Twin Pines Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in West Grove, Pennsylvania.
- Location
- 315 East London Grove Road, West Grove, Pennsylvania 19390
- CMS Provider Number
- 396114
- Inspections on file
- 22
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Twin Pines Health Care Center during CMS and state inspections, most recent first.
Surveyors found that frozen food items in the main kitchen’s walk-in freezer, including biscuits, diced carrots, spinach, and hamburger patties, were stored in opened plastic bags placed in open or unsealed cardboard boxes, rather than in properly sealed containers. These conditions were observed on multiple days in the presence of the Dietary Manager, who later confirmed that the storage methods did not meet professional food service safety standards, resulting in a deficiency citation for improper food storage.
A resident with Alzheimer’s disease, seizure disorder, and a knee contracture, who was severely cognitively impaired and dependent in all ADLs, had documented rehab recommendations for a semi‑reclining, slightly reclined high‑back wheelchair with specific trunk and leg positioning that were never added to the active care plan. The resident was later found on the floor in front of the same high‑back chair with a forehead hematoma and abrasion after being seated upright post‑meal, and a nurse reported not recalling a footrest in use. During survey observation, the resident was non‑responsive in bed while a reclined high‑back chair with footrest and board was present in the room, and the DON confirmed that the care plan did not include the rehab wheelchair positioning recommendations, showing the care plan was not revised after assessment findings.
Two residents with dysphagia and complex nutritional needs experienced significant weight loss, but staff did not promptly notify the physician or implement timely interventions. One resident with Type 2 DM lost over 7% of body weight within a month without documented physician notification or immediate adjustment of nutritional supplements. Another resident was not weighed on readmission, showed a nearly 10% loss when first weighed, and had inconsistent administration of ordered supplements due to unavailability and later discontinuation, despite documented severe malnutrition and high nutrition risk. The RD confirmed that physicians were not notified when the significant weight losses were identified and that interventions were delayed.
Surveyors found that on two reviewed days, the facility did not provide the required minimum number of nurse aides on the day shift relative to the number of residents. Staffing records showed that the nurse aide-to-resident ratio fell below the mandated standard, and the NHA acknowledged that the required nurse aide staffing ratios were not met on those days.
Surveyors determined that the facility did not maintain the required minimum of one LPN per 25 residents on several day shifts during multiple reviewed weeks. Review of staffing records showed that on multiple identified days, the number of LPNs scheduled on day shift was insufficient for the resident census. In an interview, the NHA acknowledged that the required LPN staffing ratios were not met on those days.
Surveyors determined that the facility did not consistently meet the required minimum of 3.2 hours of direct general nursing care per patient day (PPD) on several reviewed days. Staffing records for selected weeks showed that on four days the total nursing hours fell below the mandated 3.2 PPD threshold. In an interview, the NHA acknowledged that the required PPD staffing ratios were not achieved on those days.
The facility failed to notify the physician of a resident who fell from bed and sustained a fracture, delaying necessary medical intervention. Additionally, the physician was not informed of another resident's significant weight loss.
A facility failed to conduct an accurate comprehensive assessment for a resident, as a quarterly MDS incorrectly indicated a stage 2 pressure ulcer. Clinical records and staff interviews confirmed this was a data entry error, as the resident only had a skin tear, which was being treated and improving.
A facility failed to create a comprehensive care plan for a resident using supplementary oxygen. The resident, with heart failure and COPD, had an order for continuous oxygen via nasal cannula, but the care plan lacked interventions for oxygen use. The DON confirmed the oversight.
A facility failed to monitor a physician-ordered 2-liter per day fluid restriction for a resident with CHF and dementia. The clinical record lacked evidence of monitoring, and the DON confirmed the oversight. It was later determined that the resident should not have been on a fluid restriction, leading to its removal.
A resident with protein-calorie malnutrition and adult failure to thrive experienced a 6% weight loss over 14 days. The facility failed to notify the resident's physician or obtain a re-weight to verify the accuracy of the weight loss. An interview with a licensed employee confirmed these oversights.
A facility failed to follow fluid restrictions for a resident with ESRD and dementia, resulting in excess fluid intake on multiple occasions. The resident's daily fluid limit was exceeded on several dates, as confirmed by the DON.
The facility failed to maintain the privacy and confidentiality of residents' personal information on two nursing units. Computers on medication carts were left unattended with residents' physician orders displayed on multiple occasions, with several residents and staff nearby. The DON confirmed these findings.
The facility failed to complete a discharge summary on the day of a planned discharge for a resident. The resident was admitted and later discharged to home, but the discharge summary was not completed on the planned discharge day. This was communicated to the Nursing Home Administrator.
The facility failed to implement and maintain infection control practices for a resident with ESBL E. coli. Observations showed staff not following proper PPE protocols, including not wearing gowns and not washing hands. An LPN was unaware of the resident's contact precautions status, and the Infection Preventionist confirmed the lapses in adherence to the facility's policies.
Improper Storage of Frozen Food in Walk-In Freezer
Penalty
Summary
Surveyors identified a deficiency related to food safety requirements in the main kitchen’s walk-in freezer. During an observation on April 27, 2026, at 9:30 a.m., in the presence of the Dietary Manager (Employee E5), surveyors observed one bag of frozen biscuits stored inside an open plastic bag placed within an open cardboard box, and frozen diced carrots stored inside an opened plastic bag placed within an open cardboard box. These storage practices did not comply with professional standards for food service safety, as the food items were not properly sealed to prevent contamination. A subsequent observation on April 28, 2026, at 1:30 p.m., again in the presence of Employee E5, revealed additional improperly stored items in the walk-in freezer, including frozen spinach inside an opened plastic bag placed within a cardboard box and frozen hamburger patties inside an opened plastic bag placed within a cardboard box. In an interview on April 30, 2026, at 1:00 p.m., Employee E5 confirmed that the foods observed on both dates were not properly stored. These findings were communicated to the Nursing Home Administrator on April 30, 2026, at 1:40 p.m., and formed the basis of the deficiency for failure to store food in accordance with professional standards for food service safety.
Plan Of Correction
1) Immediately upon being made aware of the concern, the spinach, biscuits, and hamburgers found were all discarded as appropriate. All food that was found to have been stored improperly were immediately discarded as needed. 2) FSD completed an immediate audit of the food items stored in the walk in freezer to ensure foods were properly covered and stored within the walk-in freezer to ensure foods were properly covered and protected from contamination, freezer burn, and or any other issues that can arise from an improperly stored item. No other items were found at the time to have been stored improperly or without proper packaging/storage practices. 3) All Dietary staff was educated on proper food storage practices, facility policy, and the regulation requirements for proper food storage. This included maintain foods in covered contained or sealed packaging, preventing cross contamination, maintaining food quality, and adhering to regulatory requirement and standards. Education also provided on expectations for ongoing monitoring by all staff for freezer storage throughout each shift. 4) The FSD or designee will conduct weekly audits for one month of the walk in freezer to ensure all food is properly stored within the freezer. After one month audits will be conducted once per month to include verification that all food items are properly covered, dated if applicable, and stored to prevent contamination. 5) Findings will be reported to the QAPI committee as needed.
Failure to Update Care Plan With Rehab Wheelchair Positioning Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan to include rehabilitation recommendations for appropriate wheelchair positioning. The resident had Alzheimer’s disease, seizure disorder, and a knee contracture, with severely impaired cognition and dependence in all ADLs per a quarterly MDS. A rehab screening documented a recommendation for a semi‑reclining wheelchair, slightly reclined high‑back with trunk positioned in midline, and feet resting on leg rest calf pads due to reduced knee extension ROM. However, these specific wheelchair positioning recommendations were not incorporated into the resident’s active care plan. Prior to the survey, the resident experienced an incident in which they were found lying prone on the floor in front of their wheelchair in a common living room area, with a hematoma and abrasion to the right frontal forehead area, after having been in the same high‑back chair later observed in their room. The nurse reported the chair had been in an upright position at the time of the fall and did not recall a footrest being present. During survey observation, the resident was seen in bed, non‑responsive to repositioning or medication administration, with the high‑back chair reclined at 45 degrees and a footrest and board present in the room. The DON confirmed that the rehab recommendations for wheelchair positioning were not reflected in the resident’s care plan, demonstrating that the care plan had not been reviewed and revised to include these needs.
Plan Of Correction
1. On 4/30/26 the care plan for R9 was updated to reflect the appropriate wheel chair positioning with use of high back wheel chair. No negative outcome resulted from deficient practice. 2. All residents who utilize a high back wheel chair have the potential to be affected. DON/ designee completed audit of all residents who use a high back wheel chair to ensure that the recommended use and positioning was reflected on the care plans. Where needed, care plans were updated. 3. To prevent the potential for reoccurrence, the NHA/designee re-educated the IDT team on timely completion of all interdisciplinary plans of care and revisions as indicated by the resident's needs, wishes, or change in condition. 4. To monitor and maintain ongoing compliance, the DON/designee will audit residents with high back wheel chairs x4 weeks, then monthly x2 to ensure their care plans reflect the use and appropriate positioning of the device. The results of the audit will be forwarded to the facility QAPI committee monthly for further review and recommendations as needed.
Failure to Notify Physician and Implement Timely Interventions for Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely recognition and response to significant weight loss for two residents, including lack of physician notification and delayed nutritional interventions. One resident with diagnoses of dysphagia, oropharyngeal phase, and Type 2 DM had a documented weight of 151.9 pounds in early December and 140.9 pounds in early January, representing a 7.2% weight loss in 27 days. Despite this significant weight loss, there was no documented evidence that the physician was notified at the time the loss was identified, and no intervention was documented until early March, when the resident’s Boost Breeze supplement was increased from twice daily to three times daily. For the second resident, who also had dysphagia, oropharyngeal phase, the facility used a hospital weight of 88 pounds at readmission and did not obtain an actual weight on the day of readmission. The first in‑facility weight, taken three days later, was 79.5 pounds, reflecting a 9.7% loss from the hospital weight in three days. There was no documented evidence that the physician was notified of this significant weight loss when it was identified. The RD’s nutritional monitoring note several days later documented the weight decline, underweight BMI, variable oral intake, pureed diet with thin liquids, and ordered supplements (Boost BID and Magic Cup daily) to support caloric intake, and identified the resident as at high nutritional risk with a diagnosis of severe malnutrition. Record review of the second resident’s MAR showed that the ordered supplements were not consistently provided. The Magic Cup was not administered on multiple mornings due to “drug/item unavailable,” and Boost 8 oz BID was also not administered on several dates for the same reason. The RD later confirmed that the supplements were discontinued due to the resident’s refusal. The RD also confirmed that for both residents, the physicians were not notified of the significant weight losses and that interventions were not put in place at the time the weight losses were identified. The facility therefore did not ensure timely physician notification and implementation of interventions in response to significant weight loss for these residents.
Plan Of Correction
F 06921. On 4/30/26 the MD was made aware of significant weight losses for R 27 and R 83. Dietitian reviewed R 27 and R83, all interventions reviewed and approved by MD. 2. All resident who have experienced significant weight loss have the potential to be affected, the Dietitian/designee completed a 30 day look back to ensure that all identified significant weight losses had and intervention in place and both weight loss and intervention had been notified to the MD and were reflected in the EHR. Where applicable the notification was completed. 3. To prevent the potential for reoccurrence, the NHA/designee re-educated the IDT team on the facility weight process with an emphasis on timely provider notification of significant weight loss and implementation of interventions. 4. To monitor and maintain ongoing compliance, the DON/designee will audit residents' weights x 4 weeks, then monthly x2 to ensure any significant weight loss is communicated in a timely manner to the MD with an intervention and documented in the HER. The results of the audit will be forwarded to the facility QAPI committee monthly for further review and recommendations as needed.
Failure to Maintain Minimum Nurse Aide Day-Shift Staffing Ratios
Penalty
Summary
The facility failed to meet the required minimum nurse aide staffing ratios on the day shift, specifically the requirement of at least one nurse aide per 10 residents. Review of facility staffing data for selected weeks showed that on two dates in late December 2025, the day-shift nurse aide staffing levels did not meet this mandated ratio. The deficiency was identified through review of staffing records for the weeks of early September 2025, late December 2025, and late March 2026, which revealed that on December 29 and December 31, 2025, the number of nurse aides scheduled on the day shift was insufficient for the resident census. During an interview on April 31, 2026, the Nursing Home Administrator confirmed that the nurse aide staffing ratios were not met on those days. No specific residents, medical histories, or clinical conditions were described in the report in relation to this staffing deficiency.
Plan Of Correction
1) Staff was educated on calling off in a timely manner and following all attendance policy and procedure in regards to clocking in and out. 2) Staffing reviewed on each workday to ensure vacant nurse aide shifts are filled to meet the ratio requirements, and the hours set which have been determined by census, and the ratio requirement are accurate, and all efforts are made to replace, fill, and or meet all necessary requirements. 3) Education provided to management staff to ensure that all ratios for nursing aide staffing are adhered to in order to meet the regulated needs based on census. All processes will be reviewed with the management team in regard to utilizing the staffing call list as well as the agency platforms to acquire replacement staff if needed. 4) NHA and or designee to review staffing daily to ensure ratio requirement is met for two weeks from 5/1/26 until 5/30/26. Ongoing monthly reviews will be conducted to ensure all staffing minimums are met. All findings will be reported to the QAPI committee for continued review and revision.
Failure to Maintain Required LPN Day-Shift Staffing Ratios
Penalty
Summary
The facility failed to meet state-required LPN staffing ratios on multiple day shifts across three reviewed weeks. Review of staffing data for the weeks of September 7, 2025, December 28, 2025, and April 27, 2026, showed that the minimum requirement of one LPN per 25 residents on day shift was not met on September 7, 2025, September 13, 2025, December 28, 2025, December 29, 2025, December 31, 2025, April 25, 2026, and April 26, 2026. These findings were based solely on the facility’s own staffing records, which demonstrated insufficient LPN coverage relative to the resident census on those dates. During an interview on April 31, 2026, at 2:15 p.m., the Nursing Home Administrator confirmed that the facility did not meet the required LPN staffing ratios on the identified days. No additional resident-specific clinical information, medical histories, or conditions were documented in relation to these staffing shortfalls in the report.
Plan Of Correction
1) Staff was educated on calling off in a timely manner and following all attendance policy and procedure in regards to clocking in and out. 2) Staffing reviewed daily to ensure vacant shifts are filled to meet the ratio requirements, and the hours set which have been determined by census and the ratio requirement are accurate and all efforts are made to replace, fill, and or meet all necessary requirements. 3) Education provided to management staff to ensure that all hours, ratios, and ppd are adhered to in order to meet the regulated needs based on census. All processes will be reviewed with the management team in regard to utilizing the staffing call list as well as the agency platforms to acquire replacement staff if needed. 4) NHA and or designee to review staffing daily to ensure LPN ratio requirement is met for two weeks from 5/1/26 until 5/30/26. Ongoing monthly reviews will be conducted to ensure all staffing LPN minimum hours are met. All findings will be reported to the QAPI committee for continued review and revision.
Failure to Maintain Required 3.2 Nursing Hours Per Patient Day
Penalty
Summary
The facility failed to meet the state requirement that, effective July 1, 2024, each resident receive a minimum of 3.2 hours of direct general nursing care per patient day (PPD) over each 24-hour period. Review of staffing for the weeks of September 7, 2025, and December 28, 2025, showed that on four of twenty-one reviewed days the total nursing hours fell below this minimum. Specifically, the facility provided 3.15 PPD on September 13, 2025; 2.99 PPD on December 29, 2025; 3.03 PPD on December 31, 2025; and 3.14 PPD on January 3, 2026. During an interview on April 31, 2026, at 2:15 p.m., the Nursing Home Administrator confirmed that the required 3.2 PPD staffing ratios were not met on these dates. No additional resident-specific clinical details, medical histories, or conditions at the time of the deficiency were provided in the report.
Plan Of Correction
1) Staff was educated on calling off in a timely manner and following all attendance policy and procedure in regard to clocking in and out. 2) Staffing reviewed daily to ensure vacant shifts are filled to meet the PPD requirements which have been determined by census, and all efforts are made to replace, fill, and or meet all necessary PPD requirements. 3) Education provided to management staff to ensure that all hours, ratios, and ppd are adhered to in order to meet the regulated needs based on census. All processes will be reviewed with the management team in regard to utilizing the staffing call list as well as the agency platforms to acquire replacement staff if needed. 4) NHA and or designee to review staffing daily to ensure PPD requirement is met for two weeks from 5/1/26 until 5/30/26. Ongoing monthly reviews will be conducted to ensure all staffing minimums are met. All findings will be reported to the QAPI committee for continued review and revision.
Failure to Notify Physician of Resident's Fall and Weight Loss
Penalty
Summary
The facility failed to notify the physician of two residents regarding significant events affecting their health. Resident 72 experienced a fall from bed at approximately 5:45 a.m., was found on the floor, and complained of pain upon leg movement. Despite these events, there was no evidence that the resident's physician or nurse practitioner was notified immediately. It was only at 7:20 a.m., after the resident was unable to bear weight and continued to complain of pain, that the nurse practitioner was informed, and an x-ray was ordered. The x-ray revealed a fracture of the left femoral neck, leading to the resident's transfer to an acute care facility. The Director of Nursing confirmed that the physician was not notified at the time of the fall. Additionally, the facility failed to notify the physician of another resident, Resident 104, regarding a significant weight loss, although specific details about this resident's condition and the timeline of events were not provided in the report.
Inaccurate MDS Assessment Due to Data Entry Error
Penalty
Summary
The facility failed to conduct an accurate comprehensive assessment for a resident, identified as Resident 51, as required by regulations. A quarterly assessment MDS dated January 1, 2025, incorrectly indicated that the resident had developed a stage 2 pressure ulcer while residing in the facility. However, upon review of the clinical records and interviews with staff and the resident, it was determined that this was a data entry error. The resident's clinical records showed no orders for treatment of a stage 2 pressure ulcer, and interviews confirmed that the resident did not have such an ulcer at the time of the MDS assessment. The resident's care plan, last revised in November 2024, documented a risk for skin injury due to immobility, paraplegia, a history of stage 4 wounds, and tendon release surgery. Despite this, the resident only had a skin tear on the inner thigh, which was being treated and was improving. Interviews with the resident and staff confirmed the absence of a pressure ulcer, and the MDS Coordinator acknowledged the data entry error. This error led to the inaccurate documentation of the resident's condition in the MDS assessment.
Failure to Develop Comprehensive Care Plan for Oxygen Use
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident regarding oxygen use. The resident, who was admitted with diagnoses of acute on chronic systolic heart failure and chronic obstructive pulmonary disease, was observed using supplementary oxygen in their room. The clinical records indicated an order for continuous oxygen via nasal cannula at 2 liters per minute. However, the current care plan did not include any person-centered interventions addressing the resident's oxygen needs. The Director of Nursing confirmed the absence of a comprehensive care plan for the resident's oxygen use.
Failure to Monitor Physician-Ordered Fluid Restriction
Penalty
Summary
The facility failed to monitor a fluid restriction ordered by a physician for a resident diagnosed with congestive heart failure and dementia. The resident was admitted with a physician's order for a 2-liter per day fluid restriction. However, a review of the clinical record showed no evidence that nursing staff monitored this fluid restriction. An interview with the Director of Nursing confirmed that the nursing staff did not monitor the fluid restriction as ordered. Additionally, the Director of Nursing revealed that upon review, the resident should not have been on a fluid restriction from admission, and the restriction was subsequently removed.
Failure to Monitor Significant Weight Loss
Penalty
Summary
The facility failed to adequately monitor a resident with significant weight loss. Resident 104, diagnosed with protein-calorie malnutrition and adult failure to thrive, experienced a 6 percent weight loss over 14 days, dropping from 136.6 pounds to 128.4 pounds. The clinical record did not show evidence that the resident's physician was notified of this significant weight loss. Additionally, there was no documentation of a re-weight being obtained to verify the accuracy of the weight loss. An interview with Licensed Employee E3 confirmed that a re-weight should have been conducted and that the physician was not informed of the weight loss, which was not addressed.
Failure to Adhere to Fluid Restrictions for Dialysis Resident
Penalty
Summary
The facility failed to adhere to fluid restrictions for a resident with end-stage renal disease (ESRD) and dementia, leading to a deficiency in providing appropriate dialysis care. The resident had a physician's order for a daily fluid restriction of 1500 ml, distributed across different shifts and dietary services. However, the resident's fluid intake exceeded this limit on multiple occasions, as documented in the Fluid Task sheet. Specific instances of excess fluid intake were recorded on several dates, with amounts ranging from 180 ml to 780 ml over the prescribed limit. The Director of Nursing confirmed these findings during an interview.
Failure to Maintain Privacy and Confidentiality of Residents' Information
Penalty
Summary
The facility failed to provide privacy and confidentiality of residents' personal information on two of four nursing units (South and East). On April 2, 2024, at approximately 10:00 a.m., a computer on the medication cart in the East unit was left unattended with a resident's physician orders displayed, with several residents and staff nearby. Similar observations were made on April 3, 2024, at approximately 8:00 a.m. on the South unit, and on April 5, 2024, at approximately 8:30 a.m. on the East unit, where computers on medication carts were left unattended with residents' physician orders displayed. The Director of Nursing confirmed these findings on April 5, 2024, at 10:20 a.m.
Failure to Complete Discharge Summary on Planned Discharge Day
Penalty
Summary
The facility failed to complete a discharge summary on the day of a planned discharge for one of three residents reviewed. Resident 109 was admitted to the facility and discharged to home on March 23, 2024. However, a review of Resident 109's clinical record revealed that the discharge summary was not completed on the day of the planned discharge. This information was conveyed to the Nursing Home Administrator on April 5, 2024, at 11:00 a.m.
Failure to Implement Infection Control Practices
Penalty
Summary
The facility failed to consistently implement and maintain infection control practices for a resident requiring contact precautions. Specifically, Resident 90, who had a urinary analysis positive for Extended Spectrum Beta-Lactamase E. coli, was not properly managed according to the facility's Transmission-Based Precautions and Isolation Policy. Observations revealed that the contact precaution sign was placed face down outside the resident's room, and nursing staff were seen performing incontinence care with only gloves on, without wearing gowns as required. Additionally, staff were observed exiting the resident's room with soiled bed linens without wearing gowns and entering the room without washing their hands or donning PPE. One staff member, an LPN, was unaware that Resident 90 was on contact precautions or that the resident's UA had returned positive for ESBL E. coli. Interviews with staff confirmed the lack of adherence to the facility's infection control policies. The Infection Preventionist acknowledged that Resident 90 was on contact precautions and that all staff needed to follow the facility's transmission-based precautions and isolation policy. The failure to properly implement these precautions was confirmed by the Infection Preventionist, highlighting a significant lapse in infection control practices within the facility.
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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