plan audits weekly for a period of four weeks, subsequently transitioning to monthly audits for three months. The results will be reported at the monthly Quality Assurance meeting for assessment.
Incomplete Discharge Summary for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to provide a comprehensive discharge summary for a resident, identified as Resident CR1, who was discharged to home with home health services. The discharge summary, dated January 6, 2025, lacked critical information about the resident's medical condition during their stay, specifically omitting details about a Stage 3 Pressure Ulcer on the sacrum. The documentation inaccurately stated that there was no wound care or treatment, despite previous records indicating the presence of a significant wound requiring attention. This deficiency was identified through a closed clinical record review and staff interview, revealing that the discharge summary did not include a full recapitulation of the resident's stay, including diagnoses, course of illness, treatment, therapy, and pertinent consultation results. The omission of this vital information was discussed with the Nursing Home Administrator on March 7, 2025, highlighting the facility's failure to meet the regulatory requirements for discharge summaries.
Plan Of Correction
1. Resident CR1 was not harmed. 2. The Director of Nursing reviewed discharged residents for the last two months to ensure necessary components were documented on the discharge summaries. 3. The Director of Nursing educated the RN supervisors of the importance of including all essential elements on the discharge summary, specifically emphasizing the need to document any wound care treatments provided during their care at the facility. 4. The Director of Nursing will audit discharge summaries weekly for four weeks, then monthly for three months to ensure essential elements, specifically any wound treatments are indicated on the discharge summary.
Failure to Implement Restorative Nursing Programs
Penalty
Summary
The facility failed to provide necessary care and services to maintain or improve the ability to perform activities of daily living for two residents. Resident 5 was discharged from therapy on January 27, 2025, with recommendations for a restorative nursing program (RNP) that included sit-to-stands at grab bars. However, the RNP was not initiated until March 3, 2025, due to it being "missed," as confirmed by the Director of Therapy. This delay in implementing the RNP meant that Resident 5 was not receiving the recommended exercises to maintain her abilities during this period. Similarly, Resident 44 was discharged from skilled therapy services with a recommendation to continue with a restorative nursing program for ambulation, which included walking up to 100 feet with a roller walker and contact guard assistance. However, there was no evidence of an active RNP in her clinical record until March 5, 2025, after the surveyor's inquiry. The facility did not initiate the RNP for Resident 44's ambulation skills following the termination of skilled therapy services, as confirmed by the Nursing Home Administrator.
Plan Of Correction
1. Resident 5 and 44 were unharmed. Resident 5 is currently completing an RNP program. Resident 44 is currently completing an RNP program. 2. The Therapy Director completed an audit on any residents discharged from therapy services to indicate if they needed or had an RNP program in place. 3. The Therapy Director conducted an education with the therapy staff to ensure that the RNP is implemented upon the patient's discharge from therapy services, if necessary. 4. The Therapy Director or designee will conduct weekly audits for a duration of four weeks, followed by monthly audits for three months, to verify the implementation of the RNP for the resident, if required. The Therapy Director will bring the audit to the monthly QA meeting for review.
Failure to Implement Physician Orders for Two Residents
Penalty
Summary
The facility failed to implement physician orders for two residents, leading to deficiencies in their care. For Resident 52, the facility's consultant optometrist diagnosed significant dry eye syndrome and prescribed artificial tears to be administered twice daily. However, the clinical records showed no evidence that the staff implemented this treatment plan. This was confirmed during an interview with the Nursing Home Administrator, indicating a lapse in following the prescribed care plan for Resident 52. Similarly, for Resident 21, there were physician orders to obtain and document daily weights. The review of Resident 21's weight documentation revealed multiple instances where the staff failed to record the resident's weight on specified dates in January, February, and March 2025. This lack of documentation was also confirmed during an interview with the Nursing Home Administrator, highlighting a failure to adhere to the physician's orders for monitoring Resident 21's weight.
Plan Of Correction
1. Resident 52 was not harmed and physician orders were updated to reflect plan of care. Resident 21 was not harmed and was reviewed. 2. The Director of Nursing reviewed residents physician orders to ensure accuracy. 3. The Director of Nursing educated nursing staff on the importance of issuing physician order in the residents' charts and to follow physician orders for the plan of care for each resident's needs. 4. The Director of Nursing or designee will complete weekly audits for four weeks then monthly for three months to ensure compliance that the physicians orders are being entered and completed for each residents needs. The Director of Nursing will bring audits to the monthly QA meeting for review.
Failure to Timely Implement Wound Care Recommendations
Penalty
Summary
The facility failed to provide recommended interventions consistent with professional standards of practice to promote the healing of a pressure ulcer for a resident. The resident was admitted with a skin tear on the sacrum, which was documented by nursing staff. However, subsequent medical provider documentation did not mention the skin tear, and a comprehensive skin assessment later identified a Stage 3 pressure injury. Despite recommendations from a wound care service to treat the pressure ulcer, the facility did not initiate these treatments in a timely manner. The care plan for the resident, which included interventions for skin integrity and the pressure ulcer, was not initiated until after the resident was discharged. Additionally, physician orders for the treatment of the sacral pressure ulcer were dated after the resident's discharge, and there was no evidence in the medication/treatment administration record that the recommended treatments were completed. The facility could not provide documentation that staff were aware of or had implemented the wound care recommendations before the resident's discharge.
Plan Of Correction
1. Resident CR1 was discharged and was unharmed. 2. The Director of Nursing reviewed any current residents who have pressure ulcers to ensure proper treatments are in place and physician orders are being followed for proper wound care treatment. 3. The Director of Nursing provided education to the nursing staff regarding the significance of implementing appropriate wound care treatments and documentation tailored to each resident's needs and ensuring adherence to the established treatment plan. 4. The Director of Nursing or designee will complete weekly wound care audits for four weeks then monthly for three months and present the audits in the monthly QA meeting.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for two residents, as evidenced by observations, clinical record reviews, and staff interviews. For Resident 54, there was a physician's order to provide oxygen at 2 liters per minute via nasal cannula continuously, change the oxygen tubing every Saturday night, and ensure all tubing and nebulizer equipment was bagged when not in use. However, observations on multiple days revealed that the oxygen concentrator was set at 2.5 liters per minute, the nebulizer pipe was unbagged, and the tubing was dated February 23, 2025, indicating it had not been changed as required. Resident 54 confirmed that staff was supposed to change the tubing weekly. Similarly, for Resident 36, there were orders to change the nebulizer tubing and bag every Saturday night shift, label the tubing with the date, time, and staff initials, and ensure all equipment was bagged when not in use. Observations showed that the nebulizer pipe was unbagged, and the tubing was also dated February 23, 2025, suggesting it had not been changed for over a week. An unopened bag dated February 23, 2025, was found on the resident's bedside stand, indicating that the necessary equipment was available but not utilized. These findings were reviewed with the Nursing Home Administrator.
Plan Of Correction
1. Resident 54 tubing was changed immediately. Resident 36 tubing was changed immediately. 2. The Director of Nursing completed an audit on all residents requiring oxygen tubing including any needed devices that require oxygen tubing to be changed. 3. The Director of Nursing provided education to nursing staff to ensure all tubing is changed weekly. All residents requiring a tubing change is in the physician orders to be changed Every Saturday, nightshift. 4. The Director of Nursing and or designee will complete weekly random audits for four weeks and then monthly for three months to ensure tubing is being changed weekly. The Director of Nursing will bring audits to the monthly quality assurance meeting for review.
Failure to Implement Behavioral Health Interventions
Penalty
Summary
The facility failed to provide appropriate behavioral health interventions for a resident, identified as Resident 44, to maintain the highest practicable mental well-being. The clinical record review revealed that Resident 44 exhibited behavioral symptoms not directed towards others, such as physical symptoms and verbal/vocal symptoms. Despite these behaviors, the facility did not develop a care plan that included an intervention for two staff to provide care due to the resident's known behavior of making false accusations. The plan of care initiated on December 7, 2024, included instructions for staff to remove themselves and reattempt care when the resident was calmer, but these interventions were not implemented during an incident on February 28, 2025. During an interview, Resident 44 expressed dissatisfaction with the approach used by staff during her shower care, describing it as "slam bam." The resident recounted the incident multiple times, indicating distress. Employee 3, a nurse aide, confirmed witnessing the incident and noted that Resident 44 became agitated, falsely accusing staff of hurting her shoulder and damaging her hearing aids, which were not present during the shower. The facility's failure to implement the care plan interventions and develop a comprehensive plan addressing the resident's behavioral health needs led to the deficiency identified by the surveyors.
Plan Of Correction
1. Resident 44's care plan was updated to indicate behavioral health interventions. 2. The Social Services Director reviewed the care plans of any residents with a behavior health concern and updated the care plans as needed to indicate behavioral health interventions. 3. The Facility Administrator educated the social services department on the importance to list any behavior health interventions in the care plan to reflect the residents' needs and interventions. DON will add any interventions to the task section in PCC. 4. The Facility Administrator or designee will complete weekly audits for four weeks then monthly for four months to ensure behavior health interventions are listed on the plan of care. These audits will be brought to the monthly QA meeting for review.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to securely store medications and ensure proper medication labeling, leading to deficiencies in nursing services and pharmacy services. During a medication administration pass, an LPN crushed a Rosuvastatin tablet for a resident, despite the medication resource indicating that the tablet should be swallowed whole. The LPN confirmed that there were no instructions on the medication labeling from the pharmacy to indicate that the medication should not be crushed, and she was unaware of this precaution. Additionally, a registered nurse confirmed that the facility's medication resource also stipulated that Rosuvastatin should not be crushed. This indicates a failure in ensuring that all medication labeling included appropriate precautionary instructions. Furthermore, an observation in the main dining area of Unit One revealed a yellow-colored, round pill on the floor behind a television stand. An LPN was unable to identify the pill and proceeded to dispose of it. This incident highlights a failure in securely storing medications, as the pill was found in a common area accessible to residents and staff. The findings were reviewed in a meeting with the Nursing Home Administrator, indicating a lapse in the facility's medication storage protocols.
Plan Of Correction
1. Resident 46 was not harmed. Facility Supervisor checked with Pharmacist about Resident 46's medication tablet and the Pharmacist indicated that the medication "could be crushed" in tablet form. Resident was not harmed due to the tablet of medication being crushed. 2. The Director of Nursing reviewed any residents who required medications to be crushed to ensure contraindications was labeled on the medication label. 3. The Director of Nursing educated the Nurses on the importance of reviewing medications for proper labeling and securing medications to ensure no pills are left on the floor. 4. The Director of Nursing and or designee will complete weekly random audits for one month and monthly audits for three months to ensure proper labeling and medications are secure. These audits will be brought to the monthly quality assurance monthly meeting.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide necessary dental services for a resident, identified as Resident 52, who had dental concerns. Resident 52, who used a partial dental plate, reported that it no longer fit, and there were discussions about its replacement, but no clear timeline was provided. The resident, who had several missing front teeth, was covered by Medicaid since August 2024. Despite experiencing left-sided dental pain and visible swelling in November 2024, which required antibiotic treatment, there was no evidence of a professional dental evaluation for the infection. A progress note from February 2025 indicated that the resident had cracked and missing teeth and required extractions before a new partial denture could be fabricated. The Nursing Home Administrator confirmed that the resident was admitted in March 2024, but the facility did not offer or obtain consent for dental services until July 2024. There was no evidence of professional dental services being provided from March 2024 to February 2025, despite the resident's dental infection in November 2024. This lack of timely dental care and failure to address the resident's dental needs led to the deficiency identified in the report.
Plan Of Correction
1. Resident 52 received dental services. 2. The Facility Administrator completed a facility wide audit of current residents for dental services. 3. The Director of Nursing completed an education with nursing staff on ensuring that residents receive dental services. 4. The Facility Administrator and or designee will complete a weekly random audit for four weeks then monthly for three months and bring the completed audits for dental services to monthly QA meeting for review.
Failure to Implement Enhanced Barrier Precautions for Resident with Dialysis Catheter
Penalty
Summary
The facility failed to implement appropriate enhanced barrier transmission-based precautions for a resident with a tunneled dialysis catheter, as required by the facility's infection prevention and control program. The deficiency was identified during an observation and review of clinical records, which revealed that the resident was not on enhanced barrier precautions (EBP) despite having a medical device that necessitates such precautions. The facility's policy, aligned with CDC guidelines, mandates the use of EBP for residents with indwelling medical devices during high-contact care activities to prevent the spread of multi-drug resistant organisms. The resident in question had a current physician's order for hemodialysis and a tunneled dialysis catheter placed in the right chest, as documented in both hospital and nursing records. However, there was no evidence in the clinical record or during the observation that EBP were being implemented for this resident. Specifically, there were no signs indicating EBP precautions, no personal protective equipment available in the room or at the doorway, and no instructions for staff to consult the nurse prior to providing care. An interview with the Nursing Home Administrator confirmed that the resident was not on EBP, contrary to the facility's policy. This oversight was noted as a deficiency in the facility's infection prevention and control practices, which had been previously cited in an earlier survey. The failure to adhere to the established infection control protocols for residents with indwelling medical devices represents a lapse in maintaining a safe and sanitary environment as required by federal regulations.
Plan Of Correction
1. Resident 75 was immediately placed on Enhanced Barrier Precautions with isolation set up. 2. The Director of Nursing and IP reviewed all residents in need of EBP to ensure they had the proper isolation signage and set up. 3. The Director of Nursing completed an education with the nursing department to ensure EBP is in place for any residents who are contraindicated for Enhanced Barrier Precautions. 4. The Director of Nursing or designee will complete weekly random audits for four weeks, then monthly for four months, and bring the EBP audits to the monthly QA meeting for review.
Failure to Rotate Emergency Water Supply
Penalty
Summary
The facility failed to adhere to its established procedures for ensuring water availability in essential areas during a loss of normal water supply. The policy titled "Water Availability," last reviewed on June 13, 2024, mandates that the facility must rotate its emergency water supply regularly. However, during an observation on March 5, 2025, it was found that multiple boxes of emergency water stored on Nursing Unit 1 and in the facility's main kitchen were past their manufacturer's best by dates. Specifically, six out of nine boxes on Nursing Unit 1 and four out of ten boxes in the main kitchen were expired, with dates ranging from July 31, 2024, to September 30, 2024. Interviews with facility staff, including Employee 8 and the Nursing Home Administrator, revealed a lack of clarity and oversight regarding the disposal of expired water. Employee 4, the certified dietary manager, confirmed the presence of additional expired water boxes in the main kitchen storage. The facility did not provide evidence of regular rotation of the emergency water supply, as required by their policy, leading to the deficiency in ensuring water availability during emergencies.
Plan Of Correction
1. Expired was immediately discarded. 2. The Dietary Manager completed an audit of all emergency water to ensure no other water was expired. Dietary Manager ordered more water to replenish expired water. 3. The Dietary Manager educated the dietary department to check emergency water supply and discard of water that is expired and to note to the Dietary Manager to order to replenish. 4. The Dietary Manager or designee will complete weekly random audits for four weeks and then monthly for three months and bring emergency water supply audits to the monthly QA meeting.
Facility Fails to Meet Minimum Nurse Aide Staffing Requirements
Penalty
Summary
The facility failed to meet the required minimum staffing levels for nurse aides across multiple shifts, as evidenced by a review of nursing staffing hours and staff interviews. Specifically, the facility did not ensure a minimum of one nurse aide per 10 residents on five of 21 day shifts and four of 21 evening shifts. Additionally, the facility failed to maintain a minimum of one nurse aide per 15 residents on nine of 21 overnight shifts. These deficiencies were identified during specific periods, including October 13 to 19, 2024, December 29, 2024, through January 4, 2025, and February 28, 2025, through March 6, 2025. The report details specific instances where the number of nurse aides scheduled was insufficient for the resident census. For example, on October 13, 2024, there were only 6.38 nurse aides for a census of 75 residents, requiring 7.5 aides. Similar shortfalls were noted on other dates, such as December 31, 2024, and January 4, 2025, across various shifts. These staffing inadequacies indicate a consistent failure to comply with the mandated nurse aide-to-resident ratios, potentially impacting the quality of care provided to residents.
Plan Of Correction
1. Nursing Staff care hours will be reviewed daily for the current day and for the remainder of the week during morning meeting for compliance with current regulations of a minimum of 1 CNA per 10 Residents during the day, 1 CNA per 11 residents during the evening shift, and 1 CNA per 15 Residents on the overnight shift. 2. Will continue to actively hire and advertise open positions to meet current regulations. 3. The facility will continue to use per diem staff to fill in open shifts and ask current LPNs, current CNAs, and RNs to fill in open CNA shifts. 4. DON/designee will complete weekly audits on CNA staffing ratio for four weeks and then monthly for three months and bring to the monthly QA meeting for review.
LPN Staffing Deficiency Across Multiple Shifts
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) across multiple shifts, as evidenced by a review of nursing staffing hours and staff interviews. Specifically, the facility did not ensure a minimum of one LPN per 25 residents on eight of 21 day shifts reviewed, one LPN per 30 residents on eight of 21 evening shifts reviewed, and one LPN per 40 residents on three of 21 overnight shifts reviewed. This deficiency was identified during specific periods, including October 13 to 19, 2024, December 29, 2024, through January 4, 2025, and February 28, 2025, through March 6, 2025. The findings revealed that on several occasions, the number of LPNs scheduled was insufficient for the resident census. For instance, on October 18, 2024, there were 3.03 LPNs scheduled for a census of 76 residents, whereas 3.04 LPNs were required. Similar shortfalls were noted on other dates, such as December 29, 2024, and January 1, 2025, where the number of LPNs scheduled did not meet the required staffing levels. These discrepancies in staffing levels were consistent across day, evening, and overnight shifts, indicating a systemic issue in maintaining the mandated LPN-to-resident ratios.
Plan Of Correction
1. Nursing Staff care hours will be reviewed daily for the current day and for the remainder of the week during morning meeting for compliance with current regulations of a minimum of 1 LPN for 25 Residents during the day, 1 LPN per 30 Residents during the evening shift and 1 LPN per 40 Residents on overnight shift. 2. Will continue to actively hire and advertise open positions to meet current regulations. 3. The facility will continue to use per diem staff to fill in open shifts and ask current LPNs, and RNs to fill in open LPN shifts. 4. DON/designee will complete weekly audits on LPN staffing ratio for four weeks and then monthly for three months and bring to the monthly QA meeting for review.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day for eight out of the 21 days reviewed. This deficiency was identified through a review of nursing staffing hours and staff interviews. Specifically, the facility did not meet the required hours on several dates, including October 13 and 14, 2024, December 29 to 31, 2024, and January 2 to 4, 2025. The hours per resident per day on these dates ranged from 2.74 to 3.19, falling short of the mandated 3.2 hours. This information was confirmed during an interview with the Nursing Home Administrator on March 7, 2025.
Plan Of Correction
1. Nursing Staff PPD care hours will be reviewed daily for the current day and for the remainder of the week during morning meeting for compliance with the state regulation of the nursing hours guidance for a staff PPD of 3.2. 2. The facility will continue to actively hire and advertise open positions to meet current regulations. 3. The facility will continue to use per diem staff to fill open shifts and ask current RN's, LPN's and CNA's to fill open shifts. 4. DON and or designee will review PPD staffing hour weekly for four works then monthly three months and bring audits to the monthly QA meeting for review.
Failure to Provide Timely Medicare Coverage Termination Notices
Penalty
Summary
The facility failed to provide timely notification to residents whose payment coverage changed, as required by Medicare regulations. Specifically, for Resident 58, the facility did not deliver the Notice of Medicare Non-Coverage (NOMNC) at least two calendar days before Medicare-covered services ended. Resident 58's Medicare coverage ended on January 16, 2024, and the resident initialed the notice on the same day, indicating that the notice was not provided within the required timeframe. Similarly, for Resident 83, the facility also failed to deliver the NOMNC at least two calendar days before the end of Medicare-covered services. Resident 83's Medicare coverage ended on February 28, 2024, the same day the resident signed the notice, again failing to meet the required notification period. The deficiency was confirmed through clinical record reviews and staff interviews, including discussions with the Director of Nursing and the Nursing Home Administrator. The failure to provide timely notifications as required by Medicare regulations was evident for both residents, indicating a lapse in the facility's compliance with notification procedures. This deficiency directly impacts the residents' awareness and ability to appeal the termination of Medicare-covered services.
Failure to Maintain a Safe Environment in Beauty Shop
Penalty
Summary
The facility failed to maintain an environment free of potential accident hazards in the beauty shop. During an observation, the beauty shop door was found open with no employees present. Inside the beauty shop, there were several hazardous items including a large bottle of shampoo, conditioner, hair color with warning labels, two pairs of hair-cutting shears, a razor, a plugged-in curling iron that was warm to the touch, and a tart burner with hot melted liquid. Additionally, the water temperature at the hair washing station was measured at 121.6 degrees Fahrenheit. The beautician was found to be in a resident's room and was unaware that the beauty shop needed to be secured when unattended.
Failure to Maintain Sanitary Food Service Equipment
Penalty
Summary
The facility failed to maintain food service equipment in a sanitary manner and proper working order in the main kitchen. An observation revealed that the hood system over the stove/cooktop area contained thick visible dust buildup. Additionally, the dishwasher was observed running at a wash temperature of 126 degrees Fahrenheit, which is below the required temperature. There was no sanitizing agent connected to the dishwasher, and the dietary manager acknowledged the low wash cycle temperature. A review of the kitchen's Dish Machine Temperature Log showed that the wash temperature had not met the required temperature since March 31, 2024. The log indicated that temperatures below 150 degrees Fahrenheit should be reported to the dietary manager and maintenance. Despite this, the log consistently recorded wash cycle temperatures below the required threshold. A maintenance order dated April 1, 2024, revealed that the dishwasher was not getting up to temperature, and although the drain was fixed, the temperature issue persisted. The findings were reviewed with the Nursing Home Administrator and Director of Nursing, and a company was contacted to address the issue after the surveyor's discussion.
Failure to Implement Enhanced Barrier Precautions and Ensure Hygienically Clean Laundry
Penalty
Summary
The facility failed to implement appropriate enhanced barrier transmission-based precautions for three residents who required them. Resident 51 had a long-occurring pressure ulcer and an indwelling urinary catheter, but there was no documented evidence or observation indicating the use of enhanced barrier precautions. The Director of Nursing and the Administrator confirmed that the facility had not implemented these precautions for any residents, including Resident 51, until after the surveyor's questioning. Resident 23, who required an indwelling Foley catheter, also did not have any enhanced barrier precautions in place. The assigned licensed practical nurse was unaware of the need for such precautions. Similarly, Resident 20, who had a PICC line for intravenous antibiotic therapy following hip surgery, did not have enhanced barrier precautions implemented. The nurse assigned to Resident 20's care was also unaware of the need for these precautions, and there was no plan of care addressing this requirement. Additionally, the facility failed to ensure hygienically clean resident laundry processing. The laundry/housekeeping supervisor could not provide information on how water temperatures were monitored, the weight capacity of the washing machines, or whether the chemicals used included a sanitizing agent. The facility lacked a mechanism to ensure that laundry was processed according to CDC guidelines, and there was no evidence that hot water temperatures reached the required levels or that any chemicals used sanitized the fabrics.
Failure to Provide Adequate Care for Resident with PICC Line
Penalty
Summary
The facility failed to provide the highest practicable care for a resident with an indwelling central line catheter. The policies provided by the facility did not address the development of a plan of care, limb restriction measures, or emergency procedures necessary while the PICC line is in use. Clinical record review revealed that the presence of the PICC line was not documented upon the resident's arrival at the facility. Additionally, nursing documentation did not specify which arm was affected when the resident complained of arm pain. Observations and interviews confirmed the absence of an emergency kit in the resident's room and the lack of a comprehensive plan of care addressing the PICC line. Further review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed multiple instances where staff failed to document the completion of medications and treatments related to the PICC line. These included missed doses of Vancomycin, normal saline flushes, weekly dressing changes, and measurements of the arm circumference and external catheter length. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed these findings, indicating a significant lapse in the facility's adherence to prescribed care protocols for the resident's PICC line.
Failure to Identify and Care Plan PTSD Triggers
Penalty
Summary
The facility failed to identify and care plan triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder (PTSD). Clinical record review for the resident revealed a diagnosis of Chronic PTSD since admission. During an interview, the resident disclosed that loud noises and bright lights were triggers due to his combat experience. However, the resident's care plan did not identify these triggers. This deficiency was confirmed during an interview with the Nursing Home Administrator and Director of Nursing.
Failure to Develop and Implement Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized person-centered care plan for a resident diagnosed with dementia. Clinical record review revealed that the resident was admitted on March 30, 2023, with a diagnosis of dementia. The admission Minimum Data Set Assessment dated March 27, 2023, indicated that a care plan for dementia and cognitive loss would be developed. However, a review of the resident's current care plan showed no indication that such a care plan had been created or implemented. This deficiency was confirmed during an interview with the Administrator and Director of Nursing on April 17, 2024, at 2:15 PM. The findings were reviewed with the Administrator and Director of Nursing on April 17, 2024, at 2:15 PM.
Failure to Ensure Monthly Drug Regimen Review by Consultant Pharmacist
Penalty
Summary
The facility failed to ensure that the consultant pharmacist reviewed the drug regimen of each resident and reported any irregularities to the attending physician monthly. For Resident 26, the consultant pharmacist identified a potential medication irregularity that required evaluation for a gradual dose reduction of her antianxiety medication, Xanax, on November 26, 2023, and her antidepressant medication, Effexor, on December 26, 2023. However, Resident 26's clinical record did not contain evidence that a physician received the report pertaining to the Xanax medication until December 26, 2023, and there was no evidence that the physician received a report pertaining to the Effexor medication at all. These concerns were confirmed during an interview with the Nursing Home Administrator and the Director of Nursing on April 19, 2024, at 12:34 PM. For Resident 24, the clinical record review indicated that there was no monthly review completed for February 2024. Further review of Resident 24's clinical record revealed no evidence that the consultant pharmacist reviewed Resident 24's drug regimen in February 2024. These findings were confirmed by the Nursing Home Administrator and the Director of Nursing during an interview on April 19, 2024, at 10:52 AM.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure a medication error rate below five percent, resulting in a medication error rate of 7.69 percent based on 26 medication opportunities with two medication errors. The errors were observed during a medication administration pass involving two residents. Employee 1, a licensed practical nurse, did not follow the manufacturer's guidelines for the BD AutoShield Duo safety pen needle. Specifically, Employee 1 did not check if the needle was attached correctly by dialing up two units of insulin and ensuring liquid appeared before administering the insulin to the residents. During the medication administration pass, Employee 1 administered Insulin Aspart Flexpen to Resident 132 and Humalog Kwikpen to Resident 24 without verifying the correct attachment of the safety pen needle or ensuring the presence of liquid. These actions were confirmed during an interview with Employee 1. The failure to follow proper procedures for insulin administration led to the identified medication errors, contributing to the facility's elevated medication error rate.
Failure to Administer COVID-19 Vaccine to Resident
Penalty
Summary
The facility failed to ensure the administration of a COVID-19 immunization for one of five residents reviewed for immunization concerns. Specifically, Resident 45 did not receive a COVID-19 vaccine after October 27, 2022, despite having signed consents for vaccination on April 27, 2023, and November 2, 2023. The clinical record review revealed no evidence of the vaccine being administered, and there was conflicting documentation regarding whether the resident refused the vaccine. Interviews with staff confirmed the absence of proper documentation to support the claim that Resident 45 refused the vaccine, and the resident herself stated she was not opposed to receiving it. The facility's policy required that residents be educated about and offered the COVID-19 vaccine, with proper documentation of consent and administration. However, the facility did not adhere to this policy for Resident 45. The registered nurse infection control prevention coordinator and other staff could not provide evidence that the vaccine was offered or administered as required. This deficiency was confirmed through interviews with the Nursing Home Administrator and the Director of Nursing, who acknowledged the lack of proper documentation and the inability to identify the staff member responsible for the erroneous refusal documentation.
Failure to Accurately Assess Entrapment Risk with Specialized Mattress and Side Rails
Penalty
Summary
The facility failed to perform an accurate assessment for possible entrapment with the use of a specialized mattress and side rails for a resident diagnosed with dementia. The resident's bed had bilateral half side rails, and the air mattress in use was observed to shift side to side, creating a larger gap between the side rail and the mattress. Despite this observation, the facility's side rail entrapment assessment inaccurately indicated that the mattress fit securely without shifting. The occupational therapist confirmed that the mattress was not secured and admitted that the assessment was based on the typical bed frame and mattress used in the facility, without physically measuring the entrapment zones in the resident's room. The resident, admitted with a diagnosis of dementia and severe cognitive impairment, had a history of falls and fluctuating levels of consciousness. The facility's policy required an assessment of the space between the mattress and side rails to reduce the risk of entrapment, but it did not specify actions when side rails were deemed inappropriate or unsafe. The failure to accurately assess and address the entrapment risk was confirmed during an interview with the occupational therapist and the facility administrator.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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