Sweden Valley Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Coudersport, Pennsylvania.
- Location
- 1028 East Second Street, Coudersport, Pennsylvania 16915
- CMS Provider Number
- 395699
- Inspections on file
- 19
- Latest survey
- August 28, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Sweden Valley Manor during CMS and state inspections, most recent first.
A resident reported receiving stained coffee cups for hot beverages, and observation confirmed that most cups were stained. Documentation review showed that required weekly de-staining was not consistently performed, and Resident Council Meeting minutes indicated ongoing, unresolved concerns about dirty dining ware. The facility failed to address and resolve these grievances in a timely manner.
A resident with Medicaid coverage was charged for new eyeglasses using her personal needs allowance, despite the service being covered by Medicaid. The facility deducted payments for the glasses and an insurance premium from the resident's trust account, leaving her without personal spending money for several months. The NHA confirmed that these charges should not have been taken from the resident's personal funds.
A resident who was discharged after receiving Medicare A services did not receive the required Notice of Medicare Non-Coverage (NOMNC) at least two days before the end of covered services. Documentation and administrator interview confirmed the absence of timely notification, despite clear discharge planning and transition to home health services.
The facility did not follow its own policies requiring background and reference checks for two newly hired employees, as personnel records for a housekeeper and a cook lacked evidence of any attempt to obtain personal or professional references. This deficiency was confirmed by HR staff and identified during a review of policies, records, and staff interviews.
A resident with Alzheimer's disease and a known history of wandering was able to exit the facility despite wearing a secure care device and was later found at a nearby hospital. The facility did not promptly investigate how the resident eloped, failed to document required frequent checks, and did not immediately educate staff or review door alarm procedures following the incident.
A resident with significant weight loss was identified by the RD, who recommended a nutrition supplement twice daily, but there was a 10-day delay before the supplement was ordered and provided. No evidence was found of the supplement being given during this period, nor of further nutrition follow-up or explanation for the delay.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
The facility's main kitchen and food storage areas were found to be unsanitary, with dried spills, dust, and debris on equipment and surfaces. The coffee station, tray line, and storage areas had significant cleanliness issues, including stained jugs, broken equipment, and improper food storage practices. These conditions were reviewed with the Nursing Home Administrator and DON.
The facility failed to implement restorative nursing programs for maintaining ROM for four residents. A resident with lower extremity ROM limitations did not receive the recommended program, and another resident's plan for active ROM was not documented as completed. Additionally, a resident requiring both active and passive ROM did not receive the prescribed care, and a cognitively impaired resident's upper extremity ROM program was not documented. These deficiencies were confirmed by interviews with facility staff.
A resident experienced inadequate pain management due to the facility's failure to administer pain medication according to the physician's ordered pain scale. Despite having orders for Acetaminophen for mild pain and Tramadol for moderate to severe pain, the resident received Tramadol for lower pain levels, and Acetaminophen was not administered as needed.
A resident was observed self-administering medication without staff supervision, despite a physician's order prohibiting self-administration. The resident's medication administration record indicated that Propranolol, Sinemet, and Seroquel were administered earlier, but the medications were left in the room. The facility's administration confirmed the error.
The facility failed to maintain a clean and homelike environment on the C Nursing Unit, with observations revealing discolored and peeling sealing around a commode, dust accumulation on vents, and debris under heating units in two residents' rooms. These issues were discussed with the Nursing Home Administrator and DON.
A facility failed to ensure accurate MDS assessments for a resident admitted with pneumonia. The MDS dated August 17, 2024, incorrectly indicated an active pneumonia infection, despite no evidence of such since April 27, 2024. The DON confirmed the coding error during an interview.
A facility failed to maintain a resident's ambulation abilities as part of a nursing rehabilitation program. The resident was supposed to be ambulated with staff assistance and a wheeled walker, but there was no documented evidence of the program being completed. The DON and Nursing Home Administrator confirmed these findings, resulting in a deficiency under nursing services regulations.
A resident with macular degeneration and diabetes did not receive necessary vision services from the facility. Despite a physician's order allowing visits to eye specialists, there was no documentation of the facility offering or arranging such services. The resident's cognitive and vision impairments were noted, but the facility failed to address these needs, as confirmed by the Nursing Home Administrator and DON.
A resident with diabetes did not receive necessary foot care, resulting in elongated, thick, and yellow toenails that began to curve. The resident had not seen a podiatrist, and there was no documentation of diabetic foot care in the clinical record until after a surveyor's observation. The DON confirmed these findings.
A facility's medication error rate was found to be 7.69%, exceeding the acceptable limit of 5%. An LPN crushed extended-release tablets of Potassium Chloride and Metoprolol before administering them to a resident, contrary to guidelines that specify these medications should not be crushed. Both the LPN and the DON confirmed the error.
A resident experienced a delay in receiving a top denture due to a lack of follow-up on dental services and a misunderstanding involving her POA. Despite being cognitively intact, the resident was unaware that her denture process was halted by her POA, leading to a deficiency in timely dental care.
Failure to Address Resident Grievances Regarding Stained Coffee Cups
Penalty
Summary
A resident reported that the cups provided for hot water were stained brown. Upon observation of the kitchen's clean racks, most coffee cups were found to be stained. The dietary supervisor confirmed that evening shift dietary staff are responsible for cleaning and de-staining the cups weekly, with staff required to sign off on this task. However, review of cleaning documentation showed that the cups were only de-stained on two occasions over a six-week period, rather than weekly as required. The dietary supervisor confirmed these findings. Review of Resident Council Meeting minutes over several months revealed ongoing resident concerns about dirty utensils, glasses, and coffee cups, with repeated mentions that these issues had not been resolved. The facility did not address or resolve the residents' grievances regarding the stained coffee cups in a timely manner, as evidenced by continued complaints in multiple council meetings and lack of consistent cleaning as documented.
Improper Charges to Resident's Personal Funds for Medicaid-Covered Services
Penalty
Summary
A deficiency occurred when the facility charged a resident's personal funds for eyeglasses, a service that should have been covered by Medicaid. The resident, who is enrolled in a Medicaid plan, required new glasses following an acute vision problem and was sent to a local eye doctor. The resident reported that she had to pay for the glasses using her monthly personal needs allowance, which left her without personal spending money for several months. Clinical record review confirmed the resident's Medicaid coverage and the need for new glasses as documented by the eye doctor. Review of the resident's trust account showed deductions for medical bills related to the glasses and for an insurance premium that covers ancillary services such as vision. The Nursing Home Administrator confirmed that the charges for the glasses were taken from the resident's personal funds instead of being processed as an allowable medical expense under the resident's patient liability. The facility failed to ensure that the resident's personal needs allowance and trust account were managed in accordance with regulations, resulting in improper charges to the resident's personal funds for services covered by Medicaid.
Failure to Provide Timely Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide the required Notice of Medicare Non-Coverage (NOMNC) to a resident whose Medicare-covered services were ending. According to the review, the NOMNC, which informs beneficiaries of the termination of Medicare coverage and their right to appeal, must be delivered at least two calendar days before the end of covered services. For the resident in question, there was no evidence that this notice was given within the required timeframe. Clinical documentation showed that the resident was admitted for Medicare A services and was making progress toward discharge, with plans for home health services upon leaving the facility. Despite clear indications in the record that discharge was anticipated, the facility did not provide documentation that the resident or their representative received the NOMNC two days prior to discharge, as required by regulation. This deficiency was confirmed through both record review and interview with the Nursing Home Administrator.
Failure to Complete Required Reference Checks for New Hires
Penalty
Summary
The facility failed to implement its abuse prohibition policy by not conducting thorough investigations of prospective employees' employment histories for two out of five newly hired staff members. Specifically, the personnel records for a housekeeper and a cook did not contain any evidence that the facility attempted to obtain personal or professional reference information, as required by facility policy. The policies reviewed stated that background and reference checks must be completed and documented prior to employment offers, but these steps were not followed for the two employees in question. These findings were confirmed by the human resources staff member, who acknowledged the lack of reference checks in the personnel files. The deficiency was identified through a review of facility policies, personnel records, and staff interviews, and was discussed with the Nursing Home Administrator. The report cites violations of state code regarding management and personnel policies and procedures.
Failure to Investigate and Prevent Resident Elopement
Penalty
Summary
A resident with a history of elopement and severely impaired cognition due to Alzheimer's disease was identified as an elopement risk upon admission. The resident was ambulatory without a device and had previously wandered from home. Despite being assessed as an elopement risk and fitted with a secure care device, the resident was able to leave the facility and was found at a nearby hospital's helipad. Documentation indicated that the secure care device should have prevented exit, but there was no immediate investigation into how the resident was able to leave undetected. There was a lack of timely and thorough investigation following the elopement incident. Documentation of required 15-minute checks was missing, and there was no evidence of staff education or changes in interventions immediately after the event. Staff statements and investigation into the door alarm and secure care system were not completed until two days after the incident. Additionally, there was no documentation of secure care checks on the exit door or evidence that all staff were educated on responding to door alarms in the immediate aftermath.
Delay in Initiating Nutrition Interventions for Significant Weight Loss
Penalty
Summary
A resident experienced a significant weight loss of 9.6 pounds, or 7.1 percent, over a 30-day period, as documented in the clinical record. The registered dietitian noted the weight loss and recommended adding a nutritional supplement (Boost) twice daily to address the resident's declining meal intake. However, there was a delay of 10 days before the physician order for the supplement was entered, and there was no evidence that the supplement was provided to the resident during this period. Additionally, there was no documentation of further nutritional follow-up or explanation for the delay in implementing the recommended intervention. The resident also refused to be weighed after the initial weight loss was recorded.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Unsanitary Conditions in Kitchen and Food Storage Areas
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in the main kitchen, leading to potential food contamination. Observations revealed multiple areas of concern, including dried brown liquid spills and food splatter on walls and equipment, dust and debris accumulation, and stained and opaque plastic jugs. The coffee station area was particularly unsanitary, with a soiled cardboard box of coffee filters and a trash can covered in dried debris and spills. Further inspection of the kitchen revealed significant issues with food storage and equipment maintenance. Bag-in-box juices had sticky and dusty tubing connections, and an air compressor was covered in thick dust. The two-door cooler had a broken door gasket, and oven mitts were significantly stained with dried food. The tray line area had cracked, worn, and stained lunch trays, and carts used for food service were soiled with dried food debris and had broken or cracked surfaces. The facility's dry storage and walk-in freezer areas also exhibited unsanitary conditions. The dry storage room had thick dust on shelving units, and the walk-in freezer had significant ice buildup on the floor and shelves. Food products were stored without barriers to prevent contamination from mop water or debris. The walk-in cooler had dried food and debris on the floor, and the shelving was covered in dust and debris. The facility's failure to maintain cleanliness and proper food storage practices was reviewed with the Nursing Home Administrator and Director of Nursing.
Failure to Implement Restorative Nursing Programs for ROM
Penalty
Summary
The facility failed to implement a restorative nursing program as recommended by therapy to maintain range of motion (ROM) for four residents. Resident 22 was assessed with ROM limitations in her lower extremities, and a restorative program was recommended by physical therapy. However, there was no documented evidence that the program was implemented. Similarly, Resident 15's plan of care included a nursing rehab program for active ROM to her lower extremities, but there was no documentation indicating the program was completed. Resident 47 was to receive active ROM for his lower extremities and passive ROM for his upper extremities, as recommended by therapy, but there was no evidence of these programs being carried out. Resident 64, who had severe cognitive impairment, was to participate in an upper extremity active ROM program as tolerated, but there was no documentation of the program being completed or any refusal by the resident. These deficiencies were confirmed through interviews with the Director of Nursing, Nursing Home Administrator, and Director of Therapy.
Inadequate Pain Management for a Resident
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as Resident 48, consistent with professional standards of practice. Resident 48 reported experiencing pain in the tailbone area following a recent fall. The clinical records indicated a physician's order for Acetaminophen 325 mg, two tablets every six hours as needed for a pain level of 1-5, and Tramadol HCL 75 mg every six hours as needed for a pain level of 6-10. However, the medication administration record (MAR) for August and September 2024 showed that Tramadol was administered for pain levels of 4 and 5, which were outside the prescribed pain scale for this medication, and there was no evidence of Acetaminophen being administered on those occasions. The deficiency was confirmed through interviews with Resident 48 and a review of the MAR, which revealed that the facility staff did not adhere to the physician's ordered pain scale. This resulted in the resident receiving Tramadol for pain levels that should have been managed with Acetaminophen, according to the physician's orders. The issue was discussed with the Nursing Home Administrator and Director of Nursing, highlighting the facility's failure to administer pain medication as per the prescribed guidelines.
Medication Administration Deficiency
Penalty
Summary
The facility failed to administer medication per physician's orders for one resident. On September 17, 2024, a surveyor observed a resident lying in bed with a medicine cup containing pills on the bedside table. The resident, upon noticing the surveyor, ingested the pills without any staff present. The clinical record for this resident showed a physician's order from April 9, 2023, indicating that the resident was not permitted to self-administer medication. Despite this, the medication administration record for the same day documented that the resident was administered Propranolol, Sinemet, and Seroquel at 1:25 PM. The Nursing Home Administrator and Director of Nursing confirmed that the resident should not have had medications left in the room for self-administration.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment on the C Nursing Unit, affecting two residents. Observations on September 18, 2024, revealed that the external sealing around the base of the commode in the C Unit shower room was discolored and peeling, with a significant accumulation of dust on a ceiling vent. Further observations on September 20, 2024, showed extensive dust build-up on the heating unit vents in the rooms of two residents, along with debris accumulation under the units. These findings were confirmed during a meeting with the Nursing Home Administrator and Director of Nursing.
Inaccurate MDS Assessment for a Resident
Penalty
Summary
The facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for a resident, identified as Resident 60. Resident 60 was admitted with a diagnosis of pneumonia from a hospital setting. A review of the clinical record revealed an MDS assessment dated August 17, 2024, which incorrectly indicated that the resident still had an active pneumonia infection. However, there was no documented evidence in the clinical record to support the continuation of an active pneumonia infection since April 27, 2024. An interview with the Director of Nursing on September 19, 2024, confirmed that the pneumonia diagnosis was coded in error on the MDS.
Failure to Maintain Resident's Ambulation Program
Penalty
Summary
The facility failed to maintain a resident's ability to ambulate as part of a nursing rehabilitation program. Resident 15 was on a program that required ambulation with the assistance of one staff member and a wheeled walker, as ordered on November 7, 2023. A therapy recommendation form dated October 31, 2023, confirmed this program. However, there was no documented evidence that the ambulation program was being completed for Resident 15. The Director of Nursing and the Nursing Home Administrator were informed of these concerns and confirmed the findings on September 19, 2024. This failure to provide the necessary restorative or rehabilitation services resulted in a deficiency under 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Failure to Provide Vision Services to Resident
Penalty
Summary
The facility failed to provide necessary vision services to a resident with a history of macular degeneration and diabetes mellitus. The resident, who was admitted in 2019, expressed concerns about worsening vision and was unsure of her last vision appointment. Despite having a physician's order from February 2020 allowing visits to an optometrist and ophthalmologist, there was no evidence in the clinical records that the facility offered or arranged for vision services for the resident. The resident's Minimum Data Set Assessment indicated cognitive impairment and vision impairment, yet the facility did not document any efforts to address these needs. During a survey, the Nursing Home Administrator and Director of Nursing were unable to provide documentation showing that the resident or her responsible party was offered vision services. The facility's records lacked any indication of an eye exam being offered or conducted since the resident's admission. This deficiency was identified under 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services, highlighting the facility's failure to ensure the resident received appropriate care for her vision concerns.
Failure to Provide Diabetic Foot Care
Penalty
Summary
The facility failed to provide necessary foot care and treatment to a resident, leading to a deficiency. The resident, who was admitted with a diagnosis of diabetes, had not received diabetic foot care to manage his toenails and prevent medical complications. During an interview, the resident reported not having seen a podiatrist for his left foot. Observation revealed that the resident's toenails were elongated, with the nails on the first and second toes being thick, yellow, and beginning to curve. There was no documented evidence in the resident's clinical record indicating that the facility had initiated appropriate foot care until the surveyor's observation and interview prompted action. The Director of Nursing confirmed these findings.
Medication Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by a 7.69 percent error rate based on 26 medication opportunities with two errors. During a medication administration pass, an LPN prepared to administer Potassium Chloride 20 MEq ER and Metoprolol 100 mg ER to a resident by crushing the extended-release tablets, which is against the guidelines provided by The Institute for Safe Medication Practices. These guidelines specify that both medications should not be crushed due to their slow-release formulation. The LPN confirmed the error during an interview, and the Director of Nursing also acknowledged that the medications should not have been crushed.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide timely dental services for a resident, identified as Resident 29, who had been waiting for her top denture since at least June 2024. The process began with dental impressions made in August 2023, followed by several consults indicating ongoing treatment and adjustments needed for the denture. However, after a dental consult in March 2024, where changes to the denture were noted, there were no further records of dental visits or updates on the denture delivery. The resident expressed concern about not receiving her denture and was unaware of any issues until a recent interview. The situation was further complicated by a misunderstanding involving the resident's power of attorney (POA). An email from the consulting dental clinic indicated that the denture process was halted because the POA declined further services, despite the resident being cognitively intact and capable of making her own decisions. The resident was not informed of this decision, which contradicted her expressed wishes to continue with the denture process. The facility's failure to communicate effectively and ensure the resident's dental needs were met led to the deficiency.
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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