Westmoreland Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Greensburg, Pennsylvania.
- Location
- 2480 South Grand Blvd, Greensburg, Pennsylvania 15601
- CMS Provider Number
- 395435
- Inspections on file
- 32
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Westmoreland Manor during CMS and state inspections, most recent first.
An LPN failed to follow professional standards and state scope-of-practice rules by crushing multiple medications ordered to be given PO (including apixaban, gabapentin, magnesium oxide, potassium chloride, and midodrine) for a resident with a midline catheter and administering them via the midline instead of orally. The resident, who had a history including atherosclerotic heart disease and required staff assistance with daily care, had an order for oral tablets to be crushed and mixed in pudding and a midline specifically for IV Zosyn. Witnessing staff and the resident’s daughter raised concerns after the LPN admitted to crushing the scheduled oral medications, dissolving them in water, and pushing them through the midline using a flush syringe. Later that evening, the resident’s O2 saturation remained in the mid-80s on high-flow supplemental O2, the physician was notified, and the resident was transferred to the hospital, where hyponatremia was identified and the midline was removed.
A resident with a midline IV catheter and multiple chronic conditions had several oral medications ordered to be crushed and given by mouth. An LPN instead crushed the evening doses of apixaban, gabapentin, magnesium oxide, midodrine, and potassium chloride, mixed them with water, and administered them through the resident’s midline catheter, contrary to the prescribed route and facility policy requiring adherence to the six rights of medication administration. Other staff became aware after the resident’s family questioned the practice and IV medications could not be infused through the midline. The LPN admitted to administering the oral medications via the midline, and the resident subsequently experienced low oxygen saturations and was sent to the hospital, where evaluation showed hyponatremia but otherwise stable status.
A resident with a history of aggressive behaviors pushed another cognitively impaired resident after being tapped on the shoulder, causing a fall and a hip fracture. The incident occurred despite care plan interventions requiring close monitoring and redirection for the aggressive resident, and the facility's investigation substantiated that abuse occurred.
A resident with a history of CVA and diabetes filed a grievance alleging that an LPN repeatedly engaged in upsetting and inappropriate behaviors, including preparing incorrect insulin and making distressing comments. The facility did not document a thorough investigation into these concerns or obtain a statement from the LPN, as required by policy.
A resident with left-side hemiplegia requested coffee without a lid, which was prepared by a nurse aide using a Keurig and delivered without checking the temperature. The resident spilled the hot coffee onto his thigh, resulting in blisters and redness. Staff interviews confirmed that temperature checks for hot liquids were not routinely performed by nursing staff, and the hot liquid safety policy was not applied to them.
Two residents did not receive care in accordance with physician orders when staff failed to hold prescribed blood pressure medications despite documented low systolic blood pressure readings, as required by the orders. Medication Administration Records showed that Hydralazine and metoprolol tartrate were administered without adherence to hold parameters, and this was confirmed by Clinical Compliance.
The facility did not accurately complete MDS assessments for four residents, including failures to document administration of anticonvulsant and antiplatelet medications, incorrect coding of a resident's fall and fracture history after hospital readmission, and an error in recording a resident's discharge location. These inaccuracies were confirmed by the Director of Case Management.
A resident with renal failure and peripheral vascular disease was prescribed 250 mg calcium citrate twice daily, but was administered 950 mg calcium citrate with 200 mg calcium after the pharmacy substituted the medication due to a backorder. The pharmacy did not notify the facility, and nursing staff did not clarify the change with the provider, resulting in the administration of a non-equivalent medication without proper order clarification.
The facility did not ensure that two residents with PICC lines received IV flushes with saline before and after administration of IV antibiotics, as ordered by physicians and required by facility policy. Medication administration records lacked documentation of these flushes, and staff confirmed the omission.
Two residents received incorrect medication dosages during observed administration, resulting in a medication error rate of 6.67%. An LPN administered a higher dose of calcium citrate than ordered to a resident with renal failure and peripheral vascular disease, and only one drop of artificial tears instead of two to a resident with multiple sclerosis. The DON confirmed the discrepancies between the administered medications and physician orders.
The facility failed to maintain electrical equipment as required by NFPA 70, with two electrical panels obstructed by wheelchairs in a storage room, affecting one smoke compartment. This was confirmed by the Facility Administrator and Maintenance Director.
The facility was found to have improperly used an electrical extension cord as a fixed power source for a pump in the Maintenance/Shop Storage room. This deficiency was confirmed by the Facility Administrator and Maintenance Director.
The facility failed to maintain a safe and homelike environment in the A1 dining room, where residents reported concerns about peeling and rough tables that could cause skin tears. Observations confirmed the poor condition of all eight tables, and both the Maintenance Director and DON acknowledged the issue.
A facility failed to ensure a resident was free from unnecessary psychotropic medications by not attempting non-pharmacological interventions before administering Lorazepam. Despite a policy requiring such interventions and a psychiatric evaluation recommending them, the resident received Lorazepam multiple times without documented attempts at non-pharmacological approaches. The DON confirmed this oversight, indicating non-compliance with the facility's policy.
A facility failed to properly label medications and date multi-dose insulin vials. A resident received a different insulin dosage than labeled, and several insulin vials were not dated upon opening, as confirmed by staff interviews.
A nurse aide in an LTC facility failed to follow sanitary food handling practices by using bare hands to prepare a resident's meal, violating the facility's policy requiring gloves or barriers. This was confirmed by both the aide and the CRNP.
The facility failed to obtain required hospice documentation for two residents receiving hospice services. One resident, with cognitive impairment and malnutrition, lacked updated hospice nurse aide charting since January. Another resident, with a cerebrovascular accident, lacked updated hospice RN and nurse aide charting since admission. These deficiencies were confirmed by the DON.
The QAPI committee at the facility failed to address recurring deficiencies related to assessment accuracy, tube feeding management, drug labeling/storage, and infection control. Despite previous plans of correction, the committee was ineffective in maintaining compliance, leading to repeated citations.
A facility failed to prevent the misappropriation of medication for a resident with chronic pain. Despite documentation of five narcotic cards being received, only four were delivered to the nursing unit. An investigation confirmed that a nurse was the last person in possession of the missing card, leading to the conclusion of misappropriation.
A facility failed to update a resident's care plan to reflect her new preference for receiving medications early due to a change in her dialysis schedule. The resident's care plan was outdated, and the DON confirmed it should have been revised.
A facility failed to provide a resident with weekly showers as per their policy. The resident, who was alert and oriented, had a care plan specifying morning showers. However, during April, the resident did not receive showers on two occasions, instead receiving bed baths due to testing positive for COVID-19. This was confirmed by the DON.
A facility failed to follow its policy for feeding tube management for a resident with cognitive impairment and a feeding tube due to stroke and dementia. The policy requires that feeding tube bags be labeled with the date and time they are started, but an observation revealed that the bag in use was not labeled as required. This was confirmed by a nurse and the DON.
A facility failed to ensure proper hand hygiene during wound care for a resident with multiple ulcers, as two nurses did not wash their hands between glove changes. Additionally, a nurse aide improperly handled soiled linens by throwing them on the floor during a bed bath for another resident. These actions were confirmed by staff interviews and did not comply with the facility's infection control policies.
The facility failed to provide written notification of emergency hospital transfers to responsible parties and the State Ombudsman for three residents. One resident with end-stage renal disease was transferred after a dialysis catheter incident, another with dementia after a fall, and a third with Huntington's disease due to hypoxemia. The Nursing Home Administrator confirmed the lack of notification and was unaware of the requirement.
Improper IV Administration of Oral Medications via Midline by LPN
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services met professional standards of quality by not ensuring that medications were administered by licensed personnel in accordance with Pennsylvania medical and nursing regulations. Pennsylvania’s Nursing Practice Act specifies that LPNs must exercise sound nursing judgment, seek guidance when patient care needs exceed their scope of practice, obtain instruction and supervision for unfamiliar procedures, and are prohibited from administering medications via IV push or bolus. The facility’s own medication administration policy required that all medications be administered by licensed personnel in accordance with Pennsylvania regulations and that the six rights of medication administration, including the right route, be followed. Resident 2 was cognitively intact, required staff assistance with daily care, and had diagnoses including atherosclerotic heart disease. Physician orders directed that the resident receive multiple medications by mouth, including apixaban, gabapentin, magnesium oxide, potassium chloride extended release, and later midodrine, with an order that oral tablets be crushed and mixed in pudding. The resident also had a right upper arm midline catheter for IV administration of Zosyn. On the evening in question, the 6:00 p.m. oral medications (Eliquis 5 mg, gabapentin 100 mg, magnesium oxide 400 mg, midodrine 5 mg, and potassium 20 mEq) were instead crushed, mixed with warm water, and administered via the resident’s midline catheter. According to witness statements, an RN reported that an LPN admitted to crushing the resident’s oral medications, dissolving them in water, and administering them through the midline using a normal saline flush syringe. Another RN reported that the LPN similarly described using a Silent Knight to crush the medications, dissolving them in water, and giving them through the midline. A different LPN stated that the resident’s daughter questioned whether it was appropriate for the LPN to put medications into the midline catheter, and that when she attempted to assist with IV antibiotic administration, the midline would not infuse or flush despite the LPN stating he had just flushed it. The LPN later admitted to this nurse that he had crushed and administered the 6:00 p.m. medications through the midline. Subsequently, the resident’s oxygen saturation remained between 85% and 87% on 12 liters of supplemental oxygen, the physician was notified, and the resident was sent to the hospital, where evaluation revealed hyponatremia and otherwise stable status after removal of the midline.
Significant Medication Error from Oral Drugs Given via Midline Catheter
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident was free from significant medication errors when ordered oral medications were administered via an intravenous (IV) midline catheter instead of by mouth. Facility policy on medication administration required adherence to the six rights of medication administration, including the right route, and specified that medications be administered by licensed personnel in accordance with Pennsylvania regulations. Resident 2’s MDS indicated that the resident was cognitively intact, required staff assistance with daily care, and had diagnoses including atherosclerotic heart disease. The resident had a right upper arm midline catheter in place for IV medication administration, specifically for Zosyn. Physician orders for the resident included multiple oral medications: apixaban 5 mg by mouth twice daily for atrial fibrillation, gabapentin 100 mg two tablets by mouth three times daily for rheumatoid arthritis, magnesium oxide 400 mg by mouth twice daily for magnesium deficiency, potassium chloride ER 20 mEq by mouth three times daily for potassium deficiency, and midodrine 5 mg two tablets by mouth three times daily for hypotension. The resident also had an order for oral tablets to be crushed and mixed in pudding. On the evening medication pass, the 6:00 p.m. oral medications (Eliquis 5 mg, gabapentin 100 mg, magnesium oxide 400 mg, midodrine 5 mg, and potassium 20 mEq) were instead crushed, mixed with warm water, and administered through the resident’s right arm midline catheter. Multiple staff statements and interviews confirmed that an LPN crushed the resident’s ordered oral medications, dissolved them in water, and administered them via the midline using a normal saline flush syringe, rather than giving them orally as ordered. Another nurse became suspicious when the resident’s daughter questioned whether it was appropriate to put medications into the midline, and when attempts to infuse IV antibiotics and flush the midline were unsuccessful despite the LPN stating he had just flushed it. The LPN later admitted to several staff, including RNs, that he had crushed and administered the 6:00 p.m. oral medications through the midline catheter, stating he had made a mistake and was confused with administering medications through a gastric tube. Subsequently, the resident’s oxygen saturation remained between 85% and 87% on 12 liters of supplemental oxygen, the physician was notified, and the resident was transferred to the hospital, where emergency room evaluation revealed hyponatremia and otherwise stable condition. The physician documented that the resident had been given oral medications dissolved in water through the midline the previous evening and that the midline had since been removed.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident from abuse by another resident with a history of aggressive behaviors. According to the facility's abuse policy, staff were required to monitor, assess, and implement care planning interventions for residents with behaviors that could lead to conflict or harm. Resident 2, who had diagnoses including dementia, anxiety, and depression, exhibited multiple behavioral issues such as agitation, paranoia, and hostility, and was to be closely monitored and redirected as needed. Despite these interventions being outlined in the care plan, Resident 2 was able to push another resident, resulting in harm. On the day of the incident, Resident 3, who was also cognitively impaired and had a history of behavioral issues, approached Resident 2 and tapped him on the shoulder. Resident 2 responded by forcefully pushing Resident 3, causing her to fall and sustain a right hip fracture. The facility's investigation, supported by video evidence and staff interviews, substantiated that abuse occurred, as Resident 3 suffered significant injury as a result of the altercation.
Failure to Investigate Resident Grievance Regarding Staff Conduct
Penalty
Summary
The facility failed to conduct a thorough investigation into a resident's grievance regarding the actions and behaviors of a specific LPN. The resident, who had a history of cerebral vascular accident with right side hemiplegia and diabetes, submitted a grievance form detailing multiple incidents over the course of a year. These included the LPN preparing the wrong insulin, making upsetting comments, and engaging in behaviors perceived as passive-aggressive or intended to distress the resident. The resident also reported that the LPN made statements about her hallucinating and expressed a desire not to have this LPN involved in her care. Upon review, it was found that the facility's investigation did not include documentation addressing the resident's specific concerns about the LPN's conduct, nor was there evidence that a statement was obtained from the LPN in question. The facility's grievance policy required a thorough investigation with supporting documentation, but these steps were not completed or recorded in this case. The DON confirmed the absence of documented evidence addressing the resident's concerns or obtaining a statement from the LPN.
Failure to Ensure Hot Liquid Safety Results in Resident Injury
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for a resident with a history of cerebral vascular accident resulting in left-side hemiplegia. The resident, who was alert, oriented, and able to communicate preferences, requested a cup of coffee using his own K-Cup and specified that he did not want a lid on the cup. The coffee was prepared by a nurse aide using a Keurig machine and delivered to the resident's bedside table without the temperature being checked, as was the usual practice at the time. Shortly after receiving the coffee, the resident attempted to drink from the open cup, which slipped from his hand and spilled onto his left thigh. The incident resulted in the formation of blisters and redness on the resident's thigh, as documented in the nursing note. The resident reported mild pain, and the affected area was treated by staff. There was no evidence that the temperature of the coffee was measured prior to serving, and the facility's hot liquid safety policy was not applied to nursing staff, only to kitchen staff. Interviews with staff confirmed that the temperature of hot liquids from the Keurig was not routinely checked before serving to residents. The nurse aide involved in the incident stated that she followed the resident's request for no lid and did not measure the temperature of the coffee. The DON confirmed the lack of documentation regarding temperature checks and clarified that the policy was not extended to nursing staff at the time of the incident.
Failure to Follow Physician Orders for Blood Pressure Medications
Penalty
Summary
The facility failed to ensure that physician's orders were followed for two residents, resulting in care and treatment not being provided in accordance with professional standards of practice. For one resident with a history of congestive heart failure and hypertension, physician's orders required Hydralazine to be held if the systolic blood pressure was less than 120 mmHg. However, review of the Medication Administration Record (MAR) showed that the medication was administered on multiple occasions when the resident's systolic blood pressure was below the specified threshold, with no documentation that the medication was held as ordered. Similarly, another resident with hypertension and dementia had a physician's order for metoprolol tartrate to be held if the systolic blood pressure was less than 130 mmHg or if the heart rate was less than 60 beats per minute. The MAR indicated that the medication was not held on several occasions when the resident's systolic blood pressure was below the ordered threshold, and there was no documentation to show compliance with the physician's order. These findings were confirmed in an interview with Clinical Compliance staff.
Inaccurate Completion of MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for four residents, as required by the Resident Assessment Instrument (RAI) User's Manual. For one resident with a seizure disorder and cerebral palsy, the MDS did not accurately reflect the administration of an anticonvulsant medication during the seven-day look-back period, despite physician orders and medication administration records confirming its use. Another resident with coronary artery disease and a history of heart attack was not accurately coded for receiving an antiplatelet medication, even though both physician orders and the medication administration record indicated the medication was given during the assessment period. These inaccuracies were confirmed by the Director of Case Management. Additionally, a resident who was readmitted to the facility after a hospital stay for a hip fracture was not properly coded in the MDS to indicate this was the first assessment since reentry, which prevented the documentation of a recent fall and fracture. Another resident's discharge status was incorrectly recorded in the discharge tracking MDS, with the record indicating a discharge to the hospital instead of a personal care home, as documented in the nursing notes. These errors were also confirmed by the Director of Case Management.
Failure to Clarify Provider Order After Pharmacy Medication Substitution
Penalty
Summary
The facility failed to ensure that nursing services met professional standards of quality by not clarifying a provider's order for a resident. Specifically, a physician's order directed that a resident with renal failure and peripheral vascular disease receive 250 mg of calcium citrate twice daily for Vitamin D deficiency. However, during medication administration, the resident was given 950 mg of calcium citrate containing 200 mg of calcium, which did not match the original order. The pharmacy had substituted the medication due to a backorder but did not notify the facility or ensure the substitution was equivalent. Nursing staff, including an LPN, were unaware of the reason for the substitution and did not clarify the change with the physician. There was no documentation in the resident's clinical record indicating that the order was clarified, and the DON confirmed that the medication administered did not match the physician's order. The facility's policy required that such substitutions be communicated and orders updated, but this process was not followed, resulting in the administration of a non-equivalent medication without proper provider clarification.
Failure to Document PICC Line Flushing as Ordered
Penalty
Summary
The facility failed to ensure that peripherally-inserted central catheters (PICCs) were flushed as ordered by physicians for two residents. Facility policy required that intravenous catheters be flushed with 0.9% sodium chloride before and after medication administration. For one resident with cognitive impairment and multiple diagnoses, including heart failure and a urinary tract infection, physician orders specified administration of intravenous antibiotics. However, review of the medication administration records showed no documented evidence that the resident's PICC line was flushed after antibiotic administration, as required by policy. Another resident, who was cognitively intact and had diagnoses including peripheral vascular disease and diabetes, returned from the hospital with a PICC line and orders for daily intravenous Vancomycin, with instructions to flush the IV access site with saline before and after medication administration. The medication administration records indicated that the resident received the IV antibiotics, but there was no documentation that the PICC line was flushed with saline before and after each administration. Staff interviews confirmed the lack of documentation for both residents.
Medication Error Rate Exceeds Regulatory Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required by policy and regulation. During medication administration observations, two errors were identified out of 30 opportunities, resulting in a 6.67 percent error rate. The facility's policy required staff to verify the electronic medical record against the prescription label and adhere to the six rights of medication administration. However, these procedures were not followed in the observed instances. One cognitively intact resident with renal failure and peripheral vascular disease was ordered to receive 250 mg of calcium citrate twice daily but was instead administered 950 mg. Another cognitively intact resident with multiple sclerosis was ordered to receive two drops of artificial tears in each eye three times daily but was only given one drop per eye. Both errors were confirmed by the LPN involved and the Director of Nursing, who acknowledged that the medications administered did not match the physician's orders.
Obstructed Electrical Panels in Storage Room
Penalty
Summary
The facility failed to maintain electrical equipment in accordance with NFPA 70, National Electric Code, as required by NFPA 101 (2012 Ed.). During an observation on April 30, 2025, at 9:20 a.m., it was noted that two electrical panels were obstructed by wheelchairs in the B-2 storage room on the second floor of the B wing. This deficiency affected one out of 27 smoke compartments in the facility. An interview with the Facility Administrator and Maintenance Director on May 1, 2025, at 11:00 a.m., confirmed the presence of the electrical equipment deficiency. The obstruction of the electrical panels by wheelchairs indicates a failure to ensure clear access to electrical equipment, which is necessary for safety and compliance with the relevant codes.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. Maintenance removed the wheelchairs in the second-floor b-wing storage room that were obstructing the electrical panels on 5/1/2025. The Director of Maintenance/designee will conduct random weekly audits throughout the facility two times per week for two weeks then weekly for two weeks to ensure there are no electrical panels obstructed by wheelchairs. The results of these audits will be brought to the Quality Assurance and Performance Improvement Committee for further analysis and corrective actions.
Improper Use of Extension Cord in Maintenance Room
Penalty
Summary
The facility failed to maintain electrical wiring systems and equipment, as evidenced by the use of an electrical extension cord as a fixed power source for a small electric or mechanical pump. This deficiency was observed in the Maintenance/Shop Storage room located in the basement of the facility. The observation was made on April 30, 2025, at 10:35 a.m. During an interview conducted on May 1, 2025, at 11:00 a.m., both the Facility Administrator and the Maintenance Director confirmed the deficiency related to the electrical wiring systems.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. Maintenance removed the electrical extension cord in the Maintenance/Shop Storage room in the basement on 5/2/2025. The Director of Maintenance/designee will conduct random weekly audits in the facility two times per week for two weeks, then weekly for two weeks to ensure there are no extension cords. The results of these audits will be brought to the Quality Assurance and Performance Improvement Committee for further analysis and corrective actions.
Unsafe Dining Room Environment
Penalty
Summary
The facility failed to provide a safe and comfortable homelike environment in the A1 dining room, as required by their policy dated February 4, 2024. During an interview with a group of residents, concerns were raised about the condition of the dining room tables, which were described as peeling and rough, posing a risk of skin tears. Observations confirmed that all eight tables in the A1 dining room were peeling and had sharp edges. The Maintenance Director and the Director of Nursing both confirmed the poor condition of the tables, acknowledging that the environment was neither safe nor comfortable for the residents.
Failure to Implement Non-Pharmacological Interventions Before Administering Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications, as evidenced by the lack of documented non-pharmacological interventions prior to administering Lorazepam. The facility's policy, dated February 4, 2024, mandates the use of non-pharmacological interventions when clinically indicated to reduce the need for psychotropic medication. However, for one resident, there was no evidence that such interventions were attempted before administering Lorazepam on multiple occasions in January and February 2024. The resident in question had cognitive impairment and required assistance with transfers, with diagnoses including dementia and anxiety. Despite a psychiatric evaluation recommending the continuation of positive psychosocial and non-pharmacological approaches, the Medication Administration Records showed repeated administration of Lorazepam without prior attempts at non-pharmacological interventions. The Director of Nursing confirmed the absence of these interventions during an interview, highlighting a failure to adhere to the facility's policy and regulatory requirements.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling of medications for a resident and did not label multi-dose containers of insulin with the date they were opened. Specifically, for one resident, the label on their Lantus insulin did not reflect the correct dosage and timing as per the physician's orders. The label indicated 25 units at bedtime, while the resident was administered 20 units in the morning. This discrepancy was confirmed by an LPN during an interview, who acknowledged that a 'Change in Direction' label should have been applied. Additionally, the facility did not adhere to its policy of dating multi-dose vials upon opening. During an inspection of a medication cart, it was observed that insulin vials for several residents were opened but not dated, contrary to the manufacturer's instructions which require vials to be discarded after a specific period. This was confirmed by another LPN and the Director of Nursing, who acknowledged that the vials should have been labeled with the opening and discard dates.
Failure to Maintain Sanitary Food Handling Practices
Penalty
Summary
The facility failed to ensure that food was served under sanitary conditions, as evidenced by a violation of their policy on feeding with dignity. During a lunch meal observation in the A3 unit dining room, a nurse aide was seen handling a resident's food without using gloves or a barrier. Specifically, the nurse aide used his bare hand to place a mechanical soft prepared hamburger onto a bun for a resident, who then consumed the food. This action was in direct violation of the facility's policy, which mandates that staff cleanse hands between residents, avoid touching food with bare hands, and use gloves or barriers when handling food. The nurse aide confirmed the breach of protocol during an interview, and the Corporate Compliance/Certified Registered Nurse Practitioner corroborated the requirement for using gloves or barriers when touching residents' food items.
Failure to Obtain Required Hospice Documentation
Penalty
Summary
The facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for two residents receiving hospice services. Resident 97, who was cognitively impaired and diagnosed with malnutrition, had a care plan indicating hospice services due to a terminal illness. However, as of May 9, 2023, there was no documented evidence of updated hospice nurse aide charting in the resident's clinical record or the hospice provider's clinical record since January 2024. This was confirmed by an interview with the Director of Nursing. Similarly, Resident 228, who was cognitively intact and diagnosed with a cerebrovascular accident, had a care plan for hospice services due to terminal cerebrovascular disease. As of May 9, 2023, there was no documented evidence of updated hospice registered nurse or nurse aide charting in the resident's clinical record or the hospice provider's clinical record since the admission notes dated April 27, 2024. This deficiency was also confirmed by the Director of Nursing.
QAPI Committee Fails to Address Recurring Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to effectively address recurring deficiencies identified in multiple surveys. These deficiencies included issues with the accuracy of assessments, tube feeding management, labeling and storage of drugs and biologicals, and infection prevention and control. Despite having developed plans of correction in response to previous surveys, the QAPI committee was unable to maintain compliance with the relevant regulations, as evidenced by the repeated citations in the current survey. The deficiencies were initially identified in surveys conducted on June 13, 2023, August 15, 2023, and August 29, 2023. The facility's plans of correction included monitoring by the QAPI committee to ensure compliance. However, the current survey, ending May 9, 2024, revealed that the QAPI committee was ineffective in addressing these issues, leading to repeated citations under F641, F693, F761, and F880. The facility's inability to correct these deficiencies indicates a failure in the QAPI committee's role in maintaining regulatory compliance.
Misappropriation of Resident's Medication
Penalty
Summary
The facility failed to prevent the misappropriation of medication for one resident, identified as Resident 34. The resident was cognitively intact, required extensive assistance for daily care needs, and had a diagnosis of chronic pain. The physician's orders included Norco for pain management. On a specific date, narcotics were delivered to the B3 nursing unit, and Registered Nurse Supervisor 1 documented the receipt of five narcotic cards. However, during a shift change, it was discovered that only four cards were delivered to the unit, despite five being documented on the accountability form. An investigation revealed that Registered Nurse 2 was the last person in possession of the narcotics card, as confirmed by video footage. The footage showed Registered Nurse 2 entering the medication room alone, and there was no evidence that all five narcotic cards were delivered to the B3 unit. The investigation concluded that misappropriation of Resident 34's medication occurred, as only four cards were documented and delivered, leading to the determination that one card was missing.
Failure to Update Resident Care Plan
Penalty
Summary
The facility failed to update the care plan of Resident 66 to reflect changes in her care needs. The resident's Medication Administration Record for May 2024 showed that she was receiving medications at 6:00 a.m., despite her care plan from January 21, 2020, indicating a preference for no medications or care before 7:00 a.m. An interview with Resident 66 on May 6, 2024, revealed that she had switched to early dialysis and did not mind receiving medications early, but her care plan was not updated to reflect this change. The Director of Nursing confirmed on May 9, 2024, that the care plan was outdated and should have been revised to accommodate the resident's new preferences.
Failure to Provide Weekly Showers Due to COVID-19
Penalty
Summary
The facility failed to ensure that a resident was provided with weekly showers, as required by their policy. The policy, dated February 4, 2024, stated that residents should be offered a shower at least once a week. An annual Minimum Data Set (MDS) assessment for the resident, dated April 26, 2024, indicated that the resident was alert and oriented, and it was important for them to choose their preferred method of bathing. The resident's care plan, dated July 7, 2023, specified that they were to receive a shower in the morning. However, the resident's bathing records for April 2024 showed that they did not receive a weekly shower on April 5 and 12, instead receiving a bed bath. This was confirmed by the Director of Nursing, who stated that the resident was not showered on those dates due to testing positive for COVID-19.
Failure to Follow Feeding Tube Labeling Policy
Penalty
Summary
The facility failed to adhere to its policy regarding the management of feeding tubes for one resident, identified as Resident 159. The policy, dated February 4, 2024, mandates that the formula and tubing used for feeding tubes must be labeled with the date and time they were started and should not be used for more than 24 hours. However, during an observation on May 8, 2024, it was noted that the bag of Isosource 1.5 formula being used for Resident 159 did not have the required date and time label. This was confirmed by a Registered Nurse at the time of observation. Resident 159, who is cognitively impaired and requires staff assistance, has a feeding tube for nutrition due to diagnoses including stroke and dementia. The resident's care plan and physician's orders specify the administration of Isosource 1.5 at a rate of 38 mL/hr for 21 hours. Despite these orders being followed as per the Medication Administration Record for May 2024, the lack of proper labeling on the feeding bag represents a failure to comply with the facility's established procedures. The Director of Nursing confirmed that staff are responsible for ensuring that feeding tube labels contain the necessary information.
Infection Control Deficiencies in Hand Hygiene and Linen Handling
Penalty
Summary
The facility failed to ensure proper hand hygiene during wound care for a resident with multiple ulcers and infections. During an observation, two nurses were seen performing wound care on a resident with a Stage 3 and Stage 4 pressure ulcer on the right great toe and a venous ulcer on the right lower leg. Despite the facility's policy requiring hand washing and glove changes at specific intervals during wound care, the nurses did not wash their hands after removing soiled gloves and before applying clean ones. This lapse occurred multiple times during the treatment process, including between handling soiled and clean dressings and between treating different wound sites. Additionally, the facility did not adhere to proper infection control practices while handling soiled linens. A nurse aide was observed throwing a soiled towel and washcloth on the floor during a bed bath for another resident who required extensive assistance with daily care. The facility's protocol dictates that soiled linens should be placed in bags and taken to the dirty utility room, which was not followed in this instance. Interviews with the involved staff and the Director of Nursing confirmed the failure to follow hand hygiene protocols during wound care. Similarly, the Clinical Coordinator confirmed that the handling of soiled linens did not comply with the facility's infection control practices. These deficiencies highlight lapses in adherence to established infection prevention and control measures, as outlined in the facility's policies.
Failure to Notify Responsible Parties and Ombudsman of Emergency Transfers
Penalty
Summary
The facility failed to provide written notification of emergency hospital transfers to the responsible parties and the State Ombudsman for three residents. Resident 63, who had end-stage renal disease and required hemodialysis, was transferred to the hospital after a traumatic removal of her dialysis catheter led to uncontrollable bleeding. There was no documented evidence that a written notice of this transfer was provided to the resident's responsible party or the State Ombudsman. Similarly, Resident 82, who had cognitive impairment and dementia, was transferred to the hospital following a fall that resulted in shoulder pain. Additionally, Resident 118, who was nonverbal and had Huntington's disease, was transferred due to hypoxemia and a possible ileus. In both cases, there was no documented evidence of written notification to the responsible parties or the State Ombudsman. The Nursing Home Administrator confirmed the lack of notification and was unaware of the requirement for written notices in such situations.
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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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