William Penn Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Lewistown, Pennsylvania.
- Location
- 163 Summit Drive, Lewistown, Pennsylvania 17044
- CMS Provider Number
- 395335
- Inspections on file
- 23
- Latest survey
- April 17, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at William Penn Nursing And Rehab during CMS and state inspections, most recent first.
The facility had a 12% medication error rate based on 25 opportunities and 3 errors. An LPN gave a resident only one Lasix tablet instead of the ordered three, broke Potassium Chloride ER tablets in half before administration, and gave another resident only one Tamsulosin capsule instead of the ordered two-capsule dose. Staff interviews confirmed the errors, and the DON reviewed the findings.
Unsafe Food Storage and Unsanitary Kitchen Conditions: The main kitchen had multiple sanitation and storage issues, including a soap dispenser coming off the wall, frozen food left open to ambient air, and several outdated spice and dry goods containers. In the dish room, the ceiling had black discoloration, a wet and discolored sign showed moisture buildup, stained staff gowns had three winged insects on them, and cobwebs were observed under a table and on a pipe near the ice machine. A bent adaptive piece of silverware with tape on the handle was also found in a drawer and was reported as no longer used.
Failure to follow contact precautions occurred for two residents on TBP. One resident had VRE in a foot wound, but an LPN and nurse aides entered the room and provided care without wearing gowns or gloves as required. Another resident had C. difficile and was on TBP; gloves and gowns were available outside the room, and the report also noted lidded disposal bins at the doorway that required hand contact to open and close.
A resident’s MDS was coded to show anticoagulant use during the assessment period, but the clinical record contained no evidence that the resident received an anticoagulant. The DON confirmed the MDS was coded in error.
Incomplete Infection Control Care Plans: Two residents had care plans that did not fully address ordered contact precautions. One resident had VRE in a foot wound and a blank infection care plan entry with unspecified isolation precautions, while another resident had a PICC and MRSA in the blood, but the care plan only listed sepsis, bacteremia, and pneumonia with medication, lab, and vital sign interventions and did not address contact precautions.
A facility failed to keep PICC line emergency supplies accessible for two residents. One resident stated he wanted a pair knife to cut his line and tried to pull at the PICC, while both residents had physician orders for an emergency kit at bedside. During observations, no kit was visible in either room; gauze was later found in dresser drawers mixed with personal items, and the DON and an LPN had to search for it.
A resident receiving hemodialysis had an AV fistula in the L arm and a dialysis port in the chest, but the bedside emergency kit did not contain all items listed in the MD order, including a tourniquet and gloves, and the DON noted tubing clamps were also missing. The resident’s chart also had inconsistent limb restriction documentation, with the MD order limiting care to the L arm while the care plan and Kardex stated no BP or blood specimens from either arm.
A resident with prior pneumococcal vaccines was not shown to have been offered an updated PCV20 or PCV21 dose per CDC guidance after admission. The record included a refusal note stating he already had the vaccine, but there was no evidence the facility offered the updated immunization; an infection control preventionist confirmed the finding.
Surveyors identified that several MDS assessments contained inaccurate information, including incorrect documentation of anticoagulant use, limb and trunk restraint use, and lower extremity impairments for multiple residents. Staff interviews confirmed these were coding errors, and the DON was notified of the discrepancies.
Six residents were not assisted in obtaining routine dental care, with clinical records and staff interviews confirming that they were not offered or provided dental services every six months as required. Some had not seen a dentist in years, and others had no documentation of dental care since admission, despite having natural teeth, broken teeth, or dentures.
The facility did not track or document staff COVID-19 vaccination status as required. Instead of offering the vaccine individually, signs were posted instructing staff to seek vaccination elsewhere, and no records were maintained to show staff vaccination status or that the vaccine was offered.
A resident with a Foley catheter for urinary retention was repeatedly observed with their catheter bag uncovered and visible from the hallway, either hanging on the bed or lying on the floor. The DON confirmed these findings, indicating a failure to uphold resident dignity as required.
Two residents reported extended delays in call bell response for toileting assistance, with one experiencing waits of up to an hour and another frequently waiting over 30 minutes. Both residents attributed these delays to insufficient staffing, resulting in episodes of incontinence and unresolved grievances. Interviews and record reviews confirmed the lack of timely response and inadequate staffing levels.
A medication cart used by an LPN was found to contain significant debris and hair, along with several unsecured and unidentified medication tablets mixed in with medication punch cards. These issues were confirmed by the DON.
The facility did not post current daily nurse staffing information at the beginning of each shift for two nursing units. Observations and staff interviews confirmed that the posted information was outdated and not displayed in prominent locations at or near the nurse stations.
William Penn Nursing and Rehab failed to meet the required nurse aide-to-resident ratios as per Pennsylvania regulations. Over a 21-day period, the facility did not maintain the necessary staffing levels during the day, evening, and night shifts, as confirmed by staffing records and interviews with the administration.
The facility did not meet the required LPN to resident ratios, with deficiencies noted on both day and night shifts. On two occasions, the day shift was understaffed, and on six occasions, the night shift did not meet the required LPN per resident ratio. These staffing shortfalls were confirmed by the Nursing Home Administrator and DON.
The facility failed to accurately assess residents' status, with errors in MDS coding for restraints and anticoagulant use. Several residents were incorrectly documented as having bed rails used as restraints, despite evidence showing they were for mobility. Additionally, two residents were inaccurately noted as receiving anticoagulants, which was not supported by clinical records. These errors were confirmed by facility staff.
The facility failed to maintain a clean and safe environment in two shower rooms on Nursing Unit 1. Observations revealed dislodged tiles, debris in ceiling lights, grime on floors, peeling paint, and sharp metal tabs in the larger shower room. The second shower room had debris, wall damage, stained curtains, and spiders. A chair at Nurse Station 1 was also worn and damaged. These issues were discussed with the Nursing Home Administrator and DON.
The facility did not complete a significant change MDS assessment within the required timeframe after a resident elected hospice care. The MDS, which should have been completed within 14 days, was not documented until identified by a surveyor. This deficiency was confirmed during an interview with the Nursing Home Administrator and DON.
The facility failed to create comprehensive care plans for two residents, one with vision loss due to macular degeneration and another needing extensive dental work. The absence of these care plans was identified during a survey, and plans were only developed after the surveyor's inquiry.
A resident with a PICC line for intravenous antibiotics due to osteomyelitis did not receive proper care as per physician orders. The facility failed to change the midline dressing every seven days and did not perform required assessments of the catheter site. Observations confirmed the dressing was unchanged for 17 days, and there was no emergency kit or arm restriction signs in the resident's room. The facility lacked a policy outlining staff competencies for midline catheter care.
A facility failed to implement recommended interventions for a resident with sensorineural hearing loss. Despite an audiology assessment recommending a pocket talker to aid communication, the resident's care plan did not include this device. The deficiency was identified during an interview with the resident, who reported difficulty hearing and relied on a dry erase board for communication.
A facility failed to provide physician-ordered ROM services for a resident, as staff did not document the completion of a restorative program aimed at preventing contractures. The program included passive stretching of the left lower extremity, which was not consistently documented over several months, suggesting non-compliance with the physician's orders.
A facility failed to implement supplemental oxygen per physician orders for a resident with hypoxia. The resident's oxygen concentrator was set at one and one-half liters per minute instead of the ordered 0.5 liters per minute, despite a 99% oxygen saturation. The treatment administration record contained erroneous documentation, and the plan of care did not reflect the correct oxygen flow. Additionally, nebulizer equipment was not stored properly, violating infection control policy.
A facility failed to ensure a resident's medication regimen was free from unnecessary drugs. A pharmacist recommended dose reductions for Escitalopram and Ativan, but the physician disagreed without explanation. There was no documentation of behaviors justifying the continued use of these medications. The Nursing Home Administrator and DON were informed of these concerns.
The facility's medication error rate was 6.67%, exceeding the acceptable threshold. Errors included administering Omeprazole after breakfast instead of before meals, and a resident self-administering Fluticasone Propionate nasal spray incorrectly without intervention or assessment for self-administration capability.
A facility failed to implement enhanced barrier precautions for a resident with an open foot wound and a midline for IV antibiotics. Despite a sign indicating the need for gown and gloves, a nurse performed wound care without wearing an isolation gown, contrary to the facility's infection control policy.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure a medication error rate of less than five percent. Surveyors determined the medication error rate was 12 percent based on 25 medication opportunities with three medication errors, involving Residents 63 and 79. During observation of Resident 79’s medication administration, an LPN administered one 20 mg tablet of Lasix even though the physician order directed Furosemide 20 mg tablets, take three tablets (60 mg) by mouth once daily related to edema. The same observation also showed the LPN administered two Potassium Chloride Crys ER 20 MEQ tablets and broke both tablets in half before giving them, despite instructions that extended-release potassium chloride tablets should not be crushed, chewed, broken, or sucked. For Resident 63, the physician order directed Tamsulosin HCL 0.8 mg by mouth once daily within 30 minutes of breakfast and stated not to crush, chew, or open. The medication supply on hand was Tamsulosin HCl 0.4 mg capsules with directions to give two capsules for a total dose of 0.8 mg, but during the medication pass an LPN prepared and administered only one 0.4 mg capsule. Interviews with the involved staff confirmed the medications were administered as observed, and review with the DON showed the medication card also indicated the correct total dose of two capsules.
Unsafe Food Storage and Unsanitary Kitchen Conditions
Penalty
Summary
The facility failed to store food items in a safe and sanitary manner and maintain equipment in a sanitary condition in the main kitchen. During an initial tour with the dietitian, the wall-mounted soap dispenser next to the handwashing sink was observed coming off the wall. In the walk-in freezer, a box of bagged broccoli cuts and lima beans was open to the ambient air. The spice rack contained outdated containers of ground all spice with a use-by date of July 19, 2024, rosemary with a written use-by date of September 19, 2024, and thyme with a use-by date of March 6, 2025. The dry goods storage area contained a container of whole bay leaves with a written use-by date of December 20, 2024. Additional observations in the dishwasher room showed black, gritty discoloration on the ceiling, a wet and discolored paper sign inside a plastic protective covering on top of the dishwasher with moisture buildup inside the covering, and staff protective gowns hanging on the wall with stains and three observed winged insects on them. Cobwebs were also observed under a stainless-steel table along the wall and on a pipe going into the ceiling next to the ice machine. A bent adaptive piece of silverware with discolored scotch tape on the handle was found in a drawer on the coffee machine table, and the dietitian reported that the adaptive silverware was no longer used.
Failure to Follow Contact Precautions
Penalty
Summary
The facility failed to implement appropriate transmission-based precautions for two residents who were on contact precautions. Resident 127 was admitted on April 5, 2025, and had a physician order dated April 5, 2026, to initiate contact precautions for VRE in a foot wound. The facility policy stated that staff caring for residents on contact precautions are to wear a gown and gloves for all interactions that may involve contact with the resident or the resident’s environment, and that PPE is to be donned and doffed upon entry and exit from the room. However, on April 14, 2026, an LPN entered Resident 127’s room to obtain vital signs without putting on a gown or gloves, and on April 15, 2026, a nurse aide provided morning care to the resident’s roommate in the shared bathroom without wearing a gown or gloves while in Resident 127’s room. Later that morning, another nurse aide was at Resident 127’s bedside taking a lunch order and did not put on a gown or gloves at any point while in the room. Resident 129 had a diagnosis of enterocolitis due to Clostridium difficile and was on transmission-based precautions. The report noted that CDC guidance states strict glove use is the most effective means of preventing hand contamination with C. difficile spores, and that contamination of high-touch environmental surfaces contributes to transmission. Observation of Resident 129’s room showed the appropriate TBP items, including gloves and cloth gowns, located outside the room. The report also noted that the bins used for contaminated gowns/laundry and contaminated gloves/refuse at the doorway required the user to use a hand to access and close the lids. Similar bins with lids requiring hand contact were also observed at Resident 127’s room.
Inaccurate MDS Coding for Anticoagulant Use
Penalty
Summary
The facility failed to ensure that assessments accurately reflected a resident’s status for one of 23 residents reviewed. Clinical record review for Resident 99 showed an MDS dated February 21, 2026, in which facility staff coded the resident as receiving an anticoagulant medication during the last seven days of the assessment period. However, further review of the clinical record found no evidence that Resident 99 received an anticoagulant medication during that assessment period. The DON confirmed in interview on April 16, 2026, at 2:07 PM that the February 21, 2026 MDS was coded in error regarding anticoagulant use.
Incomplete Infection Control Care Plans
Penalty
Summary
The facility failed to implement comprehensive, person-centered care plans for infection control concerns for two residents. Resident 127 was admitted on April 5, 2026, and a physician order dated the same day directed staff to initiate contact precautions for VRE in her foot wound. Her care plan, also initiated April 5, 2026, listed "infection of" and was blank after that, and it stated staff were to maintain isolation precautions as indicated without specifying what precautions were required. Resident 128 was admitted on April 5, 2026, and a physician order dated April 6, 2026, directed staff to initiate contact precautions. Nursing documentation dated April 5, 2026, at 9:49 AM, noted that Resident 128 had a PICC in the left upper extremity and MRSA in his blood. His care plan, initiated April 5, 2026, identified infection of sepsis, bacteremia, and pneumonia, with interventions to administer medications per physician orders, obtain labs as ordered and notify the physician of results, and obtain vital signs as indicated, but it did not address contact precautions related to MRSA in his blood.
PICC Line Emergency Supplies Not Kept Accessible
Penalty
Summary
The facility failed to ensure the highest practical care related to PICC lines for two residents. Resident 128 was admitted on April 5, 2026, and nursing documentation on April 6, 2026, at 4:48 PM stated that he wanted a pair knife to cut his line, and that he then tried to pull at his PICC line. A physician order dated April 5, 2026, directed staff to maintain an emergency kit for Resident 128's PICC line at his bedside, but observation of his room on April 14, 2026, at 1:05 PM showed no emergency kit visible. On April 15, 2026, at 10:02 AM, a small bag of gauze was found in his top dresser drawer under his personal items. Resident 127 was admitted on April 5, 2026, and also had a physician order dated April 5, 2026, for staff to maintain an emergency kit for her PICC line at her bedside. Observation of her room on April 14, 2026, at 11:55 AM showed no emergency kit visible. During a follow-up observation with the DON on April 15, 2026, at 9:36 AM, the DON was unsure whether an emergency kit was in the room, and after searching, found gauze in Resident 127's dresser drawer mixed with her personal items. An LPN later searched the room for three and a half minutes before finding the gauze in the drawer with the resident's personal items. The facility failed to ensure accessibility of necessary emergency supplies for both residents' PICC lines.
Dialysis Emergency Kit Incomplete and Limb Restriction Documentation Inconsistent
Penalty
Summary
The facility failed to ensure safe, appropriate dialysis care for a resident receiving hemodialysis who had end stage renal disease, chronic kidney disease, an AV fistula in the left arm, and a right chest dialysis port. The physician order dated August 24, 2025 required dialysis precautions including no blood draws, injections, or blood pressure from the specified arm and an emergency kit at bedside containing a tourniquet, sterile gauze, gloves, and other equipment. However, when the resident’s room was observed, the bedside emergency kit contained only gauze, pressure dressing, and tape, and did not include the tourniquet, gloves, or tubing clamps that the DON stated should also be present. The resident’s record also contained inconsistent limb restriction documentation. A physician order dated August 25, 2025 stated no treatment or blood pressure to the left arm due to the AV fistula, but the care plan and Kardex documented, "Do NOT take blood pressure or blood specimens from LEFT/RIGHT arm." Staff and the DON confirmed the inconsistency and stated the facility would have to clarify the limb restriction. The facility policy on hemodialysis stated that care would be provided consistent with professional standards of practice, physician orders, the care plan, and the resident’s goals and preferences, but it did not address the emergency kit or its required contents.
Failure to Offer Updated Pneumococcal Immunization
Penalty
Summary
The facility failed to provide recommended pneumococcal immunizations for one of five residents reviewed for immunizations. The facility policy stated that residents are to be assessed for pneumococcal immunizations upon admission and offered a pneumococcal vaccine unless contraindicated or already immunized, with the specific vaccine determined by current CDC guidelines based on age, risk conditions, and prior vaccination history. Resident 3 was admitted on December 27, 2021, and the clinical record showed he had received Prevnar 13 and Pneumovax 23 before admission. A pneumococcal consent dated February 20, 2022, documented that he refused because he already had it. CDC guidance reviewed by surveyors indicated that his pneumococcal vaccinations would not be complete until he received one dose of Prevnar 20 or Prevnar 21 at least five years after the last pneumococcal vaccine dose. There was no evidence that the facility offered Resident 3 an updated pneumococcal vaccination. An infection control preventionist confirmed these findings during interview.
Inaccurate Resident Assessments Documented in MDS
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the actual status of six residents, as identified through clinical record reviews and staff interviews. For one resident, the Minimum Data Set (MDS) assessment incorrectly indicated the use of an anticoagulant, despite no evidence in the clinical record that the medication was prescribed or administered during the assessment period. Staff confirmed this was a coding error. In another case, a resident was marked as having used a limb restraint, but staff interviews revealed that the resident had never utilized such a restraint, indicating another MDS coding error. Additional inaccuracies were found in the assessments of other residents, including two residents who were incorrectly documented as having impairments of their lower extremities, and two residents who were marked as having used trunk restraints, though staff confirmed these restraints were never used. These errors were confirmed by registered nurse assessment coordinators during interviews, and the Director of Nursing was made aware of the discrepancies. The deficiencies were cited under federal and state regulations regarding the accuracy of resident assessments and nursing services.
Failure to Provide Routine Dental Services to Residents
Penalty
Summary
The facility failed to assist six out of eight reviewed residents in obtaining routine dental care as required. Observations and clinical record reviews revealed that several residents with natural teeth, broken teeth, or dentures had not been offered or provided with routine dental services every six months, as covered under the state Medicaid plan. For example, one resident with natural teeth had not seen a dentist since 2020, and another with broken teeth had no evidence of ever being seen by a dentist since admission. Interviews with staff confirmed the lack of documentation or evidence that these residents were offered or received routine dental care. Additional record reviews showed that residents with dentures or some natural teeth also lacked documentation of being offered or provided with routine dental services. Staff interviews further confirmed these findings, and the Director of Nursing acknowledged that there was no further evidence of routine dental care being provided to the affected residents. The deficiency was cited under state regulations for nursing and dental services.
Failure to Track and Document Staff COVID-19 Vaccination Status
Penalty
Summary
The facility failed to maintain and document the COVID-19 vaccination status of its staff as required. During an interview, the Infection Preventionist (a registered nurse) acknowledged that she was not tracking staff vaccination status and had no evidence of offering the COVID-19 vaccine to staff members. Instead of individually offering the vaccine, the facility posted signs near the time clock and in the employee breakroom instructing interested staff to seek vaccination from their primary care physician or local pharmacy. This lack of individualized tracking and documentation was confirmed when the surveyor requested vaccination information and none could be provided for the staff reviewed.
Failure to Maintain Dignity by Not Covering Catheter Bag
Penalty
Summary
The facility failed to maintain resident dignity by not covering the urinary catheter bag of a resident with a physician's order for a Foley catheter to straight bag drainage for urinary retention. Multiple observations over several days showed the resident in bed with the catheter bag uncovered and in full view from the hallway, either hanging on the side of the bed or lying on the floor, making it visible to anyone passing by. These findings were confirmed during an interview with the Director of Nursing. The deficiency was cited under regulations related to management and resident rights.
Failure to Provide Sufficient Nursing Staff for Timely Call Bell Response
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, specifically regarding timely response to call bells for assistance with toileting. One resident, who was cognitively intact and occasionally incontinent, reported waiting up to an hour for help to use the bathroom, resulting in incontinence and embarrassment. The resident also noted that an LPN would turn off the call bell and state they would notify a nurse aide, but no one would return to assist. A grievance was filed by this resident regarding the incident, but there was no documented resolution, and call bell audits were not conducted until nearly two weeks later. Another resident, who was frequently incontinent of bladder, expressed ongoing concerns about insufficient staffing, stating that delays in call bell response occurred on all shifts and often resulted in waiting over 30 minutes for assistance. Both residents' concerns were confirmed through interviews and clinical record reviews. These findings were discussed with facility leadership, and the lack of timely response was attributed to inadequate staffing levels.
Improper Storage and Labeling of Medications in Medication Cart
Penalty
Summary
During a medication pass on the Station Two Nursing Unit (Honey Creek Hall), a medication cart in use by an LPN was observed to have a significant accumulation of debris and dirt, including hair, in the bottom of its drawers. Additionally, several unsecured and unidentified medication tablets were found in the drawer containing medication punch cards, including two white round pills, two orange round pills, a multi-colored capsule, and a large brown pill. These findings were confirmed during a meeting with the Director of Nursing. No information was provided regarding the involvement of specific residents or their medical conditions at the time of the deficiency.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the daily nurse staffing information at the beginning of each shift for both Nursing Unit One and Nursing Unit Two. Observations on two separate occasions revealed that the nurse staffing sheet displayed near the main lobby was outdated, showing the previous day's date. Additionally, there was no nurse staffing information posted in a prominent place at or near the nurse stations for either nursing unit. Staff interviews confirmed the absence of the required postings at the nurse stations, and it was noted that the information near the main lobby was not updated until later in the day.
Non-Compliance with Nurse Aide Staffing Ratios
Penalty
Summary
William Penn Nursing and Rehab was found to be non-compliant with the Commonwealth of Pennsylvania Long Term Care Licensure Regulations regarding nursing services. Specifically, the facility failed to maintain the required nurse aide-to-resident ratios during various shifts over a 21-day review period. On one day, the day shift did not meet the required ratio of one nurse aide per 10 residents. The evening shift failed to meet the required ratio of one nurse aide per 11 residents on three separate days. Additionally, the night shift did not meet the required ratio of one nurse aide per 15 residents on seven different days. The deficiency was identified through a review of nursing staffing hours and confirmed during an interview with the Nursing Home Administrator and Director of Nursing. The facility's staffing records for specific weeks in December 2024 and January 2025 showed that the number of nurse aides scheduled was insufficient to meet the regulatory requirements based on the resident census. This failure to comply with staffing regulations was acknowledged by the facility's administration during the survey process.
Plan Of Correction
1. Facility will continue to take measures to adequately provide staff to ensure the needs of residents are met. 2. The Director of Nursing or designee will provide re-education on minimum staffing ratios to RN Supervisors, Human Resources and Scheduling Coordinator who are responsible to maintain adequate staffing and staffing ratios. 3. The Director of Nursing or designee will audit the daily schedules to ensure the minimum number of staff to resident ratios have been scheduled and will audit that protocols were followed if a call off occurred. 4. Audits will be completed weekly, and results of these audits will be reviewed at Quality Assurance and Process Improvement Meetings until substantial compliance is achieved. 5. Compliance Date: 1/27/2025
LPN Staffing Deficiency
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios as mandated by regulations effective July 1, 2023. Specifically, during the day shift, the facility did not provide the minimum of one LPN per 25 residents on two occasions within the 21 days reviewed. On December 27, 2024, there were 4.5 LPNs for a census of 113 residents, requiring 4.52 LPNs, and on December 29, 2024, there were 4 LPNs for a census of 111 residents, requiring 4.44 LPNs. Additionally, the night shift was understaffed on six occasions, failing to provide the required one LPN per 40 residents. For instance, on December 4, 2024, there were 2.19 LPNs for a census of 116 residents, requiring 2.90 LPNs, and similar shortfalls were noted on December 7, 18, 21, 26, and 30, 2024. These deficiencies were confirmed through an interview with the Nursing Home Administrator and Director of Nursing on January 2, 2025.
Plan Of Correction
1. Facility will continue to take measures to adequately provide staff to ensure the needs of residents are met. 2. The Director of Nursing or designee will provide re-education on minimum staffing ratios to RN Supervisors, Human Resources, and Scheduling Coordinator who are responsible to maintain adequate staffing and staffing ratios. 3. The Director of Nursing or designee will audit the daily schedules to ensure the minimum number of staff to resident ratios have been scheduled and will audit that protocols were followed if a call off occurred. 4. Audits will be completed weekly, and results of these audits will be reviewed at Quality Assurance and Process Improvement Meetings until substantial compliance is achieved. 5. Compliance Date: 1/27/2025
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' status, affecting 10 out of 24 residents reviewed. For several residents, the Minimum Data Set (MDS) assessments inaccurately documented the use of physical restraints, specifically bed rails, which were not used as restraints according to the CMS RAI Manual. Residents 60, 41, 97, 109, 32, 55, 63, and 85 were all incorrectly assessed as having bed rails used as restraints, despite evidence showing that these rails were used for bed mobility and not as restraints. Interviews with residents and their family members confirmed that no restraints were used, and the facility's own assessments supported this finding. Additionally, the facility inaccurately documented the use of anticoagulant medications for Residents 19 and 9. The MDS for Resident 19 noted the use of an anticoagulant, but clinical records showed no evidence of such medication being administered during the assessment period. Similarly, Resident 9's MDS indicated anticoagulant use, but a review of medication administration records for March and April 2024 revealed no anticoagulant was given. Interviews with the Nursing Home Administrator and Director of Nursing confirmed these errors in MDS coding. The errors in the MDS assessments were confirmed through interviews with the Director of Nursing, the Nursing Home Administrator, and the Registered Nurse Assessment Coordinator. These inaccuracies in the MDS coding were acknowledged as errors, with the staff confirming that the residents did not have restraints or receive anticoagulants as documented. The facility's failure to accurately assess and document the residents' status led to these deficiencies being identified during the survey.
Facility Fails to Maintain Clean and Safe Shower Rooms
Penalty
Summary
The facility failed to maintain a clean and comfortable environment in two shower rooms located on Nursing Unit 1, Windmill Hill. During an observation, a dislodged piece of tile was found on the floor around the drain area in the larger shower room. The ceiling lights in this room contained debris, including dead insects, and the tiled floor had a build-up of grime and stains. Additionally, the paint on the ceiling above the shower was peeling, and a ceiling light above the commode also had debris and a dead insect. A metal hand hygiene product dispenser base near the sink had sharp metal tabs, posing a potential hazard, and a heater vent had an extensive build-up of dust. In the second shower room, a ceiling light above the commode had debris, and there was a damaged section of the wall behind the commode. The shower curtain was stained, and multiple spiders were observed in and around the shower stall. There was also a build-up of debris on the base of the wheelchair scale. Additionally, a maroon chair at Nurse Station 1 had extensive wear, with peeling and cracked cushions. These observations were reviewed with the Nursing Home Administrator and Director of Nursing.
Failure to Timely Complete Significant Change MDS Assessment
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment in a timely manner following the election of hospice care for a resident. According to the Resident Assessment Instrument 3.0 User's Manual, a significant change MDS must be completed no later than 14 days after the effective date of the election of hospice care. For Resident 103, hospice care was ordered by their physician on June 6, 2024. However, there was no documentation indicating that the facility completed the required significant change MDS assessment until it was identified by the surveyor. This deficiency was confirmed during an interview with the Nursing Home Administrator and Director of Nursing on June 24, 2024. The failure to complete the MDS assessment as required was a violation of 28 Pa. Code 211.5 (f) regarding clinical records.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, resulting in deficiencies in maintaining the highest practicable care. Resident 41, who is legally blind due to macular degeneration, did not have a care plan addressing her vision loss. Although a care plan was initially created in September 2020, it was resolved shortly after and not updated until the surveyor's inquiry in June 2024. This oversight was confirmed during interviews with the Nursing Home Administrator and the Director of Nursing. Similarly, Resident 81, who required extensive dental work due to receding gums and the need for several teeth extractions, did not have a care plan addressing her dental issues. The absence of a care plan was noted during a surveyor's review and confirmed in discussions with facility leadership. A care plan was only developed after the surveyor highlighted the deficiency. These failures indicate a lack of comprehensive care planning for the residents' specific needs.
Deficiency in Midline Catheter Care
Penalty
Summary
The facility failed to provide the highest practicable care related to intravenous access for a resident, identified as Resident 80, who was reviewed for intravenous access concerns. The facility's policy on midline dressing changes did not include necessary interventions to prevent infection or complications from the use of a midline catheter. The policy also lacked routine assessments needed to monitor the resident during the presence of a midline catheter. Resident 80 was admitted with a PICC line in the right upper arm and had physician orders for intravenous antibiotics due to acute osteomyelitis of the right ankle and foot. Upon review of Resident 80's clinical records, it was found that the facility did not adhere to the physician's orders regarding the care and maintenance of the midline catheter. The orders included changing the midline dressing and caps every seven days and monitoring the site every shift. However, staff failed to measure the circumference of the resident's arm and the length of the external midline tubing as required. Observations confirmed that the midline dressing had not been changed for 17 days, despite orders to change it every seven days. Additionally, there was no emergency kit or signs indicating restrictions for the resident's right arm in the room. Interviews and observations with the resident and staff revealed discrepancies in the documentation and actual care provided. The treatment administration record indicated a dressing change was completed, but observations showed the dressing remained unchanged. The facility did not provide a policy or procedure outlining staff competencies or expectations for planning care for residents with a midline catheter. These findings were discussed with the Director of Nursing and the Nursing Home Administrator.
Failure to Implement Hearing Loss Interventions
Penalty
Summary
The facility failed to implement interventions to treat hearing loss for a resident who was reviewed for hearing concerns. The resident, identified as having sensorineural hearing loss bilaterally, was assessed by the facility's contracted audiology professional. The assessment recommended the use of a pocket talker, a personal sound amplifier, to aid in communication. However, the resident's plan of care did not include this recommendation, and there was no evidence that the facility implemented the audiology provider's recommendation. The deficiency was identified during an interview with the resident, who reported difficulty hearing and required a dry erase board for communication, and was confirmed through interviews with the Director of Nursing and the Nursing Home Administrator.
Failure to Provide Physician-Ordered ROM Services
Penalty
Summary
The facility failed to provide physician-ordered services to maintain a resident's range of motion (ROM) for one of the two residents reviewed. Resident 55 had a current physician's order for a restorative program to prevent contractures, which included passive stretching of the left lower extremity into knee extension, to be performed five times and held for 30 seconds during morning and evening care. However, a review of task documentation for April, May, and June 2024 revealed that staff did not document the completion of this restorative task on multiple dates across both day and evening shifts. This lack of documentation indicates that the ordered ROM exercises may not have been consistently performed as required.
Failure to Implement Physician-Ordered Supplemental Oxygen
Penalty
Summary
The facility failed to implement supplemental oxygen per physician orders for a resident diagnosed with hypoxia. The resident, who was diagnosed with rhinovirus, was observed using a room concentrator set at one and one-half liters per minute, contrary to the physician's order of 0.5 liters per minute at hour of sleep. Despite the resident's oxygen saturation being assessed at 99 percent, the oxygen flow was not adjusted according to the physician's order, and the resident did not exhibit signs of dyspnea. Additionally, the treatment administration record contained erroneous documentation of oxygen liter flow, with entries ranging from 93 to 99 liters per minute, which was not feasible with the available equipment. The facility's plan of care for the resident did not reflect the physician's ordered oxygen liter flow, and there was no policy or procedure provided regarding the use of supplemental oxygen. Furthermore, the nebulizer equipment used for the resident's medication administration was not stored in a protective bag as required by the facility's infection control policy. Interviews with staff confirmed these discrepancies, highlighting a lack of adherence to physician orders and infection control protocols.
Failure to Ensure Medication Regimen Free from Unnecessary Drugs
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from potentially unnecessary medications. A review of the clinical record for a resident revealed that a pharmacist had recommended a gradual dose reduction of Escitalopram, a medication used to treat depression, but the attending physician disagreed without providing an explanation. Additionally, there was no documentation of behaviors related to the resident's depression that would justify the continued use of Escitalopram. Similarly, a pharmacist recommended a trial dose reduction of Ativan, a medication used to treat anxiety, but the physician again disagreed without explanation. The clinical record also lacked documentation of behaviors related to the resident's anxiety that would necessitate the use of Ativan. The Nursing Home Administrator and Director of Nursing were informed of these concerns, highlighting the facility's failure to ensure the resident's medication regimen was free from potentially unnecessary drugs.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility was found to have a medication error rate of 6.67 percent, exceeding the acceptable threshold of less than five percent. This was based on 30 medication opportunities with two errors identified. One error involved the administration of Omeprazole to a resident after breakfast, contrary to the recommended practice of taking it one hour before meals to ensure optimal absorption. The registered nurse confirmed the error during an interview, acknowledging that the medication was given after the resident had eaten. Another error involved the administration of Fluticasone Propionate nasal spray to a different resident. The resident was observed administering two sprays in each nostril instead of the prescribed one spray per nostril. The nurse did not intervene to correct the resident after the first incorrect administration. Furthermore, there was no documentation indicating that the resident had been assessed for the capability to self-administer medications. The nurse confirmed the error and acknowledged the lack of assessment for self-administration capability.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBPs) for a resident with infection control concerns. The facility's policy on EBPs, last reviewed in March 2024, requires the use of gowns and gloves during high-contact resident care activities to prevent the spread of multi-drug resistant organisms. This includes activities such as wound care and device care. Despite a sign indicating the need for EBPs on the resident's door, a registered nurse did not wear an isolation gown while performing wound care on the resident's open foot wound. The resident, identified as having osteomyelitis of the right foot and receiving intravenous antibiotics through a midline, had a culture that identified pseudomonas bacteria. During an observation, the nurse conducted wound care procedures without donning an isolation gown, despite the presence of a sign indicating the requirement for enhanced barrier precautions. The nurse confirmed the oversight during an interview, acknowledging the failure to adhere to the facility's infection control policy.
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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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