William Hood Dunwoody Care Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Newtown Square, Pennsylvania.
- Location
- 3500 West Chester Pike, Newtown Square, Pennsylvania 19073
- CMS Provider Number
- 395329
- Inspections on file
- 17
- Latest survey
- April 17, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at William Hood Dunwoody Care Ctr during CMS and state inspections, most recent first.
The facility failed to maintain and inspect its sprinkler system as per NFPA 25 standards, affecting the entire facility. Missing documentation for annual control valve exercises and physical deficiencies, such as missing sprinkler escutcheons and improper anchoring of ceiling wires, were observed. These issues were confirmed during an exit interview with the Administrator and the Director of Maintenance.
The facility did not properly identify portable fire extinguishers, as all recessed, wall-mounted fire extinguisher cabinets lacked indicator signage. This issue was confirmed during an exit interview with the Administrator and the Director of Maintenance.
The facility failed to maintain documentation of weekly battery voltage inspections for the emergency generator, affecting the entire facility. This deficiency was confirmed during an exit interview with the Administrator and Director of Maintenance.
The facility failed to maintain proper building separation in sections classified as other occupancies. An observation revealed that the doorway to Country House, between skilled nursing and assisted living, lacked a 1 1/2 hour fire-resistant door. This deficiency was confirmed during an exit interview with the Administrator and the Director of Maintenance, acknowledging the lack of complete two-hour fire-resistant separation.
The facility was cited for deficiencies in egress door signage and functionality. An SLA egress door lacked required signage for delayed-egress systems, and a door towards the Hood loading dock area had a damaged closure, preventing it from closing properly. These issues were confirmed by the Administrator and Director of Maintenance.
The facility failed to maintain electrical system requirements, with unsecured junction boxes found above the ceiling on the first floor and exposed wiring in the Hood Mechanical Room. These deficiencies were confirmed during an exit interview with the Administrator.
The facility was found to have unsealed penetrations above smoke barrier doors in the trash separation room due to data lines, compromising the required 1/2-hour fire resistance rating. This issue was confirmed during an exit interview with the Administrator and the Director of Maintenance.
A resident with an indwelling catheter experienced a significant change in urinary status, including no urine output in the drainage bag and the presence of bloody, odorous urine with tan sludge after catheter replacement. Although the responsible party was notified, there was no documentation that the physician was informed of this change, resulting in a delay in treatment for a subsequent urinary tract infection. The DON confirmed the lack of physician notification.
A resident developed a new deep tissue pressure injury (DTI) on the left lower back, which was initially assessed and treated, but no further wound care was documented or provided for several days until the resident was sent to the hospital. The DON confirmed the lack of wound treatment during this time.
A resident with dementia and dysphagia experienced significant weight loss over several weeks, but staff did not reweigh the resident within 24 hours, notify the physician promptly, or implement interventions as required by facility policy. The weight loss continued over a three-month period without documented review or action by the nurse or dietitian.
A resident did not receive timely treatment for constipation as per the facility's Bowel Protocol. Despite having a physician's order for Milk of Magnesia, the resident went 15 shifts without a bowel movement before the medication was administered, contrary to the protocol requiring action after 6 shifts.
A resident with Dementia, Anemia, and Anxiety Disorder fell out of bed while receiving morning care from a non-licensed staff member who was unaware that the resident required paired care. The resident sustained a small abrasion but reported no pain. The incident occurred because the staff member did not follow the care plan instructions.
Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain and inspect its sprinkler system in accordance with NFPA 25 standards, affecting the entire facility. During a document review on April 17, 2025, it was found that the facility could not provide documentation of an annual exercise of control valves through their complete range of motion. Additionally, observations revealed physical deficiencies, including two missing sprinkler escutcheons in the oxygen room Dundale and a suspended ceiling wire improperly anchored to a sprinkler branch line in the smoke separation vestibule on the first floor, creating an external load on the sprinklers. Further observations on the same day identified another deficiency affecting one of the three levels of the facility. A missing sprinkler escutcheon was noted outside the security office and the mechanical room on the first floor. These deficiencies were confirmed during an exit interview with the Administrator and the Director of Maintenance, highlighting the facility's failure to maintain and inspect the sprinkler system adequately.
Plan Of Correction
Dunwoody will have their sprinkler vendor inspect the sprinkler control valves and will document confirmation that they exercised their complete range of motion by 5/30/2025. This will be completed and documented as part of their annual inspection going forward. Missing escutcheons will be installed by 5/30/2025 by Dunwoody Maintenance staff and checked quarterly as part of our quarterly safety inspections by the Maintenance Manager or designee. The ceiling grid wire will be removed from the sprinkler pipe by 5/30/2025 by Dunwoody's Maintenance staff. All maintenance mechanics will be inserviced on this by 5/30/2025. Missing escutcheons will be installed by 5/30/2025 by Dunwoody Maintenance staff and checked quarterly as part of our quarterly safety inspections by the Maintenance Manager or designee. All maintenance mechanics will be inserviced on this by 5/30/2025.
Lack of Indicator Signage for Fire Extinguishers
Penalty
Summary
The facility failed to ensure that portable fire extinguishers were properly identified throughout the entire facility. During an observation on April 17, 2025, at 11:05 a.m., it was noted that all recessed, wall-mounted fire extinguisher cabinets lacked indicator signage. This deficiency was confirmed during an exit interview with the Administrator and the Director of Maintenance at 11:15 a.m. on the same day.
Plan Of Correction
Dunwoody Maintenance staff will install indicator signs over all fire extinguishers by 5/23/2025. These signs will be checked quarterly as part of our quarterly safety inspections by the Maintenance Manager or designee. All maintenance mechanics will be inserviced on this by 5/23/2025.
Failure to Document Weekly Generator Inspections
Penalty
Summary
The facility failed to maintain and inspect the emergency generator, which is crucial for the safety and operation of the entire facility. During a document review on April 17, 2025, it was discovered that the facility could not provide documentation proving that weekly inspections of the battery voltage were performed. This lack of documentation indicates a failure to adhere to the required maintenance and testing protocols for the emergency generator as outlined by NFPA standards. An exit interview with the Administrator and the Director of Maintenance confirmed the absence of the necessary documentation. This deficiency affects the entire facility, as the emergency generator is a critical component of the essential electrical system, designed to provide power in the event of an outage. The failure to maintain proper records of inspections compromises the facility's ability to ensure the generator's reliability and readiness in emergencies.
Plan Of Correction
The Maintenance Manager or designee will check the battery voltage weekly on the emergency generators and document on the respective generator log. This will be added to the generator logs by 5/16/2025. All maintenance mechanics will be inserviced on this by 5/16/2025.
Failure to Maintain Building Separation
Penalty
Summary
The facility failed to maintain proper building separation in sections classified as other occupancies. During an observation on April 17, 2025, at 9:50 a.m., it was noted that the doorway to Country House, which is situated between the skilled nursing and assisted living areas, did not have a 1 1/2 hour fire-resistant door. This deficiency was confirmed during an exit interview with the Administrator and the Director of Maintenance on the same day at 11:15 a.m., where it was acknowledged that there was a lack of complete two-hour fire-resistant separation as required by the regulations.
Plan Of Correction
2-hour fire resistant doors will be purchased and installed by 7/11/2025 by Dunwoody's General Contractor. The Maintenance Manager or designee will inspect these doors weekly for the initial two months and then annually as part of our Annual Fire Door Inspection. All maintenance mechanics will be inserviced on this by 7/11/2025. Dunwoody will ask for a TLW as July 11 is close to the 90th day and if there is any type of delay by contractor or delivery or production of door it may be necessary to have the TLW.
Deficiencies in Egress Door Signage and Functionality
Penalty
Summary
The facility was found to have deficiencies related to the egress doors, specifically concerning the delayed-egress locking systems. During an observation on April 17, 2025, it was noted that an SLA egress door outside of elevator 10 lacked the required signage indicating "PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS." This deficiency was confirmed during an exit interview with the Administrator and the Director of Maintenance, who acknowledged the absence of the necessary signage for the delayed egress system. Additionally, the facility failed to maintain the means of egress without obstructions. An observation on the same day revealed that the left side door towards the Hood loading dock area on the first level had a damaged door closure, preventing the door from swinging closed properly. This issue was also confirmed during the exit interview with the Administrator and the Director of Maintenance, who acknowledged the malfunctioning door closure.
Plan Of Correction
A 15 second delayed egress sign will be installed on 5/16/2025 by Dunwoody's Maintenance staff. The Maintenance Manager or designee will inspect these doors annually as part of our Annual Fire Door Inspection. All maintenance mechanics will be inserviced on this by 5/26/2025. The damaged fire door closer will be repaired on or before 5/9/2025 by Dunwoody's Maintenance Staff. The Maintenance Manager or designee will inspect these doors weekly for the initial two months and then annually as part of our Annual Fire Door Inspection. All maintenance mechanics will be inserviced on this by 5/26/2025.
Electrical System Deficiencies Found in Facility
Penalty
Summary
The facility failed to maintain electrical system requirements as per NFPA 70 and NFPA 99, affecting one of two levels of the facility. During an observation on April 17, 2025, between 9:05 a.m. and 9:08 a.m., two unsecured junction boxes were found above the ceiling on the first floor, near the rehab area and in front of the laundry. Additionally, at 10:05 a.m. on the same day, an observation inside the Hood Mechanical Room revealed a metal clad conduit wire with exposed wiring. These deficiencies were confirmed during an exit interview with the Administrator on April 17, 2025, at 11:15 a.m.
Plan Of Correction
The junction boxes will be secured on or by 5/23/2025. The exposed wire will be correct on or by 5/23/2025. Above ceiling audits for unsecure junction boxes will be made part of the Maintenance Quarterly Safety inspections by 5/23/2025. All maintenance mechanics will be inserviced on this by 5/23/2025. The exposed wire will be replaced on or by 5/30/2025 by Dunwoody's contracted electrician. This will be inspected quarterly by the Maintenance Manager or Designee and made part of the Maintenance Quarterly Safety inspections by 5/30/2025. All maintenance mechanics will be inserviced on this by 5/30/2025.
Unsealed Penetrations in Smoke Barrier Walls
Penalty
Summary
The facility failed to ensure that smoke barrier walls were free of unsealed penetrations, which is a requirement for maintaining a 1/2-hour fire resistance rating. During an observation on April 17, 2025, at 10:05 a.m., it was noted that there were unsealed penetrations above the smoke barrier doors in the trash separation room due to data lines. This deficiency was confirmed during an exit interview with the Administrator and the Director of Maintenance on the same day at 11:15 a.m.
Plan Of Correction
This penetration will be sealed with a UL approved stop gap penetration system or before 5/16/2025. Above ceiling penetrations will be made part of the Maintenance Quarterly Safety inspections by 5/16/2025. All maintenance mechanics will be inserviced on this by 5/16/2025.
Failure to Notify Physician of Significant Change in Urinary Status
Penalty
Summary
The facility failed to notify the physician of a significant change in a resident's urinary status. The resident, who had an indwelling urethral catheter due to urinary retention and neuromuscular dysfunction of the bladder, was found to have no urine output in the drainage bag, while their brief was wet twice. Further assessment revealed that the catheter was outside the body more than it should have been. The catheter was removed and replaced, resulting in immediate output of 1700 cc of red bloody, odorous, and tan sludge urine. The responsible party was notified, but there was no documentation that the physician was informed of this significant change in the resident's condition. Subsequent physician notes indicated that the resident was later found to be somnolent and not as vocal as their baseline, prompting further laboratory tests. Blood work revealed an elevated white blood cell count and urine tests indicated a urinary tract infection, for which the physician was eventually notified and treatment was started. The Director of Nursing confirmed that there was no documented evidence of physician notification at the time of the initial significant change in urinary status, resulting in a delay in treatment.
Failure to Provide Wound Treatment for Pressure Ulcer
Penalty
Summary
The facility failed to provide wound treatment for a pressure ulcer identified on a resident's left lower back. On March 13, 2025, a new deep tissue pressure injury (DTI) was observed and documented, with the wound initially cleansed and ointment applied, and the nurse practitioner notified. However, review of the resident's treatment administration record (TAR) showed no evidence that wound treatment was administered for the DTI from March 14, 2025, until the resident was transferred to the hospital on March 17, 2025. The Director of Nursing confirmed the absence of documented wound care during this period.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to address a significant weight loss in a resident diagnosed with dementia and dysphagia. According to the facility's policy, residents' weights are to be monitored weekly, and any weight change of three pounds or more should be reweighed within 24 hours to verify accuracy. Additionally, weight losses of 5% or more are to be reported to the physician and documented, with a care plan developed to address the concern. In this case, the resident experienced an 8.8-pound (5.81%) weight loss over five days, but there was no evidence that a reweigh was performed within 24 hours, nor that the nurse or dietitian reviewed the weight loss. No interventions were implemented to prevent further weight loss, and the physician was not notified until several weeks later. Further review showed that the resident continued to lose weight, with a total loss of 7.34% from admission over a three-month period. Despite this ongoing decline, there was no documentation of interventions or care plan adjustments to address the continued weight loss. Interviews with the dietitian and DON confirmed that no actions were taken in response to the significant and ongoing weight loss. The facility did not follow its own policies for monitoring, documenting, and responding to significant weight changes.
Failure to Administer Constipation Treatment in a Timely Manner
Penalty
Summary
The facility failed to ensure timely treatment for constipation for one of 18 residents. According to the facility's Bowel Protocol policy, if a resident has not had a bowel movement for 6 shifts, the 3-11 charge nurse is to administer Milk of Magnesia at bedtime. Resident 18 had a physician's order for Milk of Magnesia to be given every 24 hours as needed for constipation. However, the resident had no recorded bowel movement from April 22, 2024, through April 26, 2024, totaling 15 shifts without a bowel movement. The medication was not administered until April 27, 2024. This was confirmed by an interview with a licensed nurse, indicating a failure to follow the protocol and physician's orders.
Failure to Follow Care Plan Leads to Resident Fall
Penalty
Summary
The facility failed to ensure that Resident 44 was free from accidents during activities of daily living care. On March 20, 2024, non-licensed staff member Employee E1 was providing morning care to Resident 44 when the resident rolled out of bed and fell onto the floor. The clinical record for Resident 44 indicated that the resident required paired care (two staff members) for such activities, as noted in the care plan dated January 20, 2023. However, Employee E1 was not aware of this requirement and was providing care alone, leading to the accident. Resident 44, who has diagnoses including Dementia, Anemia, and Anxiety Disorder, sustained a small abrasion on the left upper forehead but reported no pain following the fall. The facility's investigation confirmed that the fall occurred because Employee E1 did not follow the care instructions specified in the resident's care plan. The Nursing Home Administrator confirmed the incident and reported that Employee E1 was reeducated on following resident care plans.
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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