Valley View Rehab And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Montoursville, Pennsylvania.
- Location
- 2140 Warrensville Road, Montoursville, Pennsylvania 17754
- CMS Provider Number
- 395895
- Inspections on file
- 28
- Latest survey
- April 10, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Valley View Rehab And Nursing Center during CMS and state inspections, most recent first.
Unsafe food storage and sanitation lapses were observed in the main kitchen and resident pantries. Surveyors found unprotected serving ware, debris on cups and trays, dirty and damaged kitchen surfaces and equipment, open food items exposed to ambient air, mold-like buildup on a food container, expired items, and multiple missing tray line temp logs with no evidence temps were checked before serving. In the 700 and 300 unit pantries, expired coffee and warm refrigerated drinks were found, including items that should have been kept refrigerated.
Failure to document bed entrapment risk assessments for assist bars. The facility marked Zone 6 as "Does Not Apply" for several residents with headboards and enabler bars, including residents with gait, mobility, weakness, and ADL deficits. Records showed no further documentation that Zone 6 was assessed for entrapment risk, and an MDS staff member confirmed the zone should have been documented for those residents.
The facility failed to ensure that active physician orders matched residents’ end-of-life wishes for two residents. One resident had conflicting code-status orders for full treatment and DNR, with no POLST in the chart, and staff confirmed both orders were active. Another resident had a full-treatment order but no POLST, and the DON could not provide documentation showing the resident or representative had made that decision before surveyor questioning; a later physician note documented a conversation with the resident’s parents confirming full treatment.
Failure to report and investigate resident-to-resident physical abuse: A resident was struck in the face by another resident while eating supper, and the initial assessment noted slight bruising and redness to the cheek. The facility's investigation had no witness statements, and the DON and NHA confirmed the incident was not reported to the appropriate authorities as required by policy.
Inaccurate MDS assessments were completed for two residents. One resident was coded with bilateral lower extremity impairment despite an LPNAC confirming there was no decline in ROM and that the coding was in error. Another resident, who reported difficulty hearing and used hearing aids, was assessed as having adequate hearing without a hearing aid even though the record included an order for staff to place both hearing aids each morning and H&P documentation described the resident as extremely hard of hearing; no care plan was developed for the hearing concern.
The facility failed to develop and revise care plans for several residents and did not ensure resident participation in care plan meetings. One resident’s fall-related intervention was not added to the care plan, another resident with intact cognition was not documented as participating in care conferences and had unmet care plan updates for CPAP/O2 changes and hearing loss, and two other residents’ care plans did not include active needs for pacemaker monitoring and continuous O2. DON and NHA confirmed the missing care plan information.
Failure to provide vision and hearing services: A resident with Parkinsonism and HTN reported no professional eye appointments since admission, and the facility had no contracted eye care provider or routine eye service policy. Another resident who was very hard of hearing did not have her hearing aids available, staff kept the device in the treatment room unless she asked, and the care plan, MAR/TAR, and MDS did not reflect hearing aid use despite a prior order to place the aids each morning.
Infection control failures involved catheter equipment, respiratory equipment, and laundry handling. A resident with a Foley catheter had the large collection bag and tubing stored in an open plastic bag with the connector end uncovered, a resident's CPAP mask was left hanging uncovered in the bedside stand after the treatment had been discontinued, and a bin labeled for clean laundry was found holding dirty personal laundry in the laundry area.
The facility’s pneumococcal immunization policy did not reflect current CDC guidance for PCV15, PCV20, or PCV21, and required immunization documentation was missing from a resident’s record. A resident had received PPSV23 before admission, but the chart lacked evidence of education, consent, or refusal documentation, even though an LPN said a declination form existed in a separate folder outside the medical record.
Survey results were not readily accessible in the main lobby. A binder labeled for DOH survey information contained an outdated survey, and the NHA confirmed the most recent survey results had not been printed and placed in the binder.
Improper Disposal of Garbage and Refuse at Dumpster Area: Surveyors observed multiple medical gloves, a crumpled cigarette pack, a discarded spoon, and other debris in the grass adjacent to the main dumpster. A mattress was also discarded on the ground near the dumpster, with water and dead leaves accumulated on top. The findings were reviewed with the DON.
A resident on anticoagulant therapy for atrial fibrillation sustained a head injury and skin tear while being assisted from a wheelchair to the toilet, resulting in a forehead hematoma and initiation of neuro checks. Hours later, a provider evaluated the resident for altered mental status and the head injury, noted the resident was on Eliquis, and ordered transfer to the ER. The resident’s representative was not notified at the time of the incident and was only contacted when the resident was being sent to the hospital, leading to the representative expressing upset about not being informed immediately after the injury.
Three residents did not receive care in accordance with physician orders, care protocols, or integrated care planning. One resident with skin tears received a dressing not specified in the wound care protocol without prior physician contact. Another resident with a cardiac pacemaker lacked a care plan specifying monitoring equipment, and the device was not present until after surveyor inquiry. A third resident on hospice had a care plan that did not document hospice provider details or services.
The facility did not assess the risk of bed rail entrapment in all required zones for several residents using enabler or assist bars, as staff only evaluated zones 1-4 and omitted zone 6, despite residents having beds with headboards and footboards and active orders for these devices. Facility leadership confirmed the omission, and documentation consistently lacked evidence of zone 6 assessment.
Two residents were prescribed Ativan on an as-needed basis for anxiety and agitation without a required 14-day stop date or documented physician rationale for continued use beyond 14 days, as confirmed by the DON.
A resident with bladder cancer and urinary retention had a new order for a Foley catheter, but the care plan was not updated to include this intervention. The omission was identified during a review of clinical records and confirmed in an interview with the DON.
A nurse documented new wound care orders for a resident's skin tears without evidence of contacting the physician or obtaining a proper physician order, as required by facility policy. The LPN involved had not received updated competency training on verbal or telephone physician orders, and the physician later indicated that the correct on-call process was not followed.
Two residents with dementia did not have individualized, person-centered interventions included in their care plans. Despite documented diagnoses and assessments indicating cognitive loss, the care plans developed were generic and did not address the specific needs of each resident.
A resident with natural teeth and documented dental issues did not receive routine dental services as required by facility policy, and there was no evidence that dental care was offered after the resident became Medicaid-eligible, despite multiple care conferences and documented dental concerns.
A resident with a confirmed VRE infection did not have contact precautions implemented promptly after the infection was identified. Although the physician ordered contact precautions, there was a delay over the weekend due to the nurse supervisor not initiating the required measures, as confirmed by the infection preventionist and reviewed with the DON.
The facility failed to store food according to professional standards in the main kitchen and three nursing units. Observations revealed issues such as spills, dust, and debris in the kitchen, and undated food packets in nourishment areas. These deficiencies were discussed with the Nursing Home Administrator.
A facility reported a medication error rate of 17.95%, exceeding the acceptable threshold. An LPN was observed crushing medications that should not be crushed and improperly administering inhaled medications without following the required procedures. These actions were confirmed by the DON.
The facility failed to have a policy and procedure for facility closure or termination of its Medicare/Medicaid Provider Agreement. During an entrance conference, the Nursing Home Administrator and DON could not provide a closure plan. The DON admitted the absence of such a plan, which was previously identified in a past survey. A follow-up interview confirmed the lack of a closure policy.
The facility failed to administer COVID-19 immunization boosters to four residents despite having permission from their responsible parties. The residents, who had previous vaccination histories, did not receive boosters, and subsequently tested positive for COVID-19. The facility did not follow up adequately in one case where permission was not initially received.
A resident was injured during a mechanical lift transfer when a nurse aide operated the lift without a second person, contrary to the care plan. The resident fell and sustained head injuries after the sling attachment came loose. The lift and sling were found to have no defects, and the incident was attributed to neglect.
A resident who required two staff members for bed mobility fell from the bed while being assisted by only one staff member, resulting in injuries. The facility failed to identify the potential for neglect, did not report the incident to appropriate agencies, and did not thoroughly investigate the incident. Staff continued to provide inadequate assistance for bed mobility in subsequent shifts.
The facility failed to implement comprehensive care plans for three residents, omitting critical care needs such as a pessary for a resident with a prolapsed vaginal vault and contact precautions for two residents with infections (ESBL and VRE). These omissions were confirmed during a survey, highlighting deficiencies in maintaining the highest practicable care.
The facility did not identify or assess a decline in ADL for two residents, specifically in bed mobility. One resident's need for assistance increased from supervision to extensive assistance, while another went from independent to requiring limited assistance. There was no documentation of these declines being assessed, as confirmed by the RN assessment coordinator.
The facility failed to follow physician orders for daily weights and notify the physician of significant weight changes for a resident with CHF. Additionally, recommendations from a swallowing study for another resident with mild dysphagia were not implemented, increasing the risk of choking. The DON acknowledged these deficiencies during interviews.
A resident's medication regimen was not free from adverse reactions due to a failure to address a drug-drug interaction between Omeprazole and Clopidogrel. Despite a pharmacy note suggesting a switch to Pantoprazole, the new order was discontinued without explanation, and Omeprazole was reordered. There was no evidence of further action by the physician or pharmacist to address the interaction.
A facility failed to ensure a resident's medication regimen was free from potentially unnecessary medications. A review showed that a gradual dose reduction was due for anxiety and depression medications. The physician noted benefits without adverse effects but did not specify the benefits versus risks. No medication changes were made, and the facility lacked documentation of previous dose reduction attempts or justification for continued use, as confirmed by the DON.
An LPN failed to follow infection control procedures during the administration of Systane eye drops to a resident. The LPN did not wear gloves and used the same tissue for both eyes, contrary to facility policy. The Director of Nursing confirmed the breach in protocol.
The facility failed to investigate and report potential misappropriation of Morphine for two residents. Discrepancies in medication counts and discoloration of Morphine were noted, but no thorough investigation or notification to authorities was conducted. The DON confirmed the lack of investigation into these discrepancies.
Unsafe food storage and sanitation lapses in kitchen and resident pantries
Penalty
Summary
The facility failed to store food items in a safe and sanitary manner and failed to maintain equipment in a sanitary condition in the main kitchen and in resident pantry areas on Nursing Units 300 and 700. During the initial kitchen tour with the Culinary Manager, surveyors observed serving ware stored under the dishwasher conveyor without protection from the ambient environment, debris in multiple blue cups, clear serving bowls with accumulated debris and moisture, black discoloration and peeling paint where the ceiling met the wall in the dishwasher area, and significant dust on ceiling vents above the dishwasher area. Two garbage receptacles had broken and cracked lids, the fire extinguisher receptacle cover was broken with jagged plastic pieces at the bottom, and a plastic food storage container was on the floor behind the ice machine with debris accumulated on the floor nearby. In the walk-in freezer and cooler, surveyors found open cardboard boxes of cookies and broccoli cuts exposed to ambient air, a box of mushrooms open to ambient air, and a bucket of pickle chips with a black mold-like accumulation near the lid. The cooler also contained two large plastic tubs holding beverages, with cans, milk cartons, and nutritional drinks partially immersed in opaque water. Three open containers of Worcestershire sauce were on a spice rack with use-by dates that had passed, and a stainless-steel prep table area near electrical outlets had a significant accumulation of debris. Additional observations included food stains and debris on the base bumpers of the food warmer, a sticky side surface on the food warmer, baking racks stored on top of the oven with dust and debris, adaptive equipment on blue trays with debris and dried stains, stacked nosey cups with moisture between them, and a fork with dried food debris on the tongs. Surveyors also found expired items in the dining room suction unit, including two packaged filters that had expired and a container of unopened sterile water that had expired. Review of tray line temperature documentation for March 2026 showed multiple missing entries for breakfast, lunch, and dinner temperatures on several dates, and there was no evidence that food temperatures were checked prior to serving. In the 700 Unit pantry, surveyors observed a plastic container of coffee with a best-if-used-by date of June 4, 2023. In the 300 Unit pantry, an unopened 2% milk carton, a nutritional drink, and an orange-colored drink were sitting on top of the microwave and were warm to the touch; the nutritional drink label instructed that it be kept refrigerated. No staff were present in the pantry at the time, and an LPN discarded the warm drinks after the finding was reviewed.
Failure to Document Bed Entrapment Risk Assessments for Assist Bars
Penalty
Summary
The facility failed to assess all potential risk areas for entrapment for five residents reviewed for accident hazards. The cited policy required that after placement of assist bars, maintenance conduct a bed inspection for entrapment points using the bed measurement device and evaluate each zone, including Zone 6 between the end of the rail and the side edge of the head or footboard. However, for Residents 2 and 97, the Bed System Measurement Device Test Results Worksheets documented Zone 6 as "Does Not Apply" even though both residents had headboards and enabler bars attached to their beds, and there was no further documentation showing that Zone 6 was assessed for entrapment risk. Resident 2 had a history of a fall, gait and mobility abnormalities, difficulty walking, muscle weakness, and need for assistance with personal care. The resident had an order allowing use of a left enabler bar for increased mobility in bed, and the care plan noted an ADL self-care deficit with an intervention for use of the left enabler bar. During observation, the resident had an enabler bar attached to the left side of the bed and reported using it for increased mobility in bed. Despite this, the worksheet dated November 7, 2025, marked Zone 6 as not applicable without additional documentation of assessment. Resident 97 had a history of gait and mobility abnormalities, difficulty walking, weakness, and need for assistance with personal care. The resident had an order to use bilateral enabler bars for bed mobility, and the care plan identified an ADL self-care performance deficit related to ambulatory dysfunction with bilateral enabler bars as an intervention. Observation showed bilateral enabler bars attached to the bed and a headboard present, yet the worksheet dated February 10, 2026, also marked Zone 6 as not applicable without further assessment. Similar findings were identified for Residents 7, 12, and 14, whose beds had headboards, footboards, and assist devices, but whose worksheets likewise documented Zone 6 as "Does Not Apply" with no further documentation of entrapment risk assessment. Employee 5 confirmed that Zone 6 had been visually determined as large enough and marked not applicable, but also acknowledged that Zone 6 did apply for those residents and should have been documented.
Inconsistent and Missing End-of-Life Orders
Penalty
Summary
The facility failed to ensure that active physician orders reflected residents’ end-of-life wishes for two residents reviewed for advance directive concerns. For one resident, the clinical record contained two active physician orders that conflicted with each other: one dated May 30, 2025, directing full treatment in a medical emergency and another dated June 2, 2025, directing DNR status. The record also did not contain a POLST form. An LPN confirmed there was no POLST in either the physical or electronic record and acknowledged the presence of both active code-status orders. Physician documentation dated June 2, 2025, stated that the resident wished to be DNR, and the DON and NHA later confirmed the findings. For a second resident, the clinical record contained an active physician order for full treatment in a medical emergency, but there was no POLST in the electronic or physical record. Two LPNs confirmed the absence of a POLST. When the surveyor asked for evidence that the resident or responsible party had made the full-treatment decision, the DON could not provide documentation during the interviews. A physician progress note entered after the surveyor’s questioning documented a conversation with the resident’s parents confirming their wishes for full treatment, and the facility failed to document that communication before the surveyor’s questioning.
Failure to Report and Investigate Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to thoroughly investigate and report an allegation of resident-to-resident physical abuse involving Resident 128. Facility policy required staff to immediately report suspected abuse, complete an incident report, obtain witness statements, and make oral and written reports to the appropriate agencies within the required timeframes. In this case, nursing documentation on March 16, 2026, stated that Resident 128 was sitting at the table eating supper when another resident became agitated, reached across the table, and hit Resident 128 across the face. The initial assessment noted Resident 128's right cheek appeared slightly bruised and reddened. The facility investigation dated March 16, 2026, contained no witness statements. The interdisciplinary team review dated March 20, 2026, described the event as an isolated incident with no injuries and stated the residents were separated. During interview on April 9, 2026, the DON and NHA confirmed that the facility did not report the resident-to-resident physical abuse to the appropriate authorities.
Inaccurate MDS Assessments for Hearing and Range of Motion
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected resident status for two residents. For Resident 40, a quarterly MDS dated October 26, 2025, indicated no impairment of the lower extremities, while the next quarterly MDS later assessed bilateral lower extremity impairment. During interview, an LPNAC stated that Resident 40 did not have a decline in range of motion and confirmed that the functional limitation in range of motion had been coded in error on the later MDS. The DON reviewed these findings on April 10, 2026. For Resident 139, the resident stated she had difficulty hearing and used hearing aids, but did not know where they were at the time of interview. The clinical record showed a physician order for staff to ensure both hearing aids were placed in her ears each morning on day shift, yet an annual MDS assessed her as having adequate hearing without a hearing aid and did not proceed to a care plan for hearing concerns. The RAI instructions for the hearing section required use of the resident’s normal hearing appliance if one was available, and hospital history and physical documentation described Resident 139 as extremely hard of hearing. The NHA and DON confirmed these findings during interview.
Failure to Update and Individualize Care Plans
Penalty
Summary
The facility failed to develop, revise, and ensure resident or resident representative participation in care plan decisions for four residents. For one resident, nursing documentation showed a fall event in which the resident was found on his knees in front of a chair, and the interdisciplinary team noted that physical therapy would screen him. A physical therapy response documented that staff gave the resident a reacher to increase safety, but the resident’s care plan was not revised to include that intervention. For another resident with repeated MDS assessments showing no cognitive deficits, care conference documentation showed that the resident did not attend multiple care plan meetings, and the medical record did not document the reasons or the steps taken to include the resident. The resident stated she had no recollection of attending care plan meetings. The record also showed that her CPAP with supplemental oxygen order was discontinued, but the facility did not revise the care plan to reflect the change. In addition, the resident reported difficulty hearing, used hearing aids, and did not know where they were; staff kept the hearing aid in the locked treatment room and only provided it if requested, yet the care plan did not address hearing loss, hearing aid use, or a history of lost or broken hearing aids. For two other residents, the facility did not include active treatment needs in the care plan. One resident had a pacemaker monitoring machine at the bedside and an active order for a cardiac device check, but the care plan did not include the monitoring machine or related details such as transmission method, interruption procedures, or expected heart rate parameters. Another resident had an active order for continuous supplemental oxygen and was observed with a room concentrator running, but the care plan did not address oxygen use. Facility leadership confirmed that these items were not incorporated into the care plans until after surveyor questioning.
Failure to Provide Vision and Hearing Services
Penalty
Summary
The facility failed to implement treatment and assistive devices to maintain vision and hearing abilities for two residents reviewed for vision and hearing concerns. One resident had been admitted with diagnoses including essential hypertension and Parkinsonism and was receiving Sinemet three times daily. During interview, she stated that she had not had any professional eye appointments since admission. The record review and staff interviews showed no evidence that she had been offered or received professional eye care during her stay, and the facility had no contracted professional eye care provider or policy for routine professional eye services. Facility staff confirmed that the first documented conversation about professional eye care occurred only after the surveyor questioned the lack of eye care. The staff member who spoke with the resident after the surveyor's inquiry would not have known the resident's eye disease risk factors or reviewed the risks and benefits of an eye exam at that time. The facility also confirmed that it had no policy regarding the provision of routine professional eye services. A second resident was very hard of hearing and stated that she did not know where her hearing aids were. Staff told the surveyor that they did not give her hearing aid unless she asked for it, and the device was stored in the treatment room. Although task documentation identified that she required a hearing aid in her left ear and the care plan should have addressed hearing aid use, the care plan contained no reference to hearing aids, and the April 2026 MAR/TAR contained no documentation of hearing aid use. The annual MDS assessed her as having adequate hearing without a hearing aid, despite nursing documentation noting that she was hard of hearing and did not have her hearing aids present, and staff confirmed that a prior physician order to place both hearing aids in her ears each morning had been discontinued during hospitalization and not resumed after her return.
Infection Control Failures with Catheter Equipment, Respiratory Equipment, and Laundry Handling
Penalty
Summary
The facility failed to ensure an environment free from the potential spread of infection related to indwelling catheter equipment for one resident, respiratory equipment for one resident, and laundry processing in the main laundry area. Interview with the infection control prevention coordinator revealed the facility had no established policy or employee competency guideline for keeping indwelling urinary catheter equipment free of contamination when not in use, even though residents used a smaller leg bag during the day and a larger urinary collection bag overnight. For one resident with a Foley catheter ordered for obstructive uropathy related to benign prostatic hypertrophy, staff were observed storing the large urinary collection bag and tubing in an open plastic bag tied near the toilet, with the connector end uncovered and uncapped on two separate observations. In the main laundry facility, staff used large yellow bins to transport clean laundry, and a yellow bin labeled "Clean" was observed containing residents' personal laundry that had not yet been processed and was still dirty/soiled. Staff confirmed the laundry in the bin was not cleaned. For another resident, a respiratory mask used for CPAP treatments was observed hanging uncovered from a drawer in the bedside stand on two separate observations. Staff stated the mask should have been stored in a black bag, and the DON confirmed staff failed to remove or store the CPAP equipment appropriately after the physician discontinued the treatment more than seven weeks earlier.
Pneumococcal Immunization Policy and Documentation Deficiencies
Penalty
Summary
The facility failed to maintain policies and procedures that reflected current CDC guidance for pneumococcal immunizations and failed to ensure required documentation was present in the medical record for one resident reviewed for immunization concerns. The facility policy on influenza, RSV, pneumococcal, and COVID-19 vaccination still referenced older pneumococcal vaccine guidance, including Pneumovax23 and Prevnar13, and did not incorporate current CDC recommendations for PCV15, PCV20, or PCV21. During interviews, the Nursing Home Administrator, DON, and infection control prevention coordinator confirmed the policy was not current and that immunization documentation was expected to be scanned into the electronic medical record. Clinical record review for one resident showed she had received PPSV23 before admission, but there was no evidence in the record that she or her representative had been educated about the current CDC pneumococcal vaccine options, the risks and benefits of updating immunization, or that she had consented to or refused vaccination. Although the infection control prevention coordinator stated she had a folder in her office containing documentation that the resident declined a pneumococcal immunization, that documentation was not included in either the electronic or physical medical record available to facility staff.
Survey Results Not Posted in Main Lobby
Penalty
Summary
The facility failed to ensure that the results of the most recent survey were posted in a place readily accessible to residents, family members, and legal representatives in the main lobby. During observation of the main lobby, a binder in a wall pocket titled "Department of Health Survey / Notice of Privacy Practices" was found to contain survey results, but the most recent survey included in the binder was dated July 28, 2023. The Nursing Home Administrator later confirmed that the recent survey results had not been printed and placed in the binder.
Improper Disposal of Garbage and Refuse at Dumpster Area
Penalty
Summary
The facility failed to properly contain and dispose of garbage at the main dumpster area. During observation on April 7, 2026, surveyors found multiple medical gloves in the grass adjacent to the dumpster, along with various debris on the ground including a crumpled cigarette pack, a discarded spoon, and additional debris. A mattress was also discarded on the ground in the grass area next to the dumpster, and the top of the mattress had water and dead leaves accumulated on it. This information was reviewed with the DON on April 8, 2026.
Failure to Immediately Notify Resident Representative After Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify a resident’s representative of a significant change in condition following an accident that resulted in injury. The resident had atrial fibrillation and was receiving Apixaban (Eliquis) 5 mg orally every 12 hours as an anticoagulant, with this therapy reflected in both physician orders and the care plan. In the early morning, nursing documentation recorded that while staff were assisting the resident from a wheelchair to the toilet, the resident bent forward, hit her head on the wall, and sustained a 3 cm by 3 cm hematoma on the forehead and a skin tear to the right upper shin. Neuro checks were initiated, but the resident was uncooperative with certain components of the assessment, including pupil checks and hand grasps. Later that morning, a medical provider documented that the resident had fallen, hit her head, was on Eliquis, and had a hematoma to the right upper forehead, and recommended transfer to the ER for further evaluation and treatment. Nursing documentation shortly thereafter noted the hematoma, the resident’s use of Eliquis, receipt of an order to send the resident to the ER, and that staff spoke with the resident’s family, who agreed to the transfer. Subsequent documentation indicated that the resident’s representative was upset because they were not called when the resident initially hit her head and believed the resident should have been sent to the hospital as soon as possible. There was no evidence that the responsible party was notified of the incident and resulting injury at the time it occurred, and notification did not occur until approximately seven hours later when the resident was being transferred to the hospital, constituting a failure to immediately notify the resident’s representative of an accident involving injury that had the potential to require physician intervention.
Failure to Ensure Physician Orders, Care Planning, and Hospice Coordination
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for three residents. For one resident with two skin tears on the left leg, staff applied a Tegaderm dressing instead of the Aquacel foam dressing specified in the facility's wound care protocol. Documentation did not show that a physician was contacted prior to implementing this treatment, and the physician later clarified that proper procedures for obtaining orders were not followed, as there was an on-call provider available and no direct communication occurred before the treatment was initiated. Another resident, admitted with a cardiac pacemaker, had a baseline care plan that included instructions for pacemaker checks but did not specify the method or equipment to be used. The resident reported having a home monitoring machine prior to admission but did not have it in the facility until after the surveyor's inquiry. There was no evidence that the need for a pacemaker monitoring device was identified or addressed in the care plan upon admission, and the device was only brought to the facility after staff were prompted by the surveyor. A third resident, admitted with hospice services for terminal dementia, had a care plan that did not integrate hospice services or specify the hospice provider, disciplines involved, or frequency of services. The care plan lacked documentation of the full range of hospice services to be provided for the management of the resident's terminal illness, and there was no evidence of coordination between the facility and the hospice provider.
Failure to Assess Bed Rail Entrapment Risk in All Required Zones
Penalty
Summary
The facility failed to properly assess the risk of bed rail entrapment for six out of seven residents reviewed for accident hazards. Facility policy required maintenance staff to conduct bed inspections for entrapment points using a measurement device, following the manufacturer's test methods, but the policy did not specify all entrapment zones. Specifically, staff consistently assessed only zones 1-4 and omitted assessment of zone 6, which is the space between the end of the rail and the side edge of the headboard or footboard, as outlined in FDA guidance. This omission was confirmed through staff interviews and review of facility documentation. Multiple residents were observed with enabler or assist bars attached to their beds, and clinical records showed active physician orders for these devices. For each resident reviewed, documentation indicated that only zones 1-4 were assessed for entrapment risk, with no evidence that zone 6 was evaluated. Residents reported using the bars to assist with mobility and transfers, and their beds were equipped with headboards and footboards, making the unassessed zone 6 relevant for potential entrapment risk. The lack of assessment for this zone was consistent across all reviewed cases. During interviews, facility leadership and maintenance staff acknowledged that zone 6 was not included in their standard assessment process. Additionally, the facility was unable to provide the manufacturer's identification information for the beds and assist bars when requested by surveyors. The deficiency was cited under 28 Pa. Code 211.12 (d)(5) for nursing services.
Failure to Ensure Timely Review and Justification for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that two residents' medication regimens were free from potentially unnecessary psychotropic medications. For one resident, a consultant pharmacist recommended the use of Ativan as needed for anxiety, with a re-evaluation after 30 days. However, the physician's order for Ativan did not include a 14-day stop date, nor was there a physician's progress note providing a rationale for continuing the medication beyond 14 days. This omission was confirmed by the Director of Nursing. Similarly, another resident had a physician's order for Ativan as needed for anxiety and agitation, but the order also lacked a 14-day stop date and did not have a physician's progress note justifying the ongoing use of the medication past 14 days. The Director of Nursing confirmed these findings as well. These actions did not comply with regulatory requirements for the use of psychotropic medications and pharmacy services.
Failure to Update Care Plan for Indwelling Foley Catheter
Penalty
Summary
The facility failed to revise the comprehensive care plan for one resident following the initiation of a new physician's order for a Foley catheter due to urinary retention related to bladder cancer. Observation revealed the resident had a urinary collection bag in use, and clinical records confirmed an active order for the indwelling catheter. However, review of the resident's care plans showed that the intervention of an indwelling Foley catheter was not included, despite existing care plans addressing urinary retention, incontinence, chronic kidney disease, and urinary tract infection. This omission was confirmed during an interview with the Director of Nursing.
Failure to Ensure Nursing Staff Competency in Obtaining and Documenting Physician Orders
Penalty
Summary
The facility failed to ensure that nursing staff, specifically an LPN, possessed and demonstrated the necessary competencies related to obtaining and documenting verbal or telephone physician orders. Review of facility policies, staff competency records, and clinical documentation revealed that a nurse documented new treatment orders for a resident's skin tears without evidence of contacting the resident's physician or obtaining a proper physician order. The nurse's documentation implied that a physician had provided the order, but there was no supporting evidence that such communication occurred. Additionally, the physician later noted that messages were left on an incorrect phone line and that an on-call provider was available, but not contacted. Further review showed that the LPN in question had not received updated education or competency evaluation on obtaining and documenting verbal or telephone physician orders since 2018, despite the facility's assessment identifying this as a necessary competency for staff. The facility's own policy required that verbal or telephone orders be given to and recorded by a licensed nurse, but there was no documentation to confirm that this process was followed in the case of the resident's wound care.
Failure to Develop Individualized Dementia Care Plans
Penalty
Summary
The facility failed to develop and implement individualized, person-centered care plans for two residents diagnosed with dementia. For one resident admitted with a diagnosis of vascular dementia, the clinical record and MDS assessment confirmed the presence of cognitive loss, and the facility determined that a care plan addressing dementia would be developed. However, the care plan initiated did not include individualized interventions tailored to the resident's specific needs related to dementia and cognitive impairment. Similarly, another resident admitted with a diagnosis of dementia, as documented in the clinical record and MDS assessment, had a care plan that also lacked individualized, person-centered interventions to address their cognitive loss. Both care plans were generic and did not specify strategies or supports based on the unique presentation and needs of each resident. These findings were confirmed through clinical record review and staff interviews, and were discussed with facility leadership.
Failure to Obtain Routine Dental Services for Resident with Dental Concerns
Penalty
Summary
The facility failed to obtain routine dental services for a resident with natural teeth who was identified as having obvious or likely cavities or broken teeth on two consecutive annual MDS assessments. Although the facility's policy required at least an annual oral examination and the offering of dental services every six months, the resident's daughter initially declined dental care upon admission when the resident was not yet Medicaid-eligible. However, after the resident's payment source changed to Medicaid, the facility did not provide evidence that the daughter was offered dental services under the Medicaid benefit during the following year. Clinical records showed no care plan was developed to address the resident's dental issues, despite documentation of dental concerns in the MDS and care area assessment. Multiple care conferences occurred with the resident's daughter present or updated, but there was no documentation that dental services were discussed or offered after the resident became Medicaid-eligible. The deficiency was identified through review of facility policies, clinical records, and interviews with the resident's family and staff.
Delay in Implementing Contact Precautions for VRE Infection
Penalty
Summary
The facility failed to ensure timely implementation of transmission-based precautions for a resident with a confirmed infection. A review of the facility's policies indicated that standard and transmission-based precautions, including contact precautions for infections such as Vancomycin Resistant Enterococcus (VRE), are to be implemented as soon as a resident is known or suspected to be infected. Resident 83 was admitted on February 21, 2025, and a urine culture collected on April 23, 2025, showed the presence of enterococcus faecium VRE. The physician documented the positive result and initiated antibiotic treatment, with an order for contact precautions placed on April 27, 2025. Despite the order, there was a delay in starting the required contact precautions for the resident. The infection preventionist confirmed during an interview that the nurse supervisor did not implement the transmission-based precautions over the weekend, resulting in a lapse in infection control practices. This delay was identified during a review of the resident's clinical record and staff interviews, and the issue was discussed with the Director of Nursing.
Failure to Maintain Food Storage Standards
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety and sanitation in its main kitchen and three nursing units. Observations in the main kitchen revealed several issues, including dried brown liquid spills, dust, and debris on the coffee beverage station's lower shelf, and a stained white blanket. The tubing on juice dispensers was sticky and dusty, and the flooring under various kitchen equipment contained dried food and debris. Additionally, the wall area beside the plate warmers was covered in dried food splatter, and the lower shelves of production tables and dry storage had a buildup of dust. In the nourishment areas of the 100, 300, and 800 halls, storage cabinets contained various food packets and condiments without any identification of when they were placed there or their expiration dates. Items such as hot chocolate packets, peanut butter packs, jelly packs, and more were found in these areas, with no dates indicating their placement or expiration. These findings were reviewed with the Nursing Home Administrator, highlighting the facility's failure to adhere to food storage standards.
Medication Administration Errors and Policy Violations
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, with a reported rate of 17.95 percent based on 37 medication opportunities and 7 errors. During a medication administration pass, an LPN was observed crushing medications that were on the facility's 'Do Not Crush or Chew' list, including Metoprolol Tartrate, Potassium Chloride ER, and Paroxetine, and attempting to administer them to a resident who refused. On another occasion, the same LPN crushed and administered these medications in pudding to another resident. Additionally, the LPN did not follow proper procedures for administering inhaled medications. She administered two puffs of Albuterol Sulfate Inhaler without waiting the required 1-2 minutes between puffs and immediately followed with a different inhaler, Fluticasone-Salmeterol, without waiting. Furthermore, the LPN failed to instruct the resident to rinse and spit after using the steroid inhaler, as per facility policy. These observations were confirmed by the Director of Nursing, who acknowledged the errors in medication administration.
Lack of Facility Closure Plan
Penalty
Summary
The facility was found to be deficient in having a policy and procedure in place for facility closure or termination of its Medicare and/or Medicaid Provider Agreement. During the entrance conference, the Nursing Home Administrator and the Director of Nursing were unable to provide a closure plan when requested. The Director of Nursing admitted that the facility lacked such a plan and acknowledged that this issue had been identified during the previous full health survey. A follow-up interview with the Nursing Home Administrator confirmed the absence of a policy or procedure addressing facility closure.
Failure to Administer COVID-19 Boosters
Penalty
Summary
The facility failed to ensure the administration of COVID-19 immunization boosters for four residents, despite having received permission from their responsible parties. Resident 119, admitted in July 2023, had a history of receiving COVID-19 vaccinations in 2021 but did not receive a booster after permission was granted in December 2023. Similarly, Resident 11, admitted in 2017, had received vaccinations up to March 2023, but there was no record of a booster being administered after permission was given in December 2023. Both residents later tested positive for COVID-19 in February 2024. Resident 109, admitted in April 2023, had received vaccinations in March 2023 but did not receive a booster after permission was granted in May 2023. Resident 118, admitted in July 2023, had a history of vaccinations in 2021, and although the facility sought permission for a booster in December 2023, they did not follow up after receiving no response. Both residents also tested positive for COVID-19 in February 2024. These findings were confirmed by the infection preventionist during an interview in June 2024.
Neglect During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure that a resident was free from neglect, resulting in injury. A clinical record review revealed that a resident was being transferred using a mechanical lift when the top of the sling came loose, causing the resident to fall to the floor and sustain head injuries. The injuries included a 2.5 cm x 0.3 cm laceration to the mid back of the head and a smaller laceration measuring 0.5 cm x 0.5 cm. The facility's investigation included statements from staff members, which indicated that the lift slipped, and the resident slipped out of the sling. A nurse checked the mechanical lift sling after the fall and found no defects, and maintenance confirmed no concerns with the lift. The investigation further revealed that the nurse aide responsible for the transfer was operating the mechanical lift without a second person present, contrary to the resident's care plan, which required the assistance of two staff members. The nurse aide admitted to possibly bumping the sling attachment while moving the lift, which had sticking wheels, leading to the sling coming loose. This action was identified as neglect, as the resident's care plan was not followed, resulting in the fall and subsequent injuries.
Failure to Implement Abuse Prohibition Policy and Investigate Potential Neglect
Penalty
Summary
The facility failed to develop and implement an abuse prohibition policy to ensure a complete and thorough investigation of an incident involving potential neglect for a resident. The facility's policy, last reviewed without changes, mandates that all allegations of mistreatment, neglect, or abuse, as well as injuries of unknown source, are reported timely. However, the facility did not adhere to this policy when a resident, who required two staff members for bed mobility, fell from the bed while being assisted by only one staff member. The incident resulted in the resident sustaining a skin tear, an abrasion, and redness on their body. The incident report confirmed the nursing documentation but failed to identify the resident's need for two staff members during bed mobility or the potential for neglect due to the absence of a second staff member. The facility's intervention was limited to a physical therapy screen, and there was no second staff statement provided. Furthermore, documentation showed that staff continued to provide only one staff assistance for bed mobility for numerous shifts following the incident. The facility did not report the fall to the appropriate agencies, did not thoroughly investigate the incident for neglect, and failed to complete an abuse report or re-educate staff on the correct number of staff required for bed mobility.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in maintaining the highest practicable care. Resident 116 was admitted with a diagnosis of a prolapsed vaginal vault and required a pessary, but her care plan did not initially include this critical aspect of her care. It was only after the surveyor's intervention that the facility updated her care plan to reflect the use of the pessary. Additionally, the facility did not address the need for contact precautions in the care plans of two other residents. Resident 11 had a positive urine culture for ESBL, and Resident 119 had VRE in their urine, both requiring contact precautions. However, their care plans lacked any mention of these conditions or the necessary precautions, as confirmed by the infection preventionist during the survey.
Failure to Assess Decline in ADL for Residents
Penalty
Summary
The facility failed to identify and assess a decline in the activities of daily living (ADL) for two residents, specifically in their ability to perform bed mobility. Resident 10 was initially assessed as requiring supervision for bed mobility, but later assessments indicated a need for extensive assistance. However, there was no documented evidence that the facility identified or assessed this decline. Similarly, Resident 118 was initially assessed as independent with bed mobility, but later required limited assistance. Again, there was no documentation indicating that the facility identified or assessed this decline. These findings were confirmed during an interview with the registered nurse assessment coordinator, who was unable to provide further documentation regarding the assessment of these declines.
Failure to Implement Physician Orders and Swallowing Study Recommendations
Penalty
Summary
The facility failed to provide the highest practicable care for two residents by not adhering to physician orders and recommendations. For one resident with Congestive Heart Failure, the facility did not document daily weights as ordered and failed to notify the physician of significant weight changes on specified dates. This oversight occurred despite clear physician orders to monitor weight changes closely and report any significant increases, which are critical for managing the resident's condition. Another resident, who had a swallowing function study indicating mild dysphagia and a mildly unsafe swallow, did not have the recommended interventions implemented. The study recommended that the resident sit fully upright during and after meals to reduce choking risks. However, these recommendations were not followed, as the Director of Nursing indicated that the resident remained on speech therapy services, and staff were feeding her meals without implementing the necessary precautions.
Failure to Address Drug-Drug Interaction in Resident's Medication Regimen
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from adverse medication reactions. A clinical record review for a resident revealed a pharmacy note to the physician indicating a potential drug-drug interaction (DDI) between Omeprazole, a proton-pump inhibitor, and Clopidogrel, a platelet inhibitor. The pharmacist suggested switching from Omeprazole to Pantoprazole to avoid reducing the efficacy of Clopidogrel. The physician agreed to the change, but the new medication order for Pantoprazole was discontinued the next day without documentation explaining the reason, and Omeprazole was reordered. The facility's pharmacy communication indicated that the Pantoprazole order was flagged for a DDI, but the pharmacy approved it, and the facility subsequently canceled it. There was no evidence that the physician addressed the DDI between Omeprazole and Clopidogrel after the medication was reordered, nor was there documentation of the pharmacist addressing the DDI in subsequent reviews. The deficiency was discussed with the Director of Nursing, highlighting a failure to manage the resident's medication regimen appropriately.
Failure to Ensure Medication Regimen Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from potentially unnecessary medications. A clinical record review for Resident 89 revealed that a gradual dose reduction review was due for Buspirone and Citalopram, medications used to treat anxiety and depression, respectively. The attending physician indicated that the resident was benefiting from the therapy without adverse effects and that the benefits outweighed the risks, but did not specify what benefits outweighed what risks. There were no changes made to the medications, and the facility could not provide documentation of a previous dose reduction attempt or justification for the continued use of the medications. An interview with the Director of Nursing confirmed the lack of documentation.
Infection Control Breach During Eye Drop Administration
Penalty
Summary
The facility failed to prevent the potential spread of infection during medication administration on one of its nursing units. Specifically, during a medication pass observation, an LPN administered Systane eye drops to a resident without wearing gloves and used the same tissue to wipe both eyes. This action was contrary to the facility's policy, which requires gloves to be worn and a separate tissue to be used for each eye. The incident was confirmed by the Director of Nursing, who acknowledged that the proper procedures were not followed.
Failure to Investigate Medication Discrepancies
Penalty
Summary
The facility failed to thoroughly investigate and notify the appropriate agencies regarding potential misappropriation of medication for two residents. Discrepancies were identified in the controlled substance counts for liquid Morphine Sulfate for two residents. The medication for one resident was noted to have changed color, indicating possible contamination or diversion, yet no comprehensive investigation was conducted to address these issues. For Resident 5, a discrepancy was noted when the liquid Morphine appeared a different color than usual, and the controlled substance count did not match the documented administration records. The medication administration records showed the last dose was given in April, but the controlled medication log indicated a discrepancy in the remaining amount. Similarly, for Resident 4, the controlled medication record showed a discrepancy in the Morphine count, with no doses documented as administered between the last known dose and the identified discrepancy. Despite these discrepancies, the facility did not conduct a thorough investigation or report the potential misappropriation to the Department of Health. The Director of Nursing confirmed that no additional staff interviews or investigation documentation was available to justify the discrepancies or rule out misappropriation or diversion. The facility also failed to follow the pharmacist's recommendations for investigating the discoloration of the medication.
Latest citations in Pennsylvania
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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