Shippensburg Rehabilitation And Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Shippensburg, Pennsylvania.
- Location
- 121 Walnut Bottom Road, Shippensburg, Pennsylvania 17257
- CMS Provider Number
- 395964
- Inspections on file
- 28
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Shippensburg Rehabilitation And Health Care Center during CMS and state inspections, most recent first.
Two residents with PTSD and major depressive disorder did not receive adequate trauma-informed care when the facility failed to identify and document their specific trauma-related triggers and did not ensure follow-up mental health services. In both cases, trauma-informed care assessments showed that the residents had experienced trauma and reported distressing memories, dreams, and other PTSD-related symptoms, and their care plans broadly referenced potential behaviors related to past trauma with an intervention to identify triggers. However, the plans did not include resident-specific traumas or triggers, and one resident did not receive a psychiatry consult despite a physician order and consent, while the other had no documented follow-up related to PTSD, as confirmed by the NHA and DON.
The facility failed to ensure accurate MDS assessments for two residents. For one resident with GERD and major depressive disorder, the quarterly MDS incorrectly indicated anticoagulant use despite no documentation of anticoagulant medications in the clinical record. For another resident with documented PTSD and major depressive disorder, both the admission and quarterly MDS omitted the PTSD diagnosis, even though it was present in the clinical record. Staff interviews confirmed that these MDS assessments were coded in error and did not accurately reflect the residents’ clinical status.
Surveyors found that the facility did not consistently review and revise comprehensive, person-centered care plans as residents’ conditions and information changed. One resident with PTSD, anxiety, and depression had a known trigger of being scared by noises reported by a representative, but this trigger was never added to the behavior care plan. Another resident with dementia lacked a dedicated care plan addressing dementia, with the diagnosis only noted in the nutrition section. A third resident with atrial fibrillation and heart failure was receiving apixaban, but anticoagulant therapy was omitted from the care plan after being removed in error. The DON acknowledged that these elements should have been included or maintained in the residents’ care plans.
Surveyors found that staff did not follow physician-ordered parameters for antihypertensive medications for two residents. One resident with Parkinson’s disease and hypertension received Lisinopril doses when SBP readings were below the ordered thresholds, and PRN Lisinopril was not given when SBP readings met or exceeded the ordered level. Another resident with hypertension and heart failure received scheduled hydralazine even when BP readings were below the ordered hold parameters. The DON confirmed that the expectation was for medications to be administered according to physician orders and parameters.
A resident with Parkinson's disease and dementia was moved from a private room to a semiprivate room after a B bed became available, but neither the resident nor the representative received the required written notice explaining the room change. Facility policy required advance notice to involved parties, which could include written notification, yet documentation showed only verbal communication from the social services coordinator to the resident's spouse and a prior verbal discussion months earlier. The DON and social services coordinator confirmed that no written notice was given and that they typically relied on conversations to obtain consent for room moves, leading to the representative becoming upset when the move occurred while they were out of the building.
Surveyors found that food items in the kitchen and nourishment areas were not consistently labeled, dated, or properly stored, with some packaging left open and some items appearing freezer burned. Temperature logs for refrigerators and freezers were incomplete or missing, and kitchen equipment logs could not be provided. Staff interviews confirmed that these practices did not meet facility policy or professional standards.
A resident with CHF and other cardiac conditions experienced significant weight gains on two occasions, but staff did not notify the physician or administer PRN Lasix as ordered. The DON confirmed that these required actions were not completed according to the resident's care plan and physician orders.
The Quality Assurance Committee did not hold a required quarterly meeting during one quarter, as confirmed by review of meeting records and staff interview. The Nursing Home Administrator acknowledged the expectation for quarterly meetings, which was not met for the specified period.
The facility failed to ensure accurate assessments for two residents, leading to discrepancies in their clinical records. One resident's use of a CPAP machine was not reflected in the MDS, while another resident was incorrectly documented as having cancer despite no supporting medical records. The DON acknowledged these errors during interviews.
A resident with difficulty walking and muscle weakness was discharged to the hospital after a fall and returned to the facility. Despite an MDS assessment being completed, the care plan was not updated to reflect the fall and injury. The DON acknowledged that the care plan should have been revised according to facility policy.
A facility failed to ensure proper pacemaker monitoring and follow-up for a resident with a cardiac pacemaker. The resident's care plan lacked necessary safety interventions and follow-up details, and no physician orders were in place for pacemaker checks. The issue was identified when the resident returned from a clinic appointment, revealing missed cardiac appointments.
A resident with PTSD and severe depression did not receive culturally competent, trauma-informed care as required by facility policy. The resident's care plan lacked identification of PTSD triggers and interventions, despite a social services assessment indicating the need for such measures. Staff interviews confirmed the absence of evidence for trauma-informed care.
Failure to Provide Trauma-Informed Care and Identify PTSD Triggers
Penalty
Summary
The facility failed to provide trauma-informed, culturally competent care to residents with PTSD and related mental health diagnoses by not identifying resident-specific trauma triggers and not ensuring timely psychiatric services. For one resident with PTSD, anxiety disorder, and major depressive disorder, the trauma-informed care assessment documented that the resident had experienced trauma and reported feeling very upset when reminded of the stressful experience, feeling jumpy or easily startled, and having trouble falling or staying asleep. The comprehensive care plan included a focus on potential behaviors related to past trauma due to childhood abuse and an intervention to identify potential triggers, but the record did not contain any documentation of the resident’s specific triggers. Additionally, although there was a physician’s order for a psychiatry consult and consent from the resident’s representative, the clinical record contained no documentation that the consult had occurred, and the DON confirmed that the resident had not received psychiatric services. For a second resident with PTSD and major depressive disorder, the trauma-informed care assessment showed that the resident had experienced trauma and reported repeated, disturbing and unwanted memories of the stressful event and disturbing dreams of the stressful experience. The comprehensive care plan included a focus on potential behaviors related to past trauma with an intervention to identify potential triggers, but the plan did not specify the resident’s particular trauma or any identified triggers. The clinical record also lacked any follow-up related to the resident’s PTSD, and during interviews, the NHA and DON stated that the facility had no additional information regarding this resident’s PTSD. The DON acknowledged that the facility’s expectation was that trauma and triggers be identified and that residents receive trauma-informed care, but this had not occurred for these two residents.
Inaccurate MDS Coding for Diagnoses and Anticoagulant Use
Penalty
Summary
The facility failed to ensure that MDS assessments accurately reflected two residents' clinical status. For one resident with diagnoses including GERD and major depressive disorder, review of the quarterly MDS dated March 25, 2026, showed that Section N0415E (High-Risk Drug Classes: Use and Indication – anticoagulant) was coded to indicate the resident had taken an anticoagulant during the look-back period. However, review of the resident’s clinical record did not reveal any evidence that the resident had been receiving any anticoagulant medications, indicating inaccurate MDS coding in relation to the resident’s actual medication regimen. For another resident with documented diagnoses of PTSD and major depressive disorder, review of the admission and quarterly MDS assessments showed that PTSD was not coded as a diagnosis on either assessment. This omission occurred despite the diagnosis being present in the clinical record. Staff interviews confirmed that these MDS reports were coded incorrectly, demonstrating that the resident’s documented mental health condition was not accurately reflected on the MDS assessments for that resident.
Failure to Review and Revise Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to develop, review, and revise comprehensive, person-centered care plans in accordance with its policy and regulatory requirements. Facility policy required that comprehensive care plans be developed within seven days of the MDS and revised as resident information and conditions changed. For one resident with PTSD, anxiety disorder, and depression, the care plan included a focus on potential behaviors related to past trauma and an intervention to identify potential triggers. However, after the resident’s representative informed staff that the resident was timid and became scared by noises, this specific trigger was not added to the care plan, despite documentation of the concern in a social services progress note. The DON confirmed that the resident’s fear of noise should have been added to the care plan when the facility became aware of it. Another resident, admitted with a primary diagnosis of dementia and also diagnosed with anxiety disorder, did not have a comprehensive, person-centered care plan addressing dementia; the only reference to dementia appeared in the nutrition section of the care plan. Additionally, a third resident with atrial fibrillation and heart failure had a current physician order for apixaban (Eliquis) but the care plan did not include the resident’s use of anticoagulant medication. The DON stated that anticoagulant therapy had been removed from this resident’s care plan by accident and acknowledged that it was expected to remain on the care plan. These findings demonstrate that the facility did not ensure care plans were consistently reviewed and revised to reflect residents’ diagnoses, treatments, and identified triggers, as required by policy and 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.
Failure to Follow Antihypertensive Medication Parameters for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to administer antihypertensive medications in accordance with physician orders and facility policy for two residents. Facility policy required medications to be administered according to orders, including time frames and verification of vital signs when necessary. For a resident with Parkinson’s disease and hypertension, multiple physician orders for Lisinopril 2.5 mg included specific systolic blood pressure (SBP) parameters for administration and PRN use. Review of the August and September 2025 and January 2026 MARs showed that Lisinopril was administered when SBP values were below or outside the ordered parameters on numerous dates, including SBPs such as 118, 119, 122, 123, 131, 132, 137, 138, 139, and 140 when the order required higher SBP thresholds. Additionally, the PRN Lisinopril ordered for SBP greater than 140 was not administered on multiple dates when SBP readings met or exceeded that threshold, including readings of 140, 141, 143, 144, 149, 151, 153, 154, 156, 161, and 170. For a second resident with hypertension and heart failure, physician orders specified hydralazine HCL 20 mg twice daily with instructions to hold the medication for blood pressure less than 100/60. Review of the January 2026 MAR revealed that hydralazine was administered despite blood pressure readings below the ordered hold parameters, including 98/50, 96/57, and 84/51. During an interview, the DON stated that the facility’s expectation was that medications be administered in accordance with physician orders and ordered parameters. The survey findings concluded that the facility did not ensure care and services were provided in accordance with professional standards of practice and physician-ordered parameters for these two residents.
Failure to Provide Required Written Notice Before Resident Room Change
Penalty
Summary
The facility failed to provide written notice, including the reason for a room change, before changing a resident's room. Facility policy titled "Change of Room or Roommate" stated that, prior to making a room change or roommate assignment, all persons involved, such as the resident and their representative, would be given advance notice of the change, and that parties could be notified in person, via telephone, or in writing. For one resident with Parkinson's disease and dementia, clinical record review showed a progress note indicating that on January 6, 2026, the Social Services Coordinator informed the resident's wife that the resident would be moved from a private room to a semiprivate room because a B bed was available. Further review of the resident's clinical record did not reveal any documentation that the resident or the resident's representative received written notice of the room change or the reason for the change. During an interview, the DON and the Social Services Coordinator stated that the representative had been notified approximately six months earlier that the resident would be moved to a semiprivate room once a B bed became available, and that the Social Services Coordinator had spoken with the representative the morning of the move and obtained agreement. They reported that the representative later became upset that the move occurred while they were out of the building and felt it would negatively affect the resident due to his cognitive level. The Social Services Coordinator acknowledged that no written notice had been provided and that she typically relied on verbal conversations to obtain consent for room moves.
Failure to Store and Monitor Food and Equipment per Professional Standards
Penalty
Summary
The facility failed to store food and utilize equipment in accordance with professional standards for food service safety in the main kitchen and two nourishment areas. Observations revealed multiple instances of food items not being labeled or dated, such as bins of brown and white sugar, packs of succotash vegetables, boxes of green beans, packages of hot dog buns, and various cookies and cake mixes. Some food items were found with packaging left open or appeared freezer burned. Additionally, open containers of food, such as vanilla puddings labeled for medication pass, were left in refrigerators, and thickening powder was found with two different open dates and a scoop stored inside the container. These findings were confirmed through staff interviews, which acknowledged that food items should be labeled, dated, and stored properly per facility policy. Temperature logs for refrigerators and freezers in the kitchen and nourishment areas were incomplete or missing for several dates, and the facility was unable to provide certain kitchen equipment temperature logs when requested. Observations also noted that scoops were stored inside containers rather than in a protected area nearby, contrary to policy. The facility's policy required food to be properly labeled, dated, and stored, with temperatures monitored and recorded at least twice daily, but these procedures were not consistently followed. The Nursing Home Administrator confirmed that the facility's expectation was for expired items to be discarded and for food items and equipment to be managed according to professional standards.
Failure to Follow Physician Orders for Weight Monitoring and PRN Medication
Penalty
Summary
The facility failed to follow physician orders and the resident's care plan for a resident with diagnoses including congestive heart failure, atrial fibrillation, and hyperlipidemia. The resident had specific physician orders for daily weights, with instructions to notify the physician and administer PRN Lasix if the resident experienced a weight gain of 2 pounds in one day or 5 pounds in one week. The care plan also included interventions to obtain weights as indicated and report significant changes. On two separate occasions, the resident experienced weight gains that met the criteria for physician notification and PRN Lasix administration: a 2.8-pound gain in one day and a 4.6-pound gain in one day. However, there was no documentation that the physician was notified or that the PRN Lasix was administered as ordered. The DON confirmed during interview that these actions were not taken, despite expectations that staff would follow the physician's orders and care plan.
Failure of Quality Assurance Committee to Meet Quarterly
Penalty
Summary
The facility's Quality Assurance Committee failed to meet at least once during the first quarter of 2025, as required. Review of the committee's meeting signatory pages showed that no meeting was held in January, February, or March of that year. During a staff interview, the Nursing Home Administrator confirmed that it was the facility's expectation for the committee to meet quarterly, but this did not occur for the specified period.
Inaccurate Resident Assessments in Clinical Records
Penalty
Summary
The facility failed to ensure accurate resident assessments for two residents, leading to discrepancies in their clinical records. Resident 9, diagnosed with obstructive sleep apnea and seizures, was found to have used a CPAP machine from April 1-4, 2024, as documented in the Treatment Administration Record. However, the Minimum Data Set (MDS) completed on April 4, 2024, did not reflect this usage, as it was incorrectly coded to indicate that the resident did not use a non-invasive mechanical ventilator during the previous 14 days. This error was acknowledged by the Director of Nursing during an interview. For Resident 26, who was admitted with diagnoses including anxiety disorder, major depression, and fibromyalgia, the clinical record inaccurately indicated an active cancer diagnosis. Despite the resident's belief of having colon cancer, there was no documentation in the routine physician notes or clinical record to support this. The Quarterly MDS assessment incorrectly marked the resident as having cancer, which was not corroborated by any medical records. The Director of Nursing confirmed that the resident was being followed for fibroids contributing to abdominal pain, but there was no record of an active cancer diagnosis.
Failure to Revise Care Plan After Resident's Fall
Penalty
Summary
The facility failed to ensure that the care plan for a resident, identified as Resident 8, was reviewed and revised following a significant change in her condition. Resident 8, who had diagnoses including difficulty in walking and muscle weakness, was discharged to the hospital after a fall on May 1, 2024, and returned to the facility. Despite the completion of an MDS assessment on May 15, 2024, after her return, the care plan, which focused on minimizing the risk of falls, had not been updated since April 24, 2024, to reflect the recent fall and injury. The deficiency was identified through a combination of facility policy review, clinical record review, and interviews with the resident and staff. An observation on June 11, 2024, revealed that Resident 8 had a heavily bruised face, indicating the severity of the fall. The Director of Nursing acknowledged that the care plan should have been revised to address the fall with injury, as per the facility's policy that requires changes in a resident's condition to be reported and the care plan reviewed accordingly.
Failure to Ensure Pacemaker Monitoring and Follow-Up for Resident
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for Resident 100, who was admitted with diagnoses including hypertension, dementia, and a cardiac pacemaker. Upon review, it was found that there were no physician orders regarding pacemaker monitoring or follow-up cardiology appointments for the resident. The care plan included an intervention for pacemaker checks but lacked safety interventions and follow-up visit details. The hospital discharge paperwork indicated a scheduled cardiology follow-up, which was not reflected in the facility's records. The Director of Nursing (DON) confirmed that the facility was aware of the resident's pacemaker upon admission but failed to obtain necessary information from the cardiologist. It was revealed that a remote pacemaker check scheduled shortly after admission was canceled because the monitoring device was at the resident's previous assisted living facility. The deficiency was identified when the resident returned from a wound clinic appointment, and the after-visit summary listed all cardiac appointments, prompting the nursing staff to update the resident's orders.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide culturally competent, trauma-informed care to a resident diagnosed with PTSD and severe recurrent major depressive disorder with psychotic symptoms. The facility's policy required that residents with mental disorders or PTSD receive appropriate treatment and services to achieve the highest practicable level of mental and psychosocial well-being. However, the facility did not identify or attempt to identify the resident's PTSD triggers, nor did it develop an individualized care plan that included the source of the resident's PTSD or any known triggers or interventions. The resident, a Vietnam War veteran, suffered from PTSD due to experiences such as fighting in the war, witnessing violence, being a prisoner of war, and exposure to harmful chemicals. Despite a social services assessment indicating active signs of trauma and the need for interventions, the resident's comprehensive care plan only addressed the risk for changes in mood related to dementia, depression, and PTSD, without detailing specific triggers or interventions. Interviews with facility staff revealed a lack of further information or evidence that trauma-informed care was provided, as required by professional standards of practice.
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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