Valley Manor Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Coopersburg, Pennsylvania.
- Location
- 7650 Route 309, Coopersburg, Pennsylvania 18036
- CMS Provider Number
- 395167
- Inspections on file
- 34
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Valley Manor Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with multiple medical conditions, including an internal cardioverter/defibrillator, did not have care plan interventions documented for monitoring and care of the device, despite this need being identified in the assessment.
A resident with dementia, diabetes, and end stage renal disease, who required extensive assistance, did not have geri sleeves applied to both arms as ordered by the physician. Multiple observations showed the resident in bed without the required arm protectors, indicating staff did not follow the physician's instructions.
Two cognitively impaired residents with multiple medical conditions were not provided with required floor mats as specified in their care plans to prevent falls. Despite documented incidents of falls and clear care plan instructions, staff failed to place mats on both sides of the bed while the residents were in bed, as confirmed by observations and staff interview.
The facility did not ensure the kitchen suppression system was inspected and serviced at required intervals. During a document review, it was found that the facility could not provide documentation for two required inspections in the prior year, with only one inspection report available. This was confirmed during an exit interview with the Administrator and maintenance staff.
The facility failed to maintain its fire alarm system, affecting the entire facility. Issues included an untested pull station due to missing keys, undocumented smoke detector sensitivity values in the basement, and detectors in Zone 4 not resetting automatically. An exit interview confirmed these deficiencies were unresolved, and the facility lacked documentation for basement smoke detector sensitivity testing.
The facility failed to maintain its sprinkler system, affecting the entire facility. Inspections revealed missing documentation, a corroded sprinkler, pending hydro tests, and low temperatures in the fire pump room risking pipe damage. Additionally, recessed sprinkler heads and a low water alert in the water tower were observed, confirming the facility's failure to ensure proper maintenance.
The facility failed to conduct fire drills once per shift per quarter, affecting the entire facility. A document review revealed missing documentation of staff participation in monthly fire drills for several months in 2024 and 2025. This deficiency was confirmed during an exit interview with the Administrator and Director of Maintenance.
The facility did not ensure that rated fire door assemblies were inspected and tested annually, as required by NFPA standards. A document review revealed the absence of documentation for inspections and tests within the past 12 months, affecting the entire facility. This was confirmed during an exit interview with the Administrator and maintenance staff.
The facility did not conduct the required annual inspection of electrical receptacles in resident care areas, affecting all resident bed locations. This deficiency was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant.
The facility failed to maintain exit egress doors with delayed egress locking arrangements, as two doors did not release after 15 seconds of pressure. This issue was confirmed by the Administrator and affected two smoke compartments.
The facility failed to maintain documentation verifying that emergency backup lights were tested monthly and that a 90-minute test was performed annually on one of its two levels. This deficiency was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant.
The facility was found to have conflicting exit signage at the Great Room entrance, with one operable sign and another disabled, leading to confusion about the correct emergency exit path. This was confirmed during an exit interview with the facility's administration and maintenance staff.
The facility did not maintain a proper hazardous area enclosure on one level. On the first floor, the soiled utility room door across from room 312 was found with paper towels stuffed into the doorframe strike plate, preventing it from latching. This was confirmed during an exit interview with the Administrator and maintenance staff.
The facility did not maintain portable fire extinguishers as per NFPA 10, with 15 out of 32 extinguishers needing replacement. An inspection on January 17, 2025, identified the issue, but the extinguishers had not been replaced by the time of the survey. This was confirmed during an exit interview with the Administrator and maintenance staff.
The facility failed to maintain smoke barrier walls, as observed on the first floor above the smoke barrier doors next to the Great Room, where an unsealed MC wire penetration was found. This deficiency was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant. The unsealed penetration compromises the smoke barrier's integrity, which is essential for maintaining a 1/2-hour fire resistance rating.
The facility failed to maintain smoke barrier doors to close tightly and resist smoke passage due to blockage by a berri lift next to room 508. This was confirmed during an exit interview with the Administrator and maintenance staff.
The facility failed to maintain HVAC exhaust diffusers, as observed in the soiled utility room of the 500 wing, where a diffuser was dislodged from the ceiling and resting on cabinets. This was confirmed by the Administrator and maintenance staff.
The facility failed to maintain proper accessibility and safety of electrical panels. A supply order was stored against high voltage switch gear handles, an exposed electrical conduit was found in the kitchen, and janitorial equipment blocked access to electrical panels in a mechanical room. These issues were confirmed by facility staff.
The facility was found to be non-compliant with electrical equipment standards due to unauthorized use of power strips and extension cords. A dehumidifier was plugged into an extension cord in the basement, and a microwave, mini-fridge, and toaster were plugged into a power strip in the Admissions Office. These findings were confirmed during an exit interview with facility staff.
A propane tank was found unsecured in the basement at the outdoor dock area, stored in front of the main electrical high voltage switch gear. This deficiency was confirmed by the Administrator and Director of Maintenance, indicating a failure to adhere to NFPA 101 standards for gas equipment storage.
The facility did not comply with smoking regulations, as cigarette butts were found accumulated in mulch beds, outside resident room windows, and along the building's side driveway, outside the designated smoking area. This was confirmed during an exit interview with the Administrator and maintenance staff.
The facility failed to maintain an emergency preparedness training program based on the Emergency Preparedness Plan, lacking documentation of initial and annual staff training. This was confirmed during an exit interview with the Administrator and other staff.
The facility failed to maintain documentation of initial and annual Emergency Preparedness training for staff and volunteers, as revealed during a document review and confirmed in an exit interview with the Administrator and Director of Maintenance.
The facility failed to conduct the required annual full-scale exercise and an additional exercise to test the emergency preparedness plan, affecting the entire facility. Document review revealed the absence of these exercises within the previous 12 months, and the lack of documentation was confirmed by the Administrator and staff during an exit interview.
The facility failed to maintain required egress clearances, with the Northeast Stair Tower being narrower than required and the Basement Level having inadequate headroom clearance. These issues were confirmed by the facility's administration.
The facility was found to have smoke compartments exceeding the maximum allowable size of 22,500 square feet in the 400 wing and First Floor, affecting two of four smoke compartments. This was confirmed through observation, document review, and interviews with facility staff.
The facility failed to maintain required emergency generator components, as the generator set in the basement lacked battery back-up emergency lighting. This deficiency was confirmed through observation and an interview with the Administrator and maintenance staff.
The facility failed to document the rationale for extending PRN anti-anxiety medications for three residents. One resident with anxiety and major depressive disorder received Ativan PRN multiple times without proper documentation. Another resident with bipolar disorder was given Ativan PRN several times, also lacking documentation. A third resident with multiple conditions, including dementia, received Ativan gel and lorazepam PRN frequently, again without the necessary documentation. The administrator confirmed the absence of documentation for extending these PRN orders.
The facility failed to follow infection control policies, leading to deficiencies in implementing Transmission-Based and Enhanced Barrier Precautions. A resident with influenza A was not managed with proper PPE, and staff were unaware of precautionary statuses due to missing signage. Additionally, residents at risk of MDROs were not managed with required protective gowns, indicating systemic issues in infection control practices.
Valley Manor Rehabilitation and Healthcare Center was found non-compliant with regulations for a safe, clean, and homelike environment. Observations included broken fixtures, missing amenities, and structural issues across multiple rooms, such as chipped paint, broken tiles, and stained curtains, indicating a failure to maintain a comfortable environment for residents.
The facility failed to provide adequate grooming and hygiene services for two residents who required extensive assistance with ADLs. One resident with dementia and diabetes was observed with long and dirty fingernails, while another resident with a history of stroke and depression had long, dirty fingernails and an unshaved beard. Both residents were able to communicate their needs, and the Director of Nursing confirmed that their grooming needs should have been addressed.
A resident with cognitive impairment and multiple medical conditions, including atrial fibrillation and diabetes, had frostbite wounds on their lower extremities. Despite a physician's order for daily wound care, the facility failed to perform the required treatments on several occasions, as confirmed by the Nursing Home Administrator.
The facility did not meet the required nurse aide (NA) to resident ratios on three occasions within a 21-day period. Specifically, the day shift failed to maintain one NA per ten residents on two days, and the evening shift did not meet the one NA per eleven residents requirement on another day.
The facility did not meet the required NA to resident ratio during a day shift, failing to provide one NA per ten residents. This was confirmed by the DON after reviewing the nursing schedules.
The facility did not meet the required minimum of 3.2 hours of direct nursing care per resident in a 24-hour period, providing only 3.17 hours on one day. This was confirmed by the DON during an interview.
Two residents in the facility were not served meals according to their preferences. A resident with anxiety and hypertension received buttered carrots despite disliking them, and another resident with heart failure and diabetes was served lemonade, which he disliked. Both residents were alert and oriented, and their meal tickets indicated their preferences, which were not followed by the dietary department.
The facility did not comply with the regulation to post menus two weeks in advance. Observations revealed that only meals for two days were posted, and the Registered Dietician confirmed that menus were not distributed to residents or posted in advance. The Nursing Home Administrator acknowledged this deficiency.
The facility did not meet the required nurse aide (NA) to resident ratios as per the regulation effective July 1, 2024. A review of nursing time schedules revealed that the facility failed to maintain the minimum NA to resident ratio during the day shift on multiple occasions and during the night shift on several dates. These deficiencies were noted over a period of seven out of 21 days reviewed.
The facility did not meet the required 3.2 hours of direct nursing care per resident per day on six occasions, with care hours ranging from 2.70 to 3.07. This was determined through a review of nursing time schedules.
A resident at high risk for elopement left the facility unattended after staff failed to respond to an alarm. The resident, who was cognitively impaired, was last seen wandering the facility and was found over three hours later, having traveled 5.5 miles away. This incident was identified as an Immediate Jeopardy situation due to inadequate supervision.
The facility failed to maintain an effective pest control program in the North unit, as flies were observed in the hallway and several rooms. The Administrator confirmed the presence of flies, indicating a lapse in pest control measures.
The facility failed to prevent and report resident-to-resident physical abuse involving a resident with a history of behavioral disturbances. Two incidents occurred where the resident pushed other residents, causing harm. These incidents were not reported to the State Licensing Agency as required by facility policy.
Failure to Address Cardiac Device in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan that addressed all identified needs for one resident. Clinical record review showed that the resident was admitted with diagnoses including atrial fibrillation, multiple wounds, heart disease, and a skin infection, and was dependent on staff for care. The resident also had a history of surgeries, including the placement of an internal cardioverter/defibrillator. Despite this, there was no documentation that the care plan included interventions to monitor and care for the internal cardioverter/defibrillator, as identified in the comprehensive assessment.
Failure to Follow Physician's Order for Geri Sleeves
Penalty
Summary
A deficiency was identified when staff failed to implement a physician's order for a resident with dementia, diabetes, and end stage renal disease. The clinical record showed that the resident was cognitively impaired and required extensive assistance with dressing. A physician's order dated April 30, 2025, directed staff to apply geri sleeves (arm protectors) to both of the resident's arms at all times except during hygiene. However, during multiple observations on May 15, 2025, the resident was found in bed without the required geri sleeves on his arms, indicating that the physician's order was not followed.
Failure to Implement Fall Prevention Interventions for Cognitively Impaired Residents
Penalty
Summary
The facility failed to implement required safety interventions for two residents who were identified as being at risk for falls. Both residents had significant medical conditions, including dementia, diabetes, end stage renal disease, heart failure, and convulsions, and were assessed as cognitively impaired and dependent on staff for bed mobility and transfers. Their care plans specifically directed staff to place mats on the floor on both sides of the bed while the residents were in bed to prevent falls. However, clinical record reviews and facility documentation showed multiple incidents where one resident slid out of bed or was found on the floor, and observations confirmed that mats were not in place as required. On the day of the survey, both residents were observed in bed without mats on either side, contrary to their care plan interventions. The Administrator confirmed during an interview that mats should have been present. These findings were based on clinical record review, facility documentation, direct observation, and staff interview, demonstrating a failure to provide adequate supervision and implement safety measures as outlined in the residents' care plans.
Failure to Maintain Kitchen Suppression System
Penalty
Summary
The facility failed to ensure that the kitchen suppression system was inspected and serviced at the required intervals. During a document review on March 12, 2025, it was found that the facility could not provide documentation showing that the kitchen suppression system had been tested and maintained twice in the prior year, as required. Only one inspection report dated January 17, 2025, was available. This deficiency was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant on the same day.
Plan Of Correction
1. Kitchen suppression system will be tested again and two inspections completed for the year in June. 2. 4/28/25 3. Maintenance staff will conduct quarterly inspections in the kitchen. 4. The Director of maintenance will keep inspection reports and conduct monthly audits x3.
Fire Alarm System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its fire alarm system components in operable condition, affecting the entire facility. During a document review on March 12, 2025, it was found that the fire alarm annual report dated May 15, 2024, listed several issues. The pull station at the nurses' station could not be tested due to the unavailability of keys needed for resetting. Additionally, the smoke detector sensitivity values were not documented for the basement detectors, and the facility needed to contact Simplex to acquire these values. Furthermore, Zone 4 required investigation as the detectors did not automatically reset. An exit interview with the Administrator, Director of Maintenance, and Assistant confirmed that these deficiencies had not been resolved. The facility also failed to provide documentation for sensitivity testing on the basement smoke detectors.
Plan Of Correction
1. Tustin Fire Alarm will be scheduled to come to the facility and complete all testing. A. Keys are now available for reset. B. Tustin visited 3/31/25 and waiting on report for basement detectors. C. Zone 4 was checked when Tustin came out. Waiting on report. 2. 4/28/25 3. Maintenance staff educated on keeping up to date with the scheduling of the fire alarm system. 4. The Director of maintenance will keep all reports up to date.
Facility Fails to Maintain Sprinkler System
Penalty
Summary
The facility failed to maintain its sprinkler system, affecting the entire facility. Documentation reviewed on March 12, 2025, revealed that only two quarterly external water tank inspections and two quarterly wet sprinkler inspections were recorded for the year 2024. During an exit interview, the Administrator, Director of Maintenance, and Assistant confirmed the absence of necessary report documentation. Additionally, the 4th quarter sprinkler inspection report from December 23, 2024, indicated several issues: a corroded sprinkler in the Dietary area needed replacement, a hydro test for the fire department connection was pending, and the fire pump room's temperature was below the required 40 degrees Fahrenheit, risking pipe damage due to potential freezing. Furthermore, the facility was advised to monitor and maintain the water level in the tank consistently. Observations made on March 12, 2025, revealed additional deficiencies. Two sprinkler heads in the basement laundry chute room were recessed into the ceiling, potentially hindering immediate water spread. Moreover, the fire alarm panel indicated a supervisory alert for low water in the water tower. These findings were confirmed during an exit interview with the facility's administration and maintenance team, highlighting the facility's failure to ensure proper maintenance and functionality of its sprinkler system.
Plan Of Correction
1. The Sprinkler system will be scheduled with Tustin for testing annually. Sprinkler heads will be adjusted. At the time of the survey, the fire pump was in test mode and was discharging water, and the facility ensures proper water is filled in the water tower. The facility will inspect the external water tank at least quarterly. 2. A. Facility will schedule replacement sprinkler with Tustin. B. Facility will contact the fire department to get hydro test scheduled. C. Report was from 2024. The temperatures were good during the site visit on 3/12/25. D. Facility currently monitors the water tank daily. E. Water was flowing during the site visit on 3/12/25. 3. Tustin will be scheduled to come in and turn sprinkler heads downwards. 4. The fire alarm panel is working properly and was completing a test which led to the low water notification. The facility has a working heater that maintains adequate temperature throughout.
Failure to Conduct Quarterly Fire Drills on Each Shift
Penalty
Summary
The facility failed to conduct fire drills once per shift per quarter, which affected the entire facility. During a document review on March 12, 2025, it was revealed that the facility could not provide accurate documentation of shift participation in monthly fire drills for several months, specifically March, May, June, August, and October of 2024, and February of 2025. This deficiency was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant, who acknowledged the lack of accurate documentation.
Plan Of Correction
1. The facility will conduct fire drills immediately on all three shifts. Going forward, the facility will create a schedule for fire drills to ensure they are completed as required. 2. 4/28/25 3. The Maintenance Director was educated on conducting the fire drills once per shift per quarter and intermittently throughout the year on different dates and times. 4. The Director of maintenance will complete random audits.
Failure to Inspect and Test Fire Door Assemblies Annually
Penalty
Summary
The facility failed to ensure that rated fire door assemblies were inspected and tested annually, as required by NFPA 101 and NFPA 80 standards. During a document review conducted on March 12, 2025, it was discovered that the facility could not provide documentation proving that the rated fire door assemblies had been inspected and tested within the previous 12 months. This deficiency affects the entire facility, as confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant on the same day.
Plan Of Correction
1. Conducted rated fire door testing and inspection of fire doors. 2. 4/28/25 3. Maintenance staff educated on completing rated fire door testing. 4. Director of maintenance will audit fire doors quarterly.
Failure to Perform Annual Electrical Inspections
Penalty
Summary
The facility failed to maintain the required inspections of electrical wiring and receptacle systems, which affected all resident bed locations. During a documentation review on March 12, 2025, it was revealed that the annual inspection of receptacles in resident care areas was not performed. This deficiency was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant on the same day.
Plan Of Correction
Facility will conduct annual receptacle testing in resident care areas. 4/28/25 Maintenance staff educated on receptacle testing. The Director of maintenance will conduct random facility audits.
Delayed Egress Door Malfunction
Penalty
Summary
The facility failed to maintain proper functioning of exit egress doors equipped with delayed egress locking arrangements. During an observation on March 12, 2025, it was noted that two exit doors did not release after 15 seconds of applying pressure against the crash bar, as required. These doors were located on the first floor, specifically door # EM-1 next to the basement stairwell and door # E4 in the dining room. The deficiency was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant, who acknowledged that the doors did not release as expected. This issue affected two of the four smoke compartments in the facility, indicating a failure to comply with the necessary safety standards for egress doors.
Plan Of Correction
1. Door # EM1 repaired and released on egress and requesting a TLW for EM4 as a door repair may be necessary to be made by an outside vendor. 2. 4/28/25 3. Doors will be checked on a monthly basis. 4. Director of maintenance or designee will conduct monthly audits to ensure doors are released after 15 seconds of applying pressure.
Emergency Lighting Documentation Deficiency
Penalty
Summary
The facility failed to maintain proper documentation for emergency lighting testing and inspection on one of its two levels. During a review conducted on March 12, 2025, it was observed that the facility did not have records verifying that emergency backup lights were tested monthly and that a 90-minute test was performed annually. This deficiency was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant, who acknowledged the lack of documentation for the emergency backup lighting tests.
Plan Of Correction
1. Facility will resume testing monthly test and completed a 90-minute test. 2. 4/28/25 3. The new director of maintenance will create a new PM binder. Maintenance staff educated on testing. 4. Audits will be conducted monthly x 3.
Conflicting Exit Signage in Facility
Penalty
Summary
The facility failed to maintain proper exit signage, as observed on March 12, 2025. At the entrance to the Great Room from the corridor, there were two exit signs providing conflicting instructions for the nearest emergency exit. One sign was operable, while the other was disabled, leading to confusion about the correct exit path. This issue was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant on the same day.
Plan Of Correction
1. Exit signage corrected and operable. The other exit sign removed. 2. 4/28/25 3. Director of maintenance will check exit signs on monthly basis. 4. Audit will be conducted monthly x 3.
Hazardous Area Enclosure Deficiency
Penalty
Summary
The facility failed to maintain a proper hazardous area enclosure on one of its two levels. During an observation on the first floor, it was noted that the soiled utility room across from room 312 had paper towels stuffed into the doorframe strike plate. This obstruction prevented the door from latching properly, compromising the integrity of the hazardous area enclosure. The issue was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant.
Plan Of Correction
1. Soiled utility room door repaired to fully close and latch. 2. 4/28/25 3. Staff education completed on regulation for NFPA 101 Standard (section 8.4) stating that "doors shall be self-closing or automatic closing." 4. Director of maintenance will conduct audits monthly x 3.
Failure to Maintain Portable Fire Extinguishers
Penalty
Summary
The facility failed to maintain portable fire extinguishers in accordance with NFPA 10, affecting 15 out of 32 extinguishers. During a documentation review on March 12, 2025, it was revealed that an annual inspection had been conducted on January 17, 2025. However, the report indicated that 15 fire extinguishers required replacement. An exit interview with the Administrator, Director of Maintenance, and Assistant confirmed that these extinguishers had not been replaced at the time of the survey.
Plan Of Correction
1. The facility will replace the 15 fire extinguishers. 2. 4/28/25 3. The maintenance director will be educated on tracking and replacing fire extinguishers as needed. 4. Monthly audits will be conducted on fire extinguisher expiration dates and that they are in good working condition.
Unsealed MC Wire Penetration in Smoke Barrier
Penalty
Summary
The facility failed to maintain smoke barrier walls, which is a requirement for ensuring fire safety. During an observation on March 12, 2025, at 3:00 p.m., it was noted that on the first floor, above the smoke barrier doors next to the Great Room, there was an unsealed MC wire penetration. This deficiency was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant at 3:15 p.m. on the same day. The unsealed penetration in the rated smoke wall compromises the smoke barrier's integrity, which is essential for maintaining a 1/2-hour fire resistance rating as per NFPA 101 standards.
Plan Of Correction
1. Unsealed wire penetration was corrected and sealed using an UL approved stop gap penetration system for sealing the penetration. 2. 3/13/25 3. The maintenance director will be educated on unsealed penetrations. 4. Audits will be conducted monthly random checks behind ceiling tiles to ensure any unsealed penetrations are not found. If found, they will be corrected at that time.
Smoke Barrier Doors Blocked by Equipment
Penalty
Summary
The facility failed to ensure that smoke barrier doors were properly inspected and maintained to fully close and resist the passage of smoke in one of two wings. During an observation on March 12, 2025, at 2:50 p.m., it was noted that the smoke barrier doors next to room 508 on the first floor did not close tightly. This issue was caused by the doors being blocked by a berri lift, which prevented them from closing smoke tight. An exit interview with the Administrator, Director of Maintenance, and Assistant confirmed that the doors were indeed blocked, inhibiting their ability to close properly. This deficiency was identified as a failure to comply with the requirements for smoke barrier doors as outlined in NFPA 101, which mandates that such doors must be self-closing or automatic-closing and able to resist the passage of smoke.
Plan Of Correction
1. The Bari lift was removed; doors close properly. 2. 3/13/25 3. Staff educated on not blocking doors. 4. Director of maintenance will conduct a round audit to ensure doors are clear once a week for 2 weeks.
HVAC Exhaust Diffuser Maintenance Deficiency
Penalty
Summary
The facility failed to maintain HVAC exhaust diffusers on one of its two levels. During an observation on the first floor, inside the soiled utility room of the 500 wing, an HVAC exhaust/intake diffuser was found dislodged from the ceiling. It was powered and resting on top of wall-mounted cabinets, positioned on the intake side. This issue was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant.
Plan Of Correction
1. HVAC exhaust/intake diffuser placed back in the ceiling. 2. 4/28/25 3. Maintenance staff educated on ensuring exhaust system is back in place. 4. Director of maintenance will audit soiled utility rooms once a month.
Electrical Panel Accessibility and Safety Deficiencies
Penalty
Summary
The facility failed to ensure that electrical panels were protected and accessible, as required by NFPA standards. During an observation in the basement at the outdoor dock area, a large central supply order was found stored, leaning on, and blocking the main electrical high voltage switch gear handles. Additionally, in the kitchen, an exposed three-wire electrical conduit was observed hanging above the dishwasher drying rack discharge, with wire nuts and electrical tape on the wires, not properly terminated into an appliance. Furthermore, janitorial equipment was found obstructing access to electrical panels in the mechanical room on the first floor, across from room 330. These deficiencies were confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant.
Plan Of Correction
Order removed from the front of the main electrical panel. A. Wires capped off and placed away from the dishwasher drying rack discharge on the same day. Housekeeping director educated on not having janitorial equipment in front of electrical panels. The Director of maintenance will conduct rounds to ensure nothing is covering the panels once a month.
Unauthorized Use of Power Strips and Extension Cords
Penalty
Summary
The facility failed to maintain proper electrical wiring and equipment usage, leading to unauthorized use of power strips and extension cords. Observations on March 12, 2025, revealed that in the basement, a dehumidifier was plugged into an extension cord powered from a ceiling receptacle. Additionally, in the Admissions Office, a microwave, mini-fridge, and toaster were plugged into a power strip. These actions were confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant, indicating non-compliance with the required standards for electrical equipment usage.
Plan Of Correction
Extension cords removed from both locations. 3/13/25 Staff educated on extension cords in facility. The Director of maintenance will conduct random facility audits.
Unsecured Propane Tank Found in Facility
Penalty
Summary
The facility failed to ensure the security of portable gas cylinders, specifically a propane tank, which was found unsecured in the basement at the outdoor dock area. This propane tank was stored in front of the main electrical high voltage switch gear, posing a potential safety hazard. The observation was made on March 12, 2025, at 12:35 p.m. During the exit interview conducted on the same day at 3:15 p.m., the Administrator, Director of Maintenance, and Assistant confirmed that the portable tank was not adequately protected. This deficiency affected one of the two levels within the facility, indicating a lapse in the facility's adherence to the NFPA 101 standards for gas equipment storage and security.
Plan Of Correction
Propane tank removed from being stored in front of main electrical panel. 4/28/25 Staff educated on not storing propane tanks in front of electrical panels. The director of maintenance will conduct random facility audits.
Failure to Maintain Smoking Area Cleanliness
Penalty
Summary
The facility failed to adhere to smoking regulations as observed on March 12, 2025. During an inspection at 9:00 a.m., it was noted that there was an accumulation of cigarette butts in the mulch beds, outside resident room windows, along the building's side driveway, and outside the designated smoking area. This indicates a lack of proper disposal and management of smoking materials in the designated smoking area. The issue was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant at 3:15 p.m. on the same day.
Plan Of Correction
1. Cigarette butts were cleaned out of the mulch. 2. 4/28/25 3. Staff were educated on cigarette smoking area. There are appropriate ashtrays and appropriate metal self-closing device to empty the ashtrays. 4. Director of maintenance will audit grounds 1x a week for 2 weeks.
Deficiency in Emergency Preparedness Training Program
Penalty
Summary
The facility was found deficient in maintaining an emergency preparedness training program as required by regulations. During a document review on March 12, 2025, it was discovered that the facility failed to provide documentation of an emergency preparedness training program that is based on the Emergency Preparedness Plan. This program should include initial and annual training for all staff members, but the necessary documentation was not available. An exit interview with the Administrator, Director of Maintenance, and Assistant confirmed the facility's failure to develop an Emergency Preparedness Plan that includes a training program. This lack of documentation and development of a comprehensive training program indicates a significant oversight in the facility's emergency preparedness efforts.
Plan Of Correction
Facility conducted an annual in-service for staff on the emergency preparedness plan and training program. 4/28/25 Staff will be educated annually to remain in compliance. Director of maintenance will audit the emergency binder monthly x3 to ensure it is up to date.
Failure to Document Emergency Preparedness Training
Penalty
Summary
The facility was found to be deficient in maintaining documentation of initial and annual Emergency Preparedness training for staff and individuals providing services, including volunteers. This deficiency was identified during a document review conducted on March 12, 2025, at 3:15 p.m. The review revealed that the facility failed to provide maintained annual documentation of Emergency Preparedness training for staff members, which is necessary to demonstrate their knowledge of emergency procedures. The deficiency was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant on the same day. The interview corroborated the findings that the facility did not have the required annual records of employee training in emergency preparedness. This lack of documentation indicates a failure to comply with the regulatory requirement to provide and document such training annually. The report does not mention any specific incidents involving patients or any immediate consequences resulting from this deficiency. The focus is solely on the facility's failure to maintain proper records of emergency preparedness training, which is a critical component of ensuring staff readiness in emergency situations.
Plan Of Correction
1. Facility conducted an annual in-service for staff on the emergency preparedness plan. 2. 4/28/25 3. Staff will be educated annually to remain in compliance. 4. Director of maintenance will audit the emergency binder monthly x3 to ensure it is up to date 8/25. Director will keep record in maintenance binder.
Failure to Conduct Required Emergency Preparedness Exercises
Penalty
Summary
The facility failed to conduct the required annual full-scale exercise and an additional exercise to test the emergency preparedness plan. This deficiency was identified during a document review conducted on March 12, 2025, at 3:15 p.m. The review revealed that the facility did not perform these exercises within the previous 12 months, which is a requirement under the emergency preparedness regulations. The deficiency affects the entire facility, as the exercises are crucial for ensuring that the emergency preparedness plan is effective and that staff are adequately trained to respond to emergencies. The lack of documentation confirming the completion of these exercises indicates a significant oversight in maintaining compliance with regulatory requirements. During the exit interview on March 12, 2025, the Administrator, Director of Maintenance, and an assistant confirmed the absence of documentation for the required exercises. This confirmation further substantiates the finding that the facility did not meet the necessary standards for emergency preparedness testing.
Plan Of Correction
1. Facility conducted a tabletop exercise on an active shooter event. 2. 4/28/25. 3. The Director of maintenance will create a schedule to have tabletop exercises annually. 4. Director of maintenance will complete random facility audits.
Egress Clearance Deficiencies
Penalty
Summary
The facility failed to maintain the minimum required clearances along the means of egress, affecting both levels of the building. During an observation, it was noted that the Northeast Stair Tower had a width of 33 inches, which is below the required width of 36 inches. Additionally, the Basement Level was found to have inadequate headroom clearance along the exit access corridor, with a height of approximately six feet, six inches, which is less than the required six feet, eight inches. These deficiencies were confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant.
Smoke Compartment Size Exceeds NFPA 101 Standards
Penalty
Summary
The facility failed to comply with NFPA 101 standards regarding the subdivision of building spaces into smoke compartments. Specifically, the smoke compartments on the 400 wing (zone two) and the First Floor (zone three), encompassing Rooms 101-111 and 101-302, exceeded the maximum allowable size of 22,500 square feet. This deficiency was identified through a combination of observation, document review, and interviews conducted on March 12, 2025. During the exit interview, the Administrator, Director of Maintenance, and Assistant confirmed that the smoke compartments were larger than permitted by the regulations.
Emergency Generator Lacks Battery Back-Up Lighting
Penalty
Summary
The facility failed to maintain the required emergency generator components, which affected the entire facility. During an observation on March 12, 2025, at 12:45 p.m., it was noted that the emergency generator set, located in the electrical room in the basement, did not have battery back-up emergency lighting. This deficiency was identified through direct observation and was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant later that day. The absence of battery back-up emergency lighting in the generator set location is a critical oversight in maintaining the essential electrical systems as required by NFPA standards. The lack of this back-up lighting could potentially compromise the facility's ability to respond effectively in an emergency situation where power is lost, although the report does not explicitly state the consequences. The deficiency was confirmed through both observation and interview, indicating a lapse in the facility's adherence to established maintenance protocols for emergency power systems.
Plan Of Correction
Director of maintenance working on finding an electrician to install a battery back-up light for the emergency generator. 4/28/25 Once electrician is scheduled, director of maintenance will continue to audit the emergency generator weekly.
Lack of Documentation for PRN Psychotropic Medications
Penalty
Summary
The facility failed to document the rationale for the continued use of PRN anti-anxiety medications for three residents who were on psychotropic medications. Resident 47, diagnosed with anxiety, major depressive disorder, and end-stage renal disease, was administered Ativan PRN multiple times from January to March 2025 without documentation from the physician to extend the PRN order beyond 14 days. Similarly, Resident 106, with peripheral vascular disease, diabetes mellitus, and bipolar disorder, received Ativan PRN several times from January to February 2025, again without the necessary documentation for extending the PRN order. Resident 128, who had major depressive disorder, metabolic encephalopathy, Parkinson's disease, type 2 diabetes mellitus, anxiety, and unspecified dementia, was administered Ativan gel PRN numerous times from November 2024 to March 2025. Additionally, this resident received lorazepam PRN frequently from January to March 2025. In both cases, there was no documentation from the physician to justify extending the PRN orders beyond the initial 14 days. The facility's administrator confirmed the lack of documentation to support the rationale for extending these PRN psychotropic medications.
Plan Of Correction
1. Orders for resident 47, resident 106, and resident 128 were reviewed by the physician and end dates for PRN psychotropic medications were applied on 3/6/25. 2. DON/ADON will audit all PRN psychotropic medication orders to ensure end dates are in place. 3. DON or Designee will educate nurses on PRN end dates and reassessment after 14 days. Education will be given to provider to document rationale for any continuation for PRN psychotropic medication. 4. DON or designee will complete audit on PRN psychotropic medication orders weekly x3, and monthly x2. Results will be presented at QAPI.
Infection Control Deficiencies in PPE and Precautionary Measures
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies, resulting in deficiencies in the implementation of Transmission-Based Precautions (TBPs) and Enhanced Barrier Precautions (EBPs) for several residents. Specifically, Resident 12, who tested positive for influenza A, was not properly managed under Droplet Precautions. Observations revealed that an environmental services worker and a registered nurse entered the resident's room without the required personal protective equipment (PPE), such as gowns and eye protection, and the nurse was unaware of the resident's precautionary status due to the absence of appropriate signage. Additionally, the facility did not implement EBPs for residents at risk of Multi-Drug Resistant Organisms (MDROs). Resident 19, with a history of open wounds, and Resident 49, with a suprapubic catheter, were not managed with the necessary protective gowns, and there was no signage indicating their precautionary status. Similar lapses were observed for Resident 86, who had a permanent catheter, and Resident 131, with an indwelling catheter, as staff entered their rooms without the required protective gowns. The Director of Nursing confirmed that the facility's policies for Droplet and Enhanced Barrier Precautions were not being followed by the staff. This lack of adherence to infection control protocols was observed across two of the three nursing units, affecting five of the 28 sampled residents, and highlights a systemic issue in the facility's infection control practices.
Plan Of Correction
1. DON/Admin rounded the facility to ensure all staff were wearing proper PPE. Signage applied to identified rooms. 2. Educated staff on donning and doffing PPE. 3. Full house re-education will be provided to all staff on the proper usage of PPE, infection control, donning and doffing PPE. 4. DON or designee will complete audits weekly x2 to ensure appropriate signs are displayed outside of resident rooms and staff are wearing proper PPE while providing care. Results will be reviewed at QAPI.
Deficiencies in Safe and Homelike Environment
Penalty
Summary
Valley Manor Rehabilitation and Healthcare Center was found to be non-compliant with the requirements for providing a safe, clean, comfortable, and homelike environment as per 42 CFR Part 483, Subpart B. During the survey conducted on March 4, 2024, several deficiencies were observed across multiple rooms in the facility's Central nursing unit. These included broken fixtures, such as a doorknob in room 103 and a closet door in room 209, as well as missing amenities like paper towels in room 103. Additionally, numerous rooms had walls that were heavily marred with chipped paint, including rooms 105, 106, 107, 111, 113, 201, 202, 209, 211, 213, and 215. Other issues included window curtains being off the rod in rooms 106, 202, and 211, and privacy curtains stained in room 211. Structural problems were also noted, such as a large hole along the baseboard in room 201, broken and missing tiles in rooms 213 and 215, and closet doors peeling and separating in rooms 107, 209, and 213. These observations indicate a failure to maintain the facility in a manner that ensures a safe and comfortable environment for residents, as required by federal and state regulations.
Plan Of Correction
1. Rooms were addressed during the visit. 2. The maintenance Director and Housekeeping Director will conduct environmental rounds together to ensure room issues are rectified and addressed. 3. The maintenance director will create a painting schedule for each room and coordinate with nursing and housekeeping until completion. Housekeeping will provide deep clean/target room schedules. Staff will be educated on utilizing maintenance work order forms to report any issues identified. Maintenance director will address work order forms as received. 4. Administrator or designee will conduct weekly audits on room rounds to ensure progress is being made in rooms and issues corrected. Data will be reviewed at QAPI.
Failure to Provide Adequate Grooming and Hygiene Services
Penalty
Summary
The facility failed to provide adequate grooming and hygiene services for two residents who required extensive assistance with activities of daily living (ADLs). Resident 49, diagnosed with dementia, diabetes mellitus, and polyneuropathy, was observed with long and dirty fingernails on two consecutive days, despite the care plan indicating that staff should trim nails on shower days. The resident was able to communicate his needs and expressed that his fingernails needed to be cut. Similarly, Resident 63, who had a history of stroke, chronic pain, and depression, was also observed with long and dirty fingernails and an unshaved beard. The care plan for this resident included interventions for nail trimming and facial hair grooming on shower days. The resident communicated his desire for his fingernails to be cut and his beard shaved. The Director of Nursing confirmed that the residents' grooming needs should have been addressed during bathing and as needed.
Plan Of Correction
1. Resident 49 fingernails were cut during survey. Resident 63 fingernails were cut, and his beard was trimmed on evening shift on 3/5/25. 2. DON/ADON did a house-wide audit on current residents listed as dependent with ADL. 3. Educated Unit managers on ADL care policy, as well as CNA's and LPNs. 4. DON or designee will conduct weekly audits during rounds to sample five dependent residents on each unit to ensure they receive nail care and facial hair grooming on shower days. Audits will be conducted weeklyx3 for two weeks, and then weeklyx4. Results will be reviewed at QAPI.
Failure to Implement Physician's Orders for Wound Care
Penalty
Summary
The facility failed to implement physician's orders for a resident with multiple medical conditions, including atrial fibrillation, chronic obstructive pulmonary disease, and diabetes mellitus. The resident, who also had cognitive impairment, was found to have multiple bilateral lower extremity wounds from frostbite. A physician's order required daily wound care, including soaking the feet, applying betadine, and using specific dressings. However, the Treatment Administration Records indicated that the wound care was not performed as ordered on several occasions. This was confirmed by the Nursing Home Administrator during an interview.
Plan Of Correction
1. Wound care was completed for resident 249 on 3/4/25. Nurses on assignment were re-educated. Wound doctor assessed residents wound on 3/5/25 and there were no signs of an infection, or any harm caused to the resident. 2. DON/ADON conducted an audit on all wounds in-house to ensure they were completed and orders followed on 3/4/25. 3. IDT reviewed and updated the facility wound care policy. DON/designee provided education on the updated wound policy to licensed nursing staff. 4. DON or Designee will complete weekly wound audits to ensure wound care is being provided as ordered. Audits will be conducted weekly x2, and monthly x1. Results will be reviewed at QAPI.
Non-Compliance with Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to comply with the mandated nurse aide (NA) to resident ratios as specified in the regulation effective July 1, 2024. During a review of nursing schedules over a 21-day period from February 13, 2025, to March 5, 2025, it was found that the facility did not meet the required staffing levels on three occasions. Specifically, on February 16 and February 23, 2025, the day shift (7:00 a.m. to 3:00 p.m.) did not have the minimum one NA per ten residents. Additionally, on March 3, 2025, the evening shift (3:00 p.m. to 11:00 p.m.) failed to maintain the required one NA per eleven residents. These deficiencies indicate a failure to adhere to the staffing regulations set forth for ensuring adequate care for residents.
Plan Of Correction
1. The facility staffs the facility to at least meet the required staffing ratios of NAs, including the use of agency staff if necessary. When there are staff callouts, the facility attempts to call other staff in and notify agency staff as well. Facility continues to focus on recruitment and retention activities. 2. Valley Manor will hold staffing meetings throughout the week to monitor staffing ratio compliance. 3. NHA or designee will educate DON/ADON/ and Nursing Supervisors on state ratio staffing regulation. 4. To monitor the corrective action and ensure that it does not recur, the DON will audit nursing staff to resident ratios weekly X4; bi-weekly X 2 and monthly X 1. The results will be reviewed at the QAPI meeting.
Non-compliance with NA to Resident Ratio
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident ratio on one of the seven days reviewed. Specifically, on January 11, 2025, during the day shift from 7:00 a.m. to 3:00 p.m., the facility did not maintain the minimum ratio of one NA per ten residents. This deficiency was identified through a review of nursing schedules covering the period from January 10 through January 16, 2025. The Director of Nursing confirmed during an interview on January 17, 2025, that the facility did not meet the required staffing ratios on the specified day.
Plan Of Correction
The facility staffs the facility to at least meet the required staffing ratios of NAs, including the use of agency staff if necessary. When there are staff call outs, the facility attempts to call other staff in and notify agency staff as well. Facility continues to focus on recruitment and retention activities. Valley Manor will hold staffing meetings throughout the week to monitor staffing ratio compliance. NHA or designee will educate DON/ADON/ and Nursing Supervisors on state ratio staffing regulation. To monitor the corrective action and ensure that it does not recur, the DON will audit nursing staff to resident ratios weekly X4; bi-weekly X 2 and monthly X 1. The results will be reviewed at the QAPI meeting.
Deficiency in Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident in a 24-hour period. This deficiency was identified during a review of nursing schedules for the week of January 10 through January 16, 2025. Specifically, on January 11, 2025, the facility provided only 3.17 hours of care per resident, falling short of the mandated minimum. This shortfall was confirmed by the Director of Nursing during an interview conducted on January 17, 2025.
Plan Of Correction
The facility staffs the facility to at least meet the required staffing ratios of NAs, including the use of agency staff if necessary. When there are staff call outs, the facility attempts to call other staff in and notify agency staff as well. The facility continues to focus on recruitment and retention activities. Valley Manor will hold staffing meetings throughout the week to monitor state staffing ppd compliance. NHA or designee will educate DON/ADON/ and Nursing Supervisors on state staffing ppd regulation. To monitor the corrective action and ensure that it does not recur, the DON will audit PPD weekly X4; bi-weekly X 2 and monthly X 1. The results will be reviewed at the QAPI meeting.
Failure to Accommodate Resident Meal Preferences
Penalty
Summary
The facility failed to ensure that residents were served meals according to their preferences, as evidenced by the experiences of two residents. Resident 2, who has a diagnosis of anxiety and hypertension, was served a lunch that included buttered carrots, despite her meal tray ticket indicating a dislike for carrots. The resident confirmed that she was not offered a substitute and often received items she did not prefer. This incident was observed on January 3, 2025, and the resident was alert and oriented at the time. Similarly, Resident 3, who has heart failure and diabetes, was served lemonade with his meal, even though his meal ticket specified that he disliked lemonade. The resident, who was also alert and oriented, confirmed that he frequently received lemonade despite his stated preference. The dietary department was expected to follow the residents' preferences as identified on the meal tickets, but this was not adhered to in these cases.
Plan Of Correction
Facility provided re-education to the dietary staff on following food preferences listed for residents. NHA/Food Service Director will review job functions of the dietary tray line with the tray line staff. Re-education will include having last person on the tray line double checking items on tray against items listed on preferences. NHA/Designee will conduct audits 3 times a week for 2 weeks, then weekly for 4 weeks to ensure residents are being served items according to their listed preferences. All results will be reported to the QAPI Committee.
Failure to Post Menus Two Weeks in Advance
Penalty
Summary
The facility failed to comply with the regulation requiring menus to be planned and posted at least two weeks in advance. During a tour of the facility, it was observed that the menus posted on the nursing units only included lunch and dinner meals for January 3 and 4, 2025, rather than the required two-week advance posting. In an interview, the Registered Dietician admitted that menus were neither given to residents nor posted two weeks in advance. The Nursing Home Administrator confirmed this deficiency, acknowledging that the facility did not meet the regulatory requirement for menu posting and distribution.
Plan Of Correction
Dietary Director was posting menus in a common area daily; the NHA re-educated the director on posting menus two weeks in advance. Dietary Director will distribute two weeks' worth of menus at least weekly to residents and have them posted as well. NHA/Designee will conduct audits to ensure two weeks' worth of menus are posted and available for residents. Audit will be conducted weekly at 4 weeks, then monthly x 2. All results will be reported to the QAPI Committee.
Non-Compliance with Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to comply with the mandated nurse aide (NA) to resident ratios as specified in the regulation effective July 1, 2024. During a review of nursing time schedules from December 2 through 22, 2024, it was found that the facility did not meet the required staffing levels on several occasions. Specifically, the facility did not maintain the minimum ratio of one NA per 10 residents during the day shift on December 8, 9, 14, 15, 20, and 21, 2024. Additionally, the facility failed to meet the minimum ratio of one NA per 15 residents during the night shift on December 8, 9, 10, 14, and 15, 2024. These deficiencies were identified over a period of seven out of the 21 days reviewed.
Plan Of Correction
The facility staffs the facility to at least meet the required staffing ratios of NAs, including the use of agency staff if necessary. When there are staff call outs, the facility attempts to call other staff in and notify agency staff as well. The facility continues to focus on recruitment and retention activities. Valley Manor will hold staffing meetings throughout the week to monitor staffing ratio compliance. The NHA or designee will educate the DON/ADON and Nursing Supervisors on state ratio staffing regulation. To monitor the corrective action and ensure that it does not recur, the DON will audit nursing staff to resident ratios weekly for 4 weeks, bi-weekly for 2 weeks, and monthly for 1 month. The results will be reviewed at the QAPI meeting.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day. A review of nursing time schedules from December 2 through 22, 2024, revealed that on six specific days, the facility did not meet this requirement. On December 8, 9, 10, 13, 14, and 15, 2024, the care hours per resident were 2.70, 2.92, 2.93, 3.07, 2.97, and 2.81, respectively. This deficiency was identified based on the analysis of the nursing time schedules, indicating a shortfall in the required nursing care hours for the residents on these days.
Plan Of Correction
The facility staffs the facility to at least meet the required staffing ratios of NAs, including the use of agency staff if necessary. When there are staff call outs, the facility attempts to call other staff in and notify agency staff as well. The facility continues to focus on recruitment and retention activities. Valley Manor will hold staffing meetings throughout the week to monitor state staffing ppd compliance. The NHA or designee will educate DON/ADON and Nursing Supervisors on state staffing ppd regulation. To monitor the corrective action and ensure that it does not recur, the DON will audit nursing staff to resident ratios weekly X4; bi-weekly X2 and monthly X1. The results will be reviewed at the QAPI meeting.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide necessary supervision to prevent an elopement incident involving a resident at high risk for elopement. The resident, who had been identified as cognitively impaired and at risk for elopement since admission, was last seen wandering the facility at approximately 5:00 a.m. on the day of the incident. The resident managed to push open the front door of the facility and leave unattended, despite the presence of an alarm system. Staff failed to respond to the alarm, allowing the resident to leave the premises. The resident was found over three hours later, approximately 5.5 miles away from the facility, having crossed a four-lane highway and walked on unlit rural roads. The incident was identified as an Immediate Jeopardy situation due to the lack of adequate supervision and monitoring of the resident's whereabouts, which was a direct violation of the facility's elopement policy. The deficiency was noted as past non-compliance, and the facility was required to implement a corrective action plan.
Pest Control Deficiency in North Unit
Penalty
Summary
The facility failed to maintain an effective pest control program in one of its three nursing units, specifically the North unit. On July 25, 2024, at 10:42 a.m., flies were observed in the hallway and in rooms 304, 308, 405, and 407. A subsequent observation on the same day at 11:38 a.m. confirmed the presence of flies in the hallway and in rooms 303, 304, 308, 405, and 407. During an interview conducted on July 25, 2024, at 12:40 p.m., the Administrator confirmed the presence of flies on the North unit, indicating a lapse in the facility's pest control measures.
Failure to Prevent and Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident physical abuse and did not report the incidents to the State Licensing Agency. Resident 1, who had a history of behavioral disturbances including yelling, screaming, cursing, and pushing others, was involved in two incidents of physical abuse. On March 8, 2024, Resident 1 was documented pushing Resident 6 against a soda machine and attempting to hit them. This incident was not reported by the shift supervisor or investigated by the Administrator, Director of Nursing, or Risk Manager until March 19, 2024. On March 14, 2024, Resident 1 was involved in another incident where he pushed Resident 2, causing them to fall to the ground after a verbal altercation. This incident was also not reported to the State Licensing Agency. The facility's policy on abuse prevention and reporting was not followed, as confirmed by the Administrator and Director of Nursing during an interview on March 19, 2024. The facility's failure to report and investigate these incidents in a timely manner constitutes a deficiency in ensuring resident safety and compliance with state regulations.
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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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