Scenery Hills Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Indiana, Pennsylvania.
- Location
- 680 Lions Health Camp Rd, Indiana, Pennsylvania 15701
- CMS Provider Number
- 395313
- Inspections on file
- 25
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 2 (1 serious)
Citation history
Health deficiencies cited at Scenery Hills Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
The facility failed to maintain safe hot water temperatures in resident rooms and bathing areas, despite a policy limiting water heater settings to 110°F and requiring routine monitoring and documentation by maintenance staff. A resident reported receiving “scalding hot” water for bedside bathing, and a surveyor confirmed that the sink water was painfully hot to the touch. Subsequent measurements in multiple rooms on both halls and in a shower room showed hot water temperatures ranging from just above 110°F up to over 120°F. The Maintenance Director and the NHA acknowledged that these temperatures were too high, and surveyors determined that this failure in three resident areas created immediate jeopardy due to unsafe water temperatures.
Administration and nursing leadership failed to maintain safe hot water temperatures in all three resident areas (North Hall, South Hall, and corridor rooms). The NHA did not effectively carry out defined duties to ensure a safe, properly maintained environment and regulatory compliance, and the DON did not ensure nursing staff followed facility policies on safe water temperatures. As a result, residents were exposed to unsafe water temperatures in their rooms, creating Immediate Jeopardy under F689 (Accidents) and violating applicable state management and nursing services regulations.
A resident with PTSD, depression, and anxiety did not have their specific trauma triggers identified or addressed by staff, despite facility policy requiring trauma-informed care. The DON confirmed that no measures were in place to prevent or minimize re-traumatization for this resident.
A multi-dose vial of Tubersol Tuberculin injection used for TB skin testing was found in the medication room without an opening date, contrary to manufacturer instructions requiring disposal 30 days after opening. The DON confirmed the vial was not dated as required, resulting in noncompliance with pharmacy and nursing service regulations.
The facility failed to store food under sanitary conditions, as standing water was found in the basement dry storage area, affecting the emergency food supply and other items. A broken downspout was identified as the cause of the water intrusion, exacerbated by recent rain and snow. The presence of a sewer smell was also noted.
The facility failed to pay essential service bills on time, leading to service disruptions that jeopardized resident safety. Outstanding balances were owed to various providers, including Citizens Ambulance and REA, resulting in termination notices and halted services. Interviews confirmed these issues, and the facility had to change suppliers due to nonpayment.
The facility failed to conduct safety assessments for air mattress use for three residents with pressure ulcers and other conditions. Despite facility policy, there was no documented evidence of safety assessments before placing air mattresses on their beds. The DON confirmed the lack of specific assessments for these residents.
The facility did not comply with food safety standards by failing to discard pizza sauce in a timely manner and not maintaining the dishwasher's wash cycle temperature at the required 120 degrees Fahrenheit. The Dietary Manager acknowledged the oversight regarding the sauce, and the Nursing Home Administrator confirmed the dishwasher's temperature requirement.
The facility did not verify the Nurse Aide Registry for a newly hired nurse aide, as required by their abuse policy. The verification, which should have been completed upon hire, was delayed until several weeks after the nurse aide's start date. This oversight was confirmed by the HR Director.
The facility failed to document the administration of controlled medications for three residents, as required by its policies. Doses of oxycodone and hydrocodone-acetaminophen were signed out but not recorded as administered in the residents' clinical records, including the MARs and nursing notes. This discrepancy was confirmed by the DON.
The facility failed to securely store medications, as an LPN left a medication cart unattended with medications on top, and a resident's medications were left at the bedside instead of being returned to the cart. The DON confirmed these actions were against policy.
The facility failed to maintain complete and accurate clinical records for three residents. A resident's oxycodone administration was inconsistently documented, another resident's oxygen use was not recorded on two occasions, and a third resident's Morphine Sulfate administration was not properly documented. The DON confirmed these documentation errors.
The facility's QAPI committee failed to maintain compliance with regulations, resulting in repeated deficiencies related to accident hazards, controlled medication accountability, and medical record documentation. Despite previous plans of correction involving audits and QAPI review, the same issues were identified again, indicating ineffective quality assurance processes.
A facility failed to notify a resident's representative in writing about the reasons for multiple hospitalizations. Despite the resident being transferred to the hospital several times, there was no documented evidence of written notification. Interviews with facility staff confirmed that only verbal notifications were made, violating regulatory requirements.
Unsafe Hot Water Temperatures in Resident Care Areas
Penalty
Summary
The deficiency involves the facility’s failure to maintain safe hot water temperatures in resident care areas, contrary to its policy requiring water heaters serving resident rooms, bathrooms, common areas, and tub/shower areas to be set at no more than 110°F or the maximum allowable temperature per state regulation. The policy also required maintenance staff to check thermostats and temperature controls, record these checks in a maintenance log, and conduct periodic tap water temperature checks documented in a safety log, with staff instructed to report water that felt excessively hot to the touch. Despite these requirements, surveyors found that hot water temperatures in multiple resident rooms and a shower room on the North and South Halls and in the corridor area exceeded the facility’s stated maximum temperature. During an interview, a resident on the South Hall reported that she did not prefer to shower and instead used two basins to wash at the bedside, stating that the water provided was “scalding hot” and questioning why such hot water was given. When the surveyor ran the water in this resident’s bathroom sink, it was hot enough to cause the surveyor to remove her hand after just seconds. Subsequent temperature measurements by the Maintenance Director and surveyors showed readings ranging from just above 110°F up to 123.6°F in multiple resident rooms and the South Hall shower room sink, including specific readings of 120°F, 117.5°F, 113.9°F, 119.3°F, 122.7°F, 114.4°F, 111.2°F, 110.1°F, 111°F, 111.9°F, 112.2°F, and 120.7°F. The Maintenance Director and the Nursing Home Administrator both acknowledged that these water temperatures should not be that high. Surveyors determined that this failure to maintain safe water temperatures in three of three resident areas placed residents in immediate jeopardy of the likelihood of serious bodily injury, harm, or death.
Failure to Maintain Safe Hot Water Temperatures Resulting in Immediate Jeopardy
Penalty
Summary
Facility administration, including the Nursing Home Administrator (NHA) and Director of Nursing (DON), failed to ensure that hot water temperatures in resident care areas were maintained at safe levels. Review of the NHA’s job description showed responsibilities that included overseeing staff, explaining and assisting with facility policies and procedures, assuring the facility is properly maintained, clean and safe, maintaining necessary equipment and supplies, and ensuring adequate, properly trained personnel are on duty to meet resident needs and comply with regulations. Despite these defined duties, surveyors found that water temperatures in resident rooms on the North Hall, South Hall, and corridor rooms were not maintained at appropriate temperatures for resident safety, placing residents at risk for scalding injuries. The DON’s job description indicated responsibility for leading and managing the nursing department, overseeing clinical operations, supervising nursing staff, ensuring regulatory compliance, and collaborating with other department heads to promote quality outcomes in a resident-centered environment. However, the DON did not ensure that nursing staff followed facility policies related to safe water temperatures. As a result, residents in three of three resident areas (North Hall, South Hall, and corridor rooms) were exposed to unsafe water temperatures. Surveyors determined that this failure to maintain safe water temperatures and to ensure adherence to facility policies and regulatory requirements constituted Immediate Jeopardy under F689 (Accidents), as well as violations of specified Pennsylvania Code provisions related to licensee responsibility, management, and nursing services.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of Post Traumatic Stress Disorder (PTSD), along with depression and anxiety, was properly assessed and received trauma-informed care. The resident was cognitively intact and required staff assistance for daily care needs. Although the facility's policy required culturally competent and trauma-informed approaches that minimize triggers for trauma survivors, there was no documented evidence that the facility identified the resident's specific triggers or implemented measures to prevent or minimize re-traumatization. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that specific triggers for the resident had not been identified or addressed.
Failure to Label Multi-Dose Tuberculin Vial per Manufacturer Instructions
Penalty
Summary
Surveyors found that a multi-dose vial of Tubersol Tuberculin injection, used for Mantoux TB skin testing, was present in the medication room without a date indicating when it was opened. Manufacturer's instructions specify that such vials should be discarded 30 days after opening, making it necessary to label them with the date of first use. The Director of Nursing confirmed that the vial was not dated as required. This failure to properly label the multi-dose vial constitutes noncompliance with accepted professional principles and state regulations regarding pharmacy and nursing services. No information was provided about specific residents or their medical conditions in relation to this deficiency.
Food Storage and Preparation Deficiency Due to Water Intrusion
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food service safety, as evidenced by observations in the basement dry storage area. On December 4, 2024, standing water was found covering a 12-foot by 12-foot area, with a stream extending to a floor drain next to several metal shelves containing the emergency food supply and other items. These items included cans of chicken and dumplings, pureed beef stew, cans of chicken puree, cans of tomato soup, cans of ravioli, boxes of thick and easy Hormel dairy beverage, four cases of bottled water, and cases of plastic spoons and forks. Additionally, there was a noticeable sewer smell in the basement area, and a dehumidifier was in use by the floor drain. Interviews with the Dietary Manager and the Nursing Home Administrator, along with the Maintenance Director, confirmed the presence of standing water and the sewer odor. The Dietary Manager was unsure of the water's cause but noted a crawl space behind the wall. The Maintenance Director, upon re-examination, determined that a broken downspout was causing the excess water in the basement, which had increased significantly since it was last cleaned up. The recent rain and snow were cited as contributing factors to the increased groundwater in the basement.
Plan Of Correction
The water on the floor in the storage basement was immediately cleaned and a ventilator fan placed in the area to keep it dry. The cause was determined to be a detached drain spout along the outside wall at that point; it was immediately repaired. The other outside roof drain spouts were checked to ensure they were all in good working order and none were found to be out of order. While the entire sewer drainage system was recently rebuilt, this was not seen as a possible cause; nonetheless, a Sewer Drain contracting company was brought in with a line camera which was used to scope both drain pipes and no issues were found from the farthest point on both lines up to and including the initial drainage tank in the on-site sewage treatment plant. To ensure any rainwater or melting snow accumulation would not run down the wall to possibly penetrate the basement walls, dirt and mulch was added at the base of the exterior wall to provide drainage away from the building for any water that is not handled by the down spouts. As a preventative measure, Scenery Hill contracted with the sewage contractors for jet spray line cleaning for both the North and South halls' sewage pipes on a bi-annual basis. The roof down spouts will be added to the monthly maintenance checklist so these are reviewed monthly. The Maintenance team will be educated on the new monthly checklist requirements by the Nursing Home Administrator. They will also be educated on the new sewer cleanout contract requirements. The Maintenance Director or designee will audit the dietary storage floor for water daily for one week and weekly for three weeks. The Maintenance Director or designee will also audit the down spouts daily for a week and weekly for three weeks to ensure proper function and drainage. The results of these audits will be reviewed by the Quality Assurance Performance Improvement committee for adherence or further action. The plan of correction date of compliance will be January 7, 2025.
Failure to Pay Essential Service Bills Jeopardizes Resident Safety
Penalty
Summary
The facility failed to pay bills in a timely manner for services essential to the residents' health and safety, as evidenced by a review of the facility's accounts payable ledger and interviews with administrative staff. The outstanding balances included significant amounts owed to various service providers such as Citizens Ambulance, REA for electric service, Suburban Propane, US Foods, Liberty Healthcare, Medvan Transport, RCP O2, Twin Med, Supply Line, Penn Highlands Dubois, Hugill Sanitation, and ICMSA. These unpaid bills resulted in termination notices and service disruptions, which could jeopardize the residents' well-being. An email communication revealed that the facility had fallen behind in payments to Citizen's Ambulance Service, leading to a halt in non-emergent transportation services until the payment was settled. Additionally, a billing statement from REA indicated a significant arrears balance, and a termination notice from the Indiana County Municipal Authority highlighted an overdue water bill. Interviews with the Nursing Home Administrator and Business Office Manager confirmed the existence of these outstanding balances and the receipt of termination notices due to nonpayment. The facility had to change medical suppliers and transportation services when services were terminated for nonpayment.
Plan Of Correction
The facility cannot retroactively correct. The residents' health and safety were / are not jeopardized due to this practice. The disposition of the listed invoices are: - Citizens Ambulance - invoice to be paid December 30. - REA Energy - $3872.83 was due within the past week and was paid in full. - Suburban Propane - Was paid on 12/4 and delivery received on 12/6. - US Foods - This vendor has always been on autopay and has never been late. - Liberty Healthcare - This is a consulting firm that ended service in August of 2022. They were assigned to review the buyout and not clinically related. - MedVan - Up to date, invoice payment made. - RCP 02 - paid up and regular deliveries every Friday prior to survey and since. - Twin Med - Invoice paid December 2. - Supply Line - invoice paid under payment agreement. - Penn Highlands Dubois - We don't know what this is for as they are not a vendor. - Hugill Sanitation - no service break, invoices up to date. - ICMSA - Invoice paid 12/3/24 with no break in service at any time. The accounts payable ledger was reviewed for any other outstanding invoices with shut-off notices and none were found. REA Energy, the provider that initiated this survey, was put on the auto-pay list so their invoices will be automatically paid upon receipt. The Nursing Home Administrator (NHA) or designee will educate the Operator (person responsible for approving payment to vendors) on timely bill payment for invoices incurred in the operation of the facility that for services without which the residents' health and safety would be jeopardized. The NHA or designee will audit the monthly payment arrangement to ensure payments are made to the vendor per the arrangement plan. These audits will be performed monthly for three months, and the results of these audits will be reviewed by the Quality Assurance Performance Improvement committee for adherence or further action. The plan of correction date of compliance will be January 7, 2025.
Failure to Conduct Safety Assessments for Air Mattress Use
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards by not completing safety assessments for the use of air mattresses for three residents. The facility's policy stated that air mattresses were reserved for residents with pressure ulcers, yet there was no documented evidence of safety assessments being conducted for these residents before the air mattresses were placed on their beds. This oversight was identified for three residents who were cognitively intact and had various medical conditions, including pressure ulcers and a history of stroke. Resident 20 had a Stage III pressure ulcer and was observed with an air mattress in place without a prior safety assessment. Similarly, Resident 44, who had multiple pressure ulcers and venous and arterial ulcers, was also observed using an air mattress without a documented safety assessment. Resident 47, who had a stroke and limited range of motion, was using an air mattress with bolsters, again without a safety assessment. The Director of Nursing confirmed that no specific assessments were completed to ensure the safety of air mattress use for these residents.
Food Safety and Dishwasher Temperature Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not discarding food in a timely manner and not maintaining the appropriate washing cycle temperature for the dishwasher. During an observation in the kitchen, a plastic container of pizza sauce was found with a date indicating it should have been discarded after seven days, but it was still present nine days later. The Dietary Manager confirmed that the sauce should have been discarded. Additionally, the dishwasher's wash cycle was observed to reach only 100 degrees Fahrenheit, below the manufacturer's recommended operational temperature of 120 degrees Fahrenheit. The Dietary Manager did not express any concerns about the temperature that morning, and the Nursing Home Administrator confirmed the manufacturer's instructions regarding the required temperature.
Failure to Verify Nurse Aide Registry
Penalty
Summary
The facility failed to complete a Nurse Aide Registry verification for one of the five nurse aides reviewed upon hire. The facility's abuse policy, dated February 15, 2024, mandates that they will not employ individuals with findings of abuse, neglect, exploitation, mistreatment of residents, or misappropriation of property in the state Nurse Aide Registry. However, the personnel file for Nurse Aide 1, who was hired on May 10, 2024, lacked documented evidence of registry verification until May 28, 2024. This was confirmed during an interview with the Human Resources Director on May 30, 2024.
Failure to Document Administration of Controlled Medications
Penalty
Summary
The facility failed to maintain accountability for controlled medications for three residents, as evidenced by discrepancies in the documentation of medication administration. The facility's policy requires that the nurse administering the medication record specific details, including the resident's name, medication details, time, method, remaining quantity, and the nurse's signature. However, for Resident 6, a dose of oxycodone was signed out but not documented as administered in the clinical record, including the Medication Administration Record (MAR) and nursing notes. This lack of documentation was confirmed by the Director of Nursing. Similarly, for Resident 28, a dose of hydrocodone-acetaminophen was signed out but not documented as administered in the clinical record. Additionally, Resident 47 had multiple instances where doses of oxycodone were signed out but not documented as administered. These discrepancies were also confirmed by the Director of Nursing. The failure to document the administration of these controlled substances is a violation of the facility's policies and state regulations regarding pharmacy and nursing services.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were stored securely, as evidenced by an unattended medication cart in the hallway with a medication souffle cup containing medications in applesauce. This incident occurred when a Licensed Practical Nurse (LPN) left the cart unattended due to being called to an emergency. The LPN later confirmed that the medication should not have been left on top of the cart, and the Director of Nursing (DON) corroborated that medications should not be left unattended on the cart. Additionally, the facility did not securely store medications for Resident 28, who was cognitively intact and required assistance for daily care needs. Observations revealed that Resident 28 had a brown bottle of Flonase nasal spray and a Trelegy Ellipta inhaler on her overbed table, which the nurse forgot to take back after administration. The DON confirmed that these medications should have been returned to the medication cart and secured after administration, rather than being left at the resident's bedside.
Incomplete and Inaccurate Clinical Record Documentation
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented for three residents. For Resident 6, there was a discrepancy in the documentation of oxycodone administration. The controlled drug record indicated a dose was signed out on May 9, 2024, but there was no evidence in the clinical record that it was administered. Conversely, the MAR showed a dose was administered on May 10, 2024, without corresponding documentation in the controlled drug record. The Director of Nursing confirmed the documentation errors, attributing them to a night shift nurse's oversight. Resident 20's records also lacked documentation of oxygen administration on two observed occasions, despite the resident being on oxygen as per physician's orders. The Director of Nursing confirmed the absence of documentation for these dates. Similarly, for Resident 28, the MAR indicated a dose of Morphine Sulfate was administered, but the controlled drug record did not reflect this. The Director of Nursing acknowledged the inaccuracies in Resident 28's MAR documentation.
Ineffective QAPI Committee Leads to Repeated Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations, as evidenced by repeated deficiencies identified in the current survey. These deficiencies included ensuring that the resident's environment was free of accident hazards, accountability of controlled medications, and complete and accurate clinical record documentation. The facility had previously developed plans of correction for these issues, which included quality assurance systems with audits to ensure compliance. However, the results of the current survey indicated that these plans were ineffective, as the same deficiencies were identified again. Specifically, the facility's plans of correction for deficiencies regarding accident hazards, controlled medications, and medical record documentation, cited during the survey ending on June 22, 2023, involved conducting audits and presenting the results to the QAPI committee for further monitoring. Despite these measures, the current survey revealed that the QAPI committee was ineffective in maintaining compliance with the regulations, as the same issues were cited again under F689, F755, and F842. This indicates a failure in the facility's quality assurance processes to address and rectify these recurring deficiencies.
Failure to Provide Written Notification of Hospitalization
Penalty
Summary
The facility failed to provide written notification to the resident's representative regarding the reasons for hospitalization for one of the residents reviewed. Specifically, Resident 29, who was cognitively intact and required assistance for daily care needs, was transferred to the hospital multiple times between December 2023 and May 2024. Despite these transfers, there was no documented evidence in the clinical record that the resident's representative was notified in writing about the purpose of these hospitalizations. Interviews with the Social Services Director and the Director of Nursing confirmed that the facility only provided verbal notifications and did not document written notifications to the resident's representative. This lack of documentation was acknowledged by the facility staff, indicating a failure to comply with the requirement to notify the resident's representative in writing, as mandated by the relevant regulations.
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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