Sugar Creek Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Franklin, Pennsylvania.
- Location
- 351 Causeway Drive, Franklin, Pennsylvania 16323
- CMS Provider Number
- 395777
- Inspections on file
- 26
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Sugar Creek Care Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to maintain complete and accurate documentation of scheduled showers for four residents with conditions including diabetes, hypertension, Parkinson’s disease, hypothyroidism, and GERD. Review of the shower task records for two consecutive months showed multiple dates where showers were scheduled but had no corresponding documentation that they were provided or completed, despite facility policies requiring detailed recording of bathing care. The DON confirmed that the clinical records were incomplete and that showers were expected to be done as scheduled and documented when finished.
A resident with complex medical conditions received a G-tube flush using a hydrogen peroxide and water mixture, as instructed by a physician via telephone order. However, the physician's order for this one-time intervention was not documented in the clinical record, despite facility policy requiring such documentation. Both the Medical Director and DON confirmed the absence of the order in the record.
The facility did not provide scheduled baths or showers according to resident preferences for several individuals with complex medical needs, as confirmed by documentation, resident interviews, and observations. Additionally, communal dining and group activities were suspended for multiple residents despite slowed infection rates, impacting their psychosocial well-being. Facility leadership confirmed these deficiencies during interviews.
A resident with impaired mobility and incontinence was left in a wheelchair for several hours without being checked, changed, or repositioned, resulting in feces overflowing from two incontinence briefs onto clothing and skin, and severe skin redness. Staff and the NHA confirmed that this did not follow facility policy and failed to maintain the resident's dignity.
Two residents with significant mobility impairments were not repositioned or provided with timely incontinence care as required by their care plans and facility policy. One resident remained in a wheelchair for over seven hours without being checked or changed, resulting in severe skin redness and soiling, while another sat in a recliner for hours without a pressure-relieving cushion, leading to skin breakdown. Staff confirmed these lapses and acknowledged that facility protocols were not followed.
A resident reported that meals were often served cold, and resident council minutes documented complaints about cold food and delayed tray delivery. Observations showed that food left the kitchen at safe temperatures but sat in the hallway before being served, resulting in a test tray being unpalatable and below acceptable temperature standards. The Dietary Manager confirmed these findings.
Staff failed to follow infection control protocols during incontinence care for two residents by placing soiled briefs and clothing containing urine and feces directly on the floor, then walking across the contaminated area without sanitizing it. Facility policy requires immediate disposal of such items in designated containers, and the DON confirmed this was not followed.
A resident with a history of GERD, diabetes, and hypertension had conflicting documentation regarding life-sustaining treatment preferences, with a POLST indicating Full Code and physician orders indicating DNR. An LPN confirmed that the most recent POLST and nurse report sheet did not match the physician's orders, resulting in inconsistency between the resident's advance directives and medical orders.
An LPN administered G-Tube medications to a resident without closing the door or privacy curtain, leaving the resident exposed and visible from the hallway. The LPN confirmed the lack of privacy during the procedure.
The facility did not provide required written bed-hold policy notifications to several residents or their representatives at the time of hospital transfer, failed to communicate necessary clinical information to a receiving healthcare provider during a transfer, and did not complete or provide discharge summaries for multiple residents upon discharge. These deficiencies were confirmed through record review and staff interviews.
A resident's care plan was not updated to reflect changes in their condition, including the removal of a PICC line, discontinuation of IV antibiotics, and resolution of a C-Diff infection. Despite a care plan meeting and changes in the resident's clinical status, the care plan continued to list outdated problems and interventions, as confirmed by the DON.
Surveyors found that open insulin and Victoza pens on two medication carts were not dated, and expired loratadine tablets were not discarded as required. An LPN also left a medication cart unlocked and out of view while administering medications to a resident, contrary to facility policy. These actions resulted in deficiencies related to medication labeling, storage, and security.
A resident with multiple medical conditions had all lower teeth extracted and was left without lower dentures for nearly a year, despite repeated documentation by clinical staff and physician orders to follow up with dental services. The resident experienced ongoing eating difficulties and dissatisfaction, and interviews confirmed the delay in receiving dentures.
A resident with significant respiratory conditions returned from the hospital, but physician orders were not entered into PCC for about 18 hours, resulting in delayed medication administration and lack of breathing treatments during a documented episode of respiratory distress. The DON confirmed that the RN did not fulfill the responsibility to enter orders upon admission.
A resident with significant respiratory diagnoses returned from the hospital, but their medication orders were not entered into the electronic health record for approximately 18 hours. As a result, scheduled and PRN respiratory medications were not administered, and the resident experienced respiratory distress with low oxygen saturation. The DON confirmed the delay in entering orders led to a delay in treatment.
Two residents with PICC lines did not have complete documentation of their scheduled dressing changes, as required by facility policy and physician orders. Treatment records lacked evidence of weekly dressing changes for both individuals over several weeks, and this was confirmed by the Regional Clinical Director.
The facility did not ensure that the assigned IP had completed the required specialized infection prevention and control training, as no certificate of completion could be provided for the RN who covered the IP role during the relevant period.
A resident with chronic pain and rheumatoid arthritis did not receive multiple doses of prescribed Oxycodone due to a nursing order entry error, as confirmed by the NHA. The medication was not administered as ordered by the physician.
A resident with multiple diagnoses, including depression and Parkinson's disease, exhibited suicidal ideation and was placed on frequent safety checks. Despite a psychiatric evaluation recommending continued behavioral health services, the facility did not update the resident's comprehensive care plan to address these needs, as confirmed by facility leadership.
The facility did not have an RN available during an overnight shift, resulting in a resident missing prescribed IV antibiotics through a PICC line and two residents receiving post-fall assessments from an LPN instead of an RN, as required by state regulations. Staffing records and staff interviews confirmed the absence of an RN, leading to noncompliance with nursing service and assessment requirements.
A resident with depression, Parkinson's disease, and a history of suicidal ideation did not receive the recommended ongoing behavioral health services after a psychiatric evaluation, despite documentation of self-harm risk and a facility policy requiring such services.
The facility did not meet the required NA staffing ratios during the evening shift on two days. With a census of 97 residents, 7.96 NAs worked instead of the required 8.82, and with 95 residents, 8.13 NAs worked instead of 8.64. This was confirmed by the Nursing Home Administrator.
The facility did not meet the required minimum of 3.2 hours of direct nursing care per resident per day on four occasions. The nursing staffing documents revealed that the care hours were below the required minimum, with recorded hours of 3.19, 3.14, 3.05, and 3.03 PPD. This was confirmed by the Nursing Home Administrator.
The facility did not meet the required nurse aide (NA) staffing ratios on several occasions, failing to provide the mandated number of NAs per residents during day, evening, and overnight shifts. The Nursing Home Administrator confirmed the shortfall in staffing, which occurred over multiple days within the review period.
The facility did not meet the required 3.2 hours of direct nursing care per resident per day for ten days, with recorded hours ranging from 3.07 to 3.17 PPD. This was confirmed by the Nursing Home Administrator.
Two residents did not receive their prescribed ABHR gel due to the facility's failure to ensure timely delivery from the pharmacy. One resident, with a psychotic disorder and anxiety, missed multiple doses over several days, while another resident with bipolar disorder and anxiety missed doses over two days. The Nursing Home Administrator confirmed the medication was not available and should have been administered as ordered.
The facility failed to store food safely in two unit freezers, where ice packs used on residents' bodies were found next to food items like popsicles and ice cream. Staff, including LPNs and the DON, confirmed this improper storage practice, which violated the facility's food safety policies.
A facility failed to ensure proper foley catheter care for a resident, as the catheter was not emptied and the amount was not documented every shift per physician's orders. Despite the facility's policy requiring observation and documentation of urine levels, records showed non-compliance on multiple occasions. The DON confirmed the deficiency.
A facility failed to track and safely dispose of controlled medications for a resident, as required by policy and regulations. The resident's record lacked evidence of a controlled substance tracking log for Morphine, Ativan, and Diazepam, and there was no documentation of the destruction or return of these medications. The Director of Nursing confirmed the deficiency, which violates state regulations.
A resident with diabetes received Humalog insulin despite having blood sugar levels below the prescribed threshold, contrary to physician orders. The facility's policy requires verification of medication administration, but staff failed to hold the insulin as directed, leading to significant medication errors.
The facility failed to store Schedule II-V medications, such as Lorazepam, in a separately locked, permanently affixed compartment, as observed in the West medication room. Additionally, an open vial of Tubersol lacked an open date, preventing staff from determining the discard date. These actions violate the facility's policies on medication storage and labeling.
Incomplete Documentation of Scheduled Showers in Clinical Records
Penalty
Summary
Surveyors identified a deficiency in the facility’s documentation of showers and hygiene care, as required by its own policies and state regulations. The facility’s Bath, Shower/Tub policy required documentation of the date and time a shower or tub bath was performed and the name and title of the staff who assisted, and the ADL policy required appropriate support and assistance with hygiene, including bathing. Review of the electronic shower task documentation for four residents showed multiple dates on which showers were scheduled but lacked any documentation that the showers were provided or completed. For one resident with diabetes and hypothyroidism, the shower task records for February and March 2026 lacked documentation of showers on six specified dates. For a second resident with diabetes and hypertension, the shower task records for February and March 2026 lacked documentation of showers on six specified dates. For a third resident with hypertension and GERD, the shower task records for February and March 2026 lacked documentation of showers on nine specified dates. For a fourth resident with Parkinson’s disease, overactive bladder, and diabetes, the February 2026 shower task records lacked documentation of showers on seven specified dates. During an interview, the DON confirmed that the clinical records for all four residents did not contain complete documentation regarding showers and acknowledged that showers should be completed as scheduled in the task system and documented when done.
Incomplete Documentation of Physician's Order for G-Tube Flush
Penalty
Summary
The facility failed to maintain complete and accurate documentation regarding physician's orders for a gastrostomy tube (G-tube) flush for a resident with significant medical needs. Specifically, the clinical record for a resident with spastic quadriplegic cerebral palsy, intellectual disabilities, and diabetes did not contain a physician's order for a one-time G-tube flush using a 50/50 mixture of hydrogen peroxide and hot water, which was performed to clear a clogged tube. Nurse's notes documented that the flush was completed as instructed, but there was no corresponding physician's order in the resident's clinical record for this intervention on the date it was performed. During interviews, the Medical Director confirmed that a verbal order for the G-tube flush had been given and that the practice was considered safe. However, the Director of Nursing acknowledged that the resident's clinical record lacked evidence of the physician's order for the procedure. This deficiency was identified through review of facility policy, clinical records, and staff interviews, and it was determined that the facility did not adhere to its own policy requiring all telephone orders to be recorded in the resident's clinical record.
Failure to Provide Resident-Preferred Bathing and Maintain Psychosocial Well-Being
Penalty
Summary
The facility failed to honor resident preferences for bathing and did not provide scheduled baths or showers for four residents over a specified period. Documentation showed that these residents, who had various medical conditions such as spastic hemiplegia, depression, chronic kidney disease, and anoxic brain damage, were scheduled for baths or showers on specific days but did not receive them as planned. Interviews with these residents confirmed that they did not receive their preferred number of baths or showers, and observations noted that some had greasy hair, indicating a lack of personal hygiene care. The Nursing Home Administrator confirmed that showers were not provided according to the residents' preferences and schedules during the review period. Additionally, the facility did not support residents' psychosocial well-being by suspending communal dining and group activities for six residents. These residents expressed that they enjoyed eating meals in the dining room and participating in group activities, but these opportunities were not available due to ongoing COVID-19 precautions. Despite the facility's policy requiring daily review of outbreak status to lift restrictions as soon as possible, records indicated that the spread of infection had slowed, yet communal activities remained suspended. Observations during the survey period showed residents engaging in therapy and interacting with staff, but there were no observations of residents participating in individual or socially distanced activities, nor were meals served in a socially distanced manner in the dining room. Facility leadership confirmed that communal dining and group activities were not occurring at the time of the survey due to COVID-19 in the building.
Failure to Maintain Resident Dignity and Provide Timely Incontinence Care
Penalty
Summary
The facility failed to maintain resident dignity and provide appropriate incontinence care for one resident with spastic hemiplegia, depression, and anxiety, who required assistance with personal care. According to the resident's care plan, staff were to clean the peri-area with each incontinence episode and provide incontinence products to promote skin integrity and dignity. However, observations revealed that the resident remained in a wheelchair from 6:30 a.m. until 1:45 p.m. without being checked, changed, or repositioned, despite facility policy requiring checks every two hours. At 1:45 p.m., the resident was found with two incontinence briefs filled with feces overflowing onto clothing and skin, and with extremely reddened peri-area and buttocks. Staff confirmed that the resident had not been checked or changed as required and that the use of two briefs was not in accordance with facility protocol. The Nursing Home Administrator also acknowledged that placing two briefs on a resident was not facility policy and that the resident's dignity was not maintained. The failure to provide timely incontinence care and proper use of incontinence products resulted in soiled clothing, skin irritation, and a lack of dignity for the resident.
Failure to Provide Timely Repositioning, Pressure Relief, and Incontinence Care
Penalty
Summary
The facility failed to provide care in accordance with professional standards for repositioning, pressure relief, and incontinence care for two residents. One resident with spastic hemiplegia, limited mobility, and a history of skin integrity issues was observed sitting in a wheelchair for over seven hours without being repositioned or checked for incontinence. This resident was found with two incontinence briefs filled with feces overflowing onto their clothing and skin, and exhibited extremely reddened skin in the peri area and buttocks. Staff confirmed that the resident should have been checked and changed every two hours and that the use of two briefs was not in accordance with facility protocol. Another resident with Parkinson's disease and peripheral vascular disease, who was dependent for mobility and had existing wounds on the right buttock and hip, was observed sitting in a recliner without a pressure-relieving cushion for several hours. The care plan for this resident included the use of a pressure-relieving cushion and a turning and repositioning schedule, but these interventions were not implemented. Upon incontinence care, the resident was found to have an open area on the right buttock and redness on both buttocks. Interviews with staff, including a nursing assistant, LPN, DON, and regional clinical director, confirmed that residents unable to reposition themselves should be repositioned by staff, pressure-relieving devices should be in place, and incontinence care should be provided in a timely manner. The facility's own policies on repositioning, perineal care, and activities of daily living were not followed, resulting in the deficiencies observed for both residents.
Failure to Serve Palatable Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide food that was palatable and at an appetizing temperature, as required by its own policy and regulatory standards. Facility policy stated that food should be prepared to conserve nutritive value, flavor, and appearance, and served as close to tray service as possible to ensure acceptable temperatures. Resident council and food committee minutes documented complaints about cold food and significant delays in meal tray delivery, with reports of trays being served up to 45 minutes late. During an interview, a resident reported that their food was often served cold. On the day of observation, kitchen temperature logs showed that food items were at appropriate temperatures when leaving the kitchen. However, direct observation revealed that meal carts sat in the hallway before trays were distributed, resulting in a significant delay. When a test tray was checked at the end of the delivery process, food temperatures had dropped well below the initial readings, and the items were found to be unpalatable due to being cool. The Dietary Manager confirmed the unacceptable temperatures and poor palatability at the time of tray testing.
Failure to Prevent Cross-Contamination During Incontinence Care
Penalty
Summary
Facility staff failed to follow infection prevention and control protocols during incontinence care for two residents. During observed care, nursing assistants and an LPN removed soiled briefs and pants containing urine and feces and placed them directly onto the floor, contrary to facility policy which requires immediate disposal of such items into designated containers. After completing care, staff picked up the soiled items from the floor and disposed of them, but walked across the area where the contaminated items had been lying without sanitizing the floor. Staff interviews confirmed that the soiled briefs were placed on the floor and that the area was not sanitized afterward. The Director of Nursing acknowledged that this practice was not in accordance with facility policy, which prohibits placing soiled briefs on the floor and requires their disposal in designated containers. The actions observed created a potential for cross-contamination, as outlined in the facility's infection control policies.
Inconsistent Advance Directive and POLST Documentation
Penalty
Summary
The facility failed to ensure that a resident's physician orders and Pennsylvania Order for Life Sustaining Treatment (POLST) were consistent, as required by facility policy and state regulations. The resident in question had multiple documents in their clinical record, including a Living Will indicating Do Not Resuscitate (DNR) status and a POLST indicating Full Code status. Physician orders in the record were conflicting, with some indicating Full Code and others indicating DNR. Progress notes from both social services and nursing documented changes in the resident's code status, but the most recent POLST available in the unit binder and on the nurse report sheet still indicated Full Code, while physician orders indicated DNR. Interviews with an LPN confirmed that the documentation in the binder and on the nurse report sheet did not match the most current physician orders. The LPN acknowledged that the most recent POLST, signed by the resident and physician, indicated Full Code, while the physician's orders indicated DNR. This inconsistency between the resident's advance directives, POLST, and physician orders resulted in a failure to honor the resident's documented treatment preferences as required by policy.
Failure to Maintain Resident Privacy During Medication Administration
Penalty
Summary
The facility failed to maintain resident privacy during medication administration for one resident. During an observation, an LPN administered medications through a G-Tube while the resident's nightgown was pulled up, exposing the resident's legs, incontinence care product, and stomach. The resident was visible from the hallway because the door and privacy curtain were not closed. The LPN confirmed during an interview that the resident was exposed and acknowledged that the door and/or privacy curtain should have been closed to maintain privacy during the procedure.
Failure to Provide Bed-Hold Policy Notification and Discharge Summaries
Penalty
Summary
The facility failed to provide required written notification of its bed-hold policy, including the duration a bed can be held during a leave of absence and the associated daily cost, to residents and/or their representatives at the time of transfer to a hospital. This deficiency was identified for multiple residents whose clinical records lacked evidence of such notification upon their transfer. Additionally, the facility did not ensure that necessary clinical information was communicated to the receiving healthcare provider during the transfer process for at least one resident. These failures were confirmed by the Director of Nursing, who acknowledged the absence of documentation in the affected residents' records. Furthermore, the facility did not complete or provide discharge summaries for several residents who were discharged, including one resident discharged to home. The discharge summaries, which should include a recapitulation of the resident's stay and a final summary of their status, were missing from the clinical records and were not provided to the residents or receiving facilities as required by facility policy. The deficiencies were identified through review of facility policies, clinical records, and staff interviews.
Failure to Update Resident Care Plan to Reflect Current Status
Penalty
Summary
The facility failed to review and revise the care plan for a resident to reflect the resident's current condition and care needs. The resident was admitted with diagnoses including cellulitis of the left lower leg, diabetes, and high blood pressure. The care plan included problems such as being on enhanced barrier precautions due to a PICC line and wounds, and receiving IV antibiotics for cellulitis. However, the clinical record showed that the PICC line was dislodged and removed, and the last dose of IV antibiotics was administered on a specific date, but the care plan was not updated to reflect these changes. Additionally, the care plan included a focus on C-Difficile infection, but the clinical record indicated that the resident's C-diff results were negative and isolation was discontinued. Despite a care plan meeting being held, the Director of Nursing confirmed that the care plans were not updated to accurately reflect the resident's current status and care needs. This failure was identified through review of facility policy, clinical records, and staff interview.
Medication Labeling, Storage, and Security Deficiencies
Penalty
Summary
Surveyors identified that the facility failed to ensure proper labeling and timely disposal of medications, as well as secure storage of medication carts. During review of two medication carts, it was observed that open pens of Aspart Insulin and Victoza did not have dates indicating when they were opened, making it impossible for staff to determine appropriate discard dates. Additionally, an open bottle of loratadine tablets was found to be past its expiration date. Staff interviews confirmed that these medications should have been discarded and that the required labeling and dating procedures were not followed according to facility policy and manufacturer guidelines. Further observations revealed that an LPN prepared medications from a cart parked in the hallway and then entered a resident's room to administer the medications, leaving the cart unlocked and out of view. The LPN confirmed that the cart was left unsecured while out of sight, which is contrary to facility policy requiring medication carts to be locked when not in direct view of the administering nurse. These findings demonstrate lapses in medication management and security protocols as required by facility policy and state regulations.
Failure to Provide Timely Dental Services and Dentures
Penalty
Summary
The facility failed to provide timely dental services for one resident, as required by its own policy and state regulations. The resident, who had diagnoses including major depressive disorder, cerebral infarction, and hypothyroidism, had all remaining lower teeth extracted and was left without lower dentures for nearly a year. Clinical records showed repeated documentation by the speech therapist and physician regarding the resident's ongoing difficulties with eating and dissatisfaction due to the absence of lower dentures. Despite multiple physician orders to follow up with dental services, the resident continued to be without lower dentures for an extended period. Resident council minutes further confirmed the resident's ongoing concerns and the delay in receiving dentures, with documentation that the dental provider had reduced the frequency of visits, potentially contributing to the delay. Interviews with the resident and the Director of Nursing confirmed that the resident had not received lower dentures in a timely manner, resulting in ongoing eating difficulties and dissatisfaction with quality of life.
Failure to Timely Enter Physician Orders Delays Medication Administration
Penalty
Summary
The facility failed to follow nursing standards of practice by not ensuring that physician orders were entered into the Point Click Care (PCC) system upon a resident's admission, resulting in a delay in medication availability and administration. Specifically, after returning from the hospital, a resident with diagnoses including idiopathic pulmonary fibrosis, sleep apnea, and acute and chronic respiratory failure did not have their medication orders entered into PCC for approximately 18 hours. This delay prevented floor nurses from being alerted to scheduled and PRN medications that were due, and the resident did not receive prescribed breathing treatments during this period. Clinical records indicated that the resident experienced shortness of breath and a low pulse oximetry reading of 76% on room air, well below the desired threshold. Nurses had to contact the physician for treatment orders because the necessary medications were not available in the system. The Director of Nursing confirmed that it was the RN's responsibility to enter orders into PCC upon admission and acknowledged the failure to do so in this instance.
Delay in Entering Physician Orders Led to Missed Respiratory Treatments
Penalty
Summary
The facility failed to enter a physician's medication orders in a timely manner for a resident who returned from the hospital. According to facility policy, medications are to be administered safely, timely, and as prescribed. However, after the resident was readmitted with diagnoses including idiopathic pulmonary fibrosis, sleep apnea, and acute and chronic respiratory failure, their medication orders were not entered into the electronic health record system (PCC) until approximately 18 hours after their return. This delay meant that floor nurses were not alerted to scheduled or PRN medications that needed to be administered. During this period, the resident experienced an episode of respiratory distress, with a documented oxygen saturation of 76% on room air, which is below the desired level. The resident reported not having received any breathing treatments since returning from the hospital. The necessary medications, including Albuterol and Budesonide, were not available for administration during the episode because the orders had not been entered. The DON confirmed that the delay in entering the physician's orders resulted in a delay in treatment for the resident.
Incomplete Documentation of PICC Line Dressing Changes
Penalty
Summary
The facility failed to maintain complete and accurate documentation regarding Peripherally Inserted Central Catheter (PICC) dressing changes for two residents. Facility policy required PICC line dressings to be changed at least every seven days or sooner if the dressing became damp, loosened, or soiled. Physician orders for both residents specified weekly PICC line dressing changes. However, review of the treatment administration records showed missing documentation for several scheduled dressing changes for both residents over multiple weeks. One resident, admitted with diagnoses including hypertension, cellulitis, and diabetes, had no documented evidence of PICC line dressing changes on several specified dates in May and June. Another resident, admitted with osteomyelitis, bacteremia, and gastroesophageal reflux disease, also lacked documentation of PICC line dressing changes on multiple scheduled dates in April and May. The Regional Clinical Director confirmed that the treatment records for both residents were incomplete and that dressing changes should be performed and documented as ordered by the physician.
Infection Preventionist Lacked Required Specialized Training
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) was qualified with specialized training in infection prevention and control during the period from 4/10/25 to 5/25/25. Review of the facility's policy indicated that the IP must have specialized IPC training beyond initial professional training, with evidence provided by a certificate of completion. Registered Nurse (RN) Employee E2 served as the facility's IP from 4/16/25 to 5/21/25, but the facility was unable to produce documentation or a certificate confirming that RN Employee E2 had completed the required specialized IP training. Interviews with the Regional Clinical Director and the Nursing Home Administrator confirmed that there was no evidence of the required training for RN Employee E2 during the time they covered the IP position.
Failure to Administer Physician-Ordered Pain Medication
Penalty
Summary
The facility failed to ensure that medication was obtained and administered as ordered by the physician for one resident. According to the clinical record, the resident, who had diagnoses including rheumatoid arthritis and chronic pain, had a physician's order for Oxycodone 5 mg every six hours while awake for pain. Review of the Medication Administration Record showed that the resident did not receive Oxycodone for three doses on two consecutive days and missed an additional dose on a third day. The Nursing Home Administrator confirmed that the medication was not given as ordered due to nursing staff entering the order incorrectly, resulting in the resident not receiving the prescribed pain medication.
Failure to Update Care Plan for Behavioral Health Needs
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for one resident to reflect current care needs and services. According to facility policy, care plans must be updated as residents' conditions change and should be reviewed by an interdisciplinary team. However, documentation revealed that a resident with multiple diagnoses, including muscle wasting, depression, diabetic foot ulcer, and Parkinson's disease, exhibited significant behavioral health concerns, such as wrapping a call bell cord around their neck and expressing suicidal ideation. Progress notes indicated the resident was placed on every 15-minute safety checks, and a psychiatric evaluation recommended ongoing behavioral health services. Despite these documented changes and recommendations, there was no evidence that the facility developed or implemented a comprehensive care plan addressing the resident's behavioral health interventions and services. This deficiency was confirmed by both the Regional Clinical Consultant and the Nursing Home Administrator during an interview, who acknowledged the failure to update the care plan in response to the resident's current needs.
Failure to Provide Sufficient RN Staffing for Medication Administration and Resident Assessments
Penalty
Summary
The facility failed to provide sufficient nursing staff with the appropriate skill sets to meet the needs of residents, specifically by not having a Registered Nurse (RN) available during an overnight shift. This resulted in missed administration of prescribed intravenous antibiotics through a PICC line for a resident with complex medical needs, including a partial foot amputation, wound dehiscence, bloodstream infection, and gangrene. The resident's medication administration record showed that two doses of antibiotics were not given as ordered because there was no RN present to administer medications via the PICC line, as required by state regulations. Additionally, two residents who experienced unwitnessed falls during the same overnight shift did not receive post-fall written assessments by an RN, but rather by an LPN, contrary to state requirements. Staffing records confirmed that no RN was scheduled for the shift in question, and interviews with staff and administration corroborated that the RN who had been working was sent home after a 16-hour shift, and the DON was unable to stay to provide coverage. These actions led to the facility's failure to comply with regulations regarding nursing services and resident assessments.
Failure to Provide Recommended Behavioral Health Services After Suicidal Ideation
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of depression and a history of expressing suicidal ideation received the recommended behavioral health services. The resident, who had multiple diagnoses including muscle wasting, depression, diabetic foot ulcer, and Parkinson's disease, was admitted on 12/14/24. Documentation in the clinical record showed that the resident had wrapped a call bell cord around their neck and expressed a desire not to live. Following this incident, there were notations indicating that the resident was placed on every 15-minute checks for safety. A psychiatric evaluation conducted on 3/04/25 recommended that the resident continue with behavioral health services. However, further review of the clinical record did not show evidence that these recommended services were provided after the evaluation. During an interview, the Nursing Home Administrator confirmed that there was no documentation indicating the continuation of behavioral health services for the resident, despite the recommendation and the resident's ongoing risk factors.
Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required Nurse Aide (NA) staffing ratios during the evening shift on two specific days, February 2 and February 4, 2025. On February 2, with a census of 97 residents, the facility employed 7.96 NAs, falling short of the required 8.82 NAs. Similarly, on February 4, with a census of 95 residents, 8.13 NAs were employed, whereas 8.64 were required. This deficiency was confirmed by the Nursing Home Administrator during a telephone interview on February 6, 2025, acknowledging the failure to meet the minimum NA ratios on the specified days and shifts.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. The facility cannot correct that the nurse aide staffing ratio was not met on 2/2 and 2/4/25. 2. System changes will be put into place to ensure minimum requirements to be put into place will include: 3. Facility currently has multiple nursing assistant staff members in the onboarding process to start employment at the facility. 4. All nursing assistant positions are actively posted in recruitment. 5. Bonuses are offered on an as needed basis to nursing assistants. 6. Staff are mandated as appropriate. 7. Call offs will continue to be monitored, and disciplines will be issued, as appropriate. 8. When call offs occur, all available staff members will be called to ask if they will fill the vacancy to ensure the appropriate staffing levels. 9. On a daily basis, the Director of Nursing and/or Administrator reviews the ability to take admissions based on the staffing numbers; if not meeting staffing numbers, admissions are held for the day. 10. All RN's (Registered Nurse's) and staffing coordinator will be educated on staffing ratios. Education will be done by the Director of Nursing or designee. 11. RN supervisors will be educated that they will need to mandate staff for call off to make sure facility does not fall below staffing ratios per DOH (Department of Health) regulations. 12. Daily meetings will be held, with Director of Nursing, admission coordinator, staffing coordinator, and Administrator to review schedule with ratios. 13. Nursing supervisors will monitor on weekends. If the facility is projected to not meet staffing ratios, the nursing supervisor/or designee will call off duty facility staff, will notify Director of Nursing, and will utilize pick-up bonuses. DON (Director of Nursing) or designee will monitor staffing ratios/PPD by reviewing the current working schedule and assignment sheets prior to the day and after the day is complete to ensure compliance daily x 10 days then weekly x 6 weeks, then Q (once) monthly x2 to ensure compliance. This will be reviewed at the Quarterly QAPI (Quality Assurance/Performance Improvement) meetings.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day for four out of eleven days reviewed. Specifically, on the dates of 1/26/25, 2/01/25, 2/02/25, and 2/04/25, the facility's nursing staffing documents showed that the general nursing care hours were below the required minimum, with recorded hours of 3.19, 3.14, 3.05, and 3.03 PPD, respectively. This deficiency was confirmed during a telephone interview with the Nursing Home Administrator on 2/06/25, who acknowledged that the facility did not meet the required nursing care hours on the specified dates.
Plan Of Correction
1. The facility cannot correct that the State required PPD (per patient day) minimum hours of 3.20 was not met on 1/26, 2/1, 2/2, and 2/4/25. 2. Nursing supervisors will be re-educated regarding the daily PPD by the Director of Nursing/or Designee. 3. Daily meetings will be held to review the schedule with PPD. 4. Nursing supervisors will monitor on weekends. If the facility is projected to not meet staffing PPD, the scheduler/or designee will call off duty facility staff, notify the Director of Nursing, and will utilize pick-up bonuses. 5. All nursing positions are actively posted in recruitment. 6. Call offs will continue to be monitored, and disciplines will be issued, as appropriate. 7. On a daily basis, the facility reviews the ability to take admissions based on the staffing numbers. DON or designee will monitor staffing PPD by reviewing the current working schedule and assignment sheets prior to the day and after the day is complete to ensure compliance daily x 10 days, then weekly x 6 weeks, then Q monthly x2 to ensure compliance. This will be reviewed at the Quarterly QAPI (Quality Assurance/Performance Improvement) meetings.
Facility Fails to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) staffing ratios on multiple occasions during the review period from December 18, 2024, to December 31, 2024. Specifically, the facility did not have enough NAs on the day shift for four days, the evening shift for four days, and the overnight shift for one day. The required ratio of one NA per 10 residents during the day, one NA per 11 residents during the evening, and one NA per 15 residents overnight was not met. For instance, on December 19, 2024, with a census of 96 residents, only 9.43 NAs worked when 9.60 were required for the day shift. The deficiency was confirmed during a telephone interview with the Nursing Home Administrator on January 3, 2025, who acknowledged that the facility did not meet the minimum NA ratios on the specified days and shifts. The report provides detailed staffing numbers for each day where the facility fell short of the required NA ratios, highlighting the specific shortages in staffing that led to the deficiency.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. The facility cannot correct that the nurse aide staffing ratio was not met on 12/19, 12/22, 12/24, 12/25, 12/26, 12/28, and 12/29/24. 2. System changes will be put into place to ensure minimum requirements to be put into place will include: 3. Facility currently has multiple nursing staff members in the onboarding process to start employment at the facility. 4. All nursing positions are actively posted in recruitment. 5. Holding open interview day. 6. Bonuses are offered on an as needed basis. 7. Staff are mandated as appropriate. 8. Call offs will continue to be monitored, and disciplines will be issued, as appropriate. 9. When call offs occur, all available staff members will be called to ask if they will fill the vacancy to ensure the appropriate staffing levels. 10. On a daily basis, the facility reviews the ability to take admissions based on the staffing numbers. 11. All RN's and staffing coordinator will be educated on staffing ratios. 12. RN supervisors will be educated that they will need to mandate staff for call off to make sure facility does not fall below staffing ratios per DOH regulations. 13. Daily meetings will be held to review schedule with ratios. 14. Nursing supervisors will monitor on weekends. If the facility is projected to not meet staffing ratios the nursing supervisor/or designee will call off duty facility staff, will notify Director of Nursing and will utilize pick-up bonuses. DON (Director of Nursing) or designee will monitor staffing ratios by reviewing the current working schedule and assignment sheets prior to the day and after the day is complete to ensure compliance daily x 10 days then weekly x 6 weeks, then Q monthly x2 to ensure compliance. The DON (Director of Nursing), NHA (Nursing Home Administrator), and staffing coordinator will be in the daily meetings to monitor staffing ratios. This will be reviewed at the Quarterly QAPI meetings.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day for ten out of fourteen days reviewed. Specifically, on the dates of 12/19/24, 12/21/24, 12/22/24, 12/23/24, 12/24/24, 12/25/24, 12/26/24, 12/28/24, 12/29/24, and 12/31/24, the facility's nursing staffing documents showed that the provided hours of care were below the required minimum. The recorded hours ranged from 3.07 to 3.17 hours per patient day (PPD), falling short of the mandated 3.2 PPD. This deficiency was confirmed by the Nursing Home Administrator during a telephone interview on 1/03/25.
Plan Of Correction
1. The facility cannot correct that the State required PPD (per patient day) minimum hours of 3.20 was not met on 12/19, 12/21, 12/22, 12/23, 12/24, 12/25, 12/26, 12/28, 12/29, and 12/31/24. 2. Nursing supervisors will be re-educated regarding the daily PPD by the Director of Nursing/or Designee. 3. Daily meetings will be held to review the schedule with PPD. 4. Nursing supervisors will monitor on weekends. If the facility is projected to not meet staffing PPD, the scheduler/or designee will call off duty facility staff, notify the Director of Nursing, and will utilize pick-up bonuses. 5. All nursing positions are actively posted in recruitment. 6. Call offs will continue to be monitored, and disciplines will be issued, as appropriate. 7. On a daily basis, the facility reviews the ability to take admissions based on the staffing numbers. DON or designee will monitor PPD by reviewing the current working schedule and assignment sheets prior to the day and after the day is complete to ensure compliance daily x 10 days, then weekly x 6 weeks, then Q monthly x2 to ensure compliance. The DON (Director of Nursing), NHA (Nursing Home Administrator), and staffing coordinator will be in the daily meetings to monitor PPD. This will be reviewed at the Quarterly QAPI meetings.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that medication was obtained and provided as ordered by the physician for two residents. Resident R1, diagnosed with a psychotic disorder with delusions and anxiety, had a physician's order for ABHR gel to be applied topically four times a day. However, the medication was not administered for multiple doses from December 16 to December 22, 2024, due to the medication not being available and awaiting delivery from the pharmacy. Nursing documentation confirmed the unavailability of the medication during this period. Similarly, Resident R2, who has bipolar disorder and gastroesophageal reflux disease, also had a physician's order for ABHR gel to be applied four times a day for anxiety. The medication was not administered for several doses on December 26 and December 27, 2024, due to the same issue of awaiting delivery from the pharmacy. The Nursing Home Administrator confirmed that both residents did not receive their medication as ordered, acknowledging the failure in ensuring the medication was available and administered per physician orders.
Improper Storage of Ice Packs with Food in Unit Freezers
Penalty
Summary
The facility failed to ensure that food was stored in accordance with food safety standards in two unit refrigerators, specifically the East Unit and [NAME] Unit. Observations revealed that ice packs used for treatments on residents' bodies were stored next to food items such as popsicles and ice cream in the freezers of these units. This practice is against the facility's policy, which mandates the safe and sanitary storage, handling, and consumption of all food, including those brought in by family and visitors. Interviews conducted with staff members, including two Licensed Practical Nurses (LPNs) and the Director of Nursing, confirmed the inappropriate storage of ice packs with food items. The staff acknowledged that ice packs used on residents' bodies should not be stored in the same freezer as food. This deficiency was identified during a review of the facility's policies, observations, and staff interviews, highlighting a failure to adhere to professional standards for food service safety.
Failure to Document Foley Catheter Care
Penalty
Summary
The facility failed to ensure proper care for a resident with a foley catheter, as the catheter was not emptied and the amount was not documented every shift according to physician's orders. The facility's policy on urinary catheter care, dated 5/1/24, requires observation of urine levels and documentation of input and output. However, the clinical records for a resident with diagnoses including urine retention, heart failure, and hypertension showed that the catheter was not emptied and documented on multiple occasions in August and September 2024. The Director of Nursing confirmed the lack of evidence in the clinical record for compliance with the physician's orders.
Failure to Track and Dispose of Controlled Medications
Penalty
Summary
The facility failed to implement procedures for the accurate tracking and safe disposition of controlled medications for a resident, identified as CR87, whose closed record was reviewed. The facility's policy, dated 5/1/24, requires that Schedule II, III, and IV controlled substances be disposed of according to state and federal guidelines, with a detailed medication disposition record. However, the review of Resident CR87's clinical record revealed a lack of evidence of a controlled substance tracking log for medications including Morphine, Ativan, and Diazepam. These medications are used for pain management, anxiety, and seizures, respectively. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the absence of documentation for the tracking and disposition of the controlled substances in Resident CR87's record. The record did not show evidence of the destruction or return to the pharmacy of the remaining doses of these medications. This failure to maintain proper records and follow procedures for controlled substances is a violation of the facility's policy and state regulations, as outlined in 28 Pa. Code 211.9(a) and 28 Pa. Code 211.12(d)(3).
Failure to Adhere to Insulin Administration Orders
Penalty
Summary
The facility failed to ensure that it was free from significant medication errors for one resident, identified as Resident R75. The facility's policy on administering medications requires that medications be administered in accordance with prescriber orders, including verifying the right resident, medication, dosage, time, and method of administration. However, a review of Resident R75's clinical records and medication administration records (MAR) revealed that staff did not adhere to the physician's order to hold Humalog insulin when the resident's blood sugar (BS) was less than 120 mg/dL. On multiple occasions in August and September 2024, Resident R75 received 5 units of Humalog despite having BS levels below the specified threshold. Resident R75, who was admitted with diagnoses including diabetes, hypertension, and anxiety, had specific physician orders for the administration of Humalog insulin. The orders clearly stated that the insulin should be held if the resident's BS was less than 120 mg/dL. Despite this, the MAR showed that the insulin was administered on several dates when the BS was below the threshold. The Director of Nursing confirmed during an interview that the insulin was not administered according to the physician's orders, acknowledging the medication errors.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to its own policies regarding the storage and labeling of medications, specifically Schedule II-V controlled substances and multi-dose containers. During a review of the West medication room, it was observed that Schedule II-V medications, specifically Lorazepam, were not stored in a separately locked, permanently affixed compartment as required. Instead, the Lorazepam was found in a clear plastic box on a shelf within the refrigerator, which was not permanently affixed, allowing for easy removal. This is a direct violation of the facility's policy dated 5/1/24, which mandates that such medications be stored securely. Additionally, the facility failed to properly label and manage the discard dates of multi-dose containers. An open vial of Tubersol was found in the medication room refrigerator without a date indicating when it was opened, making it impossible for staff to determine the appropriate discard date. This oversight was confirmed by an LPN during the observation, who acknowledged that the vial should have been dated upon opening. These deficiencies highlight lapses in the facility's adherence to its medication storage and labeling policies, as outlined in their own procedures.
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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