Susquehanna Health And Wellness Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Columbia, Pennsylvania.
- Location
- 745 Old Chickies Hill Road, Columbia, Pennsylvania 17512
- CMS Provider Number
- 395400
- Inspections on file
- 32
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Susquehanna Health And Wellness Center during CMS and state inspections, most recent first.
A resident with CHF and paroxysmal AFib was mistakenly given a roommate’s medications when an LPN entered a shared room, called out the roommate’s name, and administered the prepared medications to the other bed after that resident responded. The facility’s policy required licensed staff to verify resident identity using identifiers such as ID bands, photos, or staff confirmation, but this verification was not performed. As a result, the resident received multiple unintended drugs, including aspirin, Xcopri, Aptiom, levetiracetam, lorazepam, morphine, acetaminophen, carbidopa-levodopa, and gabapentin. The resident initially appeared stable but then developed lethargy and hypotension, leading to Narcan administration, EMS activation, and hospital transfer, where records confirmed accidental ingestion of the roommate’s medications with resultant lethargy and hypotension.
The facility did not conduct required annual performance reviews for five nurse aides, as confirmed by documentation review and interviews with the Administrator and DON. No evidence was found in personnel records to show that these reviews were completed within the required 12-month period.
Surveyors observed that staff failed to use proper infection control practices during medication administration and wound care for three residents with pressure ulcers. An LPN handled medication pills with ungloved hands, and staff did not use PPE or communicate enhanced barrier precautions during wound dressing changes. PPE was not readily available in resident rooms, and there was no system to alert staff to required precautions.
A resident receiving oxygen via nasal cannula did not have a care plan addressing oxygen use. This was confirmed through clinical record review and by the DON, indicating a failure to develop and implement a comprehensive care plan as required.
Two residents experienced significant weight changes, but reweights were either delayed or not completed as required by facility policy. In one case, a reweight was performed 11 days after a discrepancy was noted, and in another, reweights were delayed or not done after notable weight fluctuations. Staff confirmed that reweights should be done promptly, but this did not occur.
A resident was observed receiving oxygen via nasal cannula at 2.0 L/min on two occasions, but there was no physician order for oxygen or respiratory care in the clinical record. The DON confirmed the absence of an order, resulting in a deficiency for not providing respiratory care according to professional standards.
Surveyors observed that five resident call bells went unanswered and lunch trays were not delivered for about 15 minutes while four staff members were gathered in a side room and a licensed employee was sleeping at the nurses' station, indicating insufficient and unresponsive nursing staff.
Surveyors observed that a medication cart contained expired and undated insulin products, including a Humalog Insulin Pen that was not labeled with an expiration date and should have been discarded after 28 days, as well as multiple open and undated insulin pens and vials. Facility policies required proper labeling and removal of expired medications, but these procedures were not followed.
Two residents did not receive appropriate BIPAP therapy as ordered by their physicians after hospital discharge. One resident lacked a physician order for BIPAP despite hospital instructions, and another was found using the wrong BIPAP machine with incorrect settings, causing discomfort. The DON could not explain the lack of proper orders or the equipment mix-up.
The facility did not meet the required nurse aide staffing levels during specific shifts over a 10-day period. The regulation requires a minimum of one nurse aide per 10 residents during the day, one per 11 residents in the evening, and one per 15 residents overnight. The facility was non-compliant on certain day and night shifts, as identified in a staffing data review and communicated to the NHA.
The facility failed to meet the required staffing levels for LPNs over a 10-day period, with insufficient coverage on several day and evening shifts. This deficiency was identified during a review of staffing data and discussed with the NHA.
The facility failed to provide the required minimum of 3.2 hours of direct nursing care per resident per day for 7 out of 10 days reviewed. The nursing staffing data showed that the provided hours per patient day (PPD) fell below the mandated threshold on several occasions, with PPDs ranging from 2.95 to 3.17. These deficiencies were identified during a review of the facility's staffing documentation.
The facility failed to ensure certified personnel repaired the fire alarm panel, which was in trouble due to a power failure for two months. Partial repairs by non-certified personnel were attempted, but no functional testing or completion records were provided. This was confirmed by the Administrator and Director of Maintenance.
The facility failed to provide written notification to residents and their representatives regarding hospital transfers for five residents. These residents, who had various cognitive impairments and medical conditions, were transferred to the hospital for issues such as abdominal pain, falls, seizures, respiratory distress, and encephalopathy without proper written notice. The Nursing Home Administrator confirmed the lack of notifications.
The facility failed to accurately complete MDS assessments for several residents, leading to discrepancies in recorded use of medical devices, medications, and discharge status. For instance, a resident's use of a CPAP/BIPAP device was not documented, and another's discharge was incorrectly recorded. These inaccuracies were confirmed by the RN Assessment Coordinator.
The facility failed to develop comprehensive care plans for six residents, resulting in omissions of necessary interventions for conditions such as diabetes, catheter use, and blood thinner management. Interviews with the DON confirmed the lack of individualized care plans, despite the facility's policy requirements.
The facility failed to administer prescribed medications and monitor weight changes as ordered for three residents. A resident with impulse disorder did not receive Depo-Provera injections on multiple occasions. Another resident with congestive heart failure was not weighed daily, and significant weight gains were not reported to the physician. Additionally, a resident with respiratory failure missed doses of Doxycycline. These deficiencies were confirmed by facility staff.
The facility failed to provide necessary assistance devices for two residents, leading to unsafe wheelchair transport, and did not adequately protect residents from violence by two others with behavioral issues. Despite care plans and interventions, these residents continued to pose safety risks, highlighting deficiencies in supervision and care planning.
The facility failed to prevent significant medication errors for two residents. One resident did not receive insulin for four days due to a pharmacy system glitch, while another resident's insulin was not held despite low blood sugar levels, contrary to physician's orders.
The facility failed to provide palatable food to residents, as evidenced by resident complaints and observations of a test tray. The chicken teriyaki served was dry, and the broccoli was mushy, with temperatures recorded at 131.7°F and 134.7°F, respectively. The Dietary Manager confirmed these issues.
The facility failed to store and serve food according to professional standards, with unlabeled and uncovered food items found in storage. Additionally, dish sanitization was inadequate, with a fan blowing dust towards the food prep area and cups having residue. The Dietary Manager confirmed these lapses.
The facility failed to maintain complete and accurate clinical records for three residents. One resident was documented as wearing a wander bracelet, which was not observed. Another resident's record lacked documentation of canceled medical appointments and transportation issues. A third resident's choking incident was not recorded in their clinical record.
A resident, who required assistance with personal hygiene, was observed with long facial hairs that caused discomfort. Despite her ability to communicate and express her dislike for the hairs, there was no record of her being offered or refusing hair removal. The DON acknowledged that staff should have addressed this issue.
A facility failed to determine a resident's bathing preference, leading to a deficiency. The resident, who required assistance with personal hygiene and had a strong preference for the type of bath, did not have these preferences documented in the care plan. This was confirmed by the DON.
A facility failed to provide a resident with written notice and the reason for a room change. The resident, who was cognitively intact, was moved from one unit to another without documented evidence of prior written notice. The resident was unaware of the reason for the move, and the Nursing Home Administrator confirmed the absence of such documentation.
The facility did not complete comprehensive admission MDS assessments within the required 14-day time frame for nine residents. The assessments were delayed, ranging from 15 to 20 days post-admission, as confirmed by the Nursing Home Administrator.
The facility failed to complete Quarterly MDS assessments within the required timeframe for seven residents, with delays ranging from one to three days. This was confirmed by the Nursing Home Administrator through a review of clinical records and staff interviews.
A facility failed to obtain a physician's order for oxygen administration for a resident with heart and respiratory failure. The resident was observed receiving oxygen without documented evidence of a physician's order, despite the care plan requiring it. This was confirmed by the Nursing Home Administrator.
The facility failed to document the administration of controlled medications for three residents, leading to discrepancies between the controlled drug records and MARs. Despite medications being signed out, there was no evidence of administration in the MARs, as confirmed by the DON.
The facility failed to label medications with the date they were opened, as required by policy. An undated Tubersol vial was found in the A unit's medication room, and insulin pens on the North B cart were also undated. Interviews with staff confirmed these items should have been dated, indicating non-compliance with medication labeling standards.
The facility did not follow CMS and CDC infection control guidelines by failing to post required signage for Enhanced Barrier Precautions (EBP) for three residents with indwelling medical devices or wounds. The absence of signs indicating the need for EBP was confirmed by the Director of Nursing, despite the facility's policy requiring such precautions.
The facility did not consistently follow care plan interventions for a resident with severe cognitive impairment, resulting in multiple falls and injuries. Specifically, toileting assistance was not provided as scheduled, leading the resident to attempt unassisted ambulation. Additionally, the facility failed to develop a comprehensive care plan for another resident with moderate cognitive impairment and aggressive behaviors, despite multiple incidents of aggression towards another resident.
The facility did not provide consistent monitoring and care for two residents receiving parenteral nutrition, leading to harm for one resident with a PEG tube. Despite physician orders, there was a lack of documented care in the Treatment Administration Records (TARs) over several months. This resident experienced infection at the PEG site, resulting in multiple hospital visits, IV antibiotic therapy, and pain. Observations and staff interviews revealed inconsistent daily care, contributing to the resident's deteriorating condition, including redness, irritation, bleeding, and foul-smelling drainage. Positive cultures for bacteria and yeast necessitated changes in antibiotic and antifungal treatments.
The facility failed to maintain a sanitary environment in the kitchen beverage area, with multiple holes and cracks observed in the walls. The Dietitian was unable to determine how long these issues had been present.
The facility failed to provide a clean, comfortable, and homelike environment for two nursing units in the B Wing. Observations revealed worn, dirty, stained, and odorous carpeting. Despite acquiring a quote for replacement, no action had been taken in the past year.
The facility failed to honor the rights of two residents regarding ambulation equipment and medication administration. One resident's walker and wheelchair were removed, preventing desired ambulation, while another resident's refusal of medication was not respected, with staff attempting to administer it multiple times, including hiding it in ice cream.
The facility failed to investigate bruises of unknown origin and thoroughly investigate allegations of rape for two residents. For one resident with PTSD and anxiety disorder, the facility did not conduct a thorough investigation after the resident reported being raped during a phone call to 911. For another resident, the facility failed to investigate bruises that were not consistent with a previous fall, assuming they were from the fall without proper documentation.
The facility failed to timely provide wound treatment to an unstageable pressure ulcer on a resident's right heel. The wound, identified upon admission, did not receive treatment until five days later when assessed by a wound consultant. The delay in treatment was confirmed by the wound nurse.
The facility failed to provide necessary behavioral services and treatment for a resident with Parkinson's Disease and Depression who exhibited aggressive behavior towards another resident on two occasions. Despite the incidents, there was no documentation that the physician was notified or that any interventions were implemented.
Significant Medication Error From Misidentification During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, resulting in the wrong medications being administered to one of three reviewed residents. The facility’s medication administration policy required that only appropriately licensed personnel prepare and administer medications and that the individual administering medications verify the resident’s identity using methods such as checking an identification band, checking a photograph attached to the medical record, and, if necessary, verifying the resident’s identity with other personnel. Despite this policy, an LPN entered a shared room, called out the roommate’s name, and when the resident in the other bed responded and requested assistance, the LPN proceeded to give that resident the medications intended for the roommate. The resident who received the wrong medications had diagnoses including congestive heart failure and paroxysmal atrial fibrillation. Clinical record review showed that the resident was initially assessed after the error and was alert and oriented, with vital signs including a temperature of 97.4°F, BP 105/58, HR 66, and oxygen saturation of 91%. The CRNP was notified of all medications the resident had received in error and instructed that only the resident’s Eliquis be given and all other medications held. When the LPN went to administer Eliquis, the resident was observed to be slightly lethargic, and repeat vital signs showed a BP of 85/50, temperature 98°F, HR 70, RR 15, and oxygen saturation of 92%, with continued lethargy. Further review of the clinical and hospital records revealed that the resident had been given multiple medications not prescribed for them, including aspirin 325 mg, Xcopri 300 mg, Aptiom 800 mg, levetiracetam 1500 mg, lorazepam 1 mg, morphine sulfate 0.25 ml, acetaminophen 650 mg, carbidopa-levodopa 25-100 mg two tablets, and gabapentin 600 mg. Subsequent vital signs showed a BP of 78/52 and increased lethargy, with the resident later unable to state their location. The CRNP ordered Narcan administration and later ordered the resident to be sent to the emergency department for evaluation. Hospital documentation confirmed accidental ingestion of the roommate’s medications, including Ativan (lorazepam), Keppra (levetiracetam), gabapentin, morphine, and Xcopri, with resultant lethargy and hypotension that improved with Narcan, IV fluids, and monitoring.
Failure to Complete Annual Nurse Aide Performance Reviews
Penalty
Summary
The facility failed to complete annual performance reviews for five nurse aides, as required by federal regulations. Personnel records for these nurse aides, with hire dates ranging from 2019 to 2023, were reviewed and showed no evidence that a performance review had been conducted at least once every 12 months for any of them. This deficiency was identified through documentation review and confirmed during interviews with the Nursing Home Administrator and the Director of Nursing. The lack of documented performance reviews means that the facility did not assess the job performance of these nurse aides on an annual basis. Additionally, there was no indication that in-service education was provided based on the outcomes of such reviews, as required. The findings were based solely on the absence of required documentation and confirmation from facility leadership.
Plan Of Correction
Performance reviews were completed on E4, E5, E6, E7, E8. Current nurse aide files were reviewed, and follow-up was completed as needed. Education will be completed by the Administrator/designee with supervisors and the interdisciplinary team to ensure performance reviews are completed based on the employees' hire date. The DON/designee will review nurse aide performance reviews to ensure they are completed based on their hire date, with weekly reviews for 4 weeks then monthly for 2 months. The results of the audits will be reviewed by the Quality Assessment and Assurance Committee for the need to complete further audits.
Failure to Follow Infection Control Procedures During Medication and Wound Care
Penalty
Summary
Surveyors identified that the facility failed to follow proper infection control procedures during medication administration and wound care for three residents. During a medication pass, a licensed employee placed medication pills into their ungloved hands before transferring them to a medication cup, contrary to the facility's policy requiring adherence to infection control practices such as hand hygiene and glove use. For residents with pressure ulcers, there was no system in place to communicate the need for enhanced barrier precautions to staff, and personal protective equipment (PPE) was not readily available in the rooms of affected residents. Observations revealed that staff did not use PPE during wound dressing changes for residents with stage II and stage III pressure ulcers. Additionally, there were no visible indications or signage in the rooms to alert staff to the required precautions. Clinical record reviews confirmed the presence of pressure ulcers in the affected residents, and direct observations documented repeated failures by staff to utilize PPE during wound care. These lapses were observed and reported to facility leadership during the survey, highlighting a breakdown in the implementation of the facility's infection prevention and control program as required by regulation.
Plan Of Correction
E9 had a medication competency completed. R6, R22, R136 were placed on Enhanced Barrier Precautions. PPE and signage were placed for each resident. Residents requiring Enhanced Barrier Precautions related to pressure injuries were reviewed for proper signage, and PPE was available. Education will be completed by the DON/designee for all direct care staff and the interdisciplinary team on Enhanced Barrier Precautions use for Pressure Injuries. Licensed staff will be educated on following infection control practices during medication administration. The DON/designee will audit 5 residents that require Enhanced Barrier Precautions weekly for 4 weeks, then monthly for 2 months to ensure precautions are being utilized, proper PPE is available, and signage is posted for all pressure injuries/wounds. Five medication administration audits will be completed for 4 weeks, then monthly for 2 months. The results of the audits will be reviewed by the Quality Assessment and Assurance Committee for the need to complete further audits. F 0880
Failure to Develop Care Plan for Oxygen Therapy
Penalty
Summary
Surveyors observed that a resident was receiving oxygen therapy via nasal cannula on two separate occasions. Upon review of the resident's clinical record, it was found that there was no care plan in place addressing the use of oxygen for this resident. An interview with the Director of Nursing confirmed that the resident did not have a care plan for oxygen use. This lack of a comprehensive care plan for a resident receiving oxygen constituted a failure to meet regulatory requirements for developing and implementing person-centered care plans based on identified medical needs.
Plan Of Correction
F 0656 The care plan for R1 was updated to include oxygen therapy. Residents requiring oxygen therapy have had their care plans updated to reflect their current condition. Education will be completed by the DON/Designee with licensed nurses and interdisciplinary team to ensure care plans are updated timely with any changes. The DON/designee will audit 10 resident care plans per week for 4 weeks then monthly times 2 months to ensure that residents requiring oxygen therapy have the appropriate care planned. The results of the audits will be reviewed by the Quality Assessment and Assurance Committee for the need to complete further audits.
Delayed and Missed Reweights After Significant Weight Changes
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for two residents by not completing timely reweights after significant weight changes were identified. For one resident, a discrepancy in weight was noted upon readmission, with an initial weight recorded at 181.3 pounds and a reweight not completed until 11 days later, confirming a weight of 135.0 pounds. Staff confirmed that the reweight was not performed promptly after the discrepancy was identified. For another resident, multiple significant weight changes were documented, including an 8.7% decrease and an 8.3% increase between monthly weights. In one instance, a reweight was not completed after a significant weight increase because the change did not trigger a reweight according to staff. In other instances, reweights were delayed, occurring 14 days and 5 days after the initial weight changes were identified. Facility policy required reweights to be completed the next day after a significant change, but this was not consistently followed.
Plan Of Correction
R4 is no longer in the facility. R22 has not needed a reweight since May 21, 2025. Residents requiring reweights will be reviewed daily by the dietician, and reweights will occur if there is a change of 5% or more since the last weight assessment. Reweights will be retaken the next day. Education will be completed by the DON/designee with all direct care employees and the interdisciplinary team to ensure that residents requiring reweights are completed timely. The dietician will review all weights per week for 4 weeks, then monthly for 2 months, to ensure reweights are being completed in a timely manner. The results of the audits will be reviewed by the Quality Assessment and Assurance Committee for the need to complete further audits.
Oxygen Therapy Provided Without Physician Order
Penalty
Summary
A deficiency was identified when a resident was observed receiving oxygen therapy via nasal cannula at a flow rate of 2.0 liters per minute on two separate occasions. Review of the resident's clinical record revealed there was no physician order for oxygen or respiratory care documented. During an interview, the Director of Nursing confirmed that the resident did not have an order for oxygen use. This failure to ensure respiratory care was provided in accordance with professional standards and without a proper order led to the cited deficiency.
Plan Of Correction
R1's orders were updated to reflect the use of oxygen therapy. Residents requiring oxygen therapy had their orders reviewed for oxygen use. Education will be completed by DON/designee with all licensed staff to ensure physician orders are placed when oxygen therapy is ordered. The DON/designee will review 5 residents per week for 4 weeks then monthly for 2 months to ensure residents with oxygen therapy have physician orders entered. The results of the audits will be reviewed by the Quality Assessment and Assurance Committee for the need to complete further audits.
Failure to Maintain Sufficient and Responsive Nursing Staff
Penalty
Summary
On July 23, 2025, observations on the B Wing nursing unit revealed that five resident call bells were illuminated and audibly ringing, indicating that residents were seeking assistance. At the same time, lunch carts had been delivered to the hallway but the trays had not been distributed to the residents. Four employees were observed gathered in a side room with the door closed, and a licensed employee was seen sleeping in front of the computer at the nurses' station. These conditions persisted for approximately 15 minutes, during which the resident call bells remained unanswered and the lunch trays were not delivered. The findings were communicated to the Nursing Home Administrator and Director of Nursing. The report cites a failure to ensure adequate and competent staffing levels to promptly respond to resident needs, as required by federal and state regulations.
Plan Of Correction
1. Licensed nurse was educated on sleeping and received disciplinary action for sleeping. Nursing staff on B wing were educated on timely tray pass and call light response time. 2. Call response times have been reviewed with resident council members to ensure timely response. 3. Education will be completed by the DON/designee with all direct care staff and interdisciplinary team related to call light response, congregating at nurses' station, sleeping, and meal tray delivery. 4. The DON/designee will review call bell response times, sleeping, congregating at nurses' station, and meal tray delivery three days per week for 4 weeks then monthly for 2 months. The results of the audits will be reviewed by the Quality Assessment and Assurance Committee for the need to complete further audits.
Failure to Properly Label and Remove Expired Insulin Medications
Penalty
Summary
Surveyors found that the facility failed to ensure medications were properly labeled with open and expiration dates and failed to ensure expired medications were not administered on one of three medication carts reviewed. Facility policies required that discontinued, outdated, or deteriorated drugs be returned to the pharmacy or destroyed, and that expiration or beyond-use dates be checked prior to administration, with the date of opening recorded on multi-dose containers. However, observations revealed a Humalog Insulin Pen that had been opened on June 20, 2025, was still present on the cart without an expiration date, even though it should have expired 28 days after opening. Additional observations on the same medication cart included an unopened and undated Humalog Insulin Pen, two open and undated insulin aspart pens, and one open and undated insulin glargine vial. These findings indicate that the facility did not consistently follow its own policies or manufacturer instructions regarding the labeling and storage of insulin products, resulting in the presence of expired and undated medications on the medication cart.
Plan Of Correction
The 5 undated/expired insulin pens/vials were discarded. An audit was completed of the medication cart to ensure that insulin pens/vials are dated when opened and undated/expired are discarded immediately. Education will be completed by the DON/designee for licensed nurses on the policy for dating medications with shortened expiration dates when open. The DON/designee will audit 6 medication carts to ensure insulin pens/vials are dated weekly for 4 weeks then monthly for 2 months. The results of the audits will be reviewed by the Quality Assessment and Assurance Committee for the need to complete further audits.
Failure to Provide Appropriate Respiratory Care and Follow Physician Orders for BIPAP Therapy
Penalty
Summary
The facility failed to provide appropriate respiratory care and follow physician orders for two residents who required BIPAP therapy following recent hospitalizations for acute respiratory failure. For one resident, hospital records indicated a BIPAP order with specific settings, and the hospital discharge summary included instructions for BIPAP use. However, upon admission to the facility, there was no physician order for BIPAP, nor evidence that the physician was notified of the hospital's BIPAP order. Although the necessary equipment was ordered and delivered, the lack of a corresponding physician order meant the resident did not receive the prescribed respiratory support. For the second resident, hospital records also documented a BIPAP order with specific settings and instructions for use during naps and bedtime. The facility's physician order was for BIPAP use every night shift, but observations revealed the resident was using a BIPAP machine with incorrect settings, resulting in discomfort and the resident removing the device. Further investigation showed that the resident was using another resident's BIPAP machine, as confirmed by serial numbers, rather than the machine with the physician-ordered settings. The DON was unable to explain how this mix-up occurred or why the correct orders and equipment were not in place.
Staffing Deficiency in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides during specific shifts over a 10-day period from January 6, 2025, to January 16, 2025. The regulation mandates a minimum of one nurse aide per 10 residents during the day shift, one nurse aide per 11 residents during the evening shift, and one nurse aide per 15 residents during the night shift. However, the facility did not comply with these requirements on the day shifts of January 11 and January 12, 2025, and the night shift of January 15, 2025. This deficiency was identified through a review of the facility's staffing data and was communicated to the Nursing Home Administrator (NHA) during a telephone conversation on January 17, 2025.
Plan Of Correction
1. CNA ratios for the dates noted in the survey cannot be corrected as this is a past event. 2. Calculation of shift CNA ratios will be completed and reviewed daily for accuracy by the scheduler. 3. The facility has developed internal incentives to retain and attract new staff. Agency staff are being utilized in an effort to reach daily shift ratios. Programs such as Apploi, Indeed, and CareerLink will be utilized to enhance recruiting efforts. Indeed employment ads will be posted. The scheduler will look ahead for a minimum of 1 week at projected staffing patterns to enable more time to achieve appropriate CNA ratios as needed. 4. CNA ratios will be audited by the scheduler and DON daily for 4 weeks, then 3 days per week for 2 months or until substantial compliance is achieved. Results will be reported to the QAPI committee.
LPN Staffing Deficiency
Penalty
Summary
The facility failed to meet the state-mandated staffing requirements for Licensed Practical Nurses (LPNs) over a 10-day period from January 6, 2025, to January 16, 2025. Specifically, the facility did not provide the minimum required LPN coverage on several shifts. On the day shift, the facility was short on January 3, 11, and 12, 2025, with actual hours worked being less than the required 52.16 and 52.48 hours. On the evening shift, the facility was short on January 13, 2025, with actual hours worked being 40.25 instead of the required 43.73 hours. This deficiency was identified during a review of facility staffing data and was discussed with the Nursing Home Administrator (NHA) on January 17, 2025.
Plan Of Correction
1. LPN ratios for the dates noted in the survey cannot be corrected as this is a past event. 2. Calculation of shift LPN ratios will be completed and reviewed daily for accuracy by the scheduler. 3. The facility has developed internal incentives to retain and attract new staff. Agency staff are being utilized in an effort to reach daily shift ratios. Programs such as Apploi, Indeed, and CareerLink will be utilized to enhance recruiting efforts. The facility will utilize Indeed ads. The scheduler will look ahead for a minimum of 1 week at projected staffing patterns to enable more time to achieve appropriate LPN ratios as needed. 4. LPN ratios will be audited by the scheduler and DON daily for 4 weeks, then 3 days per week for 2 months or until substantial compliance is achieved. Results will be reported to the QAPI committee.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the required minimum of 3.2 hours of direct nursing care per resident per day for 7 out of 10 days reviewed. Specifically, from January 6, 2025, through January 16, 2025, the facility's nursing staffing data showed that the provided hours per patient day (PPD) fell below the mandated threshold on several occasions. On January 7, 2025, the PPD was 3.05; on January 11, 2025, it was 3.17; on January 12, 2025, it was 2.95; on January 13, 2025, it was 3.09; on January 14, 2025, it was 3.12; on January 15, 2025, it was 2.95; and on January 16, 2025, it was 2.99. These deficiencies were identified during a review of the facility's staffing documentation, indicating a consistent shortfall in meeting the state's minimum staffing requirements.
Plan Of Correction
1. The PPD cannot be corrected as this it is an event in the past. 2. The PPD will be completed and reviewed daily for accuracy by the scheduler. 3. The facility continues to develop a recruitment plan to attract nursing staff. The facility scheduler, DON, HR, and NHA will meet daily to review compliance with ratios. In the event of call-offs, every effort to contact regular full-time and part-time staff as well as PRN and agency staff will be made by facility personnel. Programs such as Apploi, Indeed, and CareerLink will be utilized to enhance recruiting efforts. Recruiters will seek out applicants sourcing Indeed and Apploi for staff. The facility will offer 12-hour shifts to enhance employment offers. 4. PPD will be monitored daily by the scheduler and DON/designee. Facility compliance with PPD will be monitored through the monthly QAPI process. Ratios will be monitored daily by the scheduler and/or DON/designee. Audits of PPD will be completed by the DON/designee daily for 4 weeks, then 3 times per week for two months or until substantial compliance is achieved. The results of the audits will be reviewed at the monthly QA meeting.
Fire Alarm Panel Repair and Documentation Deficiency
Penalty
Summary
The facility failed to ensure that certified personnel completed repair work on the fire alarm panel, which had been in trouble due to a power failure for approximately two months. The issue was not related to the battery, and partial repairs were attempted by non-certified personnel. During the survey, it was observed that the fire alarm panel remained in trouble, indicating that the repairs were not successful or complete. Additionally, the facility did not provide documentation of functional testing after the repair work was completed, nor did they provide a record of completion for the repairs. This lack of documentation and testing was confirmed during an interview with the Administrator and Director of Maintenance, who acknowledged the ongoing trouble with the fire alarm panel and the incomplete repair process.
Plan Of Correction
1) The facility will have the fire panel inspected by certified personnel from Sciens Building Solutions to ensure completed repair work to the fire alarm panel is functional. Sciens Building Solutions will provide documentation of functional testing after repair certification to the fire alarm panel and provide a record of completion of inspection of repair to the fire alarm panel. 2) Maintenance director and Administrator will be educated that all repairs to the fire panel must be completed by certified personnel. 3) Maintenance Director/Administrator will ensure certified repair personnel work on fire panel and suppression system by auditing credentials of repair technician before any repairs are completed to fire safety system. Results of the audits will be reviewed at monthly QAPI for any trends and further recommendations. 4) Sciens Building Solutions will start inspection of fire control panel 01/10/2025. Corrective action will be completed by 02/10/2025.
Failure to Notify Residents and Representatives of Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents and their representatives regarding the reasons for hospital transfers for five residents. Resident 18, who was cognitively impaired and diagnosed with dementia, was transferred to the hospital for abdominal pain and a urinary tract infection without written notice to the responsible party. Similarly, Resident 36, who had dementia and required assistance for personal care, experienced an unwitnessed fall and a significant change in condition, leading to hospital transfers without written notification to the resident or their representative. Resident 38, severely cognitively impaired with idiopathic epilepsy, was transferred to the hospital due to a seizure and a dislodged feeding tube, again without written notice. Resident 77, moderately cognitively impaired with dementia and heart failure, was transferred due to respiratory distress without notification. Lastly, Resident 85, severely cognitively impaired with dementia, seizure disorder, and a stroke, was transferred for encephalopathy without written notice. The Nursing Home Administrator confirmed the lack of written notifications for these transfers.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for seven residents, as required by the Resident Assessment Instrument (RAI) User's Manual. For Resident 28, the MDS assessment did not indicate the use of a CPAP/BIPAP device, despite physician's orders and medication administration records (MAR) confirming its use every night during the assessment period. Similarly, Resident 52's MDS assessment incorrectly noted the use of a wander/elopement alarm, which was not documented in the clinical records during the look-back period. Resident 53's MDS assessment inaccurately coded the presence of an indwelling catheter and urinary incontinence, despite the care plan indicating the use of a suprapubic catheter. For Resident 91, the MDS assessment failed to record the administration of antidepressant and antiplatelet medications, even though physician's orders and MAR confirmed their daily administration. Resident 94's MDS assessment also omitted the use of an anti-anxiety medication, which was documented in the MAR. Additionally, Resident 139's MDS assessment did not reflect the administration of an antidepressant medication, contrary to the MAR records. Lastly, Resident 162's discharge MDS inaccurately indicated a discharge to a short-term general hospital, while physician's orders specified a discharge to home. These discrepancies were confirmed by the Registered Nurse Assessment Coordinator during an interview.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for six residents, as required by their policy for Comprehensive Person-Centered Care Plans. The policy mandates that care plans be developed within seven days of the completion of the required MDS assessment and no more than 21 days after admission. However, the facility did not adhere to this policy, resulting in incomplete care plans for several residents with specific medical needs. Resident 8, who was cognitively impaired and dependent on staff for personal care, had a diagnosis of diabetes and was prescribed insulin. Despite this, there was no documented care plan addressing her diabetes management. Similarly, Resident 25, who had renal insufficiency and an indwelling catheter, required enhanced barrier precautions, but her care plan did not reflect these needs. Resident 27, who was cognitively intact and receiving antibiotic treatment through a PICC line for osteomyelitis, also lacked a care plan addressing her infection and treatment needs. Additionally, Resident 38, who was cognitively impaired and had a neurogenic bladder with an indwelling catheter, did not have a care plan for enhanced barrier precautions. Resident 53, with Parkinson's disease and a suprapubic catheter, also lacked a care plan for necessary precautions. Lastly, Resident 120, who was on a blood thinner, did not have a care plan addressing the use of this medication. Interviews with the Director of Nursing confirmed these omissions, indicating a failure to develop and implement individualized care plans for these residents.
Failure to Follow Physician's Orders for Medication and Monitoring
Penalty
Summary
The facility failed to follow physician's orders for three residents, leading to deficiencies in care. Resident 104, who had cancer and anxiety, was prescribed 150 mg of Depo-Provera intramuscularly once a day every seven days for impulse disorder. However, the Medication Administration Record (MAR) showed no evidence of the medication being administered on several specified dates in July and August 2024. The Director of Nursing confirmed the lack of documentation for these administrations. Resident 112, who was admitted to the hospital with congestive heart failure, had orders to be weighed daily and for the physician to be notified of significant weight gains. The resident was not weighed on several days in July and August 2024, and there was no documentation of physician notification for weight gains on August 11 and 16, 2024. The Registered Nurse Supervisor and the Director of Nursing confirmed these oversights. Additionally, Resident 139, who had respiratory failure and was prescribed Doxycycline for a respiratory tract infection, missed two doses of the antibiotic on July 1, 2024, as confirmed by the Nursing Home Administrator.
Failure to Prevent Accidents and Resident Violence
Penalty
Summary
The facility failed to ensure that residents received necessary assistance devices to prevent accidents, as observed in the cases of two residents. Resident 109, who was cognitively intact and required extensive assistance for daily care, was observed being transported in a wheelchair without footrests, causing her feet to drag. The nurse aide responsible was unaware of the need for footrests. Similarly, Resident 125, who used a manual wheelchair for mobility and required moderate assistance, was also transported without footrests, with the activities aide unsure of their necessity. The Director of Nursing confirmed that footrests should have been used in both cases. The facility also failed to protect residents from violence, as evidenced by incidents involving two residents with behavioral issues. Resident 52, diagnosed with Parkinson's disease and schizophrenia, had a history of aggressive behavior, including hitting other residents. Despite a care plan to monitor and redirect him, he was involved in multiple physical altercations with other residents, causing concern for their safety. The Director of Nursing acknowledged the difficulty in predicting and preventing his aggressive behaviors due to his intellectual disabilities. Resident 85, who was cognitively impaired and had a history of physical and verbal aggression, was involved in several incidents of violence against other residents. Despite interventions such as medication adjustments and one-to-one supervision, Resident 85 continued to exhibit aggressive behavior, including hitting and pushing other residents. The facility's failure to revise his care plan and develop an individualized behavior management plan contributed to the ongoing safety risk to other residents. Interviews with staff highlighted the challenges in managing Resident 85's impulsive and unpredictable behavior.
Medication Errors in Insulin Administration
Penalty
Summary
The facility failed to ensure that it was free from significant medication errors for two residents. For one resident, who was cognitively impaired and dependent on staff for personal care needs, a new physician's order was issued to change the insulin medication from Levemir to Toujeo SoloStar. However, due to a glitch in the pharmacy system, the new insulin order was not processed, resulting in the resident not receiving insulin for four consecutive days. Another resident, who was cognitively intact and had diabetes, had physician's orders to hold insulin administration if their blood sugar was less than or equal to 120 mg/dL. Despite this, the resident's insulin was not held on multiple occasions when their blood sugar levels were below the specified threshold. The Director of Nursing confirmed that the insulin should have been held according to the physician's orders.
Food Quality and Temperature Deficiency
Penalty
Summary
The facility failed to serve food that was palatable to residents, as determined through observations and interviews. On August 19, 2024, two residents expressed dissatisfaction with the quality of the food, describing it as terrible and rough. On August 20, 2024, a test tray was observed on the lunch meal cart, which included chicken teriyaki, fluffy steamed rice, seasoned broccoli, and sherbet. The cart arrived at the unit at 11:59 p.m., and the last resident was served by 12:15 p.m. At that time, the chicken teriyaki was found to be dry with a temperature of 131.7 degrees Fahrenheit, and the broccoli was mushy with a temperature of 134.7 degrees Fahrenheit. The Dietary Manager confirmed these observations, acknowledging that the chicken appeared dry and the broccoli was over-cooked.
Deficiencies in Food Storage and Dish Sanitization
Penalty
Summary
The facility failed to adhere to professional standards for food storage and service safety, as well as dish sanitization. Observations in the walk-in refrigerator and dry storage area revealed that cooked eggs/omelets were stored in Styrofoam containers without labels or dates, and a gallon of corn syrup was open without a lid. The Dietary Manager confirmed these lapses, indicating a failure to follow the facility's policy for food storage, which requires leftover food to be stored in covered containers, clearly labeled, and dated. Additionally, the facility did not effectively sanitize dishes during mechanical dishwashing. A fan with dust accumulation was observed blowing towards the food prep/service area, and clear cups had a white, removable residue inside them. The facility's policy for pot and pan washing was not followed, as Dietary Aide 6 was observed removing items from the sanitizing solution after only a few seconds, rather than allowing them to soak for the required time. The Dietary Manager confirmed these deficiencies, acknowledging the need for proper cleaning and sanitization procedures.
Incomplete and Inaccurate Clinical Records for Residents
Penalty
Summary
The facility failed to ensure that residents' clinical records were complete and accurately documented for three residents. For Resident 94, staff documented that the resident was wearing a wander bracelet from June 14 through August 20, 2024, despite observations on August 20, 2024, confirming that the resident was not wearing the device. This discrepancy was confirmed by a registered nurse during an interview. Resident 98's records contained conflicting information regarding his cognitive status and lacked documentation of his canceled medical appointments. Although the resident was scheduled for teeth extractions and a gastrointestinal procedure, he canceled these appointments without informing the facility and refused to allow staff to reschedule them. The resident's medical record did not reflect these cancellations or his attempts to arrange unsupervised transportation, which was acknowledged by the Social Services Director. For Resident 112, the clinical record did not document a choking episode that required the Heimlich maneuver, as noted in a speech therapy report. The Director of Nursing confirmed the absence of this critical information in the resident's medical record. These deficiencies indicate a failure to maintain accurate and complete clinical records in accordance with professional standards.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as Resident 48, by not addressing her personal hygiene needs. The resident, who was capable of understanding and communicating, required assistance with personal hygiene and had a diagnosis of diabetes. Observations on multiple occasions revealed that the resident had long, white hairs protruding from under her chin, which she expressed discomfort about, as they sometimes got caught on her blankets and pulled her skin. Despite this, there was no documentation in her clinical record indicating that she was offered or refused the removal of her facial hair. An interview with the Director of Nursing confirmed that the staff should have provided care to remove the visible facial hair.
Failure to Determine Resident's Bathing Preference
Penalty
Summary
The facility failed to determine a resident's preference for bathing, which led to a deficiency. Resident 48, who was understood and able to communicate, required assistance with personal hygiene care and had a strong preference for choosing between a tub bath, shower, bed bath, or sponge bath. The admission Minimum Data Set (MDS) assessment for the resident indicated these preferences. However, the care plan did not specify the resident's preferred method of bathing, and there was no documented evidence that the resident's shower preferences were identified. This oversight was confirmed during an interview with the Director of Nursing.
Failure to Provide Written Notice for Room Change
Penalty
Summary
The facility failed to ensure that Resident 139 received written notice, including the reason for a room change, before the change was made. Resident 139, who was cognitively intact and able to understand and communicate, was moved from the B-wing to the A-unit on August 12, 2024. A social service note indicated that the resident toured the A-unit and agreed to the room at that time. However, there was no documented evidence that the resident was provided with a written notice prior to the move. An interview with Resident 139 revealed that she was unaware of the reason for the room change. The Nursing Home Administrator confirmed the lack of documented evidence of written notice regarding the room change.
Delayed Completion of Admission MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive admission Minimum Data Set (MDS) assessments within the required time frame for nine residents. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, an admission MDS assessment must be completed no later than 14 days following admission. However, the assessments for Residents 22, 82, 112, 120, 131, 136, 153, 155, and 157 were completed between 15 to 20 days after their respective admissions, exceeding the mandated time frame. The deficiency was confirmed through a review of the Resident Assessment Instrument User's Manual, clinical records, and staff interviews. The Nursing Home Administrator acknowledged that the admission MDS assessments for the mentioned residents were not completed within the required time frames. This failure to adhere to the regulatory guidelines for timely assessments was documented under 28 Pa. Code 211.5(f) Clinical Records.
Failure to Complete Quarterly MDS Assessments on Time
Penalty
Summary
The facility failed to ensure that Quarterly Minimum Data Set (MDS) assessments were completed within the required timeframe for seven residents. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, a quarterly assessment is due every 92 days, with the completion date being the Assessment Reference Date (ARD) plus 14 days. However, the facility did not adhere to these guidelines, resulting in late assessments for several residents. Specifically, the assessments for Residents 21, 26, 64, 70, 98, 139, and 148 were completed one to three days past the required timeframe. The Nursing Home Administrator confirmed that these assessments were not completed within the required time frames. This deficiency was identified through a review of the RAI User's Manual, clinical records, and staff interviews.
Failure to Obtain Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to obtain a physician's order for the administration of oxygen for a resident. The resident, who was cognitively intact and had medical diagnoses including heart failure and respiratory failure, was observed receiving oxygen via nasal cannula at a flow rate of 2.0 liters per minute. Despite the care plan indicating that oxygen should be administered as ordered by a physician, there was no documented evidence of such an order. This deficiency was confirmed through an interview with the Nursing Home Administrator.
Failure to Document Controlled Medication Administration
Penalty
Summary
The facility failed to maintain accountability for controlled medications for three residents, as evidenced by discrepancies between the controlled drug administration records and the Medication Administration Records (MARs). For one resident, physician's orders included administering Tramadol for pain, but the MARs showed no documented evidence of administration on several dates, despite the controlled drug records indicating the medication was signed out. Similarly, another resident had orders for Ativan to manage anxiety, but the MARs lacked documentation of administration on dates when the drug was signed out. Interviews with the Director of Nursing confirmed the absence of documentation for these medications. A third resident, who was dependent on staff for daily care needs and had a diagnosis of stroke, also had discrepancies in the administration of Ativan. The controlled drug records showed the medication was signed out, but the MARs did not reflect its administration. The Director of Nursing confirmed the lack of documentation for the signed-out doses. These findings indicate a failure to adhere to the facility's medication administration policy, which requires staff to document medication administration on the MARs immediately after giving each dose.
Medication Labeling Deficiency
Penalty
Summary
The facility failed to properly label medications with the date they were opened, as required by their policy and professional standards. During a review, it was found that an opened vial of Tubersol in the medication room refrigerator on the A unit was not labeled with the date it was opened. This was confirmed by a registered nurse who acknowledged the oversight. Additionally, the facility's policy stated that multi-dose vials should be dated and discarded within 28 days unless otherwise specified by the manufacturer. However, the Tubersol package insert indicated a 30-day discard period, which was not adhered to due to the lack of labeling. Further observations revealed that insulin pens on the North B cart were also not dated when opened. Specifically, a Basaglar pen for one resident and both a Humalog and Lyumjev pen for another resident were found undated. Interviews with LPNs confirmed that these insulin pens should have been dated upon opening. Additionally, during a medication pass, an LPN administered Lyumjev to a resident without the pen being dated, which was also confirmed by the Director of Nursing. These findings indicate a failure to comply with medication labeling requirements, as outlined in the facility's policy and professional standards.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection control guidelines from CMS and CDC, specifically regarding the implementation of Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices or wounds. Three residents were identified as not having the required signage to alert staff and visitors of the need for EBP. Resident 25, who had an indwelling catheter, Resident 77, with a nephrostomy, and Resident 94, who had a vascular wound, all required EBP due to their medical conditions. However, observations revealed that there were no signs posted on their doors or walls to indicate the necessary precautions. The Director of Nursing confirmed that these residents required EBP and acknowledged the absence of the necessary signage. The facility's policy, updated in June 2024, mandates the use of EBP for residents with wounds or indwelling medical devices, regardless of MDRO colonization, and requires signs to be posted to inform staff and visitors of the precautions. The lack of signage for these residents represents a failure to comply with both the facility's policy and the updated CMS and CDC guidelines, potentially increasing the risk of infection transmission.
Non-Compliance with Care Plan Interventions for Fall Prevention and Aggressive Behavior Management
Penalty
Summary
The facility failed to follow care plan interventions to prevent falls for Resident 106, who has diagnoses including Dementia, Down's syndrome, cognitive communication deficit, unspecified Psychosis, and generalized Muscle Weakness. Despite having a severe cognitive impairment, Resident 106 experienced multiple falls resulting in injuries, including a laceration to the head requiring staples. The care plan interventions to offer toileting at specific times were not consistently followed, leading to the resident attempting to ambulate unassisted and subsequently falling. Additionally, the facility did not develop a comprehensive care plan regarding aggressive behaviors for Resident 39, who has diagnoses of Parkinson's Disease and Depression with moderate cognitive impairment. Resident 39 exhibited signs of aggression towards another resident on multiple occasions, including yelling and expressing a desire to confront the other resident physically. Despite these incidents, a comprehensive care plan addressing Resident 39's aggressive behavior was not documented or implemented by the facility.
Inadequate Monitoring and Care for Residents with PEG Tubes
Penalty
Summary
The facility failed to provide appropriate monitoring, care, and services for two residents receiving parenteral nutrition, resulting in harm to Resident 18. Resident 18, who had a percutaneous endoscopic gastrostomy (PEG) tube, experienced an infection at the site of the tube feed, leading to multiple hospital trips, IV antibiotic therapy, and pain. Despite physician orders for care of the PEG insertion site, there was a lack of documented care in the Treatment Administration Records (TARs) from October 2023 to March 2024. The resident's condition deteriorated, with symptoms including redness, irritation, bleeding, and foul-smelling drainage from the PEG site. Furthermore, Resident 18's clinical record revealed positive cultures for bacteria and yeast, leading to changes in antibiotic treatment and antifungal medications. The lack of consistent, daily care to the PEG site was highlighted during observations and interviews with facility staff, including the Infection Preventionist. The failure to provide adequate care resulted in Resident 18 experiencing ongoing pain, infection, and complications, ultimately requiring intensive medical interventions and hospital visits.
Sanitary Environment Deficiency in Kitchen Beverage Area
Penalty
Summary
The facility failed to ensure a sanitary environment in the beverage area of the kitchen. During an observation conducted in the presence of Dietitian Employee E5, a hole approximately half a foot in length and one foot in width was found on the bottom wall behind the beverage area. Additionally, the right-side wall of the beverage area had one baseball-sized hole, one ping-pong-sized hole, and a crack approximately two feet long. These observations were made on two separate occasions, and Employee E5 was unable to determine how long the cracks and holes had been present. This failure to maintain the kitchen walls in a sanitary condition constitutes a deficiency under 42 CFR 483.60(i)(2) and relevant state codes.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for two nursing units in the B Wing. Observations during the survey revealed that the carpeting in these units was worn, dirty, stained, and odorous. An interview with the Nursing Home Administrator confirmed that although a quote had been acquired to replace the carpeting, no replacement had been completed in the past year. This deficiency was noted on two of the four nursing units observed.
Violation of Residents' Rights in Ambulation and Medication Administration
Penalty
Summary
The facility failed to honor residents' rights relating to ambulation equipment and medication for two residents. Resident 100, who sustained a fall on February 16, 2024, had their walker and wheelchair removed from sight and reach to prevent unassisted ambulation. This action was taken despite the resident's inability to ambulate without the equipment and the requirement to ring the call bell for assistance, which the resident was continually educated on but failed to do. This removal prohibited Resident 100 from ambulating as desired, violating their right to self-determination and communication. Resident 145, diagnosed with dementia, refused all morning medications on three separate attempts, including when the medication was hidden in ice cream. The facility's actions to force medication administration, despite the resident's clear refusal, violated the resident's right to refuse treatment. The facility's failure to honor Resident 145's refusal of medications demonstrates a disregard for the resident's rights and preferences. These deficiencies were identified through clinical record reviews, facility documentation, and staff interviews.
Failure to Investigate Allegations of Rape and Bruises of Unknown Origin
Penalty
Summary
The facility failed to investigate bruises of unknown origin and thoroughly investigate allegations of rape for two residents. For Resident 58, who has PTSD and an anxiety disorder, the facility did not conduct a thorough investigation after the resident reported being raped during a phone call to 911. Despite the resident's claims and the involvement of two staff members who overheard the conversation, the facility did not interview other staff who might have had contact with the resident. The physician's evaluation found no physical signs of altercation but noted the resident's marked confusion and erratic behavior. The facility's documentation did not show a comprehensive investigation into the resident's allegations of rape. For Resident 100, the facility failed to investigate bruises of unknown origin. The resident was found with bruises on the right upper flank and right lateral breast, which were not consistent with a previous fall where the resident landed on the left side. The Assistant Director of Nursing assumed the bruises were from the fall, but no documentation was provided to support this assumption. The facility did not investigate the bruises to rule out abuse, leading to a failure in ensuring the resident's safety and well-being.
Failure to Timely Provide Wound Treatment
Penalty
Summary
The facility failed to timely provide wound treatment to an unstageable pressure ulcer on Resident 122's right heel. Upon admission, the resident had an unstageable wound measuring 10.0 x 9.0 cm with 80% necrotic tissue and a foul smell. The initial treatment plan was to apply betadine and cover with a dressing. However, the February 2024 Treatment Administration Record (TAR) did not include a treatment order for the wound identified on February 9, 2024. The wound did not receive any treatment until a wound consultant assessed it on February 14, 2024, five days after admission, and recommended a new treatment plan involving Dakin's solution, Santyl, and an alginate dressing. An interview with the wound nurse confirmed that the wound treatment was not initiated upon admission and that there was no documented wound treatment until the wound consultant's assessment. This delay in treatment resulted in the facility failing to ensure timely care for Resident 122's unstageable wound, as required by the resident's care plan and physician's orders.
Failure to Provide Behavioral Services for Aggressive Resident
Penalty
Summary
The facility failed to provide necessary behavioral services and treatment for a resident exhibiting aggressive behavior towards another resident. Resident 39, who has a diagnosis of Parkinson's Disease and Depression, and a moderate cognitive impairment, was involved in two incidents of aggression. On February 4, 2024, Resident 39 was observed in a power chair looking for another resident who allegedly threatened them. Despite this, there was no documentation that the physician was notified or that any interventions were implemented. The social worker spoke to Resident 39 the following day, but the resident did not recall the event. On February 9, 2024, Resident 39 was again involved in an aggressive incident in the lobby with another resident. Staff separated and redirected both residents, and the social worker managed to calm Resident 39 temporarily. However, Resident 39 returned to the lobby shortly after, looking for the other resident. Again, there was no documentation that the physician was notified or that any behavioral services or treatments were provided. The facility failed to ensure that Resident 39 received the necessary behavioral health care and services after these incidents of aggression.
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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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