Twinbrook Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Erie, Pennsylvania.
- Location
- 3805 Field Street, Erie, Pennsylvania 16511
- CMS Provider Number
- 395041
- Inspections on file
- 30
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Twinbrook Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
Failure to Provide Transfer Information and Bed-Hold Notice: The DON confirmed that multiple residents transferred to the hospital had records lacking evidence that required clinical information was sent to the receiving provider and that the resident and/or representative received the written bed-hold policy notice. The affected residents had diagnoses including COPD, CHF, CKD, GERD, dialysis dependence, diabetes, dementia, and other significant conditions, but the charting did not show the required transfer documentation or bed-hold disclosure.
Failure to Provide Baseline Care Plan and Order Summary: The facility did not provide a written summary of the baseline care plan and order summary to six residents or their representatives, and the records lacked evidence of receipt or a signature verifying the summary was given. The affected residents had diagnoses including hemiplegia, DM, CKD, COPD, A-fib, GI hemorrhage, TIA/cerebral infarction, cellulitis, and pain.
The facility failed to provide oxygen as ordered for three residents with respiratory impairment. Two residents were observed with O2 concentrators set above the ordered flow rate, and one resident was observed with the concentrator set below the ordered flow rate. One resident's concentrator had no filters in place, and two residents' filters were covered with a gray fluffy substance. An RN confirmed the O2 settings were not in accordance with MD orders and that the filters should be clean per orders.
Improper Dating and Expired Medications in Medication Carts: An open inhaler on one med cart lacked an open date, and an LPN confirmed the date was missing. On another med cart, an open Humalog insulin pen was expired and two open Lantus insulin pens lacked open dates; the LPN confirmed the expired insulin should have been discarded and the Lantus pens were not dated.
PRN psychotropic meds were used without the required 14-day stop date or documented clinical rationale for continued use, and the records did not show non-pharmacological interventions were tried before administration. One resident with a pulmonary nodule, pain, and a retroperitoneal hematoma received repeated PRN lorazepam and one PRN haloperidol dose, while another resident with COPD, A-fib, and HTN received daily PRN lorazepam. The DON confirmed the missing documentation.
Failure to Transcribe Turning and Repositioning Orders: A resident with COPD, CHF, HTN, and a stage three pressure ulcer had repeated wound clinic orders for q2h turning and repositioning and avoiding direct pressure to the wound site, but the facility did not transcribe those orders into the physician orders. Observations showed the resident lying on his/her back multiple times, and the DON confirmed the orders were not transcribed.
Incomplete Dialysis Communication Records: The facility failed to maintain complete and accurate dialysis communication records for a resident receiving hemodialysis. The resident had ESRD-related dialysis dependence, DM, and GERD, with an order for hemodialysis three times weekly. Review of the dialysis communication forms showed they were not completed and/or sent for every treatment, and the resident stated the form was not always sent to dialysis. The DON confirmed there was no evidence the forms were completed for every dialysis treatment.
A resident's clinical record lacked evidence of the last time the physician reviewed, signed, and dated the resident's orders. The DON confirmed the missing physician signature documentation and stated that orders should be reviewed and signed at required physician visits, including on admission and at set intervals thereafter. The resident had diagnoses including GI hemorrhage, HTN, and TIA/cerebral infraction.
Failure to ensure required physician visits. A resident with diagnoses including GI hemorrhage, HTN, and TIA/cerebral infarction was admitted and the clinical record lacked evidence of physician visits every 30 days during the first 90 days after admission. The resident stated he/she had not seen the physician, and the DON confirmed the record did not show the required visits.
The facility failed to follow infection control practices for a resident with an indwelling catheter and another resident receiving nebulizer treatments. The room of a resident with a Foley catheter had no EBP signage and no gloves or gowns available, despite policy requiring them for device care. For another resident, the nebulizer machine was left on the bedside stand and the mask was found on the floor, contrary to policy requiring the kit to be stored in a clean, labeled bag in the resident’s drawer.
The facility failed to follow its own policies for meal supervision, nutritional assessment, and implementation of dietary interventions. A resident with CVA, hemiplegia, dysphagia, and a history of pocketing food, who was care planned to need supervision with eating, was observed eating lunch without staff present, and the speech therapist confirmed supervision was required. Several residents with conditions such as muscle wasting, morbid obesity, diabetes, heart failure, and respiratory failure experienced notable weight loss without documented comprehensive nutritional assessments after earlier dates or after admission as required. In addition, when an RD documented significant recent weight loss for a resident and recommended a reweigh, there was no evidence the reweigh occurred, and when another resident’s assessment called for adding a House Shake at dinner due to unplanned significant weight loss, there was no documentation that this supplement was added to the meal plan or orders.
The facility failed to promptly notify a physician of an abnormal potassium lab result for a resident with Alzheimer's disease, atrial flutter, muscle weakness, and hypertension. A lab specimen showed an abnormal potassium level, but documentation showed the result was not reviewed with the physician until weeks later, at which time the resident was transferred to the hospital. The facility's own policy required prompt notification of changes in a resident's condition, and the ADON confirmed there was no evidence of timely physician notification.
Surveyors observed that the facility did not maintain a sanitary, orderly, and homelike environment on two nursing units, noting brown-stained ceiling tiles in a secured unit hallway and in the East 1 resident lounge, as well as broken or missing baseboard registers in two resident rooms. These environmental issues were confirmed by the DON during the survey.
The facility did not post the required daily nurse staffing information. During an observation, surveyors were unable to locate any publicly displayed staffing posting, and the DON confirmed that the required information was not posted, resulting in a deficiency related to the licensee’s responsibilities.
On one occasion, insufficient nursing staff led to significant delays in administering medications and starting enteral feedings for three residents. Only one nurse was available during a shift, resulting in delayed care, as confirmed by staff interviews and facility records.
Surveyors found that the facility did not maintain required dishwashing machine rinse temperatures, with observed readings below the manufacturer's minimum standard. Additionally, temperature logs for the evening shift were not completed for an entire month, and staff did not consistently document or report temperature deficiencies as required.
Staff did not follow infection control protocols for Enhanced Barrier Precautions (EBP), including failing to use required PPE and perform hand hygiene during wound care for a resident with a chronic pressure ulcer. PPE was not available for residents needing EBP, and an LPN was observed handling medications with contaminated gloves after touching multiple surfaces. Staff interviews confirmed these lapses in infection control practices.
A resident with dementia and other medical conditions did not have a properly completed POLST form or documentation of advance directive wishes in their record. The only order present was for Full Code (CPR), and there was no evidence that the resident or their representative had been provided information or assistance regarding advance directives. A nurse confirmed the POLST was incomplete and not signed by a physician, resulting in inconsistent documentation of the resident's life-sustaining treatment preferences.
Surveyors observed that three resident rooms were not maintained in a clean and sanitary condition, with black substances and peeling paint on walls, and a bathroom sink that was not draining, causing a resident to use another room for personal hygiene. The Maintenance Director confirmed these issues, which were inconsistent with facility policy requiring a safe and homelike environment.
The facility did not provide written summaries of the baseline care plan and order summary to two residents with complex medical conditions, nor to their representatives, within the required timeframe after admission. This was confirmed by a registered nurse and was not documented in the residents' clinical records.
A resident with diabetes, paraplegia, and hypertension had physician orders and therapy recommendations for the use of a resting hand splint/palm roll splint to manage contractures, but no care plan was developed to address this intervention. The Therapy Director confirmed the omission of the required care plan.
A resident with diabetes, paraplegia, and hypertension, who required a palm roll splint for contracture management per physician's orders, was repeatedly observed without the splint applied as directed. Documentation did not show evidence of the splint being used as ordered, and the DON confirmed the resident was not receiving the prescribed intervention.
Surveyors found that multiple medication carts and a medication room contained open insulin pens and vials, as well as a Tubersol vial, that were either not labeled with open dates or kept past their recommended discard dates. LPNs confirmed that these medications should have been discarded according to facility policy and manufacturer guidelines.
The facility did not ensure that the DON worked full-time in the building, as required. Instead, the DON was assigned to work as a charge nurse and floor nurse on several days, which did not fulfill the full-time DON responsibilities.
Required daily nurse staffing information was not posted in a publicly accessible area, as confirmed by observation and interview with the DON.
The facility failed to follow physician's orders for lab tests for three residents, resulting in missed or delayed blood draws. A resident with COPD and respiratory failure had a CBC drawn late and a CMP not drawn at all. Another resident with COPD and dementia missed routine potassium level checks, and a third resident with diabetes did not have ordered CMP and CBC tests collected. The DON confirmed these lapses.
The facility failed to provide timely and accurate laboratory services due to an unorganized system and insufficient supplies, affecting four residents. Orders for various blood tests were not completed as required, and the laboratory binder contained incomplete documentation. The DON confirmed these issues, highlighting the facility's inability to meet residents' laboratory needs.
A facility failed to maintain a homelike environment for a resident when the baseboard heating system in their room was found detaching from the wall, creating a noticeable gap. This issue was observed during a survey, and the DON confirmed that it was not homelike and should have been addressed, as per the facility's policy requiring maintenance to ensure a comfortable environment.
The facility failed to ensure timely physician documentation for six residents, with progress notes delayed beyond the required timeframe. Residents had various medical conditions, including dementia, Alzheimer's, and diabetes. The DON confirmed the delays, which ranged from 27 to 51 days.
The facility failed to develop comprehensive care plans for four residents regarding supplemental oxygen use. Despite physician orders, the care plans lacked specific interventions to guide staff, as confirmed by the Assistant Director of Nursing. This deficiency affected residents with conditions like heart disease, COPD, and respiratory failure.
The facility failed to update care plans for three residents to reflect current care and services. One resident's care plan did not address a CPAP requirement, another's was not updated for pain management, and a third's did not reflect the correct oxygen order. The DON confirmed these deficiencies.
The facility failed to maintain cleanliness and prevent infection spread in respiratory care equipment for six residents. Observations showed outdated oxygen tubing and dirty concentrator filters, contrary to the facility's policy. A CPAP mask was also found on the floor without a barrier. The DON confirmed these issues, indicating non-compliance with physician orders.
The facility failed to maintain privacy and dignity for two residents by not covering their urinary catheter drainage bags, as required by facility policy. Observations showed the bags were visible from the hallway, and the DON confirmed the lack of privacy covers.
A facility failed to provide a written summary of the baseline care plan and order summary to a resident with chronic respiratory failure, pneumonia, and epileptic seizures within 48 hours of admission. The facility's policy requires this summary to include initial goals, medications, dietary instructions, and services to be provided. The DON confirmed the absence of this documentation in the resident's clinical record.
A facility failed to provide appropriate pain management for a resident by administering acetaminophen in excess of the manufacturer's recommendations. Despite guidelines to not exceed six tablets in 24 hours, a physician's order allowed for up to 12 tablets, leading to the resident receiving 1,000 mg doses on consecutive days. The DON confirmed the error in dosage administration.
A facility failed to follow procedures for the safe disposition of controlled medications for a resident. The review found no evidence of two licensed nurses being present and signing for the removal and destruction of a Fentanyl patch, nor documentation for the destruction or return of Methadone tablets. The Director of Nursing confirmed the lack of required documentation.
A facility did not act on a pharmacist's recommendation for a resident with heart disease and sleep apnea. The pharmacist identified medication irregularities, but the resident's record lacked a report addressing these issues. The DON confirmed the absence of the report.
Failure to Provide Transfer Information and Bed-Hold Notice
Penalty
Summary
The facility failed to provide the resident and/or resident representative with a written notice of the bed-hold policy, including how long a bed could be held during a leave of absence and the cost per day. The deficiency was identified during review of facility policy, clinical records, and staff interviews, and it involved multiple residents whose records did not show that this notice had been given when they were transferred to the hospital. The facility also failed to ensure that necessary resident information was communicated to the receiving health care provider upon transfer for nine residents: R5, R7, R8, R15, R17, R84, R94, R105, and R109. The facility policy required transfer information to include the practitioner’s contact information, resident representative contact information, advance directive information, resident status, reason for transfer, recent vital signs, diagnoses, allergies, medications including when last received, relevant labs and diagnostic tests, special instructions or precautions, and care plan goals. Clinical records for these residents showed hospital transfers, but the records lacked evidence that this required information was sent. The residents involved had varied medical histories, including COPD, CHF, hypertension, CKD, GERD, renal dialysis dependence, diabetes, chronic respiratory failure, muscle weakness, toe amputation, dysphagia, difficulty walking, gastrointestinal hemorrhage, TIA/cerebral infarction, dementia, depression, cellulitis, and dorsalgia. During an interview on 4/15/26, the DON confirmed that the records lacked evidence that the necessary clinical information was provided to the receiving healthcare provider and lacked evidence that the bed-hold policy was provided to the resident and/or representative upon transfer.
Failure to Provide Baseline Care Plan and Order Summary
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for six of 28 residents reviewed: R1, R10, R55, R56, R94, and R109. Facility policy entitled Baseline Care Plan, dated 2/2/26, stated that the person providing the written summary of the baseline care plan shall obtain a signature from the resident/representative to verify that the summary was provided and make a copy of the summary for the medical record. Clinical records for each of the six residents lacked evidence that the written summary of the baseline care plan and order summary was provided. The affected residents had multiple diagnoses documented in their records, including hemiplegia, hypertension, diabetes, solitary pulmonary nodule, pain, retroperitoneal hematoma, chronic kidney disease, low back pain, COPD, atrial fibrillation, gastrointestinal hemorrhage, transient ischemic attack/cerebral infarction, cellulitis, and dorsalgia. During an interview on 4/15/26 at 2:53 p.m., the Assistant Director of Nursing confirmed there was no evidence that the written summary of the baseline care plan and order summary were provided to these residents and/or their representatives.
Failure to Follow Oxygen Orders and Maintain Respiratory Equipment
Penalty
Summary
The facility failed to provide oxygen according to physician orders for three residents receiving respiratory care. Resident R1 had diagnoses including hemiplegia, hypertension, and diabetes, and had an order for oxygen at 4 L/min via nasal cannula every shift. Resident R5 had diagnoses including COPD, diabetes, and chronic respiratory failure, and had an order for oxygen at 2 L/min every shift. Resident R15 had diagnoses including COPD, GERD, and chronic respiratory failure, and had an order for oxygen at 4 L/min via nasal cannula every shift. Each resident also had a care plan intervention related to respiratory impairment and oxygen use per physician orders. During observations, R1 and R5 were both found with supplemental oxygen in place and the oxygen concentrator set at 3 L/min, while R15 was found with the concentrator set at 2 L/min instead of the ordered 4 L/min. In addition, R5's oxygen concentrator did not have filters in place, and R1 and R15's concentrator filters were observed with a large amount of gray fluffy substance covering them. The RN confirmed that the oxygen flow rates were not in accordance with the physician's orders and that the filters should be clean per the orders.
Improper Dating and Expired Medications in Medication Carts
Penalty
Summary
The facility failed to ensure that medications were properly dated when opened and failed to ensure an expired medication was discarded in a timely manner in two of three medication carts reviewed, specifically the East Two Cart and the South Cart. Review of the facility’s Medication Administration policy showed that expiration dates must be checked on packages and containers, that no expired medication is to be administered, and that injectable multi-dose vials are to be discarded 28 days after opening or per manufacturer guidelines. Manufacturer guidelines reviewed for Fluticasone Propionate and Salmeterol Powder indicated that the inhaler should be used within one month after opening. On observation of the East Two medication cart, an open Fluticasone Propionate and Salmeterol Powder inhaler was found without an open date, and the LPN confirmed the missing date. On observation of the South medication cart, an open Humalog insulin injector pen had an open date that showed it was expired, and two open Lantus insulin injector pens were found without open dates. The LPN confirmed that the Humalog insulin had expired and should have been discarded, and that the two Lantus insulin pens lacked open dates.
PRN Psychotropic Medications Lacked Required Rationale and Non-Pharmacological Attempts
Penalty
Summary
The facility failed to provide a clinical rationale for the continued use of PRN psychotropic medications beyond 14 days and failed to show that non-pharmacological interventions were attempted before administering PRN psychotropic medications for two residents. Facility policy stated that non-pharmacological approaches should be used unless contraindicated and that PRN psychotropic medications were subject to a 14-day stop order. During review of the clinical record for one resident admitted with diagnoses including a solitary pulmonary nodule, pain, and a retroperitoneal hematoma, a PRN order for lorazepam was entered without a stop date, and later a PRN order for haloperidol was also entered without a stop date. The record showed repeated use of lorazepam across February, March, and April 2026, and one use of haloperidol, but lacked evidence that non-pharmacological interventions were attempted before each administration. A second resident, admitted with COPD, A-fib, and hypertension, had a PRN lorazepam order entered without a stop date. The medication was used daily from March 1 through April 15, 2026, but the clinical record lacked the required clinical rationale for continued use beyond 14 days and lacked evidence that non-pharmacological interventions were attempted before administration. During interview, the DON confirmed that the PRN lorazepam and haloperidol orders lacked the required stop date or clinical rationale for continued use beyond 14 days, and that the records lacked evidence of non-pharmacological interventions before giving the PRN medications.
Failure to Transcribe Turning and Repositioning Orders
Penalty
Summary
The facility failed to transcribe physician orders for turning and repositioning for one resident with a stage three pressure ulcer. Resident R5 had diagnoses that included COPD, chronic congestive heart failure, and hypertension. The resident’s care plan included wound clinic referral and follow-up as ordered. Wound clinic visit reports showed that on 2/12/26 and on subsequent visits on 2/19/26, 2/27/26, 3/5/26, 3/12/26, 3/19/26, 3/26/26, 4/2/26, and 4/9/26, the resident returned with orders for turn and reposition every two hours and to avoid direct pressure to the wound site, including hip-to-hip repositioning at minimum every two hours. Review of the resident’s clinical record showed that these turning and repositioning orders were not transcribed into the physician orders. Observations on 4/14/26 and 4/15/26 showed Resident R5 lying in bed on his/her back at multiple times throughout the day. During interview on 4/16/26, the DON confirmed that the facility failed to transcribe the turning and repositioning orders received from the wound clinic and stated that these orders should have been transcribed into the physician orders.
Incomplete Dialysis Communication Records
Penalty
Summary
The facility failed to maintain complete and accurate records related to dialysis communication for one resident who required hemodialysis. The resident had an admission date of 11/16/20 and diagnoses that included dependence on renal dialysis, diabetes, and gastro-esophageal reflux disease. A physician order dated 11/25/25 directed hemodialysis every Tuesday, Thursday, and Saturday. Facility policy titled Hemodialysis stated that ongoing communication and collaboration with the dialysis facility was required, including communication about significant weight changes, nutritional concerns, medication administration or withholding of certain medications prior to treatment, and documentation of that communication. Review of the resident’s dialysis communication forms showed that forms were not completed and/or sent for every dialysis treatment. During interview, the resident stated that the dialysis communication form was not always sent with him/her to dialysis treatments. The DON confirmed that there was no evidence that dialysis communication forms were completed for every dialysis treatment for the resident and acknowledged that a dialysis communication form should be completed and sent with the resident for every dialysis treatment.
Physician Orders Not Signed and Dated
Penalty
Summary
The facility failed to ensure that the physician signed and dated all orders during visits for one resident, R94. Facility policy stated that the attending physician would visit residents in a timely fashion consistent with applicable state and federal requirements, and that physician orders and progress notes would be maintained in accordance with OBRA regulations and facility policy. R94 was admitted on 2/17/26 with diagnoses including gastrointestinal hemorrhage, hypertension, and transient ischemic attack/cerebral infraction. Review of R94's clinical record found no evidence of the last time the physician reviewed, signed, and dated the resident's physician orders. During interview, the DON confirmed that the physician orders for R94 lacked evidence of physician review and signature, and stated that physician orders should be reviewed and signed with every physician visit on admission, then every 30 days for the first 90 days, then every 60 days.
Failure to Ensure Required Physician Visits
Penalty
Summary
The facility failed to ensure that physician visits were conducted at least once every 30 days for the first 90 days after admission and at least every 60 days thereafter for one resident. Review of the resident’s clinical record showed an admission date of 2/17/26 and diagnoses that included gastrointestinal hemorrhage, hypertension, and transient ischemic attack/cerebral infarction. The record lacked evidence that the resident was seen by the physician every 30 days during the first 90 days after admission as required by facility policy and applicable regulations. During an interview on 4/12/26, the resident stated that he/she had not seen the physician. During an interview on 4/15/26, the DON confirmed that the clinical record lacked evidence that the resident was seen by the physician as required and stated that all residents should be seen every 30 days for the first 90 days after admission and then every 60 days thereafter.
Infection Control Lapses With EBP and Nebulizer Storage
Penalty
Summary
The facility failed to follow acceptable infection control practices related to enhanced barrier precautions for a resident with an indwelling Foley catheter. Review of the facility’s Enhanced Barrier Precautions Policy dated 2/2/26 stated that gowns and gloves must be worn during device care, clear signage must be placed at the room entry indicating the EBP requirement, and gowns and gloves must be immediately accessible. Resident R7 was admitted 8/16/22 with diagnoses including chronic kidney disease, GERD, and high blood pressure, and had a physician’s order dated 4/9/26 for an indwelling catheter. On 4/13/26, the resident was observed sitting in a wheelchair in the room with the catheter positioned below the bladder, and the room had no EBP signage and no PPE such as gloves or gowns available inside or outside the room. An LPN later confirmed that the room lacked EBP signage and appropriate PPE and that signage should have been posted with PPE readily available. The facility also failed to prevent potential cross-contamination for a resident receiving nebulizer treatments. Review of the facility’s Nebulizer Use, Cleaning, and Maintenance policy dated 2/2/26 stated that the nebulizer kit should be stored in a clean, breathable, labeled bag inside the resident’s bedside drawer. Resident R15 was admitted 7/7/22 with diagnoses including COPD, GERD, and chronic respiratory failure, and had an order for albuterol sulfate nebulization solution 2.5 mg/3 ml inhale via nebulizer twice daily dated 8/4/25. On 4/13/26, the nebulizer machine was observed sitting on the bedside stand next to the bed, and the mask was lying on the floor during two separate observations. An RN confirmed that the mask was lying on the floor and stated that it should not be on the floor and should be stored in a bag in the resident’s drawer.
Failure to Provide Meal Supervision, Nutritional Assessments, and Ordered Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate assistance and supervision with meals and to follow its own policies for nutritional assessment and interventions. One resident with a history of CVA, right-sided hemiplegia, dysphagia, and documented history of pocketing food was care planned and listed on the Kardex as needing supervision with eating. Despite this, surveyor observations during a lunch meal showed the resident eating without any staff present to supervise or assist. The speech therapist confirmed that the resident required staff supervision during meals due to dysphagia and pocketing of food and that staff should have been present during the observed lunch. The facility also failed to complete required nutritional assessments for multiple residents who experienced significant weight changes. The facility’s policy required baseline weights on admission, routine weight monitoring, and comprehensive nutritional assessments by the RD within 14 days of admission and periodically thereafter, with additional monthly reviews for high-risk residents. However, several residents with diagnoses such as muscle wasting, morbid obesity, diabetes, heart failure, respiratory failure, and muscle weakness had documented weight losses over time without corresponding nutritional assessments. Specifically, residents admitted in 2021, 2024, and 2025 had weight records showing notable decreases, yet their clinical records lacked evidence of comprehensive nutritional assessments after earlier dates, including after admission for one resident. Additionally, the facility did not implement or follow through on nutritional interventions identified in RD assessments. One resident’s nutritional assessment noted a 20-pound decrease in the past month and questioned whether the most recent weight might be an error, recommending a reweigh; the record contained no evidence that a reweigh was completed. Another resident’s nutritional assessment documented an unplanned significant weight loss over 30 days and recommended adding a House Shake at dinner, with notification to Dietary the same day; the facility’s records lacked evidence that the House Shake was added to the resident’s meal plan or orders. During an interview, the Nursing Home Administrator confirmed the absence of required nutritional assessments, the lack of meal supervision for the resident requiring it, and the failure to complete recommended nutritional interventions.
Failure to Timely Notify Physician of Abnormal Lab Result
Penalty
Summary
The facility failed to ensure timely physician notification of an abnormal laboratory result for one resident, as required by its policy on changes in a resident's condition. The facility policy dated 2/02/26 stated that the resident, attending physician, and resident representative would be promptly notified of changes in the resident's medical or mental condition or status. Resident R2 was admitted on 1/22/22 with diagnoses including Alzheimer's disease, atrial flutter, muscle weakness, and high blood pressure. A lab report in the resident's clinical record showed that a specimen collected on 11/26/25, received and reported on 11/27/25, revealed an abnormal potassium level. Progress notes documented that the abnormal potassium findings were not reviewed with the physician until 12/11/25, at which time the resident was transferred to the hospital related to the potassium level obtained on 11/26/25. The record lacked evidence that the physician was notified in a timely manner of the abnormal potassium result, despite the facility's policy requiring prompt notification of changes in condition. During an interview on 3/04/26, the Assistant Director of Nursing confirmed that there was no evidence of timely physician notification and acknowledged the lack of immediate notification regarding the abnormal potassium level from 11/26/25.
Environmental Deficiencies in Ceiling Tiles and Baseboard Registers
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable homelike environment on two of five nursing units (East 1 and the secured unit). During observations conducted with the DON at approximately 1:10 p.m. on 2/8/26, surveyors noted several brown-stained ceiling tiles in the secured unit’s common hallway and in the East 1 resident lounge. Additional observations revealed broken or missing sections of baseboard registers in two resident rooms (rooms 919 and 928). The DON confirmed the presence of the stained ceiling tiles and the damaged or missing baseboard registers at the time of the observations. No specific resident medical histories or conditions were described in relation to these environmental deficiencies.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that required daily nurse staffing information was posted. On 2/7/26 at 11:45 a.m., an observation revealed that the daily staffing posting was not publicly displayed anywhere in the facility. During an interview conducted at the time of this observation, the Director of Nursing confirmed that the required staffing information was not posted. This deficiency was cited under 28 Pa. Code 201.14(a), which addresses the responsibility of the licensee.
Delayed Medication and Enteral Feeding Due to Insufficient Nursing Staff
Penalty
Summary
The facility failed to provide sufficient nursing staff with appropriate skill sets to meet the needs of all residents, as required by facility policy and state regulations. On a specific date, there was only one nurse available for the entire building during the 3:00 p.m. to 11:00 p.m. shift, resulting in significant delays in the administration of medications and enteral feedings. Clinical records showed that one resident's enteral feeding, scheduled for 4:00 p.m., was not started until 9:42 p.m., and their Lispro Insulin, ordered before dinner at 5:00 p.m., was also delayed until 9:42 p.m. Another resident's enteral feeding, also scheduled for 4:00 p.m., was not started until 10:24 p.m., and a third resident's feeding, scheduled for 6:00 p.m., was delayed until 7:46 p.m. Multiple staff interviews confirmed that the delays were directly related to short staffing on the identified date. The only nurse on duty during the affected shift was responsible for all medication cart keys and the care of all residents, which contributed to the significant delays in medication and feeding administration. The Nursing Home Administrator also confirmed that the staffing shortages led to these delays for the affected residents.
Failure to Maintain Required Dishwashing Machine Temperatures and Incomplete Temperature Logging
Penalty
Summary
The facility failed to maintain dishwashing machine water temperatures in accordance with manufacturer recommendations for food service safety. Observations in the kitchen dishroom revealed that the dishwashing machine's rinse cycle temperature was measured at 166-168 degrees F, which is below the required minimum of 180 degrees F as specified by the manufacturer and facility policy. The Dietary Manager confirmed at the time of observation that the rinse cycle temperature did not meet the required standard. Additionally, a review of the dishwasher temperature log for the month of April 2025 showed that the evening shift did not record any dishwasher temperatures for the wash and rinse cycles for the entire month. The Dietary Manager acknowledged that staff are expected to log these temperatures and notify management and maintenance if the required temperatures are not met. These failures were confirmed through staff interviews and review of facility records.
Failure to Follow Enhanced Barrier Precautions and Infection Control Practices
Penalty
Summary
The facility failed to adhere to established infection prevention and control practices, specifically regarding Enhanced Barrier Precautions (EBP) across all five resident units. Facility policy required the use of gowns and gloves for high-contact care activities involving residents with chronic wounds, indwelling devices, or colonization/infection with multi-drug resistant organisms (MDROs). Observations revealed that staff did not don appropriate personal protective equipment (PPE), such as gowns and gloves, when providing wound care to a resident with a chronic stage three pressure ulcer who was under EBP. The staff member also failed to perform hand hygiene before the procedure and did not change gloves or wash hands after removing a soiled dressing, contrary to facility policy. Interviews with staff confirmed these lapses in following EBP protocols. Additionally, PPE was not readily available at the doorways or hallways for rooms housing residents requiring EBP, including those with chronic wounds, indwelling catheters, tube feedings, and other medical devices. During medication administration, an LPN was observed wearing gloves while preparing medications but touched multiple surfaces and personal items without changing gloves, then handled medications directly with the same gloves. The LPN also picked up dropped medications and placed them into the medication cup without changing gloves. Staff interviews confirmed awareness of the correct procedures but acknowledged the failures to follow them during the observed events.
Failure to Ensure POLST and Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that a resident's Pennsylvania Order for Life Sustaining Treatment (POLST) and physician orders were consistent and accurately reflected the resident's or their representative's wishes regarding life-sustaining treatment. Review of the clinical record for a resident with diagnoses including dementia, anxiety, and gastroesophageal reflux disease showed that the POLST form was incomplete, lacking documentation of the resident's or representative's advance directive wishes. Additionally, the only documented order in the clinical record was for Full Code (CPR), with no evidence that the resident or their representative had been provided written information on advance directives or assisted in formulating such directives. During staff interview, a registered nurse confirmed that the POLST for this resident did not reflect the required information and had not been properly completed or signed by a physician to indicate the resident's current wishes. The nurse also acknowledged that staff rely on the paper chart to determine life-sustaining treatment preferences during emergencies, but in this case, the necessary documentation was missing. This deficiency was cited under multiple Pennsylvania state codes related to management, resident rights, medical records, and resident care policies.
Failure to Maintain Clean and Sanitary Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in three resident rooms, as evidenced by multiple observations of black substances on the walls, particularly around window sills, and areas where paint was peeling off. These conditions were confirmed by the Maintenance Director, who acknowledged the presence of the black substance and the peeling paint, and stated that such conditions should not exist in resident rooms. Facility policies reviewed indicated that maintenance and housekeeping are responsible for ensuring the building is kept in good repair, free from hazards, and maintained in a sanitary and comfortable manner. Additionally, a resident reported that their bathroom sink had not drained since admission, requiring them to use another room to wash up. Multiple observations confirmed that the sink was full of water and not draining, with a brown substance running down the wall under the sink and a bubbled appearance on the wall and floor tiles extending to the toilet. The Maintenance Director confirmed these findings and agreed that the sink should drain properly and the wall and floor should not have a bubbling appearance. These deficiencies were found to be in violation of facility policy and state code regarding the responsibility of the licensee to maintain a safe and homelike environment.
Failure to Provide Baseline Care Plan Summaries Upon Admission
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan and order summary to two residents and/or their representatives within 48 hours of admission, as required by facility policy. Specifically, the clinical records for one resident with diabetes and hypertension, and another resident with diabetes, paraplegia, and hypertension, did not contain evidence that these documents were given to the residents or their representatives. This deficiency was confirmed by a registered nurse who acknowledged the absence of documentation in the clinical records for both residents.
Failure to Develop Care Plan for Hand Splint Use
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing the use of a resting hand splint/palm roll splint for one resident. The resident, who had diagnoses including diabetes, paraplegia, and hypertension, was admitted with orders and therapy recommendations for the use of a hand splint to manage contractures. Despite a therapy discharge summary and physician's order specifying the use of the splint for set periods each day, a review of the resident's care plans showed no evidence that a care plan was created for this intervention. The Therapy Director confirmed during an interview that the care plan for the splint was missing and acknowledged that it should have been developed.
Failure to Apply Physician-Ordered Palm Roll Splint for Contracture Management
Penalty
Summary
A resident with a history of diabetes, paraplegia, and hypertension was admitted to the facility and had documented limited range of motion. The resident was discharged from therapy with instructions to wear a resting hand splint on the left hand for up to 8 hours. Subsequently, a physician's order was issued for the resident to wear a palm roll splint for 4 hours in the morning and 4 hours in the evening for contracture management. However, review of the resident's documentation showed no evidence that the palm roll splint was applied as ordered. Multiple observations over several days revealed that the resident was consistently found without the palm roll splint on the left hand, despite the splint being present in the room or on the bedside stand at times, and at other times not visible in the room. During an interview, the Director of Nursing confirmed that the resident did not have the palm roll splint applied per physician's orders. This failure to provide the ordered treatment and services for contracture management constituted a deficiency in care for the resident with limited range of motion.
Failure to Discard Outdated Medications and Label Opened Drugs
Penalty
Summary
The facility failed to properly manage and discard outdated medications across multiple medication carts and a medication room. Observations revealed that open insulin pens and vials, including Lantus, Lispro, and Humalog, were found without dates indicating when they were opened, making it impossible for staff to determine appropriate discard dates. In one instance, an open Lantus insulin pen was found with an open date that exceeded the manufacturer's recommended 28-day usage period. Additionally, an open vial of Tubersol was found with an open date that was beyond the 30-day discard period specified by the manufacturer. Staff interviews confirmed that the medications in question lacked required open dates or were kept past their recommended usage periods, and staff acknowledged that these medications should have been discarded. The facility's policy requires that the expiration or beyond-use date be checked prior to administration and that the date opened be recorded on multi-dose containers, but these procedures were not followed for the medications observed.
Failure to Maintain Full-Time Director of Nursing Coverage
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) worked full-time, defined as 35 hours per week, in the building. Review of facility deployment sheets showed that the DON was assigned to work as a charge nurse and floor nurse on multiple days, rather than performing the duties of the DON. During an interview, the DON confirmed working in these alternate nursing roles instead of fulfilling the required full-time DON responsibilities, resulting in the DON not meeting the mandated hours for the position. No information about specific residents or their medical conditions was included in the report.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the required daily nurse staffing information was posted in a publicly accessible area. On 4/25/25 at 10:46 a.m., an observation revealed that the daily staffing posting was not displayed as required. This absence of posting was confirmed during an interview with the Director of Nursing at the time of the observation. No information regarding residents or their medical conditions was included in the report.
Failure to Follow Physician's Orders for Lab Tests
Penalty
Summary
The facility failed to adhere to physician's orders for laboratory blood draws for three residents, leading to a deficiency in providing appropriate treatment and care. Resident R1, diagnosed with chronic obstructive pulmonary disease, muscle weakness, and respiratory failure, had a physician's order for a Comprehensive Metabolic Panel (CMP) and a Complete Blood Count (CBC) with differential to be drawn on a specific date. However, the CBC was drawn a day late, and there was no evidence that the CMP was drawn at all. Resident R2, with diagnoses including COPD, respiratory failure, and dementia, had a physician's order for routine potassium level checks on specific days of the month, but there was no evidence that these were conducted in December. Similarly, Resident R3, diagnosed with type 2 diabetes, muscle weakness, and lack of coordination, had orders for a CMP and CBC with differential, which were not collected as ordered. The Director of Nursing confirmed these lapses during an interview, indicating a failure to follow physician's orders for laboratory testing.
Plan Of Correction
Twinbrook Healthcare acknowledges the importance of adhering to physician orders to ensure quality care and has taken immediate corrective actions to address the cited deficiencies. Following identification of the missed laboratory draws for Residents R1, R2, and R3, the attending physicians were promptly notified, and new orders for the required laboratory tests were obtained and completed. A review of the clinical records confirmed that no adverse reactions occurred as a result of the missed labs for the residents cited. To ensure ongoing compliance, the Director of Nursing (DON) or designee conducted a full audit of all current lab orders for facility residents to verify that laboratory tests were completed as ordered. No additional issues were identified during the audit. Moving forward, lab requests will be reviewed by way of electronic medical record generated reports of all physician ordered labs three (3) times a week for four (4) weeks and then monthly for two (2) months by the DON or designee to confirm compliance with physician orders. Any discrepancies will be immediately addressed, and findings will be reviewed in Quality Assurance Performance Improvement (QAPI) meetings. In addition, all nursing staff have been re-educated on the facility's policy for taking and complying with lab draw orders. Education sessions, led by the DON or designee, emphasized the importance of following physician orders for diagnostic testing and maintaining accurate documentation. Education completed by 1/20/2025, and compliance will be reinforced through ongoing training during new staff orientation and regular in-service sessions. These measures have been implemented to ensure adherence to professional standards of practice and the delivery of quality, person-centered care. Full implementation of this Plan of Correction was completed by 1/20/2025.
Deficiency in Laboratory Services and Supplies
Penalty
Summary
The facility failed to ensure an organized system and adequate supplies for timely and accurate laboratory services for four residents. Observations revealed a lack of necessary supplies for in-house blood draws. Resident R1 had a physician's order for a Comprehensive Metabolic Panel (CMP) and a Complete Blood Count (CBC) with differential, but only the CBC was drawn, and the CMP was not completed. Resident R2 had a standing order for potassium level checks, but there was no evidence of these tests being conducted as ordered in December. Resident R3's orders for a CMP and CBC with differential were not fulfilled, and Resident R4's redraw for ACTH and BNP tests was not completed as requested by the laboratory. The Director of Nursing confirmed the deficiencies, attributing them to the absence of an organized laboratory system and insufficient supplies. The facility's laboratory binder contained incomplete order sheets for all four residents, further indicating a lack of proper documentation and follow-through on laboratory orders. These findings highlight the facility's failure to meet the regulatory requirements for providing or obtaining necessary laboratory services to meet the residents' needs.
Plan Of Correction
Twinbrook Healthcare recognizes the importance of timely and accurate laboratory services to meet the needs of our residents. Following identification of the deficiencies cited, immediate corrective actions were taken to address the issues related to lab supply shortages and the organization of laboratory services. The laboratory supply room was promptly restocked to ensure an adequate supply of materials necessary for in-house blood draws. Additionally, nursing staff were re-educated by Director of Nursing (DON)/designee on the process for monitoring and replenishing laboratory supplies, and supply levels will be audited weekly for four [4] weeks and monthly for two [2] months by the Director of Nursing (DON) or designee to ensure availability of necessary items. Regarding the residents cited in the findings, the attending physicians for Residents R1, R2, R3, and R4 were immediately notified of the missed laboratory draws, and the labs were obtained and completed. A thorough audit of all current laboratory orders for facility residents was conducted to ensure compliance, and no further issues were identified. Weekly reviews of lab requests will be conducted via use of electronic medical records generated reports of physician ordered labs three (3) times a week for four [4] weeks, followed by monthly reviews for two [2] months, to confirm that laboratory tests are being ordered, documented, and completed as required. All nursing staff have been re-educated on the facility's policy for taking and complying with lab draw orders. This education, conducted by the DON or designee, emphasized the importance of adhering to physician orders, maintaining accurate documentation, and ensuring timely completion of all laboratory tests. Education completed by 1/20/2025, and compliance will continue to be reinforced through ongoing education during regular staff in-service sessions. Any discrepancies will be immediately addressed, and findings will be reviewed in Quality Assurance Performance Improvement (QAPI) meetings. Finally, it has been verified that no adverse reactions occurred as a result of the missed laboratory draws for the residents cited in this finding. Full implementation of this Plan of Correction will be completed on 1/20/2025.
Facility Fails to Maintain Homelike Environment Due to Maintenance Issue
Penalty
Summary
The facility failed to maintain a homelike environment for one of the nine residents reviewed. Specifically, the baseboard heating system in Resident R5's room was observed to be detaching from the wall, creating a noticeable gap. This observation was made during a survey on December 22, 2024, at approximately 10:30 a.m. The facility's policy, dated November 8, 2024, mandates that housekeeping and maintenance services should ensure a sanitary, orderly, and comfortable environment. During an interview later that day, the Director of Nursing confirmed that the gap was not homelike and acknowledged that it should have been repaired or replaced.
Plan Of Correction
This Plan of Correction constitutes this facility's written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state and federal law. Twinbrook Healthcare has taken immediate corrective action to address the cited deficiency and ensure the facility provides a safe, clean, comfortable, and homelike environment for all residents. The gap between the baseboard heating system and the wall in Resident R5's room was repaired on 12/22/24. Additionally, a full-house audit was conducted by the Maintenance staff and was completed on the same day to verify that all baseboard heating systems throughout the facility were securely attached to the walls. No other issues were identified during this audit. To prevent recurrence, Twinbrook Healthcare has implemented an inspection process for all baseboard heating systems to check for proper attachment to walls to maintain a homelike environment to be completed weekly for two [2] weeks and monthly for two [2] months. These inspections will be conducted by the Maintenance Director or a designated staff member for a period of two months, with findings reviewed in Quality Assurance Performance Improvement (QAPI) meetings. Any identified issues will be addressed promptly. The Maintenance Director or designee will re-educate all staff on the facility's policy regarding reporting maintenance concerns, including the importance of promptly notifying the Maintenance Department of any issues affecting the safety, cleanliness, or comfort of the environment. Re-education sessions will be completed by 1/20/2025, and ongoing education will be provided during orientation for new hires and as part of regular staff training. Through these actions, Twinbrook Healthcare reaffirms its commitment to maintaining a high standard of living for its residents, ensuring their safety and comfort at all times. Full implementation of this Plan of Correction is completed by January 20, 2025.
Physician Documentation Delays in LTC Facility
Penalty
Summary
The facility failed to ensure that physicians wrote, signed, and dated progress notes at required visits for six residents. The facility's policy mandates that attending physicians provide a progress note reflecting the resident's current status, recent history, medications, and treatments at each visit. These notes should be written or entered at the time of the visit or returned to the facility within 30 days if prepared afterward. However, the review of clinical records revealed that the progress notes for all six residents were not provided within the stipulated timeframe, ranging from 27 to 51 days after the physician's visit. The residents involved had various medical conditions, including dementia, Alzheimer's disease, anorexia, malnutrition, stroke, Type 2 Diabetes, and other complex health issues. For instance, one resident's progress note was delayed by 36 days, while another resident's note was delayed by 51 days. In one case, a resident's clinical record lacked any evidence of a physician's visit progress note 43 days after admission. The Director of Nursing confirmed during an interview that the physician did not provide the progress notes in a timely manner for placement in the residents' medical records.
Inadequate Oxygen Therapy Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for four residents, specifically regarding the use of supplemental oxygen. The facility's policy on oxygen administration requires care plans to include specific interventions based on resident assessments and physician orders. However, the clinical records for Residents R19, R51, R54, and R66 lacked evidence of such comprehensive care plans. For instance, Resident R19, with diagnoses including heart disease and obstructive sleep apnea, had a physician's order for supplemental oxygen but no corresponding care plan to guide staff. Similarly, Resident R51, with respiratory failure and other conditions, had care plans that did not adequately address the use of supplemental oxygen. Resident R54, diagnosed with heart disease and COPD, had care plans that were inconsistent with the physician's order for oxygen administration. The care plans did not provide clear guidance on the use of supplemental oxygen. Resident R66, with COPD and other serious conditions, also had a care plan that lacked specific interventions for oxygen use. The Assistant Director of Nursing confirmed that the care plans for these residents were inadequate in guiding staff on providing resident-centered care for oxygen therapy.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to review and revise comprehensive care plans to reflect the current care and services for three residents. Resident R4, who was admitted with diagnoses including obstructive sleep apnea, hypertension, diabetes, and hyperlipidemia, had a physician order for continuous positive airway pressure (CPAP) dated December 5, 2023. However, the care plan for Resident R4 lacked evidence of addressing the CPAP requirement. Similarly, Resident R20, admitted with diabetes, hypertension, and chronic kidney disease, had a care plan to address pain with a target date of April 9, 2024, but there is no indication that the care plan was updated by this date. Resident R58, with diagnoses including chronic obstructive pulmonary disease, hypertension, and anxiety, had a physician order for oxygen at four liters per minute dated January 5, 2024. The care plan for Resident R58, however, only addressed oxygen at two liters per minute with a revision date of March 28, 2024. During an interview, the Director of Nursing confirmed that the care plans for these residents were not reviewed or revised to reflect current care and services, acknowledging that care plans should be updated as required.
Deficiency in Respiratory Care Equipment Maintenance
Penalty
Summary
The facility failed to maintain cleanliness and prevent the potential spread of infection regarding respiratory care equipment for six residents. The facility's policy on oxygen administration required weekly cleaning and changing of oxygen tubing, masks, and concentrator filters, as well as the use of sterile water for humidification. However, observations revealed that the oxygen tubing for several residents was not changed as per the schedule, and the concentrator filters were covered with a white, fluffy substance, indicating they had not been cleaned. Resident R19's oxygen tubing was dated several weeks prior, and the humidifier bottle was nearly empty with the tubing disconnected. Resident R51 and Resident R54 also had outdated oxygen tubing and dirty concentrator filters. Resident R66's equipment was similarly neglected, with the oxygen tubing and concentrator filters not maintained according to the physician's orders. Additionally, Resident R4's CPAP mask was found on the floor without a protective barrier, posing a risk of contamination. The Director of Nursing confirmed the discrepancies in the maintenance of the respiratory equipment for these residents, acknowledging that the equipment should have been cleaned and changed as per the physician's orders. The failure to adhere to the facility's policy and physician's orders resulted in a deficiency in providing safe and appropriate respiratory care for the affected residents.
Failure to Ensure Privacy and Dignity for Residents with Catheters
Penalty
Summary
The facility failed to uphold the residents' rights to privacy and dignity by not covering urinary catheter drainage bags for two residents. The facility's policy on Indwelling Catheter Use and Storage, dated 4/26/24, mandates that catheter bags should be covered to maintain resident dignity and privacy. However, observations on 5/14/24 revealed that the urinary catheter drainage bags of two residents were hanging on their bed frames, visible from the hallway, and lacked privacy covers. Resident R8, who has diagnoses including neuromuscular dysfunction of the bladder, diabetes, and heart failure, was observed with an exposed catheter bag. Similarly, Resident R69, with diagnoses of diabetes, orthostatic hypotension, and venous thrombosis, also had an exposed catheter bag. The Director of Nursing confirmed during an interview that the catheter drainage bags for both residents were not covered, acknowledging that all catheter drainage bags should be covered to ensure resident privacy and dignity.
Failure to Provide Baseline Care Plan Summary
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan and order summary to a resident and/or their representative within 48 hours of admission. The facility's policy, dated 4/26/24, mandates that a written summary of the baseline care plan should be provided in a language understandable to the resident or representative. This summary must include the resident's initial goals, a summary of medications and dietary instructions, and any services and treatments to be administered by the facility. However, for a resident admitted with chronic respiratory failure, pneumonia, and epileptic seizures, there was no evidence in the clinical record that such a summary was provided. The Director of Nursing confirmed this omission during an interview, acknowledging the lack of documentation in the resident's clinical record.
Inappropriate Pain Management for a Resident
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident, identified as Resident R19, who required such services. The deficiency was identified through a review of the manufacturer's recommendations, facility policy, clinical records, and staff interviews. The manufacturer's guidelines for administering acetaminophen (Tylenol) specified not to exceed six tablets in 24 hours. However, a physician's order dated 4/12/24 instructed staff to administer two acetaminophen 500 mg tablets every four hours as needed for pain, which could result in up to 12 tablets in 24 hours, exceeding the manufacturer's recommendations. Resident R19, who had diagnoses including heart disease, irregular heartbeat, heart failure, and obstructive sleep apnea, was administered acetaminophen 1,000 mg on two separate occasions on consecutive days, further exceeding the recommended dosage. The Director of Nursing confirmed the discrepancy between the physician's order and the manufacturer's recommendations, as well as the incorrect administration of acetaminophen.
Failure in Controlled Medication Disposition Procedures
Penalty
Summary
The facility failed to implement procedures for the accurate and safe disposition of controlled medication records for a resident, identified as CR94, whose closed clinical record was reviewed. According to the facility's policy on the disposal of medications, controlled substances remaining in the nursing care center after discontinuation must be securely stored and destroyed in the presence of two licensed nurses, with documentation maintained as per federal and state regulations. However, the review revealed that there was no evidence of two licensed nurses being present and signing for the removal and destruction of Resident CR94's Fentanyl patch on two occasions. Additionally, there was no documentation of the destruction or return to the pharmacy of the resident's remaining Methadone tablets. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the lack of documentation for the required presence and signatures of two licensed nurses during the medication disposition process for Resident CR94. The absence of proper documentation and adherence to the facility's policy and state regulations regarding the handling of controlled substances was identified as a failure in the facility's pharmaceutical services, specifically concerning the safe and accurate disposition of controlled medications.
Failure to Act on Pharmacist's Recommendation for Medication Irregularities
Penalty
Summary
The facility failed to ensure that a pharmacist's recommendation was reviewed and acted upon for a resident, identified as Resident R19. According to the facility's policy on Medication Regimen Review, staff are required to address all recommendations made by the pharmacist. Resident R19, who was admitted with diagnoses including heart disease, irregular heartbeat, heart failure, and obstructive sleep apnea, had irregularities identified in their medication regimen by a consultant pharmacist on January 27, 2024. However, the clinical record for Resident R19 lacked evidence of a pharmacy recommendation report addressing these irregularities. This was confirmed during an interview with the Director of Nursing, who acknowledged the absence of the report in the resident's clinical record.
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Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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