Sena Kean Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Smethport, Pennsylvania.
- Location
- 17083 Route 6, Smethport, Pennsylvania 16749
- CMS Provider Number
- 395775
- Inspections on file
- 31
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Sena Kean Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Resident Council concerns were not addressed or communicated in a timely manner. Residents reported repeated issues with staff shutting off call lights before needs were met, not following the smoking plan, and meal trays being passed late, resulting in cold food. These concerns were raised in multiple council meetings over several months, but no timely resolution or update was shown.
Improper Storage of Supplemental Oxygen Tubing: A facility failed to maintain supplemental O2 equipment for four residents receiving respiratory services. Oxygen and nebulizer tubing were observed lying on the floor, hanging over portable tanks on wheelchairs, and in one case wrapped around a wheelchair wheel and requiring cutting to free it. An RN and LPN confirmed the tubing should be stored in a bag to keep it clean and dry, consistent with the facility policy.
Insufficient overnight nursing staffing contributed to a failure to clean multiple residents’ wheelchairs as required by facility policy. Observations showed wheelchairs with dried food, dried liquids, dust, dirt, and debris on the frames, wheels, arm rests, seats, cushions, and leg rests. An RN confirmed the condition, and the NHA stated the facility frequently lacked adequate staff on the overnight shift.
Confidential Resident Information Visible on Unattended Medication Carts: Two medication carts were observed unattended in hallway locations with computer screens displaying resident information visible to anyone passing by. An LPN acknowledged the lack of privacy on each cart, and the facility policy required screens to be shielded or cleared when unattended.
Unsecured medication carts left unattended. Two medication carts, the East A Cart and the [NAME] B Cart, were observed parked in hallways unlocked and unattended. Facility policy required medication compartments and carts to be locked when not in use, and an LPN confirmed one cart should have been locked while another LPN verified the East A Cart was not secured while he/she left to attend to a resident.
Two residents experienced actual harm when staff failed to follow care plans requiring two-person assistance for transfers and bed mobility. One resident suffered a femur fracture during a transfer performed by a single CNA, while another sustained a laceration above the right eyebrow after being rolled out of bed by one CNA instead of two, as required by their care plans and physician orders.
A resident with a history of left femur fracture and mobility issues was transferred by a CNA without the required two-person assist, contrary to physician orders and facility policy. During the transfer from a shower chair to a wheelchair, towels were placed under the resident's feet, leading to a slip and fall that resulted in a left hip/femur fracture. Staff interviews and documentation confirmed the transfer was not performed according to the care plan, resulting in actual harm.
A facility failed to follow a physician's order for a resident with a suprapubic catheter. Despite an order not to change the catheter, a nurse attempted to do so, removing the existing catheter and failing to insert a new one. This was confirmed by the Nursing Home Administrator and DON.
A facility failed to follow Enhanced Barrier Precautions during the care of a resident with a gastric tube. An LPN did not wear a gown, as required, and there was no signage or PPE available outside the resident's room. The deficiency was confirmed by the LPN and the Infection Preventionist, highlighting a lapse in infection control practices.
The facility failed to provide baseline care plan summaries to three residents or their representatives within 48 hours of admission, as required by policy. Despite having conditions such as COPD, hypertension, heart failure, hypothyroidism, hyperlipidemia, dementia, and dysphagia, the residents did not receive the necessary documentation outlining goals, medications, dietary instructions, and treatments. This deficiency was confirmed by a review of clinical records and an interview with the Regional Nurse Consultant.
A facility failed to ensure proper medication administration for a resident with chronic conditions, leaving medications unattended at the bedside. The resident reported that staff do not wait for them to take their pills, and a medication was found on the floor. An LPN was assisting other residents, and a nurse confirmed the breach of policy.
The facility failed to discard an outdated vial of Novolog Insulin on the West A Hall medication cart. The facility's policy requires checking expiration dates before administering medications and recording the opening date on multi-dose containers. A vial of Novolog Insulin, opened on 4/10/24, was found during an observation, exceeding the 28-day expiration period. An LPN confirmed the vial should have been discarded, violating facility policy and state regulations.
Resident Council Concerns Not Addressed or Communicated Timely
Penalty
Summary
The facility failed to ensure residents were updated in a timely manner regarding Resident Council concerns and failed to correct those concerns for a period of four months. Facility policy stated that the Resident Council is intended to provide residents, families, and resident representatives a forum to discuss concerns and suggestions for improvement, and that a Resident Council Response Form would be used to track issues and their resolution. The policy also stated that the department related to any issue would be responsible for addressing the concern, with QAPI review as applicable. Review of Resident Council minutes from February 2026 through April 2026 showed a pattern of concerns involving staff shutting call lights off without meeting residents' needs, failure to follow the facility smoking plan to assist residents who wanted to smoke, and dietary trays not being passed by nursing staff in a timely manner, resulting in cold food for residents. During a Resident Council meeting, interviews with residents who regularly attended the meetings indicated these concerns had been raised in several prior monthly meetings with no resolution. The residents stated that waiting until the next monthly Resident Council meeting was not a timely response to learn of facility resolutions, and no evidence was provided showing timely corrective actions or timely updates to residents regarding those concerns.
Improper Storage of Supplemental Oxygen Tubing
Penalty
Summary
The facility failed to appropriately maintain supplemental oxygen equipment for four residents reviewed for respiratory services: R54, R38, R92, and R60. A facility policy dated 1/12/26 stated that any tubing not in use would be placed in a bag to ensure it remained clean and dry. On 4/19/26, R38’s oxygen tubing was observed hanging on the portable oxygen tank attached to the back of the wheelchair without being placed in a bag, and the tubing for the resident’s respiratory nebulizer machine was lying on the floor. At 3:33 p.m., an LPN picked up R38’s nebulizer tubing from the floor and attached it to the nebulizer mask to administer an as-needed medicated nebulizer treatment. During that time, an RN confirmed that R38’s oxygen and nebulizer tubing should be stored in a bag and should be discarded. Also on 4/19/26, R54’s oxygen tubing was observed lying next to the bed on the floor and not in a bag, and an RN later confirmed that the tubing should be stored in a plastic bag to prevent contamination. On 4/20/26, R92’s oxygen tubing for the portable tank attached to the back of the wheelchair was observed hanging over the top of the portable tank, with a clear bag hanging on the concentrator. R60’s supplemental oxygen tubing for the portable tank was observed wrapped around the right wheel of the wheelchair and required cutting to release it. An LPN confirmed these observations and cut R60’s oxygen tubing from the wheel. On 4/21/26, R38’s oxygen tubing for the portable tank and R54’s oxygen tubing for the portable tank were again observed hanging over the top of the portable tanks on the backs of their wheelchairs. An RN confirmed these observations and stated that the oxygen tubing should be stored in a bag to prevent contamination.
Insufficient overnight nursing staffing left resident wheelchairs uncleaned
Penalty
Summary
The facility failed to provide sufficient nursing staff every day to meet resident needs and to have a licensed nurse in charge on each shift, resulting in seven of 23 residents being affected: R15, R23, R28, R38, R54, R82, and R83. A facility policy dated 1/12/26 stated that wheelchairs are to be cleaned according to the resident's shower schedule on the 11:00 p.m. to 7:00 a.m. shift prior to the shower day. Observations on 4/19/26 and 4/20/26 showed that the wheelchairs used by these residents had copious amounts of dried food particles, dried liquids, dust, dirt, and debris on the frames, wheels, arm rests, seats, seat cushions, and leg rests. An RN confirmed the condition of the wheelchairs during interview, and the Nursing Home Administrator stated that the wheelchairs were to be cleaned on the overnight shift by nursing staff and that the facility frequently failed to maintain adequate staff on that shift, which could have contributed to the failure to clean the wheelchairs.
Confidential Resident Information Visible on Unattended Medication Carts
Penalty
Summary
The facility failed to maintain the privacy of confidential resident information during medication administration for two medication carts, West A Cart and East A Cart. A facility policy on Computer Terminals/Workstations dated 1/12/26 stated that computer terminals should be positioned or shielded so screens are not visible to the public or unauthorized staff, that only authorized users may access resident and facility information, and that users may not leave a workstation unattended unless the screen is cleared and the user is logged off. On 4/19/26 at 3:55 p.m., the West A medication cart was observed parked in the West A hallway and left unattended with the computer screen showing resident information visible to anyone passing in the corridor; during the observation, LPN Employee E1 acknowledged the lack of privacy. On 4/20/26 at 8:35 a.m., the East A medication cart was observed parked in the East A hallway and left unattended with the computer screen showing resident information visible to anyone passing in the corridor; during the observation, LPN Employee E5 acknowledged the lack of privacy.
Unsecured medication carts left unattended
Penalty
Summary
The facility failed to prevent the opportunity for potential unauthorized access to medications on two medication carts, the East A Cart and the [NAME] B Cart. A facility policy titled Medication Labeling and Storage dated 1/12/26 stated that compartments containing medications and biologicals are to be locked when not in use and that trays or carts used to transport such items are not to be left unattended if open or otherwise potentially available to others. On 4/19/26 at 3:51 p.m., the [NAME] B Medication Cart was observed parked in the [NAME] B hallway, unlocked and unattended, and an LPN confirmed at 3:55 p.m. that the cart should have been locked. On 4/20/26 at 8:35 a.m., the East A Medication Cart was observed parked in the East A hallway, unlocked and unattended, and an LPN verified that the cart was not secured while he/she left the cart to attend to a resident.
Failure to Follow Care Plans Results in Resident Harm
Penalty
Summary
The facility failed to protect two residents from neglect during care, resulting in actual harm. In the first incident, a resident with orders requiring transfer assistance from two staff members and a wheeled walker, and who was assessed as fully dependent for mobility, was transferred by a single CNA. During the transfer from a shower chair to a wheelchair, towels were placed under the resident's feet to keep them dry, but the resident stepped off the towels and slipped. The CNA attempted to lower the resident to the floor, but the resident sustained a left femur fracture. Documentation and staff interviews confirmed that the transfer was performed without the required second staff member, contrary to the resident's care plan and physician's orders. In the second incident, another resident, who was dependent on two staff for bed mobility due to cognitive impairment and physical limitations, was being rolled in bed by a single CNA during morning care. The CNA rolled the resident too far, causing the resident to fall out of bed from a height of approximately 18 inches. The resident sustained a laceration above the right eyebrow and forehead, which required sutures and further medical evaluation. The care plan, Kardex, and task documentation all indicated that two staff were required for bed mobility, but this was not followed. Both incidents were confirmed through facility documentation, clinical records, and staff interviews. The Director of Nursing and Nursing Home Administrator acknowledged that in both cases, staff failed to follow established care plans and physician orders requiring two-person assistance for transfers and bed mobility. These failures resulted in actual harm to the residents, including a femur fracture and a laceration requiring stitches.
Improper Transfer Results in Resident Fracture Due to Failure to Follow Two-Person Assist Policy
Penalty
Summary
A deficiency occurred when a resident, who had a history of left femur fracture, difficulty walking, atrial fibrillation, and asthma, was not transferred according to the facility's established policy and physician's orders. The resident's care plan and orders specified that transfers required the assistance of two staff members and, as needed, the use of a stand-up lift or walker. Despite these requirements, a CNA attempted to transfer the resident from a shower chair to a wheelchair with only one staff member present and placed towels under the resident's feet to keep them dry. During the transfer, the resident stepped off the towels, slipped, and fell to the floor. The CNA was able to support the resident's upper body and lower them to the ground, but the resident's lower body fell, resulting in significant pain and an inability to move the left leg. Assessment revealed the left lower extremity was bent and externally rotated, and the resident reported severe pain. The resident was subsequently sent to the emergency room, where a left hip/femur fracture was confirmed. Staff interviews and facility documentation confirmed that the CNA did not follow the resident's care plan or the facility's policy, which required two-person assistance for transfers. The incident was further corroborated by statements from other staff and the Director of Nursing, who verified that the transfer was performed improperly with only one staff member. This failure to follow established protocols directly resulted in actual harm to the resident.
Failure to Follow Physician's Orders for Catheter Care
Penalty
Summary
The facility failed to ensure that physician's orders were followed for a resident with a suprapubic catheter. The resident, who was admitted with diagnoses including anxiety, urinary retention, and bladder infections, had a physician's order dated 9/26/24, instructing staff not to change the suprapubic catheter. However, a nurse's note from 10/21/24 documented that a nurse attempted to change the catheter against these orders, removing the existing catheter and unsuccessfully attempting to insert a new one. This incident was confirmed during an interview with the Nursing Home Administrator and Director of Nursing on 11/09/24.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to acceptable infection control practices concerning Enhanced Barrier Precautions (EBP) during the care of a resident with a gastric tube. The facility's policy on Enhanced Barrier Precautions, implemented in April 2024, requires the use of gowns and gloves during high-contact resident care activities, especially for residents with indwelling medical devices like feeding tubes. However, during an observation of enteral tube feeding administration for a resident, it was noted that the LPN only wore gloves and did not use a gown, which is a requirement under EBP. Additionally, there was no signage indicating the need for EBP, nor was there any personal protective equipment (PPE) available outside the resident's room. The deficiency was confirmed through interviews with the LPN involved and the facility's Infection Preventionist, both acknowledging that EBP were not in place as required. The LPN admitted that both gloves and a gown should have been worn during the procedure, and the Infection Preventionist confirmed the absence of necessary precautions and PPE. This oversight indicates a failure to implement the facility's infection control policies effectively, particularly concerning residents with indwelling medical devices.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility failed to provide a summary of the baseline care plan to three residents or their representatives within 48 hours of admission, as required by their policy. The policy mandates that a written summary of the baseline care plan, including goals and objectives, a summary of medications, dietary instructions, and treatments, be provided to the resident and/or their representative. However, for Residents R31, R103, and R105, there was no evidence that such summaries were shared. This was confirmed by a review of their clinical records and an interview with the Regional Nurse Consultant. Resident R31 was admitted with chronic obstructive pulmonary disease, hypertension, and heart failure, while Resident R103 had hypothyroidism, hypertension, and hyperlipidemia. Resident R105 was diagnosed with dementia, hypertension, and dysphagia. Despite these conditions, the facility did not provide the required baseline care plan summaries to these residents or their representatives, as evidenced by the lack of documentation in their clinical records and the confirmation from the Regional Nurse Consultant.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that medications were consumed by Resident R55 during a medication administration review. The facility's policy on administering medications, dated 1/17/24, requires that medications be administered in a safe and timely manner, with staff remaining with the resident until each medication is swallowed. However, during an observation on 5/29/24, a medication cup filled with multiple unknown medications was found on Resident R55's bedside tray table without staff present. Resident R55, who has diagnoses including chronic obstructive pulmonary disease, chronic kidney disease, and disorientation, stated that staff do not wait for them to take their pills because it takes a while. Further observations revealed a small white unknown medication on the floor in front of Resident R55's bedside tray table, and the LPN responsible for administering the medications was assisting other residents down the hallway. During an interview, Registered Nurse Employee E1 confirmed the presence of the medication cup on the bedside table and acknowledged that medications should not be left at the bedside and that the nurse should stay with the resident until the medications are ingested. This incident is a violation of the facility's medication administration policy and the relevant state codes for pharmacy and nursing services.
Failure to Discard Outdated Novolog Insulin
Penalty
Summary
The facility failed to appropriately discard outdated medications, specifically a vial of Novolog Insulin, on one of the three medication carts reviewed, namely the West A Hall medication cart. The facility's policy on administering medications, reviewed on 1/17/24, requires that the expiration or beyond-use date on the medication label be checked prior to administration, and that the date of opening be recorded on multi-dose containers. According to the manufacturer's guidelines for Novolog Insulin, a vial may be kept at temperatures below 30 degrees Celsius (86 degrees Fahrenheit) for up to 28 days after initial use. However, during an observation of drug storage on 5/30/24, a vial of Novolog Insulin with an open date of 4/10/24 was found, which exceeded the 28-day expiration period. During an interview conducted at the time of the observation, an LPN confirmed that the Novolog Insulin vial should have been discarded as it was beyond the 28-day period after opening, yet it remained in the medication cart for resident use. This oversight was in violation of the facility's policy and the manufacturer's guidelines, as well as state regulations regarding management, pharmacy services, and nursing services.
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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