Somerset Healthcare & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Somerset, Pennsylvania.
- Location
- 228 Siemon Drive, Somerset, Pennsylvania 15501
- CMS Provider Number
- 395398
- Inspections on file
- 41
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Somerset Healthcare & Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that the facility’s Emergency Preparedness (EP) Plan did not include required written procedures describing the facility’s role under a Section 1135 waiver declared by the Secretary of Health and Human Services. During document review and staff interviews, the EP Plan was confirmed to lack policies addressing how the facility would provide care and treatment at an alternate care site designated by emergency management officials when such a waiver is in effect.
Improper Storage of Open and Undated Food Items: Surveyors observed multiple food items in the kitchen that were opened and undated, including pasta salad, cheese slices, applesauce, and Lactaid milk, along with biscuits and thickener left open to the air. The Dietary Director confirmed the items should have been dated and not left exposed.
A cognitively intact resident who was dependent on staff for toileting and always incontinent of bowel and urine was left waiting in the dining area after asking to return to her room. A nurse aide told her to wait while trays were handled, another aide ignored her request, and she was not returned to her room until later, when she was found incontinent. The resident said she did not want to state her need for privacy in the dining area, and the ADON confirmed she should have been returned when requested.
Failure to maintain a clean, comfortable, and homelike environment for a resident. The resident was cognitively intact and had MS, yet observations showed a bed footboard with an approximately 6-inch hole. The D of Maintenance said he was unaware of the damage and confirmed the bed should have been replaced.
A resident who was cognitively intact and had anxiety received PRN Lorazepam repeatedly over an extended period. The MAR showed multiple administrations of the antianxiety medication, but there was no documented physician rationale to extend the PRN psychotropic order beyond the 14-day limit required by facility policy.
Failure to notify resident representatives in writing of hospital transfers and provide required bed-hold notices was identified for four residents. One resident was sent out after coughing following intake, another after a wound began bleeding heavily, a third after a fall from a mechanical lift with injury, and a fourth after becoming unresponsive; in each case, there was no documented written notice to the representative or ombudsman, and the SW stated she did not notify them and was unaware she was supposed to.
Incomplete and Not Implemented Care Plans: The facility failed to develop and/or implement resident-specific care plans for two residents. One resident with cancer had a mediport used for chemotherapy, but there was no documented care plan for the mediport. Another resident with severe cognitive impairment had a care plan calling for a Velcro STOP banner across her doorway, but observations and staff interviews confirmed the banner was not in place as planned.
The facility failed to follow a physician order for a resident’s eye drops, as the ordered ophthalmic solution was not found in the resident’s room and the resident said she had not had it for over a year. The facility also failed to obtain urine culture results for another resident with a chronic indwelling catheter and UTI, while the resident was receiving an antibiotic without documented culture sensitivities; the DON and an LPN were involved in the findings.
Unsafe bed equipment and sling selection led to resident incidents. Beds for multiple residents would not safely lock, and one resident was nearly rolled out of bed when the bed moved during care. In a separate event, a cognitively intact resident who required a mechanical lift and 2 staff for transfers slid out of a sling during a bed-to-wheelchair transfer, sustaining a head laceration and pain. Staff reported sling choice was based on visual judgment or checking with the resident or an LPN, and the facility had no formal system for selecting the correct sling.
A resident with a chronic indwelling urinary catheter related to cancer was observed sitting in a wheelchair with the catheter bag and tubing in direct contact with the floor and no dignity/privacy cover on the bag. The resident had been admitted with a fall and UTI, and the catheter was draining dark, amber urine. The care plan required urinary output monitoring and documentation every shift, but the record lacked output documentation for multiple shifts, which the RN and DON confirmed should have been documented.
A resident with a PEG tube, cancer, and assistance needs had orders for enteral feedings and tube flushes, but the clinical record lacked documentation that tube placement was verified before feedings, fluids, or meds as required by facility policy. The DON confirmed the missing documentation, and the resident’s care plan directed staff to check tube placement and gastric residuals per protocol.
Missing Documentation for Controlled Pain Medication Administration: The facility failed to maintain accountability for controlled meds for two residents receiving PRN oxycodone for pain. Although the narcotic was signed out in the controlled drug records, there was no documented evidence in the MAR or clinical record that the doses were actually administered, and the DON confirmed the missing documentation.
A facility failed to provide a separately locked, permanently affixed compartment in the med refrigerator for controlled drugs in one of one med rooms reviewed. In the A-Wing med room, two locked compartments were secured to a shelf that was not secured to the refrigerator and could be removed. The shelf contained two opened bottles and one unopened bottle of liquid lorazepam. An RN and the NHA confirmed the shelf with the fixed locked narcotic box was not permanently affixed to the refrigerator.
Incomplete Controlled Medication Documentation: The facility failed to keep complete and accurate clinical records for two residents. For one resident, MAR entries showed oxycodone administrations that were not documented on the controlled medication record; for another resident, the MAR showed oxycodone and clonazepam administrations that were not properly reflected on the narcotic record, and the DON confirmed the missing and erroneous documentation.
QAPI Committee Failed to Correct Recurring Deficiencies: The facility’s QAPI committee did not successfully implement prior plans of correction tied to repeated citations for care plan development/implementation, quality of care, infection control, and medication labeling/storage/disposal. Earlier survey findings were to be monitored through audits and QAPI review, but the current survey again cited the same areas, showing the committee was ineffective in maintaining compliance with cited regulations.
Missing EBP Signage for Residents on Isolation Precautions: The facility failed to post EBP signage for two residents who were ordered EBP due to a feeding tube and an indwelling catheter. Care plans and physician orders identified both residents as being on EBP, but observations found no signs posted at the room entrances or inside the rooms, and the ADON/Infection Preventionist confirmed the missing signage.
Beds for multiple residents were observed to move freely even when locked. One resident was cognitively intact and dependent on staff for daily care, another was cognitively intact and needed moderate assistance with bed mobility and transfers, and a third resident’s bed also failed to lock securely. Staff knew at least some of the beds were not locking fully, but the issue was not reported to maintenance, and the LPN did not verify whether the wheels were actually securing.
The facility failed to complete thorough investigations to rule out abuse or neglect after two residents were injured during care. One cognitively intact resident who was dependent on staff had shoulder pain after an aide turned the resident and the resident’s arm was jammed into a nightstand, but there was no documented investigation. Another cognitively intact resident with diabetic neuropathy fell head first to the floor during a mechanical lift transfer and sustained a head laceration, but the investigation did not document the lift or sling type and size used.
The facility failed to provide sufficient nursing staff to ensure scheduled personal care, including showers, was delivered and documented for two residents who were dependent on staff for ADLs. One resident with severe cognitive impairment received only one of two scheduled weekly showers, with no record of a second shower being offered or refused. Another cognitively intact resident with vertebral and sacral osteomyelitis did not receive any scheduled showers over a two-week period, with no documentation of offers or refusals. The resident reported inadequate staffing, citing delayed tray pickup, and two CNAs on a unit of approximately 37 residents stated they were often shorthanded and unable to complete all care, including showers. The DON confirmed the lack of documentation that showers were offered or refused and acknowledged noncompliance with CNA hours and HPPD while the facility continued to admit new residents.
Surveyors found that a resident receiving hospice services and psychotropic medications, including an antipsychotic for anxiety, depression, and dementia, had multiple dose increases of Seroquel ordered without documented evidence that the resident’s representative was informed in advance of the risks, benefits, and treatment alternatives. Facility policy required that residents or their representatives be informed and that this discussion be documented prior to initiating or increasing psychotropic medications, but review of the clinical record and confirmation by the DON showed that no such documentation existed for these Seroquel dose changes.
A cognitively impaired resident who required staff assistance for daily care and was care planned as being at risk for falls experienced multiple falls and related incidents in their room, including being found on the floor and on their knees with a bruised elbow after tripping over oxygen tubing. Although facility policy required notification of the resident’s representative when changes occurred that required notification, there was no documentation that the resident’s daughter, who held power of attorney, was informed of any of these events, and the DON confirmed that notification did not occur.
A resident with cognitive impairment and a history of GI bleed had physician’s orders for staff to obtain three stool samples and test them for occult blood. Review of the Treatment Administration Record showed that no stool samples were collected or tested as ordered. In an interview, the DON confirmed that staff did not perform the ordered stool occult blood testing and acknowledged that it should have been done.
The facility failed to follow its fall prevention policy and ensure residents’ environments were free of accident hazards. One resident with severe cognitive impairment and dependence for care had documented falls and a care plan intervention for a weighted blanket to reduce anxiety and restlessness, yet required fall risk assessments were not completed at the prescribed intervals and the weighted blanket was not in place, with the LPN unaware of the intervention. Another cognitively impaired resident with dementia, a history of falls, and a two-person transfer status using a pivot disc experienced an assisted fall during a transfer, but no witness statements were obtained, no thorough post-fall investigation was completed to identify contributing factors, and no new fall interventions were documented, as confirmed by the DON.
Surveyors found that three cognitively impaired residents, including individuals with hypertension, osteoporosis, hemiplegia, and dementia, did not have documented evidence of receiving their scheduled showers or complete bed baths on multiple days. Each resident’s MDS and task list showed dependence on staff for bathing and specific shower schedules on dayshift, but the bath/shower records lacked entries showing that care was provided, offered, or refused on several scheduled dates. The Interim DON confirmed the absence of documentation for these missed bathing events.
The facility did not consistently serve food at safe and appetizing temperatures, as required by policy and regulation. A resident reported that hot foods were often served cold, and observations during a meal service confirmed that both hot and cold items were not maintained at appropriate temperatures. The Dietary Manager acknowledged that food should be served at correct temperatures and be palatable.
The facility failed to serve food at appetizing temperatures, as residents reported meals being served cold. Observations confirmed that food temperatures were not maintained during service, with lukewarm temperatures recorded. The Dietary Manager was aware of the complaints and the facility's policy.
The facility failed to develop comprehensive care plans for three residents, including one with a feeding tube requiring Enhanced Barrier Precautions, another with smoking permissions lacking a timely care plan, and a third with a PEG tube without a care plan for its management. These deficiencies were confirmed by nursing leadership.
A resident with moderate cognitive impairment and left hemiplegia experienced unplanned weight loss due to the facility's failure to provide a recommended Med Pass supplement. The supplement was not re-ordered after the initial order was completed, leading to a significant weight decrease.
A facility failed to document the application of Gentamicin ointment to a resident's peritoneal dialysis site as ordered by the physician. The resident, who had end-stage renal disease, did not have documented evidence of the treatment on several specified dates, as confirmed by the DON.
A resident with moderate cognitive impairment and right-sided hemiplegia was found without a call bell within reach, contrary to the facility's policy and the resident's care plan. Observations and interviews confirmed the deficiency, highlighting a failure to accommodate the resident's needs for assistance.
A facility failed to maintain the confidentiality of a resident's medical information. A laptop on a medication cart in a hallway was left open, displaying the MAR for a resident, visible to staff, residents, and visitors. A nurse admitted to leaving the screen open while stepping away, and the Nursing Home Administrator confirmed that such information should not be left unattended or viewable by unauthorized individuals.
The facility failed to provide written notification to residents and their legal guardians regarding hospital transfers for three residents. A resident with an elevated white blood cell count, another with a hip fracture, and a third with low oxygen levels were transferred without documented written notices. Staff interviews confirmed the lack of documentation, violating resident rights and discharge policy.
A resident with hypertension, diabetes, and COPD was transferred to the hospital due to low oxygen levels. The facility failed to issue a bed-hold notice to the resident or their representative, as required by policy, during this emergency transfer.
A facility failed to complete a comprehensive significant change MDS assessment within the required time frame for a resident admitted to hospice care due to an end-stage illness. The RAI User's Manual mandates that such assessments be completed no later than 14 days after a significant change in status. Despite physician's orders and a care plan indicating the need for hospice care, there was no documented evidence of the assessment being completed. The Nursing Home Administrator confirmed the oversight.
The facility failed to accurately complete MDS assessments for several residents, leading to incorrect documentation of medications and treatments such as antiplatelet medications, dialysis, and anticonvulsants. These errors were confirmed through staff interviews and a review of clinical records.
The facility failed to update care plans for two residents, leading to deficiencies in their care. One resident's care plan included interventions that were not being applied, and another resident's care plan inaccurately reflected medication administration. Staff confirmed the discrepancies, but the care plans were not revised accordingly.
A facility failed to complete a discharge summary for a resident who was discharged home with Home Health services, including physical therapy, occupational therapy, and nursing. Despite physician's orders and a nursing note indicating the discharge, there was no documented evidence of a discharge summary as of over two months later. This was confirmed by the Assistant DON.
The facility failed to follow physician's orders for medication administration for a resident with septicemia, resulting in incomplete courses of Doxycycline and Erythromycin. Additionally, bowel protocols were not followed for two residents, leading to severe constipation and a moderate colonic ileus for one resident. These deficiencies were confirmed by interviews with nursing staff.
A resident with Alzheimer's and a non-stageable pressure ulcer was not repositioned every two hours as recommended, leading to a deficiency. Despite staff interviews confirming the need for regular repositioning, observations showed the resident remained in the same position for over three hours, and the facility did not document repositioning efforts.
The facility failed to label a multi-use vial of Aplisol properly and secure a medication cart. An open, undated vial was found in the medication room refrigerator, contrary to the manufacturer's guidelines. Additionally, a medication cart was left unlocked and unattended in a hallway. Both incidents were confirmed by staff and the Nursing Home Administrator, indicating non-compliance with facility policies and state regulations.
A facility failed to obtain the required hospice election form for a resident receiving hospice care, as stipulated in an agreement with the hospice provider. Despite the resident's care plan and physician's orders for hospice admission, the form was missing from both the resident's and hospice provider's records. This deficiency was confirmed by a registered nurse, and the form was later faxed by the hospice provider.
The facility's QAPI committee failed to address recurring deficiencies effectively, leading to repeated citations for issues such as personal privacy, abuse policy implementation, resident assessments, care plans, quality of care, and infection control. Despite plans of correction, the facility did not achieve compliance, indicating systemic issues in quality assurance processes.
A facility failed to adhere to infection control protocols when an LPN did not wear a gown during wound care for a resident with a pressure ulcer, despite guidelines requiring Enhanced Barrier Precautions (EBP). The resident, with Alzheimer's and a non-stageable pressure ulcer, was dependent on staff for care. The lapse was confirmed by the LPN and the Infection Control Preventionist.
The facility failed to complete necessary background checks and verifications for newly hired nursing staff, including Nurse Aide Registry verifications, nursing license checks, and criminal background checks. This oversight involved two nurse aides and three nurses, with the Nursing Home Administrator confirming the lack of documented evidence for these verifications, which should have been completed prior to hiring.
A facility failed to maintain the confidentiality of a resident's health information during medication administration. An LPN left a medication cart unattended with a computer screen displaying a resident's personal health information facing the hallway. Both the LPN and the DON confirmed that the information should have been secured, as per the facility's policy on electronic health records.
The facility failed to secure medication carts, as observed when an A unit cart was left unlocked and unattended with medications on top, and a C unit cart was also found unlocked. LPNs admitted to leaving the carts unsecured, and the DON confirmed the carts should have been locked.
A resident's food preferences were not honored after new ownership took over the facility. The resident, who was cognitively intact, preferred yogurt and a banana for breakfast but was instead given eggs, which she disliked. The Dietary Manager was instructed not to purchase these items unless needed for nutritional intervention, leading to the resident's preferences being unmet.
The facility failed to provide nightly snacks to residents as per their preferences, despite a policy stating snacks should be available upon request. Interviews and records showed that several residents, including those with diabetes, were not consistently receiving evening snacks. The DON confirmed the issue, acknowledging that snacks should be offered nightly.
The facility failed to monitor intake and output for a resident with a suprapubic catheter and did not follow bowel protocols for another resident with cognitive impairment. Despite care plans and physician's orders, there was no documentation of intake/output monitoring or administration of bowel medications during periods of constipation, as confirmed by nursing staff interviews.
The facility failed to accurately complete MDS assessments for two residents. One resident's assessment incorrectly documented urinary continence and influenza vaccination status, while another resident's assessment inaccurately recorded the reason for not receiving the influenza vaccine. These errors were confirmed by the Assistant Director of Nursing.
Failure to Include 1135 Waiver Role in Emergency Preparedness Plan
Penalty
Summary
The deficiency involves the facility’s failure to include required procedures in its Emergency Preparedness (EP) Plan addressing the facility’s role under a waiver declared by the Secretary of the Department of Health and Human Services in accordance with Section 1135 of the Social Security Act. During a review of the EP Plan, surveyors determined that it did not contain policies or procedures describing how the facility would provide care and treatment at an alternate care site identified by emergency management officials when such a federal waiver is in effect. On the survey date and time, an interview and documentation review confirmed that there were no written procedures in the EP Plan outlining the facility’s responsibilities or actions under an 1135 waiver scenario. In a subsequent interview, the Facility Administrator and Maintenance Director acknowledged that the EP Plan lacked a written plan describing the facility’s role during a waiver declared by the Secretary of the Department of Health.
Plan Of Correction
The facility added the information related to 1135 waiver under the Stafford Act or National Emergency Act to out disaster plan in the event that the President declares a disaster or emergency. Also the HHS Secretary declares a public health emergency under Section 319 of the Public Health Service Act. The department heads will be in serviced on this added information by the Maintenance director / designee. The review of this information as well as the entire disaster manual will be reviewed yearly by the maintenance director and Nursing Home Administrator to ensure that the policy and procedures remain pertinent to regulations. The review of emergency policy and procedures will be discussed in Quality Assurance and Performance Improvement committee meetings monthly for two months then annually.
Improper Storage of Open and Undated Food Items
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food service safety. The facility’s refrigerated food storage policy, dated February 4, 2026, stated that refrigerated foods were to be stored wrapped or in covered containers, labeled and dated, and arranged to prevent cross contamination. During an observation of the main kitchen on April 13, 2026, surveyors found a bowl of pasta salad that was opened and undated, a package of American cheese slices that was opened, wrapped in cellophane, and undated in the walk-in refrigerator, approximately one half of a jar of applesauce that was opened and undated, and one container of Lactaid milk that was opened and undated in the pantry refrigerator. Surveyors also observed a box of biscuits in the breakfast freezer that was open to the air and a box of thickener in dry storage that was open to the air. The Dietary Director confirmed that the foods should have been dated and not left open to air.
Delayed Response to Resident’s Request for Toileting Assistance
Penalty
Summary
The facility failed to provide care in a manner that promoted and enhanced a resident’s dignity and quality of life by not responding in a timely manner to the resident’s request for assistance. Resident 28 was cognitively intact, dependent on staff for toileting needs, and always incontinent of bowel and urine. The resident’s care plan addressed bowel and bladder incontinence, chronic urinary tract infections, IBS, and the need for staff to check for incontinence and change the resident every two hours and as needed. The care plan also indicated the resident required extensive assistance from two staff members for bed mobility. During observations, the resident asked a nurse aide to take her back to her room while waiting in the small dining area, but was told to wait. Later, another nurse aide walked into the dining area, removed a tray from another resident, and told the resident she would be right back to take her to her room while ignoring and not acknowledging her. When the resident again requested to go back to her room, a second nurse aide got the first nurse aide to assist. Upon returning to her room, the resident was found to be incontinent. The resident stated she had requested to return to her room because she was incontinent but did not want to say that in the dining area with other residents around. The Assistant Director of Nursing confirmed the resident should have been returned to her room when requested.
Failure to Maintain a Homelike Resident Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for one resident. The facility policy dated February 4, 2026 stated that residents were to be provided a clean, comfortable, and homelike environment. Resident 49’s quarterly MDS assessment dated February 18, 2026 showed that the resident was cognitively intact and had diagnoses including multiple sclerosis. Observations on April 13, 2026 at 11:02 a.m. and April 14, 2026 at 10:50 a.m. showed the resident lying in bed with a hole in the footboard of the bed measuring approximately six inches in diameter. The Director of Maintenance stated on April 14, 2026 at 11:34 a.m. that he was unaware the bed had a hole in the footboard and confirmed that it should have been replaced.
Unnecessary PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that Resident 37’s medication regimen was free from unnecessary psychotropic medication. Resident 37’s significant change MDS dated March 16, 2026, identified the resident as cognitively intact, needing assistance with daily care needs, receiving antianxiety medications, and having a diagnosis of anxiety. Physician orders dated March 25, 2026, directed 0.5 mg of Lorazepam every 12 hours as needed for anxiety. Review of the MAR for March and April 2026 showed repeated administration of the PRN Lorazepam on multiple dates from March 25 through April 14, 2026. The facility policy dated February 4, 2026, stated that PRN psychotropic medications are limited to no more than 14 days unless the attending physician or prescribing practitioner documents the rationale for extending the order and specifies a duration. There was no documented evidence that a physician provided the required rationale to extend Resident 37’s PRN Lorazepam beyond 14 days. The DON confirmed on April 16, 2026, that the facility failed to ensure the PRN Lorazepam was limited to 14 days or had a clinical rationale for continuation beyond 14 days.
Failure to Notify Representatives of Hospital Transfers and Bed-Hold Information
Penalty
Summary
The facility failed to notify residents’ representatives in writing of hospital transfers and failed to ensure that bed-hold notices were provided to responsible parties for four residents reviewed. For Resident 1, a nursing note dated February 14, 2025, documented coughing after eating a cookie and a large amount of fluids, after which the physician was notified and directed transfer to the emergency room; however, there was no documented evidence that the resident’s representative or the ombudsman was notified in writing of the transfer. Similar findings were identified for Resident 10, whose record showed transfer to the emergency room after a wound began spraying a steady stream of blood during a dressing change and another later transfer to UPMC Somerset Emergency Room, with no documented written notification to the representative or ombudsman. Resident 47’s record showed a fall from a mechanical lift during a transfer, resulting in injuries and hospital transfer, but there was no documented evidence of written notification to the resident’s representative or ombudsman. Resident 82 was documented as unresponsive and being sent to the emergency room, and again there was no documented evidence that the resident’s representative or ombudsman was notified in writing. During interview, the Social Worker stated she did not notify the resident’s representative or the ombudsman of the hospital transfer and was not aware that she was supposed to.
Incomplete and Not Implemented Care Plans
Penalty
Summary
The facility failed to develop and/or implement comprehensive, resident-specific care plans for two residents. For one resident with cancer, a significant change MDS assessment showed the resident was cognitively intact, needed assistance with care needs, and had a diagnosis of cancer. The care plan indicated the resident was receiving chemotherapy, and the resident stated he was going for a PET scan, received chemotherapy every three weeks, had completed about four rounds, and had a mediport in the right chest that was used for chemotherapy and flushed during treatments. However, there was no documented evidence in the clinical record that a care plan was developed for the mediport, and the DON confirmed this absence. For another resident with severe cognitive impairment, vascular dementia, and anxiety, the quarterly MDS showed the resident required extensive staff assistance. Her care plan, last revised in May 2025, directed that a Velcro STOP sign be placed across her doorway. Observations on multiple days showed no STOP safety banner in place across her doorway as care planned. The Social Service Director, an LPN, and the ADON all confirmed that the banner was not present, and staff also noted that another resident roamed throughout the facility while four other residents had STOP banners across their doorways to discourage entry.
Failure to Follow Orders for Eye Drops and Obtain Urine Culture Results
Penalty
Summary
The facility failed to follow physician’s orders for one resident who had an order for Refresh Relieva Ophthalmic Solution to be instilled in both eyes three times daily for dry eyes and kept at bedside for unsupervised self-administration. On April 16, 2026, observation of the resident’s room showed no evidence of the ordered eye drops. An LPN stated she was not aware the resident did not have the ordered eye drops and believed the resident would tell staff when more were needed. The resident stated she had not had the eye drops for over a year, and the DON confirmed the resident should have had the eye drops per the physician’s order. The facility also failed to obtain urine culture results needed for effective antibiotic treatment for another resident admitted with a chronic indwelling catheter, a fall, and a urinary tract infection. Hospital discharge instructions noted a pending urine culture, and the resident was ordered Sulfamethoxazole-Trimethoprim for the UTI. Physician notes documented that the resident had a urinalysis showing many bacteria and that staff were waiting on culture results. As of April 14, 2026, there was no documented evidence the facility had obtained the urine culture results from the hospital. The results were later obtained and showed Enterococcus faecalis greater than 100,000 colonies with sensitivities to Ampicillin, Daptomycin, Linezolid, and Vancomycin, while the resident had been receiving Sulfamethoxazole-Trimethoprim since admission.
Unsafe Bed Equipment and Mechanical Lift Sling Selection
Penalty
Summary
The facility failed to maintain an environment free from potential safety hazards related to resident beds for three residents. During care to one resident, the bed moved several feet in the opposite direction while the resident was being rolled, and the resident was close to rolling out of bed because the bed wheels could not be safely secured and locked. Observations of two other residents' beds showed that the wheels did not safely lock and secure with the residents in the beds. The Maintenance Director stated he had not been notified of concerns that the beds could not be locked and secured, and confirmed the beds should have been able to be locked and secured so they did not move during care, repositioning, or transfers. The facility also failed to have a formal system for choosing the correct mechanical lift sling for one resident who required transfer with a mechanical lift and two staff members. That resident was cognitively intact, dependent on staff for daily care needs, and had diabetic neuropathy. During a transfer from bed to wheelchair using a mechanical lift, the resident fidgeted in the sling, reached for the wheelchair, and slid out of the sling onto the floor headfirst, sustaining a 3-cm laceration to the back of the head and complaints of arm, back, and hip pain. Facility observations later showed several slings of different colors and fabrics with faded labels and no indication of weight limits, size information, or compatibility with the lift equipment. Staff interviews confirmed that sling selection was based on visual judgment, resident input, or checking with an LPN, and the ADON and NHA confirmed the facility did not have a formal system for choosing the correct sling.
Failure to Provide Proper Indwelling Catheter Care and Output Documentation
Penalty
Summary
Appropriate care was not provided for a resident with a chronic indwelling urinary catheter related to cancer. The resident was admitted with a fall and urinary tract infection, and the catheter was documented as draining dark, amber-colored urine. On observation, the resident was sitting in a wheelchair with the urinary catheter bag hanging under the wheelchair, with the bag and tubing in direct contact with the floor and no dignity/privacy cover on the bag. An RN confirmed that the catheter bag and tubing were lying on the floor and that there was no dignity/privacy cover, and the Nursing Home Administrator also confirmed that the bag and tubing should not have been on the floor and that a dignity/privacy cover should have been present. The resident’s care plan directed staff to monitor and document urinary output per facility policy, and the facility task required catheter output to be documented every shift. Review of the clinical record showed no documented catheter output on the day shift of one date, the evening shift of another date, and the night shift across multiple dates. The DON confirmed that the urinary catheter output was not documented on those shifts and that it should have been documented.
Failure to Verify Feeding Tube Placement Before Feedings and Medications
Penalty
Summary
The facility failed to ensure that a resident receiving enteral feedings received appropriate treatment and services to prevent complications. Resident 5 was cognitively intact, required assistance with care needs, had a feeding tube, and had a diagnosis of cancer. The resident’s care plan directed staff to check tube placement and gastric contents/residual per facility protocol, and physician orders directed Glucerna 1.2 Cal enteral feedings via the PEG tube, with later orders changing the regimen to bolus feedings four times daily. Facility policies dated February 4, 2026 required licensed nurses to monitor and check that the feeding tube was in the right location and to verify tube placement before beginning feedings and before administering medications. The resident’s clinical record did not contain documented evidence that feeding tube placement was verified prior to beginning feedings or prior to administering fluids or medications. The DON confirmed on April 16, 2026 that there was no documented evidence in the record that tube placement was verified before feedings and before and prior to administering any fluids or medications as required by facility policy.
Missing Documentation for Controlled Pain Medication Administration
Penalty
Summary
The facility failed to maintain accountability for controlled medications for two residents who were receiving PRN oxycodone for pain. Facility policy dated February 4, 2026, required staff to sign the MAR after medication administration and to sign the narcotic book when the medication was a controlled substance. Resident 37 was cognitively intact, required assistance with daily care needs, and had physician orders for oxycodone 5 mg every six hours as needed for pain. Review of the controlled drug records showed oxycodone was signed out on multiple occasions in February, March, and April 2026, but there was no documented evidence in the resident’s clinical record that those doses were administered. Resident 49 was also cognitively intact, required assistance with daily care needs, and had an order for oxycodone 5 mg every six hours as needed for pain. Review of the controlled drug records for February 2026 showed oxycodone was signed out on one occasion, but there was no documented evidence in the resident’s clinical record that the dose was administered. The DON confirmed during interview that there was no documented evidence in either resident’s record showing the signed-out oxycodone doses were administered at the documented times.
Unsecured Narcotic Storage in Medication Refrigerator
Penalty
Summary
The facility failed to provide a separately locked, permanently affixed compartment in the medication refrigerator for controlled drugs in one of one medication rooms reviewed. During observation of the A-Wing medication room, two locked compartments in the medication refrigerator were found secured to a shelf that was not secured to the refrigerator and could be removed. The unsecured shelf contained two opened bottles of liquid lorazepam and one unopened bottle of liquid lorazepam. An RN confirmed at the time of the observation that the shelf with the fixed locked narcotic box was not secured to the refrigerator and could be removed, and the NHA also confirmed that the shelf with the fixed locked narcotic box in the A-Wing medication room should be permanently affixed to the refrigerator and not able to be removed.
Incomplete Controlled Medication Documentation
Penalty
Summary
The facility failed to maintain clinical records that were complete and accurately documented for two residents. Facility policy dated February 4, 2026 stated that staff are to sign the MAR after a medication is administered and, for controlled substances, sign the narcotic book. Resident 37 was cognitively intact, required assistance with daily care needs, and was receiving routinely scheduled and as needed pain medication. Physician orders included oxycodone 5 mg every six hours as needed for pain. The MAR showed oxycodone was administered on January 29, 2026 at 8:35 a.m., April 4, 2026 at 7:16 a.m., and April 5, 2026 at 7:16 a.m., but the controlled medication record did not document that oxycodone was signed out for those administrations. The DON confirmed there was no documented evidence on the controlled medication record for those dates and times. Resident 49 was cognitively intact, required assistance with daily care needs, and was receiving as needed pain medication. Physician orders included oxycodone 5 mg every six hours as needed for pain and clonazepam 0.5 mg every 12 hours. The MAR showed oxycodone was administered on March 10, 2026 at 8:17 p.m. and clonazepam was administered on April 1, 2026 at 9:00 a.m., but the controlled medication record did not document oxycodone being signed out for that administration and showed clonazepam signed out in error on that date and time. The DON confirmed there was no documented evidence on the controlled medication record to confirm those medications were administered as recorded.
QAPI Committee Failed to Correct Recurring Deficiencies
Penalty
Summary
The facility’s QAPI committee failed to correct recurring quality deficiencies identified in prior and current surveys. A State Survey and Certification survey ending March 13, 2025, cited the facility for deficiencies involving comprehensive care plans, quality of care, infection control, and medication storage/labeling/disposal, and the facility’s plans of correction stated that audits would be completed and results reported to the QAPI committee for review. The current survey ending April 16, 2026, found repeated deficiencies under F656, F684, F761, and F880, showing that the facility’s QAPI committee did not successfully implement its prior plans to ensure ongoing compliance with regulations regarding care plan development and implementation, quality of care, infection control, and medication labeling/storage/disposal. The report states that the facility developed plans of correction after the earlier survey that included quality assurance systems intended to maintain compliance with cited nursing home regulations. However, the current survey found that the QAPI committee was ineffective in maintaining compliance in the same areas previously cited. The report specifically notes that the facility’s plans for care plan deficiencies, quality of care, infection control, and medication storage/labeling/disposal were not successfully implemented through the QAPI process.
Missing EBP Signage for Residents on Isolation Precautions
Penalty
Summary
The facility failed to ensure that appropriate Enhanced Barrier Precautions (EBP) signage was posted for two residents with special infection control isolation needs. Resident 5 had a feeding tube, was cognitively intact, required assistance with care needs, and had a cancer diagnosis. The resident’s care plan and physician’s orders both indicated EBP related to the feeding tube, but observations of the room on April 13 and April 15, 2026, found no EBP signs posted at the entrance to the room or inside the room. Resident 79 was admitted with a urinary tract infection and had an indwelling catheter in place. The resident’s care plan and physician’s orders indicated EBP related to the indwelling catheter, but observations of the room on April 13, 2026, found no EBP signs posted at the entrance to the room or inside the room, and a later observation the same day again found no signage. The Assistant Director of Nursing/Infection Preventionist confirmed that there was no signage posted at either resident’s room to indicate they were on EBP.
Beds Not Securing Properly for Multiple Residents
Penalty
Summary
The facility failed to ensure resident beds were in safe operating condition for 3 of 33 residents reviewed. Resident 28’s annual MDS dated April 8, 2026, showed she was cognitively intact and dependent on staff for daily care needs. During an April 13, 2026 observation, her bed was locked but moved freely while locked. Resident 28 stated the bed not locking had been an issue. A nurse aide said she was aware the bed had not been locking and had informed the LPN when she first noticed it, and the LPN confirmed she was told the bed moved but only instructed the nurse aides to lock it without checking whether the wheels were actually locking securely. Resident 37’s significant change MDS dated March 16, 2026, showed she was cognitively intact, required moderate assistance with bed mobility, and was dependent on staff for transfers between bed and chair. During observation, her bed was locked but moved freely while locked, and Resident 37 stated the bed not locking had been an issue. A nurse aide said she knew the bed did not lock fully and moved, but did not make anyone aware. In addition, Resident 63’s bed was observed locked but moving freely while locked. The director of maintenance confirmed he had not been made aware verbally or in writing through a work order that the wheels on the beds mentioned did not lock securely.
Incomplete Investigation of Resident Injury Events
Penalty
Summary
The facility failed to conduct a thorough investigation to rule out abuse or neglect for two residents after injury events were documented. For one resident, an annual MDS assessment showed the resident was cognitively intact and dependent on staff for daily care needs. A nursing note documented that during care, a nurse aide assisted with turning the resident, the bed moved, and the resident’s arm was jammed into the nightstand, causing shoulder pain. The record did not contain documented evidence that the facility investigated the incident to determine whether abuse or neglect caused the injury, and the Assistant DON and NHA confirmed the investigation should have been conducted. For another resident, a quarterly MDS assessment showed the resident was cognitively intact, dependent on staff for daily care needs, and had diabetic neuropathy. Investigation documents showed the resident was being transferred from bed to wheelchair using a mechanical lift with two staff members when the resident fidgeted in the sling, reached for the wheelchair, slid out of the sling, and fell head first to the floor, sustaining a 3 cm laceration to the back of the head. Witness statements confirmed the resident slipped from the sling during the transfer. However, the investigation did not document what type of lift was being used or what type and size of sling was in use at the time of the transfer, and the DON confirmed there was no documented evidence that this was determined.
Insufficient Nursing Staff Leading to Missed and Undocumented Showers
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ personal care needs and to document required care, specifically scheduled showers, for two residents. An annual MDS for Resident 2 showed severe cognitive impairment, with the resident rarely or never understanding and being totally dependent on staff for personal care. The resident’s care plan indicated two showers per week, but documentation from March 22 through March 28, 2026, showed only one shower provided, with no evidence that a second shower was offered or refused. A significant change MDS for Resident 3 indicated that the resident was cognitively intact, diagnosed with vertebral and sacral osteomyelitis, and dependent on staff for personal care, with an order for two showers per week. Review of bathing documentation for Resident 3 from March 15 through March 28, 2026, revealed that no showers were provided and there was no documentation that showers were offered or refused. Resident 3 reported that there was not enough help, pointing to a breakfast tray that had not been picked up and stating that the facility needed to hire more people, expressing concern that there was not enough staff to provide overall care. Confidential interviews with two nurse aides on A wing indicated they were often shorthanded, could not always complete their work, and that some residents went without showers. They reported that two nurse aides were responsible for approximately 37 residents on A wing, and the facility’s matrix showed that new residents continued to be admitted as of April 7, 2026. The DON confirmed that the nurse aide task documentation reflected residents’ shower preferences and that there was no documentation that Residents 2 and 3 were offered or refused showers as scheduled, and acknowledged awareness that the facility was out of compliance with nurse aide hours and hours per patient per day.
Failure to Inform Resident Representative of Psychotropic Medication Risks and Alternatives
Penalty
Summary
Surveyors determined that the facility failed to inform a resident’s representative in advance about the risks, benefits, and treatment alternatives related to psychotropic medication dose increases. The facility’s policy on psychotropic medications, dated February 4, 2026, required that prior to initiating or increasing such medications, the resident, family, and/or representative be informed of the benefits, risks, alternatives, and any black box warnings, and that this discussion be documented in the clinical record. Review of the clinical record for Resident 4 showed that this required documentation was absent. Resident 4’s quarterly MDS dated January 28, 2026, indicated cognitive impairment, limited ability to be understood, usual ability to understand others, no behavioral symptoms, receipt of hospice services, and use of psychotropic medications including antipsychotic and antidepressant drugs, with diagnoses of anxiety, depression, and dementia. A nursing note on October 30, 2025, documented a new hospice order to increase Seroquel to 50 mg twice daily for behaviors, and physician orders on October 31, 2025, and January 27, 2026, further increased Seroquel to 50 mg twice daily and then 100 mg twice daily. There was no documented evidence that the resident’s representative was informed in advance of the risks, benefits, and treatment alternatives before these dose increases, a lack of documentation confirmed by the DON during interview.
Failure to Notify Resident Representative of Multiple Falls
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of changes in condition as required by facility policy. The facility’s notification policy dated February 4, 2026, stated that the resident’s representative would be notified when there was a change requiring notification. A quarterly MDS assessment dated July 26, 2025, showed that Resident 2 was cognitively impaired and required staff assistance for daily care, and the resident’s care plan identified a risk for falls. Nursing notes documented that on August 1, 2025, the resident fell in his room; on August 9, 2025, the resident was found on his knees in his room with a bruised elbow; and on August 15, 2025, the resident was found on the floor in his room after tripping over oxygen tubing. There was no documented evidence that the resident’s daughter, who was the power of attorney, was notified of any of these falls, and the DON confirmed in an interview that the daughter was not notified and should have been. This failure to notify the resident’s representative of multiple fall events for a cognitively impaired resident at risk for falls constituted noncompliance with the facility’s own notification policy and with 28 Pa. Code 211.12(d)(1)(3)(5) related to nursing services.
Failure to Follow Physician’s Orders for Stool Occult Blood Testing
Penalty
Summary
Facility staff failed to follow a physician’s order for a cognitively impaired resident with a history of gastrointestinal bleed who required assistance with care needs. A quarterly MDS assessment dated July 26, 2025, documented the resident’s cognitive impairment and care needs, and physician’s orders dated August 7, 2025, directed staff to obtain three stool samples and test them for occult (hidden) blood. Review of the resident’s August 2025 Treatment Administration Record showed that no stool samples were obtained or tested as ordered. In an interview on February 19, 2026, at 1:34 p.m., the Director of Nursing confirmed that staff did not obtain or test any stool samples for blood for this resident and acknowledged that they should have done so. This failure to carry out the physician’s orders for stool testing constituted noncompliance with 28 Pa. Code 211.12(d)(1)(3)(5) related to nursing services.
Failure to Follow Fall Prevention Policy and Implement Post-Fall Interventions
Penalty
Summary
The deficiency involves the facility’s failure to follow its fall prevention policy and ensure residents’ environments were free from accident hazards. The policy required fall risk assessments every 90 days and with changes in condition, with nurses to identify fall risk and initiate care plan interventions accordingly. For one resident with severe cognitive impairment who was dependent on staff for daily care and transfers, a fall on September 24, 2025 led to the addition of a weighted blanket as a new intervention to decrease anxiety and restlessness, and the care plan was updated to reflect this. However, the clinical record showed fall risk assessments were only completed on January 2 and September 5, 2025, with no evidence of 90‑day reassessments as required. On observation in February 2026, the resident was in bed without the ordered weighted blanket, and the LPN caring for the resident stated she was not aware that the resident was supposed to have a weighted blanket. The Nursing Home Administrator confirmed that fall risk assessments should have been completed every 90 days and that the resident should have had a weighted blanket. The deficiency also includes the facility’s failure to complete a thorough post‑fall investigation and implement fall interventions for another resident. This resident was cognitively impaired, had dementia, a history of falls, was dependent with transfers, and used a pivot disc with two‑person assistance for transfers. A nursing note documented that the resident experienced an assisted fall during a transfer from a recliner to bed when he became weak and was lowered to the floor and then assisted to bed for evening care. The incident report for this fall indicated there were no witness statements and no fall investigation completed to identify contributing factors. There was no documentation that staff transfer technique was evaluated or that any new fall interventions were implemented after the fall to minimize the risk of further falls. The DON confirmed there were no witness statements, no further investigation reports, and no documented evidence of post‑fall interventions for this resident.
Failure to Provide and Document Scheduled Bathing for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled showers or complete bed baths for multiple dependent residents as documented in their clinical records and task lists. One resident with cognitive impairment, hypertension, and osteoporosis was assessed as dependent on staff for bathing and had showers scheduled every Wednesday and Sunday on dayshift. Review of this resident’s bath/shower records for December 2025 through January 2026 showed no documented evidence that a shower or complete bed bath was provided on several scheduled dates, specifically December 3, 10, 14, 21, 28, and 31, 2025, and January 11, 2026. A second resident, with severe cognitive impairment and hemiplegia, was also dependent on staff for bathing and had showers scheduled every Tuesday and Saturday on dayshift. Review of this resident’s bath/shower records for November and December 2025 revealed no documented evidence that a shower or complete bed bath was provided on November 11, 18, 25, 2025, and December 6, 2025. A third resident, with severe cognitive impairment and dementia, required supervision and touch assistance for bathing and had showers scheduled every Tuesday and Saturday on dayshift. Review of this resident’s records showed no documented evidence of a shower or complete bed bath on a scheduled date in December 2025. The Interim DON confirmed there was no documentation that these residents were offered, refused, or received their scheduled showers or complete bed baths on the identified dates.
Failure to Serve Food at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food was served at palatable and safe temperatures, as required by its own policy and state regulations. The policy specified that hot foods should be held above 135 degrees Fahrenheit and cold foods below 41 degrees Fahrenheit. During resident food committee meetings, attendees reported that foods were only sometimes served at the proper temperature. An interview with a resident revealed that hot foods were often served cold. Observations during a lunch meal service showed that a test tray took 38 minutes to reach a resident area, and temperature checks revealed that the hot entrée and vegetables were below the required temperature, while the milk and juice were above the safe cold holding temperature. The Dietary Manager confirmed that food should be served at correct temperatures and be palatable.
Failure to Serve Food at Appetizing Temperatures
Penalty
Summary
The facility failed to serve food items at appetizing temperatures, as determined through a review of facility policies, observations, and interviews with residents and staff. The facility's policy, dated February 24, 2025, stated that food should be palatable, attractive, and served at a safe and appetizing temperature. However, Food Committee meeting minutes from February 5 and March 7, 2025, revealed resident complaints about food being served cold. Interviews with several residents confirmed these complaints, with residents reporting that meals were often served cold, whether eaten in their rooms or the main dining room. Observations in the main kitchen on March 11, 2025, showed that food was not maintained at appetizing temperatures during service. The food cart for C-wing left the kitchen at 12:03 p.m. and the last resident was served at 12:15 p.m. At that time, the temperature of the crusted pork was 126.3 degrees Fahrenheit and the peas were 127.7 degrees Fahrenheit, both of which were lukewarm. The Dietary Manager confirmed awareness of the resident complaints and the facility's policy on food temperatures. This deficiency was cited under 28 Pa. Code 211.6(b) Dietary Services.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, which is a violation of their policy and professional standards. Resident 38, who is cognitively intact and receives nutrition through a feeding tube, did not have a care plan addressing the need for Enhanced Barrier Precautions (EBP) despite having physician's orders for EBP due to the feeding tube. This was confirmed by the Assistant Director of Nursing, who acknowledged the absence of a care plan for EBP. Resident 57, who is cognitively intact and independent with personal hygiene, had physician's orders allowing smoking but lacked a care plan addressing smoking until several months later. The Assistant Director of Nursing confirmed that the care plan should have been developed when the resident was identified as a smoker. Additionally, Resident 60, who is cognitively intact and dependent on staff for daily care, had orders for PEG tube checks every shift but did not have a care plan for the care and treatment of the PEG tube. The Director of Nursing confirmed the absence of a care plan for the PEG tube as of the survey date.
Failure to Provide Nutritional Supplement as Recommended
Penalty
Summary
The facility failed to ensure that interventions to prevent weight loss were provided as recommended by the dietician for a resident with moderate cognitive impairment and left hemiplegia following a stroke. The resident had a care plan indicating the potential for nutritional problems, and a registered dietician was to evaluate and make diet change recommendations as needed. The resident was to receive a Med Pass supplement, a fortified nutritional shake, to provide additional calories and protein. However, a review of the Medication Administration Record (MAR) revealed no documented evidence that the resident was provided the Med Pass supplement between February 10, 2025, and March 11, 2025. The resident's weight decreased from 177.8 pounds on February 4, 2025, to 162.4 pounds on March 4, 2025. An interview with the Assistant Director of Nursing revealed that the Med Pass supplement order was not re-ordered per the dietician's recommendation after it was completed on February 9, 2025.
Failure to Document Dialysis Treatment
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident with end-stage renal disease who required peritoneal dialysis. The resident, who was cognitively intact, had physician's orders for the application of 0.1 percent Gentamicin ointment to the peritoneal dialysis site every day shift and to receive peritoneal dialysis every night shift. However, the Treatment Administration Records for February and March 2025 showed no documented evidence that the Gentamicin ointment was applied on multiple specified dates. This deficiency was confirmed through an interview with the Director of Nursing, who acknowledged the lack of documentation for the treatment on the mentioned dates.
Failure to Ensure Call Bell Accessibility for Resident
Penalty
Summary
The facility failed to ensure that call bells were within reach for a resident, identified as Resident 8, who was reviewed during a survey. The facility's policy, dated February 24, 2025, mandates that call lights be accessible to residents to allow them to call for assistance. Resident 8, who had moderate cognitive impairment and right-sided hemiplegia following a stroke, required assistance from staff for care needs. The resident's care plan, updated on March 7, 2025, highlighted the risk for falls and instructed staff to ensure the call light was within reach and to encourage its use. On March 10, 2025, an observation revealed that Resident 8 was lying in bed without the call bell in sight or within reach. When asked how he would call for help, the resident shrugged his shoulders, indicating a lack of awareness or ability to access the call bell. Interviews with a Licensed Practical Nurse and the Director of Nursing confirmed that the call bell should have been within the resident's reach, as per the facility's policy and the resident's care plan.
Confidentiality Breach of Resident's Medical Information
Penalty
Summary
The facility failed to maintain the confidentiality of medical information for one resident. The facility's policy, dated February 24, 2024, requires employees to ensure computer screens with health information are minimized or closed to protect resident confidentiality. On March 12, 2025, at 8:00 a.m., a laptop on a medication cart in the hallway outside a resident's room was observed with the Medication Administration Record (MAR) for a resident visible to staff, residents, and visitors. No nurse was present near the cart. A Registered Nurse admitted to leaving the laptop screen open while she stepped away, acknowledging that she should have minimized the screen. The Nursing Home Administrator confirmed that laptop screens with confidential information should not be left unattended or viewable by unauthorized individuals.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents and their legal guardians regarding the reasons for hospitalization for three residents. Resident 27, who was cognitively intact, was transferred to the hospital due to an elevated white blood cell count and symptoms of abdominal pain, nausea, and chills. However, there was no documented evidence that a written notice of this transfer was provided to the resident's representative. Similarly, Resident 49, who was cognitively impaired and had a left hip fracture, was sent to the hospital without documented evidence of written notification to the resident or their responsible party. Resident 71, who had diagnoses including hypertension, diabetes, and COPD, was transferred to the emergency department due to lethargy and low oxygen saturation levels. Despite the critical nature of the transfer, there was no documented evidence that a written notice was provided to the resident or their responsible party. Interviews with facility staff, including the Assistant Director of Nursing, Director of Nursing, and Nursing Home Administrator, confirmed the lack of documentation for these notifications, which is a violation of resident rights and discharge policy as per 28 Pa. Code 201.25 and 28 Pa. Code 201.29(f)(g).
Failure to Issue Bed-Hold Notice During Resident Transfer
Penalty
Summary
The facility failed to issue a bed-hold notice at the time of an anticipated leave of absence for one resident. According to the facility's policy, in the event of an emergency transfer, a written notice of the bed-hold policy should be provided to the resident or their representative within 24 hours. The policy also requires documentation of attempts to notify the representative and a signed copy of the notice to be kept in the resident's file. However, there was no documented evidence that such a notice was issued to the resident or their representative when the resident was transferred to the hospital. The resident involved was understood to have conditions including hypertension, diabetes, and COPD. On the day of the incident, the resident was lethargic and had a low oxygen saturation level, prompting a CRNP to increase oxygen support and eventually send the resident to the emergency department for further evaluation. Despite these actions, the facility did not provide the required bed-hold notice, as confirmed by the Nursing Home Administrator.
Failure to Complete Timely MDS Assessment for Hospice Admission
Penalty
Summary
The facility failed to complete a comprehensive significant change Minimum Data Set (MDS) assessment within the required time frame for a resident who experienced a significant change in condition. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, the Assessment Reference Date (ARD) and the significant change comprehensive MDS assessment should be completed no later than 14 calendar days after determining a significant change in the resident's status. In this case, a care plan dated July 24, 2024, indicated that the resident required hospice care due to an end-stage illness, and physician's orders dated July 23, 2024, confirmed the resident's admission to hospice. However, there was no documented evidence that the required MDS assessment was completed following the resident's admission to hospice care. The Nursing Home Administrator confirmed on March 11, 2025, that the assessment was not completed within the mandated time frame.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for seven residents, as required by the Resident Assessment Instrument (RAI) User's Manual. The inaccuracies were identified in various sections of the MDS assessments, which are crucial for evaluating residents' care needs and abilities. For instance, several residents who were prescribed and received aspirin, an antiplatelet medication, during the assessment period were incorrectly coded as not having received it. This error was confirmed through interviews with the Registered Nurse Assessment Coordinator (RNAC) and the Nursing Home Administrator. Additionally, a resident who was undergoing hemodialysis was not accurately documented in the MDS assessment, as the section indicating dialysis treatment was incorrectly coded. This discrepancy was confirmed by the RNAC during an interview. Another resident's MDS assessment inaccurately reflected the administration of as-needed pain medication, despite records showing no such medication was given during the look-back period. Furthermore, a resident receiving gabapentin, an anticonvulsant medication, was incorrectly coded as not having received it in the MDS assessment. This error was confirmed by the Director of Nursing. These inaccuracies in the MDS assessments highlight a failure in the facility's assessment processes, as the documentation did not accurately reflect the residents' medical treatments and needs during the specified assessment periods.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update and revise the care plans for two residents, leading to deficiencies in their care. For one resident with moderate cognitive impairment and right-sided hemiplegia, the care plan included the application of TED hose and a right-hand thumb splint. However, there was no documented evidence that these interventions were being applied, and observations confirmed the resident was not wearing them. The Director of Nursing acknowledged that these items had been discontinued, but the care plan was not updated to reflect this change. Another resident, who was cognitively intact and had diagnoses including Spina Bifida with hydrocephalus, had a care plan indicating the use of anticoagulant and antidepressant medications. However, there was no evidence that these medications were being administered, and the Nursing Home Administrator confirmed that the resident was not receiving them. The care plan should have been revised to reflect the current medication regimen, but it was not.
Failure to Complete Discharge Summary for Resident
Penalty
Summary
The facility failed to ensure that a discharge summary, including a recapitulation of the resident's stay, was completed for a discharged resident. Physician's orders for the resident, dated January 4, 2025, included instructions for the resident to be discharged home with Home Health services, including physical therapy, occupational therapy, and nursing. A nursing note from the same date indicated that the resident was discharged at 11:15 a.m. with all possessions. However, as of March 13, 2025, there was no documented evidence of a completed discharge summary for the resident. This was confirmed during an interview with the Assistant Director of Nursing on March 13, 2025.
Failure to Follow Physician's Orders for Medication and Bowel Protocols
Penalty
Summary
The facility failed to adhere to physician's orders for medication administration for Resident 27, who was cognitively intact and diagnosed with septicemia. The resident was prescribed Doxycycline for cellulitis and Erythromycin ointment for blepharitis and bacterial conjunctivitis. However, the initial doses of these medications were not administered on time due to delays in pharmacy delivery, and there was no documentation indicating that the courses of these medications were extended to fulfill the prescribed duration. This was confirmed by the Assistant Director of Nursing. Additionally, the facility did not follow the bowel protocol for Residents 9 and 60. Resident 9 had physician's orders for a bowel protocol involving Milk of Magnesia, Bisacodyl suppository, and Fleets enema, which were not administered despite the resident not having bowel movements for several days. Similarly, Resident 60, who was cognitively intact and dependent on staff for daily care, did not receive the prescribed bowel protocol medications over a 10-day period, resulting in severe constipation and a moderate colonic ileus, as confirmed by x-ray results. Interviews with the Director of Nursing confirmed that the bowel protocols were not followed for both residents on the specified dates. The facility's failure to administer medications as ordered and to adhere to bowel protocols resulted in deficiencies in providing appropriate treatment and care according to physician's orders and resident needs.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to provide the necessary pressure ulcer interventions for a resident, leading to a deficiency in care. The resident, who had Alzheimer's disease and non-traumatic brain dysfunction, was dependent on staff for all care and had a non-stageable pressure ulcer on the left heel that was not present upon admission. Despite recommendations from a skin and wound practitioner to turn and reposition the resident every two hours, observations revealed that the resident remained in the same position for over three hours without being repositioned. This lack of adherence to the recommended care plan contributed to the deficiency. Interviews with staff confirmed that the resident was supposed to be turned and repositioned every two hours using pillows or a wedge cushion. However, the facility did not document these repositioning efforts, as it was considered a nursing measure. The Nursing Home Administrator acknowledged that the resident should have been repositioned, indicating a lapse in the implementation of the care plan. This failure to follow through with the recommended interventions for pressure ulcer prevention and management resulted in a deficiency as identified by the surveyors.
Medication Labeling and Security Deficiencies
Penalty
Summary
The facility failed to properly label and secure medications as required by their policies and professional standards. During an observation in the A-wing medication room, a multi-use vial of Aplisol was found open and undated in the refrigerator. The manufacturer's directions specify that vials in use for more than 30 days should be discarded due to potential oxidation and degradation affecting potency. A Licensed Practical Nurse confirmed the vial was not dated and should be discarded. The Nursing Home Administrator also confirmed that the vial should have been dated when opened. Additionally, an observation revealed an unlocked and unattended medication cart in the hallway outside a resident's room. A Registered Nurse admitted to leaving the cart unlocked while she stepped away for a few minutes. The Nursing Home Administrator confirmed that medication carts should be locked when not in use. These findings indicate a failure to adhere to the facility's medication labeling and storage policies, as well as state regulations regarding pharmacy and nursing services.
Failure to Obtain Required Hospice Election Form
Penalty
Summary
The facility failed to ensure that the designated interdisciplinary team member obtained the required hospice election form from the contracted hospice provider for a resident receiving hospice care. An agreement between the facility and the hospice provider, dated April 8, 2024, stipulated that the hospice provider would supply the hospice election form to the facility to facilitate coordination of care. However, as of March 11, 2025, there was no documented evidence in the resident's clinical record or the hospice provider's clinical record that the facility had obtained this form. The resident in question, identified as requiring hospice care due to an end-stage illness, had a care plan dated July 24, 2024, and physician's orders dated July 23, 2024, for admission to hospice. Despite these orders, the hospice election form was missing from the records. This deficiency was confirmed during an interview with a registered nurse on March 11, 2025, who acknowledged the absence of the form in both the resident's and the hospice provider's clinical records. The hospice provider subsequently faxed the form to the facility on the same day.
Repeated Deficiencies in Quality Assurance and Care Compliance
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address recurring deficiencies effectively, as evidenced by repeated citations in multiple surveys. These deficiencies included issues related to personal privacy and confidentiality of records, abuse and neglect policy implementation, accuracy of resident assessments, comprehensive care plans, and care plan revisions. Despite developing plans of correction that involved audits and QAPI committee reviews, the facility did not achieve compliance with the cited regulations. The deficiencies also extended to the quality of care provided, including the treatment and prevention of pressure ulcers, management of accident hazards, and provision of dialysis services. The facility was cited for failing to label and store drugs and biologicals properly, as well as for not maintaining the nutritive value, appearance, preferred temperature, and palatability of food. Infection prevention and control practices were also found lacking, with repeated citations indicating ongoing non-compliance. The repeated nature of these deficiencies across several surveys suggests systemic issues within the facility's quality assurance processes. The QAPI committee's inability to implement effective corrective actions and maintain compliance with regulations highlights significant challenges in the facility's management and oversight of care and services.
Inadequate PPE Use During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper use of Personal Protective Equipment (PPE) during wound care for a resident. The Centers for Disease Control and Prevention (CDC) guidelines and the facility's own policy require the use of Enhanced Barrier Precautions (EBP), including gowns and gloves, during high-contact care activities for residents with chronic wounds or indwelling medical devices. However, during an observation of wound care for a resident with an unstageable pressure ulcer, a Licensed Practical Nurse (LPN) did not don a gown, only wearing gloves, contrary to the established guidelines and facility policy. The resident involved had a history of Alzheimer's disease and non-traumatic brain dysfunction, was dependent on staff for all care, and had a non-stageable pressure ulcer on the left heel. The resident's care plan and physician's orders specified the use of EBP due to the pressure ulcer. Despite these directives, the LPN failed to adhere to the required infection control measures, as confirmed by both the LPN and the Infection Control Preventionist during interviews. This oversight highlights a lapse in the facility's adherence to infection control protocols, potentially compromising the safety and well-being of the resident.
Failure to Complete Required Staff Verifications and Background Checks
Penalty
Summary
The facility failed to adhere to its own policies and procedures designed to prevent abuse, neglect, and theft by not completing necessary background checks and verifications for newly hired nursing staff. Specifically, the facility did not conduct Nurse Aide Registry verifications for two newly hired nurse aides, nor did it verify nursing licenses with the Pennsylvania State Board of Nursing for three newly hired nurses. Additionally, criminal background checks were not completed for four out of five newly hired nursing staff members. The personnel files reviewed revealed that these verifications and checks were not completed even months after the staff members were hired. Interviews with the Nursing Home Administrator confirmed the absence of documented evidence for these required verifications and checks, which should have been completed prior to the hiring dates. This oversight is a violation of the facility's abuse policy, which mandates background, reference, and credential checks for all potential employees.
Confidentiality Breach During Medication Administration
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's personal health information during medication administration. On December 30, 2024, at 9:05 a.m., it was observed that a Licensed Practical Nurse (LPN) left her medication cart unattended, with the computer screen displaying Resident 2's personal health information facing the hallway. This was confirmed during an interview with the LPN at 9:11 a.m., where she acknowledged that she should have secured the computer screen to cover the resident's information when leaving the medication cart. The Director of Nursing also confirmed at 12:31 p.m. that the computer screen should have been covered when unattended, in accordance with the facility's policy on electronic health records dated March 19, 2024, which mandates that residents' health information remain private.
Medication Storage Security Lapse
Penalty
Summary
The facility failed to ensure that medications were stored securely, as evidenced by observations and staff interviews. On December 30, 2024, the medication cart for the A unit long hall was found unlocked and unattended in the hallway, with a medication cup containing various medications left on top of the cart. A Licensed Practical Nurse (LPN) confirmed that she was called away by a nurse aide, leaving the cart unsecured and the medications exposed. The Director of Nursing (DON) also confirmed that the cart should have been locked and the medications should not have been left unattended. Similarly, the medication cart for the C Unit was observed to be unlocked and unattended. An LPN admitted to leaving the cart unsecured while attending to a resident. The DON confirmed that the cart should have been secured when staff were not present. These incidents demonstrate a failure to adhere to the facility's policy on medication administration, which requires that medication carts be kept closed and locked when out of sight of the medication nurse.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of a resident, identified as Resident 5, who was cognitively intact and able to communicate her needs clearly. According to a quarterly Minimum Data Set (MDS) assessment, Resident 5 was independent with her care needs. During an interview, Resident 5 expressed dissatisfaction with the breakfast options provided, stating that she was no longer able to receive yogurt and a banana, which she preferred over eggs. This change occurred after new ownership took over the facility. The Dietary Manager confirmed that she was instructed not to purchase yogurt and bananas unless they were needed for nutritional intervention, not for preference. Resident 5's preference for yogurt and bananas was initially listed on her special request list, but the banana was replaced with canned fruit, and no replacement was provided for the yogurt. The Dietary Manager later received permission to order a case of yogurt and bananas, but this was not the standard practice at the time of the deficiency.
Failure to Provide Nightly Snacks to Residents
Penalty
Summary
The facility failed to provide nightly snacks to residents in accordance with their preferences, as evidenced by a review of facility policies, clinical records, and interviews with residents and staff. The facility's policy dated March 19, 2024, stated that snacks should be provided between meals and at nighttime per resident request. However, resident council meeting minutes from November and December 2024 indicated that residents were not receiving evening snacks as desired. Clinical records for seven of nine residents reviewed showed multiple instances where residents did not receive evening snacks on specific dates in November and December 2024. Interviews with residents revealed dissatisfaction with the availability and consistency of evening snacks. Residents expressed that snacks were not offered regularly, and some residents with specific dietary needs, such as those with diabetes, were not receiving snacks as needed. The Director of Nursing confirmed that residents were requesting evening snacks but were not consistently receiving them, acknowledging that snacks should be provided upon request and offered nightly. This deficiency was noted under 28 Pa. Code 201.29(i) Resident Rights.
Failure to Monitor Catheter Output and Follow Bowel Protocols
Penalty
Summary
The facility failed to monitor intake and output for a resident with an indwelling urinary catheter and did not follow physician's orders related to bowel protocols for another resident. Resident 3, who had a suprapubic catheter due to a neurogenic bladder, was admitted to the facility with a care plan that required monitoring and documenting intake and output. However, a review of the resident's clinical records, including the Medication Administration Record and Treatment Administration Record, showed no evidence that the facility measured and recorded the resident's intake and output as per the care plan. This was confirmed by an interview with the Director of Nursing. Additionally, the facility did not adhere to the bowel protocol for Resident 6, who was cognitively impaired and frequently incontinent of bowel. The resident's physician's orders included administering Milk of Magnesia, Biscolax suppository, and Fleets enema as needed for constipation. Despite the resident not having a bowel movement for extended periods in November and December, there was no documented evidence that the staff administered any of the bowel protocol medications. This was confirmed by an interview with the Assistant Director of Nursing.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to complete accurate comprehensive Minimum Data Set (MDS) assessments for two residents. For one resident, the quarterly MDS assessment inaccurately coded the resident's urinary continence status despite having an indwelling urinary catheter, and incorrectly indicated that the resident received the influenza vaccination when they did not. The Assistant Director of Nursing confirmed these inaccuracies during an interview, acknowledging that the MDS assessment should have reflected the resident's actual condition and vaccination status. For another resident, the MDS assessment inaccurately documented the reason for not receiving the influenza vaccination. The assessment stated that the vaccine was not offered, while the clinical record showed that the resident was offered and declined the vaccine. This discrepancy was confirmed by the Assistant Director of Nursing/Infection Preventionist, who acknowledged that the assessment should have indicated that the resident declined the vaccination.
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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