Sunnyview Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Butler, Pennsylvania.
- Location
- 107 Sunnyview Circle, Butler, Pennsylvania 16001
- CMS Provider Number
- 395788
- Inspections on file
- 46
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 74 (1 serious)
Citation history
Health deficiencies cited at Sunnyview Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple medical conditions, including diabetes and a lower leg fracture, received IV cefazolin via a midline catheter, but the physician orders did not specify the type of IV access, flushing protocol, dressing change schedule, or end-cap changes. Facility policy required specific midline flushing and care procedures, and nursing documentation noted that the midline was flushing easily. During an interview, the DON confirmed that the orders were incomplete and that adequate treatment and care for the midline catheter were not provided.
A resident with high blood pressure, muscle weakness, heart failure, and a stage 2 coccyx pressure injury had a physician’s order for daily wound care, including cleansing with wound cleanser, drying, applying triad paste, and covering with bordered gauze. Review of the TAR showed that this treatment was not administered on two documented days, and the DON confirmed that the ordered pressure ulcer treatments were not provided as required.
A resident with PTSD, multiple sclerosis, and asthma, who was receiving Duloxetine and buspirone for PTSD and anxiety, reported that a male NA repeatedly entered her room in the early morning hours to check if she needed the restroom, which made her very uncomfortable due to a history of being raped at night during military service. Review of her trauma-informed care evaluation and care plan showed no identified PTSD triggers or related interventions. The social worker acknowledged that the facility did not provide trauma-informed care to eliminate or mitigate triggers that could cause re-traumatization.
The facility did not consistently monitor or record food holding temperatures as required, resulting in multiple meals being served without documentation of safe temperature ranges. Several residents and their representatives reported that food was frequently served cold, and staff confirmed the lack of temperature monitoring, creating a potential risk for foodborne illness.
Resident representatives were unable to reach facility staff or receive responses to their communications over several weeks due to unresolved phone system changes following administrative office relocation. The DON confirmed that the current phone situation prevented effective communication with key personnel.
A resident with an enteral feeding tube did not receive appropriate care, as the feeding bag lacked required labeling and the water bag used for flushes was outdated. An LPN and the DON confirmed these deficiencies, which were not in accordance with facility policy and physician orders.
A nurse aide was re-hired without documented completion of required abuse, neglect, and misappropriation training, as mandated by facility policy. The DON confirmed that training records did not show the employee received this education upon re-hire.
Two residents with cognitive impairments and a history of exit-seeking behaviors were able to elope from the facility due to failures in supervision, incomplete risk assessments, and non-functioning or unchecked electronic monitoring devices. Staff did not consistently update care plans or ensure monitoring systems were operational, resulting in one resident being found attempting to exit the building and another found outside with injuries after a fall.
A poster with Ombudsman contact information was observed to include only a phone number, lacking the required name, address, and email address. The NHA confirmed the omission, resulting in a deficiency for not fully posting all required contact details for the State Long-Term Care Ombudsman program.
A nurse aide trainee was allowed to work for more than four months without obtaining required certification, as confirmed by facility records and staff interview. The individual continued working as a nurse aide trainee well past the 120-day limit set by federal regulations.
Surveyors observed that food items in storage areas were not properly labeled or dated, including snacks, grits, chicken tenders, and soft pretzels. A refrigerator contained a soiled rag, and loose sugar was found on the dry storage floor. Meat was stored touching the freezer ceiling, and large icicles were present on the freezer floor. The hand washing sink lacked towels, and equipment such as the meat slicer and floor mixer were left uncovered, exposing them to contamination. The Food Service Director confirmed these failures in food labeling, sanitation, and hand hygiene supply maintenance.
The NHA and DON did not effectively manage the facility to prevent the elopement of two residents, despite being responsible for maintaining systems to ensure resident safety and regulatory compliance. This failure resulted in an immediate jeopardy situation, as identified through review of job descriptions, clinical records, and staff interviews.
Multiple residents reported delays in receiving meals, infrequent showers, and long wait times for call bell responses due to insufficient nursing staff. Staff confirmed that low staffing levels made it difficult to provide timely care, with some shifts having only three aides for 60 residents. The administrator acknowledged the facility's failure to provide adequate nursing and related services to meet residents' needs.
The facility did not provide required medically related social services to several residents with mental health conditions such as schizophrenia, depression, and anxiety. Documentation and interviews showed that residents did not receive consistent psychosocial support or follow-up, and there was no process in place to identify or track those needing regular psychiatric social services.
The facility did not ensure that monthly medication regimen reviews were reviewed by the attending physician for three residents with complex medical and psychiatric conditions. Instead, CRNPs completed and signed the reviews and made medication decisions, with no documented response from the attending physician as required by policy.
The facility did not employ a qualified Food Service Director for an extended period, with the individual in the role lacking required education or certification, and the RD only performing clinical duties without managing kitchen operations.
A resident was not allowed to share a room with their spouse or roommate of choice, and did not receive written notice before a change in room assignment was made, violating their rights.
A resident with mental health and seizure disorders, who had been placed in a private room for behavioral reasons, was moved to another room so that another resident with similar needs could have the private room. The transfer was made for facility convenience rather than the resident's needs, violating the resident's right to refuse non-requested transfers.
A resident with anemia, muscle weakness, and a need for personal care assistance was found to have their call bell out of reach while in bed. Facility staff confirmed the call bell was not accessible, failing to meet the resident's needs as required by policy.
A resident with anemia and recent weight loss required personal assistance with eating, as requested by a family member. The facility did not document or respond to this grievance, and staff confirmed the concern was not addressed, resulting in a failure to honor the resident's right to voice grievances.
A resident with dementia and a left below-knee amputation, who required staff assistance for toileting, was found lying in bed with a soiled gown and sheets saturated in urine, despite documentation indicating toileting assistance had been provided. The assigned nurse aide confirmed that the resident had not been assisted as required, resulting in neglect.
The facility did not ensure that necessary information, such as care plan goals, advanced directives, and ongoing care instructions, was communicated to the receiving health care provider for two residents who were transferred to the hospital and returned. The DON confirmed that this information was not provided as required.
A resident with hemiplegia and muscle weakness, who required a smoking apron for safety as documented in their care plan, was observed smoking without the apron. The staff member supervising was unaware of this requirement, resulting in the care plan intervention not being implemented.
A resident with dementia and a left below-the-knee amputation, who required staff assistance for toileting, was found lying in bed with soiled clothing and bedding after not receiving the necessary toileting care. Documentation indicated care was provided, but staff later confirmed that assistance had not been given as required by the care plan and facility policy.
Two residents with diabetes experienced either repeated refusals of prescribed insulin injections or had multiple instances of elevated blood glucose levels, but the nursing staff did not notify the physician as required by orders and facility policy. Instead, staff relied on a nurse practitioner to review blood sugar records, resulting in a failure to provide care and treatment according to physician instructions.
A resident with diabetes, hyperlipidemia, and chronic kidney disease was found to have a urinary catheter in use without a corresponding physician order on file, as required by facility policy. Staff confirmed that only a hospital order existed and no new order was obtained upon admission, resulting in a deficiency.
The facility did not consistently complete and send required dialysis communication forms for two residents with ESRD who received hemodialysis at an outside center. Multiple treatment days lacked complete documentation, and staff confirmed these omissions, resulting in incomplete communication between the facility and the dialysis center.
Two residents with PTSD did not have care plans addressing trauma-informed care or identifying triggers that could cause re-traumatization. Staff confirmed the absence of appropriate interventions and documentation for these residents.
A resident with dementia, anxiety, and severe cognitive impairment, who was grieving and exhibiting suicidal ideation, did not receive appropriate one-to-one supervision as required by facility policy. Although staff removed dangerous items and initiated frequent checks, the resident was left without continuous observation during an episode of active suicidal behavior, resulting in a deficiency in mental health care services.
A resident diagnosed with dementia did not receive the necessary treatment and services to address their condition, as required by care standards.
Nursing staff did not consistently document or verify controlled medication counts during shift changes on two medication carts, as required by facility policy. LPNs confirmed that no alternative verification methods were used, resulting in incomplete records for controlled substances.
A medication cart was found to contain an outdated Humalog insulin pen for a resident, despite facility policy requiring removal of expired drugs. An LPN confirmed the medication was not properly removed or stored.
A resident with dementia and a history of hoarding, who was care planned to receive only disposable eating items for infection control, was observed using reusable plate and silverware. An LPN confirmed the facility did not follow the care plan by failing to provide the required special eating equipment and utensils.
A deficiency was identified when the lid of the middle outdoor dumpster was found open during an observation, contrary to facility policy requiring dumpsters to be closed and free of surrounding litter. This was confirmed by the Food Service Director.
Staff did not use required gown and gloves during a wound dressing change for a resident with an order for enhanced barrier precautions. The facility's policy mandates EBP for residents with wounds or indwelling devices, but two LPNs performed the procedure without proper protective equipment, as confirmed by the resident.
A nurse aide did not receive the mandatory annual training on Effective Communication as required by facility policy, which was confirmed by the RN Educator upon review of training records.
A nurse aide did not receive the mandatory annual training on Resident Rights as required by facility policy. Review of personnel records and staff interview confirmed that this staff member missed the required training within the specified timeframe.
A nurse aide did not receive mandatory annual training on abuse, neglect, and exploitation as required by facility policy, a lapse confirmed by the RN Educator during review of staff records.
A nurse aide did not receive mandatory annual training on the Quality Assurance and Performance Improvement (QAPI) program as required by facility policy. Review of personnel records and staff interview confirmed the absence of this training for the staff member within the specified timeframe.
A nurse aide did not receive the mandatory annual Infection Control training as required by facility policy, with a review of personnel records confirming the absence of this training for the specified period. The RN Educator verified that the training had not been completed for this staff member.
A nurse aide did not receive the required annual Compliance and Ethics training as mandated by facility policy. Review of personnel records showed the absence of this training within the specified period, and the omission was confirmed by the RN Educator.
The facility did not provide the required annual in-service education and dementia management training for a nurse aide and an LPN, as confirmed by personnel file reviews and staff interviews. This failure was in violation of facility policy and state regulations regarding staff development.
A nurse aide did not receive mandatory Behavioral Health training as required by facility policy, which mandates annual completion of this training for all staff. This lapse was confirmed through personnel file review and staff interview.
The facility did not provide the required minimum number of nurse aides on several day, evening, and night shifts, as confirmed by staffing schedules and the DON. There was no evidence of additional higher-level staff compensating for these shortages.
Facility staff did not provide the required number of LPNs during certain day and night shifts, as confirmed by review of schedules and census data. The DON acknowledged that there were no additional higher-level staff to compensate for these shortages.
Facility staff did not provide the required 3.2 hours of direct nursing care per resident per day on multiple days, as confirmed by review of schedules and census data and acknowledged by the DON.
A dietary employee was observed working in the main kitchen without properly restraining his facial hair by wearing a beard guard, as required by facility policy. This was confirmed by the Food Service Manager, who acknowledged the failure to follow the established hygiene standards for food service staff.
The facility did not follow standardized recipes or serve food at required temperatures, resulting in multiple hot and cold food items being served outside of policy guidelines. A resident and another individual had previously raised concerns about food temperature and quality. Observations confirmed that food items were unappetizing in appearance and taste, with several dishes missing key ingredients or being improperly prepared.
The facility did not consistently provide food according to resident preferences, including serving incorrect vegetables and adding gravy despite documented dislikes, as reported by several residents and confirmed through tray line observation.
The facility did not provide lunch meals in a timely manner, with significant delays between meal delivery carts resulting in some residents waiting nearly two hours to be served. Multiple residents reported that their meals were consistently late, and the Food Service Manager acknowledged the issue, confirming that the delay created an undignified dining experience.
Incomplete Orders and Care for Midline Catheter
Penalty
Summary
The facility failed to provide adequate treatment and care for a resident’s midline catheter by not ensuring complete and appropriate physician orders for its use and maintenance. Facility policy on Midline Catheter Care and Maintenance, last reviewed 1/27/26, required that midline catheters be flushed with 10 cc normal saline after each intermittent infusion, after discontinuing a continuous IV, or every shift when not in use, and specified that only RNs and LPNs with approved IV certification could perform midline care. The resident, who had diagnoses including hypertension, diabetes, and a left tibia fracture, was admitted on a specified date and later had a nursing progress note indicating that an IV infusion company was notified for midline placement. Subsequent physician orders for this resident’s IV therapy directed cefazolin sodium 2 grams IV every 8 hours for a wound infection for 7 days but did not include the type of IV access, instructions for flushing the IV, dressing change frequency, or changing the IV end cap. A nursing progress note documented that the resident was tolerating the IV and that the midline was flushing easily, but there were no corresponding detailed orders addressing midline care. In an interview, the Director of Nursing confirmed that the physician orders lacked these essential components and acknowledged that the facility failed to provide adequate treatment and care for the midline catheter for this resident.
Failure to Provide Ordered Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide ordered pressure ulcer treatment for a resident with a stage 2 coccyx pressure injury. The resident was admitted with diagnoses including high blood pressure, muscle weakness, and heart failure, and an MDS assessment was completed. A physician’s order dated 1/13/26 directed staff to cleanse the stage 2 coccyx wound with wound cleanser, pat dry, apply triad paste, and cover with bordered gauze daily. Review of the Treatment Administration Record showed that this ordered treatment was not provided on 1/15/26 or 1/23/26. In an interview on 2/5/26, the Director of Nursing confirmed that the facility failed to provide the pressure ulcer treatments as ordered for this resident. The deficiency was cited under 28 Pa. Code: 201.14(a) Responsibility of licensee, 211.10(c)(d) Resident care policies, and 211.12(d)(1)(2)(5) Nursing services.
Failure to Provide Trauma-Informed Care for Resident With PTSD
Penalty
Summary
Surveyors found that the facility failed to provide trauma‑informed care to a resident with a diagnosis of PTSD. The resident, who also had multiple sclerosis and asthma and was receiving Duloxetine for PTSD and buspirone for anxiety, reported that a male NA repeatedly entered her room around 3:00 a.m. to ask if she needed to use the restroom. The resident stated this made her very uncomfortable and disclosed that she had been in the military and developed PTSD after being raped in the middle of the night. Review of her Trauma Informed Care Evaluation showed no identified triggers, and her care plan also contained no PTSD triggers or related interventions. During interview, the social worker confirmed that the facility failed to provide trauma‑informed care to eliminate or mitigate triggers that could cause re‑traumatization.
Failure to Monitor and Record Food Holding Temperatures
Penalty
Summary
The facility failed to properly monitor and record food holding temperatures in the Main Kitchen, as required by facility policy. The policy specified that hot foods must be held above 135 degrees and cold foods below 41 degrees. A review of the Food Temperature and Evaluation Log for several days in December revealed that staff did not record the required holding temperatures for multiple breakfast, lunch, and dinner meals. This omission was confirmed by the Food Service Director, who acknowledged that the facility did not document the holding temperatures as required. Multiple resident representatives and residents reported concerns about receiving cold food, with several stating that food was often or always cold, particularly at lunch. These concerns were documented on several occasions and corroborated by resident interviews. The failure to monitor and record food temperatures created the potential for foodborne illness, as confirmed by staff interviews and facility documentation.
Failure to Ensure Resident Communication Rights Due to Phone System Issues
Penalty
Summary
The facility failed to ensure that residents and their representatives had the right to communication and access to persons and services within the facility. Review of facility policy confirmed that residents are entitled to such communication. However, concerns from resident representatives indicated repeated unsuccessful attempts to contact facility staff over a period of weeks, with voicemails and emails going unanswered and no correspondence or returned calls from the administration office. During staff interview, the DON explained that administrative offices had recently been relocated, requiring new phone extensions, but the process was delayed due to maintenance staff absence. The DON acknowledged that the current phone situation did not allow residents or their representatives to easily communicate with facility personnel.
Failure to Ensure Proper Labeling and Maintenance of Enteral Feeding Supplies
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with an enteral feeding tube. Review of the facility's policy required that the formula label include initials, date, and time when the formula was hung or administered, and that the label be checked against the order. Clinical record review showed that the resident was admitted with a right hip fracture, post-surgery, and pain, and had physician orders for enteral feeding and water flushes to maintain tube patency. During observation, the resident's enteral feeding bag was found without a label, initials, date, or time, and the water bag used for flushes was three days old. An LPN confirmed the absence of a label on the feeding formula and the outdated water bag. The DON also confirmed that the facility did not ensure appropriate treatment and services to prevent potential complications for the resident with an enteral feeding tube.
Failure to Document Required Abuse Training for Re-Hired Staff
Penalty
Summary
The facility failed to implement its written policies and procedures regarding abuse, neglect, and misappropriation training for staff, as evidenced by the lack of documentation showing that a nurse aide received required abuse training upon their most recent re-hire. Facility policy mandates that all employees complete abuse, neglect, and misappropriation/exploitation training upon hire and at least annually. However, a review of training records for one nurse aide did not include evidence of such training at the time of their re-hire. During interviews, the Director of Nursing confirmed the absence of documentation and acknowledged that the required training could not be verified for this employee.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Monitoring
Penalty
Summary
The facility failed to provide adequate supervision and prevent accident hazards, resulting in two residents eloping from the premises. One resident with dementia, severe cognitive impairment, and a history of exit-seeking behaviors was not properly assessed for elopement risk initially, and their care plan was not updated in response to repeated exit-seeking incidents. The resident repeatedly removed their electronic monitoring device, and staff failed to ensure the device was in place and functioning. Documentation showed that the device was not checked on several occasions, and when the resident was found attempting to exit the building, the wander guard was not on their person. Additionally, the facility's monitoring systems, such as the wander guard system on elevators, were not consistently checked or functioning, as evidenced by maintenance records and staff interviews. Another resident with paranoid schizophrenia and moderate cognitive impairment was also identified as an elopement risk and had a history of wandering. Despite being ordered to wear an electronic monitoring device, the resident was able to leave the facility undetected. Staff and witness statements indicated that the wander guard system did not alarm when the resident exited via the elevator, and the resident was later found outside the facility with injuries after a fall. Staff interviews revealed gaps in supervision and a lack of recognition when residents at risk for elopement left the premises. The facility's elopement risk assessment tool was found to be inadequate, lacking a comprehensive scoring system, and staff were not consistently reeducated on elopement prevention following incidents. There were also failures in updating individualized care plans and implementing new interventions after repeated elopement attempts. The combination of insufficient monitoring, lack of timely care plan updates, and failure to ensure the functionality of safety devices contributed to the residents' ability to elope, creating an immediate jeopardy situation.
Removal Plan
- The Facility is obligated to provide adequate supervision which does not rely on the Wander guard System and is based on the individual resident's assessed needs and the risks identified in the Exit Seeking Elopement Evaluation/ Wandering Tool, which does not replace an electronic monitoring device.
- Review and revise the elopement evaluation/wandering assessment to include comprehensive scoring system.
- Current residents in-house will be reassessed for exit seeking / elopement by the Director of Nursing/designee.
- Residents will be assessed for exit seeking/elopement by the admitting RN upon admission.
- Elopement binder will be revised upon completion of all assessments by the Director of Nursing/designee.
- Per results of assessments, care plans will be updated and implemented with resident-specific interventions by Director of Nursing/designee as warranted.
- Elopement policies will be reviewed and revised as necessary by Nursing Home Administrator/designee.
- Wander guard system will continue to be audited by Environmental Director/designee.
- Education of all facility staff will be conducted by Director of Nursing/designee on Elopement Risk and Supervision of residents.
- QA/QAPI will be conducted related to plan of correction for F689. Meetings will be conducted regularly.
Incomplete Ombudsman Contact Information Posted
Penalty
Summary
The facility failed to post complete contact information for the State Long-Term Care Ombudsman program as required. During an observation on Roseview Hallway, a poster was found displaying only the Ombudsman’s phone number, without the name, address, or email address. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the required information was not fully posted. The report cites this as a failure to meet regulatory requirements for providing residents with access to pertinent State agencies and advocacy groups.
Nurse Aide Trainee Worked Beyond Certification Timeframe
Penalty
Summary
The facility failed to ensure that a nurse aide trainee, Employee E28, became certified within the required four-month period as mandated by federal regulations. Documentation showed that Employee E28 was hired as a nurse aide trainee and completed the facility's nurse aide training program, but continued to work as a nurse aide trainee from July 2024 to July 2025, exceeding the 120-day limit for uncertified nurse aides. This was confirmed by a review of personnel records, timecards, and an interview with the Human Resource Director, who acknowledged that Employee E28 worked past the allowed timeframe without obtaining certification. The deficiency was identified for one of four nurse aides reviewed.
Deficiencies in Food Storage, Labeling, Sanitation, and Hand Hygiene in Main Kitchen
Penalty
Summary
The facility failed to comply with its own policies and professional standards regarding food storage, labeling, sanitation, and hand hygiene in the Main Kitchen. During observations, surveyors found that food items in various storage areas, including refrigerators and freezers, were not properly labeled or dated. Specifically, a meat and cheese stick snack, an opened box of grits, chicken tenders, and soft pretzels were all found without labels or dates. Additionally, a rag with brown and black substances was found in a refrigerator, and loose sugar was scattered on the floor in the dry storage area. Meat was stored in a way that it touched the ceiling of the walk-in freezer, and large icicles were found on the freezer floor. Further deficiencies included the lack of essential supplies at hand washing stations, as the hand washing sink in the Main Kitchen did not have towels for drying hands. Equipment such as a meat slicer and floor mixer were observed to be uncovered and not in use, leaving them exposed to potential contamination. These findings were confirmed by the Food Service Director, who acknowledged the failures in labeling, dating, sanitation, and hand hygiene supply maintenance.
Failure to Prevent Resident Elopement Resulting in Immediate Jeopardy
Penalty
Summary
The Nursing Home Administrator (NHA) and Director of Nursing (DON) failed to effectively manage the facility, resulting in the elopement of two residents. Review of job descriptions confirmed that the NHA was responsible for establishing and maintaining efficient and effective systems to safely meet residents' needs in compliance with regulations, while the DON was responsible for the organization and oversight of all nursing operations and supervision of resident care. Despite these responsibilities, the facility did not prevent the elopement of two residents, which created an immediate jeopardy situation. This failure was identified through review of job descriptions, clinical records, and staff interviews, and it was determined that the NHA and DON did not fulfill their essential job duties to ensure adherence to federal and state guidelines and regulations.
Insufficient Nursing Staff Resulting in Delayed Care and Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple resident and staff interviews, as well as direct observations. Residents reported delays in receiving meals, with food often arriving cold due to late distribution. Several residents stated that they did not receive regular showers, particularly on weekends, and had to wash themselves or argue with staff to receive basic hygiene care. Residents also reported long wait times, up to 15-20 minutes, for staff to respond to call bells. Seven residents in a group interview expressed concerns about chronic understaffing. Staff interviews corroborated these concerns, with nurse aides reporting that they were sometimes responsible for as many as 60 residents with only three aides available. Staff stated that this level of staffing made it impossible to answer call lights promptly or provide showers as scheduled. The nursing home administrator confirmed that the facility did not have enough nursing staff to provide necessary care and services to maintain the highest practicable well-being of the majority of residents reviewed. These findings were cited as violations of state regulations regarding staffing and resident care.
Failure to Provide Medically Related Social Services for Residents with Mental Health Needs
Penalty
Summary
The facility failed to provide medically related social services to four residents with significant mental health diagnoses, including schizophrenia, major depressive disorder, mood disorder, anxiety disorder, and seizure disorder. Documentation review revealed that these residents did not receive consistent psychosocial support or follow-up for their mental health needs, despite recommendations for regular therapy and psychiatric follow-up. For example, one resident with paranoid schizophrenia and major depressive disorder had no current psychosocial support documented, while another with multiple mental health diagnoses had no consistent psychosocial reviews or follow-up after a physician appointment. Another resident was recommended for weekly psychiatric visits but had no documented interventions following behavioral incidents, and a fourth resident had no clinical documentation of psychosocial support after a recommendation for weekly therapy. Interviews with the facility's social worker confirmed that there was no established process for identifying residents in need of additional psychiatric social services, nor was there a maintained list of residents requiring regular psychosocial support. The social worker acknowledged that while a personal list was kept, it was not reflected in the clinical records of the affected residents and was not provided upon request. This lack of documentation and process resulted in the failure to provide necessary medically related social services as required by facility policy and regulatory standards.
Lack of Attending Physician Review of Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to provide evidence that monthly medication regimen reviews (MRR) were reviewed by the attending physician for three residents. For each resident, the clinical records showed that the MRRs were completed and signed by a Certified Registered Nurse Practitioner (CRNP), but there was no documented response or review from the attending physician as required. Specifically, for one resident with dementia, anxiety, and cognitive decline, the MRR did not include the attending physician's response, and the CRNP made decisions regarding gradual dose reduction for multiple psychotropic medications. Another resident with adult failure to thrive, hypertension, and dementia also had an MRR lacking the attending physician's review, with the CRNP making medication discontinuation decisions. A third resident with dementia, anxiety, depression, and Alzheimer's disease similarly had their MRR reviewed and signed by a CRNP, with decisions made about not completing gradual dose reductions for several medications, but without the attending physician's documented involvement. During staff interviews, it was confirmed that the facility did not ensure the attending physician reviewed the MRRs monthly for these residents, and that the reviews were instead conducted by nurse practitioners. This practice was not in accordance with facility policy and regulatory requirements, as the attending physician's review and response were missing from the medical records for all three residents involved.
Unqualified Food Service Director Employed
Penalty
Summary
The facility failed to employ a qualified Food Service Director (FSD) to manage the daily operations of the Dietary Department for nine out of twelve months. The individual serving as FSD during this period stated she had no relevant education or certification, specifically not being a Certified Dietary Manager. The Registered Dietitian (RD) employed at the facility confirmed her role was limited to clinical duties and did not include management of the kitchen operations. The Nursing Home Administrator acknowledged that there was no documented evidence to show that the FSD met the required qualifications for the position, as required by regulation.
Failure to Honor Resident's Roommate Choice and Provide Written Notice
Penalty
Summary
A deficiency was identified when the facility failed to honor a resident's right to share a room with their spouse or roommate of choice. Additionally, the resident did not receive written notice prior to a change being made regarding their room assignment. This action was not in accordance with the resident's rights as outlined in regulatory requirements.
Resident Rights Violation: Unwarranted Room Transfer for Staff Convenience
Penalty
Summary
A resident with diagnoses of schizophrenia, anxiety disorder, and seizure disorder was admitted to the facility and had been residing in a private room for an extended period due to behavioral reasons. According to the clinical record and census review, the resident occupied the private room from 6/21/24 to 7/10/25. Staff interviews revealed that the resident was moved out of the private room to accommodate another resident who also required a private room for behavioral reasons. The social worker confirmed that the decision to move the resident was based on facility needs rather than the resident's needs, and that the resident was not able to pay for the private room. The facility failed to ensure that the room change was not completed for staff convenience, as required by resident rights regulations. The social worker acknowledged that the move was made to meet facility needs and not the needs of the resident, despite being aware that both residents had similar behavioral concerns necessitating a private room. This action resulted in a deficiency related to the protection of the resident's right to refuse certain types of non-requested transfers within the facility.
Failure to Ensure Call Bell Accessibility for Resident
Penalty
Summary
The facility failed to accommodate the call bell needs of one resident. According to facility policy, the call system must be accessible to residents while in bed or other sleeping accommodations. A review of the clinical record showed that the resident had diagnoses of anemia, muscle weakness, and required assistance with personal care. During an observation, the resident's call bell was found hanging from the wall unit at the head of the bed, out of the resident's reach. A registered nurse confirmed that the call bell was not accessible or available for the resident's use, indicating the facility did not meet the resident's needs for call bell accessibility.
Failure to Address Resident Grievance Regarding Assistance with Eating
Penalty
Summary
The facility failed to follow up on a grievance raised by a resident's family member regarding the need for assistance with eating due to the resident's recent weight loss. Documentation review showed that the family member requested help for the resident, who had anemia and required personal assistance, but there was no evidence in the clinical record that the facility responded to this concern. Staff interviews, including with the Nursing Home Administrator, confirmed that the concern was not addressed, indicating a failure to honor the resident's right to voice grievances and to ensure prompt resolution as required by federal and state regulations.
Failure to Provide Required Toileting Assistance Resulting in Resident Neglect
Penalty
Summary
A deficiency occurred when a resident with a history of dementia, left below-knee amputation, and anxiety, who required staff assistance for toileting due to an activity of daily living (ADL) self-care deficit, was not provided the necessary care. The resident's care plan and facility policy required assessment and provision of appropriate transfer and toileting assistance. Documentation by a nurse aide indicated the resident was incontinent and received toileting hygiene assistance in the morning. However, during an observation later that morning, the resident was found lying in bed with a soiled gown saturated in urine, soiled bed sheets, and a noticeable odor of urine present. Further review confirmed that the assigned nurse aide did not assist the resident with toileting as required, despite documentation stating otherwise. The aide acknowledged that the resident was saturated in urine and that the sheets needed to be changed. This failure to provide necessary toileting assistance and hygiene resulted in the resident being left in a soiled condition, constituting neglect as defined by the facility's policies and state regulations.
Failure to Communicate Required Resident Information During Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider during facility-initiated transfers for two of three sampled residents. For both residents, the clinical records showed that they were transferred to the hospital and later returned to the facility. However, there was no documented evidence that the facility provided the receiving health care provider with essential information, including the residents' care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the residents' specific needs at the receiving facility. One resident had diagnoses of high blood pressure, hyperlipidemia, and required assistance with personal care, while the other had high blood pressure, hyperlipidemia, and muscle weakness. Despite these medical needs, the required communication and documentation were not present in the clinical records for either transfer. The Director of Nursing confirmed during an interview that the necessary information was not communicated for these residents.
Failure to Implement Smoking Safety Intervention per Care Plan
Penalty
Summary
The facility failed to implement the comprehensive care plan for a resident who required safety interventions while smoking. According to the resident's care plan and quarterly smoking assessment, the resident, who had diagnoses including high blood pressure, hemiplegia, and muscle weakness, was required to wear a smoking apron during smoking activities. However, during an observation, the resident was seen smoking in the designated area without the required smoking apron, despite this intervention being clearly documented in the care plan. Further investigation revealed that the staff member supervising the smoking session, a receptionist, was not aware that the resident was supposed to wear a smoking apron. The receptionist confirmed during an interview that they had never been informed of this requirement and acknowledged that the resident was not wearing the apron as indicated in the care plan. This failure to communicate and implement the care plan intervention resulted in noncompliance with facility policy and state regulations regarding resident care policies and nursing services.
Failure to Provide Required Toileting Assistance
Penalty
Summary
A deficiency was identified when a resident with a left below-the-knee amputation, dementia, and anxiety, who required staff assistance for toileting due to an activities of daily living (ADL) self-care deficit, did not receive the necessary care. According to the resident's care plan and facility policy, staff were required to provide assistance with toileting and document any refusals. On the date in question, documentation by a nurse aide indicated the resident was incontinent and had been provided with toileting hygiene assistance. However, during an observation later that morning, the resident was found lying in bed with a soiled gown saturated in urine, soiled bed sheets, and a noticeable odor of urine present. The nurse aide assigned to the resident confirmed that the resident was saturated in urine, the sheets needed to be changed, and that toileting assistance had not been provided. The Nursing Home Administrator also confirmed the failure to provide toileting assistance for this resident.
Failure to Notify Physician of Insulin Refusal and Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to notify the physician as required when two residents either refused prescribed insulin injections or experienced elevated capillary blood glucose (CBG) levels, as specified in physician orders and facility policy. For one resident with diagnoses including schizophrenia, anxiety disorder, seizure disorder, and type 2 diabetes mellitus, there were multiple documented refusals of prescribed Humalog insulin injections. However, the clinical notes did not indicate that the physician was notified of these refusals, contrary to facility policy and physician orders. For another resident with diabetes mellitus, hyperlipidemia, and PTSD, physician orders required notification if CBG levels exceeded certain thresholds. The resident's records showed several instances of CBG readings well above the specified threshold, but there was no documentation that the physician was notified of these elevated levels as required. The facility's policy on hyperglycemia management and the specific physician orders both mandated physician notification under these circumstances. Interviews with facility leadership confirmed that the nursing staff did not notify the physician as required, and instead relied on the nurse practitioner to review printed blood sugar records. The lack of timely physician notification for both medication refusals and elevated CBG levels constituted a failure to provide care and treatment according to physician orders and resident needs.
Failure to Obtain Physician Order for Urinary Catheter
Penalty
Summary
A deficiency was identified when the facility failed to obtain appropriate physician orders for a urinary catheter for one resident. The facility's policy requires that any resident admitted with an indwelling catheter, or who subsequently receives one, must be assessed for removal unless clinically necessary, and that proper physician orders must be obtained. Review of the resident's admission and care plan records indicated the presence of a catheter, but there was no corresponding physician order for its use after admission. The only order on file was from the hospital prior to admission. During observation, the resident was found with a catheter in use, and staff interviews confirmed that there was no specific physician order for the catheter in the facility's records. The Assistant Director of Nursing acknowledged that the required physician order had not been obtained as mandated by facility policy and state regulations. The resident had a medical history including diabetes, hyperlipidemia, and chronic kidney disease, and was being monitored for incontinence at the time of the deficiency.
Failure to Maintain Consistent Dialysis Communication
Penalty
Summary
The facility failed to provide consistent and complete communication with the dialysis center for two residents who required hemodialysis. According to facility policy, a communication form must be completed and sent with the resident to dialysis, and upon return, the form should be reviewed and post-dialysis information documented. For one resident with diagnoses including high blood pressure and End Stage Renal Disease, clinical records showed missing or incomplete dialysis communication forms on three separate treatment days within a specified period. A registered nurse unit manager confirmed these omissions. For another resident with similar diagnoses, the clinical record lacked complete communication forms for eight treatment days within a one-month period. Some forms were missing dates, and one treatment day had no form at all. A registered nurse confirmed the absence of these required forms, indicating the facility did not maintain consistent and complete communication with the dialysis center as required by policy.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for two residents with a diagnosis of post-traumatic stress disorder (PTSD). Facility policy requires the identification of triggers that may re-traumatize residents with a history of trauma. However, a review of the clinical record for one resident revealed the absence of a PTSD care plan with identified triggers, despite documentation of agitation, yelling profanities, and aggressive behavior. The resident's diagnoses of PTSD, depression, and insomnia were current at the time of review. Similarly, another resident with a diagnosis of PTSD did not have a care plan developed with goals and interventions related to PTSD. The care plan review did not include any trauma-informed strategies or identification of triggers. During staff interviews, it was confirmed that the facility failed to provide trauma-informed care to eliminate or mitigate triggers that could cause re-traumatization for both residents.
Failure to Provide Appropriate Supervision for Suicidal Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident who displayed mental and psychosocial adjustment difficulties, specifically suicidal ideation. The resident, who had diagnoses of dementia, anxiety, and cognitive decline, was grieving the loss of their spouse and had a history of severe cognitive impairment as indicated by a BIMS score of 4. On the day of the incident, staff removed potentially harmful objects from the resident's room after the resident expressed suicidal thoughts and behaviors, including statements about self-harm and intent to die. The resident's family confirmed concerns about suicidal ideation. The resident became agitated, and their roommate was relocated for safety. The resident was placed on every 15-minute checks for suicide prevention until being transferred to the hospital. Despite these interventions, the facility did not implement a one-to-one observation for the resident when they were actively suicidal, as confirmed by both the Nursing Home Administrator and the Nurse Practitioner. Facility policy and staff interviews indicated that one-to-one observation is expected in such situations to ensure the resident is not left alone. The failure to provide this level of supervision constituted a deficiency in ensuring the resident received appropriate treatment and services for their mental and psychosocial needs.
Failure to Provide Appropriate Dementia Care
Penalty
Summary
A resident who displays or is diagnosed with dementia did not receive the appropriate treatment and services as required. The facility failed to ensure that the necessary care was provided to address the resident's dementia-related needs. This deficiency was identified during the survey process, indicating a lapse in the delivery of care specific to dementia management for the affected resident.
Failure to Accurately Account for Controlled Medications on Medication Carts
Penalty
Summary
The facility failed to implement its own procedures for the accurate accounting of controlled medications on two medication carts, specifically the Cardinal East and Cardinal Southwest carts. According to the facility's policy, controlled medications are required to be counted by two professional nurses at the beginning and end of each shift, with documentation of the count and signatures to verify accuracy. However, a review of the narcotic count record logs revealed that nursing staff did not sign the records during shift changes on multiple occasions for both medication carts. Specific dates were identified where outgoing nurses failed to sign off, indicating that the required verification of controlled drug counts was not completed as per policy. Interviews with LPNs confirmed that there was no alternative method in place to verify narcotic counts other than the paper log, and that the required documentation was not completed. The deficiency was communicated to the Nursing Home Administrator, confirming that the facility did not follow its established procedures for controlled medication management as required by state regulations.
Outdated Medication Found in Medication Cart
Penalty
Summary
The facility failed to properly store medications in one of its medication carts, specifically the Dogwood [NAME] Medication Cart. During an observation, an outdated Humalog insulin pen belonging to a resident was found in the cart, with an open date of 6/17/25 and an expiration date of 7/14/25. Facility policy requires that discontinued, outdated, or deteriorated drugs be returned to the pharmacy or destroyed, but this was not followed. A Licensed Practical Nurse confirmed the presence of the outdated medication and acknowledged the failure to adhere to proper medication storage procedures.
Failure to Provide Special Eating Equipment as Care Planned
Penalty
Summary
A resident with diagnoses including dementia, acquired absence of the left leg below the knee, and anxiety was care planned to receive all disposable eating items from dietary services due to hoarding behaviors, which posed an infection control concern. Despite this care plan, the resident was observed using a reusable plate and silverware during a meal service. Staff confirmed that the facility failed to provide the required special eating equipment and utensils as specified in the resident's care plan, resulting in noncompliance with the established infection control measures for this individual.
Improper Containment of Outdoor Garbage Dumpster
Penalty
Summary
The facility failed to properly contain and dispose of garbage in one of three outside dumpsters, specifically the middle dumpster. Review of the facility's policy indicated that outside dumpsters must be closed and free of litter around the area. During an observation, it was noted and confirmed by the Food Service Director that the lid on the middle dumpster was not closed, which did not comply with the facility's garbage and rubbish disposal policy.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Facility staff failed to implement enhanced barrier precautions (EBP) during a wound dressing change for one resident who had a physician order for EBP. According to the facility's Transmission Based Precautions policy, EBP requires the use of gown and gloves during high-contact care activities for residents at increased risk, such as those with wounds or indwelling medical devices. During an observed dressing change, two LPNs did not don gowns and gloves as required. The resident involved confirmed that staff do not wear gowns during such procedures. This failure to follow established infection control protocols created the potential for cross contamination.
Failure to Provide Required Effective Communication Training to Staff Member
Penalty
Summary
The facility failed to provide mandatory training on Effective Communication to one of five direct care staff members, specifically a nurse aide (Employee E6). According to the facility's Staff Development Training Program policy, all employees are required to attend training on several topics, including Effective Communication, upon hire and at least annually. A review of Employee E6's personnel file showed that this staff member did not receive the required Effective Communication training during the specified annual period. This deficiency was confirmed by the Registered Nurse Educator during an interview, who acknowledged that the training had not been provided as required by facility policy and state regulations.
Failure to Provide Required Resident Rights Training to Staff Member
Penalty
Summary
The facility failed to provide mandatory training on Resident Rights to one of five staff members, specifically a nurse aide (NA) identified as Employee E6. According to the facility's Staff Development Training Program policy, all employees are required to attend training on Resident Rights upon hire and at least annually. A review of Employee E6's personnel file showed that, despite being hired on 12/2/14, there was no documentation of Resident Rights training between 12/2/23 and 12/2/24. This deficiency was confirmed during an interview with the Registered Nurse Educator, who acknowledged the lapse in required training for this staff member.
Failure to Provide Required Abuse, Neglect, and Exploitation Training to Staff Member
Penalty
Summary
The facility failed to provide mandatory training on Abuse, Neglect, and Exploitation to one of five staff members, specifically a nurse aide who was employed during the review period. According to the facility's Staff Development Training Program policy, all employees are required to attend training on these topics upon hire and at least annually. Review of the nurse aide's personnel file showed no documentation of this required training within the specified annual period. This deficiency was confirmed by the Registered Nurse Educator during an interview, who acknowledged that the required training had not been provided as stipulated by facility policy and state regulations. No information regarding residents' medical history or condition at the time of the deficiency was included in the report.
Failure to Provide Required QAPI Training to Staff Member
Penalty
Summary
The facility failed to provide mandatory training on the Quality Assurance and Performance Improvement (QAPI) program to one of five staff members, specifically a nurse aide. According to the facility's Staff Development Training Program policy, all employees are required to attend training on QAPI upon hire and at least annually. Review of the nurse aide's personnel file showed no documentation of QAPI training within the required annual period. This deficiency was confirmed by the Registered Nurse Educator during an interview, who acknowledged that the required QAPI training had not been provided to the staff member as stipulated by facility policy.
Failure to Provide Required Infection Control Training to Staff Member
Penalty
Summary
The facility failed to provide mandatory annual Infection Control training to one of five staff members, specifically a nurse aide who was employed since 12/2/14. According to the facility's Staff Development Training Program policy, all employees are required to attend training on Infection Control upon hire and at least annually. Review of the nurse aide's personnel file showed no documentation of Infection Control training for the period between 12/2/23 and 12/2/24. This deficiency was confirmed during an interview with the Registered Nurse Educator, who acknowledged that the required training had not been provided to the staff member as stipulated by facility policy.
Failure to Provide Required Compliance and Ethics Training to Staff Member
Penalty
Summary
The facility failed to provide mandatory Compliance and Ethics training to one of five staff members, specifically a nurse aide who was hired on 12/2/14. According to the facility's Staff Development Training Program policy, all employees are required to attend training on Compliance and Ethics upon hire and at least annually. A review of the nurse aide's personnel file showed no documentation of Compliance and Ethics training between 12/2/23 and 12/2/24. This deficiency was confirmed during an interview with the Registered Nurse Educator, who acknowledged that the required training had not been provided as stipulated by facility policy.
Failure to Provide Required Annual Training for Staff
Penalty
Summary
The facility failed to ensure that nurse aides and licensed practical nurses received the required annual training, including a minimum of 12 hours of in-service education and specific training on dementia management. Review of personnel files revealed that one nurse aide did not receive any in-service education or dementia management training during the specified annual period. Additionally, a licensed practical nurse also did not receive the required annual dementia management training within the designated timeframe. These findings were confirmed by the Registered Nurse Educator during staff interviews. Facility policy mandates that all employees must attend annual training on several topics, including dementia care, accident prevention, infection control, resident rights, and abuse prevention. The personnel files reviewed showed non-compliance with these requirements for the identified staff members, as there was no documentation of completed training for the relevant periods. The deficiency was cited under state regulations regarding staff development and the responsibility of the licensee.
Failure to Provide Required Behavioral Health Training to Staff
Penalty
Summary
The facility failed to provide required Behavioral Health training to one of five nurse aides, as evidenced by a review of staff development records and facility policy. The facility's policy mandates that all employees must complete training on Behavioral Health upon hire and at least annually. Documentation for one nurse aide showed no record of Behavioral Health training within the specified annual period. This deficiency was confirmed during an interview with the Registered Nurse Educator, who acknowledged the lapse in required training for the identified staff member. No information regarding residents' medical history or condition at the time of the deficiency was provided in the report.
Failure to Meet Minimum Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required minimum nurse aide (NA) staffing levels as mandated by regulation. Specifically, on one day during the day shift, the number of NAs present was below the required ratio of one NA per 10 residents. On five separate days during the evening shift, the facility did not provide the minimum of one NA per 11 residents. Additionally, on two nights, the night shift did not meet the minimum requirement of one NA per 15 residents. These deficiencies were confirmed through a review of nursing time schedules, facility census data, and staff interviews, including confirmation by the Director of Nursing. There was no indication that additional higher-level staff were present to compensate for the NA shortages on these shifts. No information was provided regarding specific residents affected, their medical history, or their condition at the time of the deficiency.
Plan Of Correction
The Center continues to have retention and recruitment activities in place, which met on 7.16.2025. Nursing leadership did all things reasonably possible to meet the required ratios through bonuses, a day off on another day, and split shifts. We call/text unscheduled staff were contacted, and supplemental staffing were contacted to send replacement staff. Ancillary staff were available and assisted in various tasks such as call bell attendant, delivery and removal of meal trays, delivery of water, bed making, and performance of other tasks within their scope of practice. The facility will continue to ensure the schedule reflects the required staffing ratios and address call-offs. Our Human Resource Clerk is scheduled to attend the Career link job fair and meet with the organizer on 7/21/25. An off-shift scheduler continues to perform scheduling duties after hours to maintain ratio. Staff and supplemental staffing have been reminded of the importance of them reporting to work as assigned. A weekend Manager program has been implemented, which will add extra monitoring on the weekends. No residents were affected. To monitor and maintain ongoing compliance, the DON/designee will audit 5 staffing sheets x 4 weeks to ensure CNA ratios are being met on day and night shifts. Audit results will be reviewed with QAPI Committee meeting monthly to determine the need for further audits.
Failure to Meet Minimum LPN Staffing Requirements
Penalty
Summary
Facility administrative staff failed to meet required minimum staffing levels for licensed practical nurses (LPNs) on several occasions. Specifically, on one day during the reviewed period, the facility did not provide at least one LPN per 25 residents during the day shift, and on two separate nights, did not provide at least one LPN per 40 residents during the night shift. Review of nursing time schedules and census data confirmed these staffing shortages, and the Director of Nursing acknowledged that there were no additional higher-level staff present to compensate for the deficiency on those shifts. No information was provided regarding the involvement or condition of specific residents during the times of the staffing shortages.
Plan Of Correction
The Center continues to have retention and recruitment activities in place, which met on 7/16/2025. Nursing leadership did all things reasonably possible to meet the required ratios through bonuses, a day off on another day, split shifts, etc. All unscheduled staff were contacted, and supplemental staffing was contacted to send replacement staff. Ancillary staff were available and assisted in various tasks such as call bell attendant, delivery and removal of meal trays, delivery of water, bed making, and performance of other tasks within their scope of practice. Our Human Resource Clerk is scheduled to attend the Career Link job fair and meet with the organizer on 7/21/25. The facility will continue to ensure the schedule reflects the required staffing ratios and address call-offs. An off-shift scheduler was hired to perform scheduling duties after hours to maintain ratio. Staff and supplemental staffing have been reminded of the importance of them reporting to work as assigned. A weekend Manager program has been implemented, which will add extra monitoring on the weekends. No residents were affected. To monitor and maintain ongoing compliance, the DON/designee will audit 5 staffing sheets x 4 weeks to ensure LPN night shift ratios are being met. Audit results will be reviewed with the QAPI Committee meeting monthly to determine the need for further audits.
Failure to Meet Minimum Nursing Care Hours Requirement
Penalty
Summary
Facility administrative staff failed to provide the minimum required 3.2 hours of direct general nursing care per resident per day on nine out of twenty-one reviewed days. Review of nursing time schedules and census data showed that on these dates, the provided nursing hours per patient day (PPD) ranged from 2.72 to 3.18, falling short of the regulatory requirement. This deficiency was confirmed by the Director of Nursing during an interview, who acknowledged that the facility did not meet the mandated nursing care hours on the specified days. No specific information about individual residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
DON/designee completed education with the scheduler to schedule the staffing for 3.20 and above to maintain required PPD. An off-shift scheduler continues to perform scheduling duties after hours in an attempt to maintain PPD. Nursing supervisors will be educated to make phone calls to replace call-offs and no-shows. To monitor and maintain ongoing compliance, the DON/designee will audit 5 schedules weekly for 2 weeks to ensure staffing PPD is 3.20 or above. Audit results will be reviewed with the QAPI Committee during the monthly meeting to determine the need for further audits. I Certify This Document to be a True and Correct Statement of Deficiencies and Approved Facility Plan of Correction for the Above-Identified Facility Survey
Failure to Ensure Proper Hair Restraint in Kitchen
Penalty
Summary
A deficiency was identified when a dietary employee in the main kitchen was observed not properly restraining his facial hair by failing to wear a beard guard as required by facility policy. The facility's Personal Hygiene policy, dated 4/1/25, specifies that dietary staff must properly restrain their hair by wearing hair nets and beard guards. During an observation, the employee was seen without a beard guard while working in the kitchen. This was confirmed in an interview with the Food Service Manager, who acknowledged that the employee did not comply with the policy, creating the potential for food borne illness.
Failure to Serve Palatable and Properly Tempered Food
Penalty
Summary
The facility failed to follow its own policies and standardized recipes regarding food preparation and service, resulting in food being served at improper temperatures and with poor palatability. During a lunch meal, a test tray audit revealed that multiple hot food items, including herb rubbed pork, beef and rice stuffed pepper casserole, mashed potatoes, apple bread stuffing, broccoli, and carrots, were served below the required minimum temperature of 135°F. Cold items such as fruit cup and milk were served above the maximum allowable temperatures. Additionally, coffee was served below the required temperature for hot beverages. These findings were confirmed by the Food Service Manager, who acknowledged that the food products did not meet point of service temperature standards. Observations and interviews further indicated that the food was not only served at incorrect temperatures but also failed to meet standards for appearance and taste. The herb rubbed pork did not appear oven roasted or properly seasoned, the apple bread stuffing lacked the expected flavors, and the beef and rice casserole was missing key ingredients and did not resemble a casserole. Broccoli was overcooked and mushy, failing to maintain its color and texture. Residents had previously voiced concerns about the temperature and quality of the food, as documented in interviews and the facility's grievance log.
Failure to Honor Resident Food Preferences During Meal Service
Penalty
Summary
The facility failed to provide food products according to resident preferences for four residents. Facility policy required trays to be checked for accuracy and resident dislikes, but observations and interviews revealed multiple failures. One resident reported not receiving requested food items on her menu. During tray line observation, two residents who were supposed to receive pureed broccoli were instead served pureed carrots, despite tray cards indicating their preference. Another resident, who preferred not to have gravy and whose tray card was marked 'NO GRAVY,' was served food with gravy. These incidents demonstrate that the facility did not consistently follow resident food preferences as documented and requested.
Delayed Meal Service Resulting in Undignified Dining Experience
Penalty
Summary
The facility failed to provide timely lunch meal service to residents across all five nursing units, resulting in an undignified dining experience. Facility policy required meals to be served in a timely manner, but review of the Meal Delivery Log showed a delay of approximately 50 minutes between the arrival of the first and second meal delivery carts. Observations confirmed that on the day in question, the first cart arrived at 11:50 am and the second at 1:26 pm, with the last resident receiving their meal at 1:47 pm, nearly two hours after the first trays were served. Multiple residents voiced concerns about consistently late meal delivery, and the Food Service Manager confirmed the failure to deliver trays in a timely manner.
Latest citations in Pennsylvania
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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