Accela Rehab And Care Center At Springfield
Inspection history, citations, penalties and survey trends for this long-term care facility in Glenside, Pennsylvania.
- Location
- 850 Papermill Road, Glenside, Pennsylvania 19038
- CMS Provider Number
- 395545
- Inspections on file
- 51
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Accela Rehab And Care Center At Springfield during CMS and state inspections, most recent first.
A resident with a history of intracranial injury and seizures continued to receive both 200 mg and 25 mg doses of Lamotrigine daily despite neurology consultation instructions to stop the extra 25 mg dose. The resident reported that the Lamotrigine regimen had not been changed and stated that an attempt to give the after-visit summary to the unit manager was unsuccessful. The DON acknowledged ongoing problems obtaining clinic recommendations because the resident did not authorize direct information sharing or portal access and did not consistently provide after-visit summaries. A unit clerk reported making a single undocumented call to the neurology clinic to obtain recommendations, received no response, and did not follow up, resulting in the consultation recommendation not being implemented.
The facility failed to develop and revise a comprehensive, person-centered care plan for a resident with anemia, hypertension, peripheral vascular disease, renal failure on dialysis, anxiety, depression, schizophrenia, and moderate cognitive impairment who required supervision for ADLs and mobility. Despite multiple documented falls, including one from a dining room chair and another leading to hospitalization with a low hemoglobin and subdural hematoma, the care plan contained only minimal fall-risk and mobility interventions and was not updated to reflect the resident’s progressive weakness, poor safety awareness, or need for increased supervision. After the resident’s return from the hospital, the IDT did not revise the care plan to add enhanced safety measures or formal neuro checks, and staff relied mainly on a low bed position, routine safety checks, and general nursing assessments without implementing additional individualized fall-prevention strategies.
A resident’s clinical record was found to be inaccurate when nursing documentation and assessments did not reflect multiple recent falls or current psychotropic medication use. Despite prior documentation of falls and active MD orders for psychotropic drugs including Seroquel, Fluphenazine, Divalproex sodium, Benztropine, and Clonazepam, a readmission assessment recorded the resident as alert and oriented x3, with normal gait and balance and no falls in the preceding months, and the monthly medication review stated no psychotropic use in the prior week.
The facility did not submit required PB-22 forms for six reported events involving allegations of abuse, neglect, or misappropriation of property by staff, including nurse aides, a van driver, the DON, and a nurse. Despite multiple reminders and confirmations from leadership, the forms remained incomplete for all events.
The facility did not ensure that food and drink were served at palatable and safe temperatures. Two residents reported dissatisfaction with food quality and temperature, and direct observation with the Food Service Director confirmed that several cold food items were served well above the required temperature, making them unpalatable.
A dietary staff member delivered meal trays containing uncovered canned fruit in open bowls, as coverings were not available for all nursing units. The Food Service Manager confirmed this practice, resulting in moist, ready-to-eat food being transported and served without protection from contamination.
A resident received a written discharge notice that did not specify the location to which the resident was being transferred or discharged. Review of the clinical record and staff interview confirmed the omission, and staff were unaware of the requirement to include this information.
A resident with impaired safety awareness and a risk for elopement was able to leave the facility unsupervised for approximately 30 minutes due to insufficiently trained agency staff who lacked competency in dementia and behavioral health care. Staff on duty had no prior knowledge of the unit or residents, and were observed providing minimal interaction, failing to implement care plan interventions.
A resident with dementia and a known risk for elopement was able to leave a secured unit unsupervised after staff failed to provide appropriate supervision and redirection as outlined in the care plan. All staff on duty were new agency personnel unfamiliar with the resident and the unit, and were observed providing minimal interaction. The resident exited through a staff-controlled door and was found by police at a neighbor's house before being returned to the facility.
A resident with chronic pain and mobility issues did not receive prescribed PRN Oxycodone in a timely manner after requesting it, resulting in a delay of nearly two hours. Staff interviews and facility records confirmed that the nurse on duty failed to administer the medication as ordered, despite the resident's repeated requests and documented need.
A resident with severe cognitive impairment experienced an unwitnessed fall, and the facility did not conduct a timely or thorough investigation as required by policy. Key staff interviews and documentation were delayed or missing, and there was no evidence that all relevant caregivers were interviewed or that the resident's condition was adequately documented following the incident.
A resident with severe cognitive impairment experienced an unwitnessed fall resulting in a head injury and toe fracture. Facility staff did not perform or document required neurological assessments or monitoring after the incident, and the injuries were only discovered when the resident's family member observed bruising and swelling the following day. The lack of timely assessment and documentation was confirmed by staff interviews and clinical record review.
Surveyors found that the facility did not ensure a clean, comfortable, and homelike environment in resident care areas, with observations of food debris, soiled linens, dirty bathrooms, mouse droppings, broken or missing furniture, strong urine odors, and improper storage of resident belongings. Staff confirmed these unsanitary and disorganized conditions during the survey.
A resident with multiple psychiatric diagnoses was not permitted to return to the facility for five days after being medically cleared for discharge from the hospital. Despite the hospital's notification that the resident was ready for return, facility staff delayed readmission, citing staffing arrangements and the resident's expressed preference for transfer, though the resident did not refuse to return. This delay was not consistent with the facility's bed-hold and return policy.
Several residents did not receive their preferred food and beverages, including coffee at breakfast, due to a shortage of hot beverage cups and burned food items. Staff confirmed the lack of supplies and inability to provide replacements, and one resident's meal was delayed and served cold due to equipment issues. The administrator acknowledged the supply shortage but could not provide documentation of corrective actions.
A resident with a PICC line and multiple wounds was not provided with enhanced barrier precaution signage on the door, and gowns were not readily available outside the room, despite facility policy requiring these measures for infection prevention. This was confirmed during an interview and observation with the DON.
A resident with severe cognitive impairment was found to have opened food and mouse droppings in their room, with staff confirming that family members sometimes bring in food unnoticed. Pest control logs and reports showed ongoing issues with mice and roaches in both a nursing unit and the kitchen, incomplete documentation of pest control measures, and poor sanitation in the kitchen and dumpster areas.
A sewage backup led to the kitchen being shut down, causing significant delays in meal service. Residents experienced late and incomplete meals, with some waiting hours past scheduled times and others receiving inadequate food options. Staff confirmed that meals had to be sourced and delivered from offsite, resulting in further delays and disruption to residents' dietary needs.
A resident who was admitted for rehabilitation after a previous fall experienced another fall and required assistance to return to bed. Although a nurse supervisor was assigned to notify the physician and the resident's responsible party, there was no documentation that the responsible party was informed, and the resident's daughter later expressed concern about not being notified.
Surveyors found that two nursing floors were not maintained in a clean, safe, or homelike condition. Strong urine odors were present near the nurse's station and in a resident bathroom, where a detached sink, dirty shower, and a soiled incontinent brief were observed. The stairwell door was missing a handle, leaving a sharp opening, and staff confirmed these issues during interviews.
A resident with mobility issues did not receive physician-ordered wound care on multiple occasions when the regular wound nurse was on vacation. Documentation and staff interviews confirmed that wound care treatments were missed, and the resident reported that agency staff did not provide the required care during the nurse's absence.
Surveyors found multiple safety hazards, including a missing stairwell door handle with sharp edges, a walk-in shower with a missing drain cover and exposed pipe, and a detached bathroom sink creating a tripping hazard for confused, ambulatory residents. Additionally, a hypodermic syringe was left unattended on a medication cart in a hallway, contrary to facility policy, with the DON confirming the lapse in supervision.
Accela Rehabilitation and Care Center at Springfield was found non-compliant with food safety standards. During a survey, it was observed that several food items, including hamburger buns, loaves of bread, and hot dog buns, were not labeled as required. Additionally, in the main walk-in refrigerator, unlabeled lettuce with discolored edges, chopped vegetables, watermelon, and opened packages of salami and ham were found. These issues indicate a failure to follow the facility's food receiving and storage policy.
A female resident receiving skilled nursing care was found to be sharing a common bathroom with two male residents, and the bathroom lacked a locking mechanism to ensure privacy. This arrangement was confirmed by an LPN and acknowledged by the facility administrator as not being in line with facility policy, resulting in a failure to maintain resident privacy and dignity.
A resident was found to have a non-functioning overbed light, as observed by surveyors and confirmed by an LPN. The facility did not ensure that essential equipment, specifically overbed lighting, was maintained in safe working order for this resident.
Multiple residents reported sightings of mice in the facility, and pest control records confirmed ongoing treatment for rodents in the main kitchen and resident rooms. Observations found a significant gap in a door near the kitchen and loading dock, providing easy access for pests. The administrator confirmed the issue and the pest control operator's documentation of needed repairs.
The facility did not maintain an effective, data-driven QAPI program as required, with no documentation showing that previously identified quality deficiencies were addressed or resolved. The current administrator could not locate QAPI records or meeting minutes from prior months, indicating a lack of adherence to QAPI processes and regulatory requirements.
Four residents with chronic health conditions, including heart failure, asthma, malnutrition, and renal insufficiency, did not have evidence in their records of receiving or being offered influenza or pneumococcal vaccines. The DON confirmed there was no documentation of these immunizations.
Survey results binders were kept behind the main lobby desk, making them inaccessible to residents and visitors without assistance, and the information in the binders was outdated. The Administrator confirmed awareness of the issue but had not updated the binders.
Grievance forms and submission boxes were not available or accessible on nursing units, and residents were unaware of their location or how to submit anonymous grievances. Staff were unable to locate the forms when asked, despite facility policy requiring their availability.
The facility was cited for a medication error rate of 14.81% after multiple instances where nursing staff failed to follow physician orders, including incorrect dosing, failure to instruct residents to rinse their mouths after inhaled corticosteroids, not administering insulin due to unavailability, and giving medications orally instead of via G-tube without updated orders. Nursing staff and the DON confirmed these findings.
A resident was found lying in bed on urine-soaked linens during morning care, with both the resident and a nursing aide confirming that overnight staff failed to provide necessary incontinence care. The DON was unaware of the neglect until it was reported in the morning.
Three bariatric residents were left without properly fitting gowns or linens, resulting in exposure and discomfort. One resident was transported covered only by a sheet due to lack of suitable gowns, another was found lying on a plastic mattress without sheets and reported discomfort, and a third stated that available gowns were too small but would wear a properly fitted one if provided. Staff confirmed limited supplies and difficulty accessing bariatric gowns, despite an increase in residents needing them.
A licensed nurse used a personal iPad without technical safeguards to access resident PHI during a medication pass, violating facility policy that prohibits personal device use for this purpose and bypassing established security measures designed to protect confidential health information.
The facility did not update PASRR applications to include current mental health diagnoses for three residents and failed to refer two residents with serious mental illness for required Level II PASRR reviews, as confirmed by staff interviews and record review.
The facility did not develop or document comprehensive care plans for two residents who had physician orders for oxygen administration and wound care, resulting in missing focus areas, interventions, and measurable outcomes for these treatments. These deficiencies were confirmed by the DON.
Two residents who were dependent on staff for activities of daily living did not receive adequate grooming and hygiene care. One resident with a history of stroke and muscle weakness had long, untrimmed fingernails and reported not having had a shower in a month, while another resident with upper extremity limitations was observed with greasy, uncombed hair, dirty fingernails, and extremely dry skin, and reported only receiving a bed bath once a week.
Two residents did not receive care in accordance with physician orders: one did not have weekly weights obtained as ordered, resulting in unmonitored weight loss, and another received medications orally instead of via g-tube as per orders, with staff confirming the orders were not updated to reflect the resident's current needs.
A resident with a documented hearing deficit was not evaluated by a hearing specialist as required by facility policy, despite staff and clinical assessments confirming moderate hearing impairment. Staff had to speak loudly and the resident kept the television volume high to compensate, but no professional assessment or assistive device intervention was provided.
A resident with a physician order for a 16FR/10CC supra pubic catheter was found to have a 22FR/10CC catheter in place, a discrepancy confirmed by a licensed nurse during review.
A resident with multiple respiratory conditions was observed receiving oxygen at a higher flow rate than ordered by the physician. The order specified 2 L/min via nasal cannula to maintain oxygen saturation above 93%, but the resident was given 3 L/min. This discrepancy was confirmed by an LPN at the time of observation.
Two residents with significant mental health diagnoses did not receive required behavioral health services or psychiatric evaluations. One resident, prescribed multiple psychotropic medications, had not been evaluated by a psychiatrist for over six months and had unaddressed requests for psychological services and facility transfer. Another resident, eligible for mental health services, did not receive behavioral health programs due to lack of qualified personnel, and was observed exhibiting aggressive behavior and social withdrawal.
A resident with diabetes did not receive their prescribed insulin with meals because a nurse could not locate the medication in the cart and was unaware that more insulin was available in storage. Miscommunication among staff led to a delay in administration, contrary to facility policy requiring timely and accurate medication delivery.
Surveyors found that a medication cart contained two opened insulin vials without opened dates marked, despite both vials having valid manufacturer expiration dates. An LPN confirmed that these vials should have been discarded, indicating a failure to follow professional standards for medication labeling and disposal.
A resident who was cognitively intact requested dental care for a broken tooth and a cleaning, but did not receive any dental services after the request was made. Nursing staff notified the consulting dental service, which confirmed the need for extractions and fillings and scheduled an appointment, but no dental care was provided. This failure to provide timely dental services was confirmed by the DON and identified through record review and staff interviews.
Three residents had personal food items brought in by family or visitors that were not labeled, refrigerated, or stored according to facility policy. Observations included opened condiments and perishable foods left unrefrigerated or on the floor, with staff confirming improper storage and handling.
Accela Rehab and Care Center at Springfield failed to report the outcomes of investigations into allegations of abuse, neglect, and misappropriation to the State Survey Agency within the required timeframe. Incidents involved a resident's missing money, a verbal altercation with a van driver, neglect claims, and rough treatment by nurse aides. Despite internal investigations, the facility did not document the required reporting, resulting in a deficiency.
The facility failed to maintain a safe and sanitary environment across multiple nursing units. Issues included a clogged sink causing repeated flooding, broken furniture, missing fixtures, and visibly soiled areas. These deficiencies were confirmed by staff and observed during a facility tour.
A facility failed to conduct a Level 1 PASARR screening for a resident with mental disorders, including PTSD, schizophrenia, and depression. Despite the facility's policy requiring such screenings for all new admissions, there was no documented evidence of this process for the resident, who was receiving medications for depression and bipolar disorder. This deficiency was confirmed by the Nursing Home Administrator.
The facility failed to maintain proper agreements for outside transportation services, leading to issues for a resident with PTSD, schizophrenia, and depression. The resident reported problems with Uber transportation, including incorrect drop-off locations and long wait times. The facility had an unsigned agreement with a contracted ambulance service and no formal agreement with Uber.
Failure to Implement Neurology Consultation Medication Change
Penalty
Summary
The deficiency involves the facility’s failure to ensure that consultation recommendations regarding medication management were reviewed and followed for one resident. The resident was admitted with diagnoses of unspecified intracranial injury and unspecified convulsions and had physician orders for Lamotrigine 200 mg once daily and a separate order for Lamotrigine 25 mg once daily, both dated the same day. Review of the MAR for April 2026 showed that the resident continued to receive both the 200 mg and 25 mg Lamotrigine doses daily at 9 AM. A neurology after-visit summary from a local hospital dated April 8, 2026, directed that Lamotrigine 200 mg be continued and that the extra 25 mg daily dose being given at the facility be stopped. An interview with the resident confirmed that the Lamotrigine regimen had not been changed and that the resident attempted to give the after-visit summary papers to the unit manager, who allegedly did not take them. Interviews with staff revealed communication and follow-up gaps related to obtaining and acting on the neurology consultation recommendations. The DON confirmed that the resident attended a neurology clinic consultation and stated that the facility had difficulty obtaining information from the clinic because recommendations were given directly to the resident, who did not authorize direct transmission of visit summaries to the facility or grant portal access. The DON also stated that the resident did not always provide after-visit summaries upon return from appointments, requiring staff to call the clinic after each visit. The unit clerk reported calling the neurology clinic two days after the appointment to follow up on recommendations because the resident had not provided the after-visit summary, but she did not receive a response, did not make a follow-up call, and there was no documentation of her attempt. As a result, the facility did not implement the neurologist’s order to discontinue the extra 25 mg Lamotrigine dose.
Failure to Revise Person-Centered Care Plan After Recurrent Falls and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to develop and revise a comprehensive, person-centered care plan related to fall risk for a resident with multiple medical and cognitive conditions. Facility policies required individualized care plans with measurable goals, ongoing assessment, and interdisciplinary review and revision after significant changes in condition, hospitalizations, and recurrent falls. The resident had anemia, hypertension, peripheral vascular disease, renal failure requiring dialysis, anxiety, depression, and schizophrenia, and required supervision for toileting, showering, dressing, transfers, and walking, with a BIMS score of 9 indicating moderate cognitive impairment. Nursing documentation showed multiple falls, including a fall from a dining room chair with minor bleeding, a stumble to the knees without injury, and a subsequent hospitalization where the resident was diagnosed with a hemoglobin of 6.6 and a subdural hematoma, followed by readmission to the facility. Despite these events and documented weakness, decreased safety awareness, and repeated falls, the resident’s care plan did not include specific, individualized interventions to address progressive functional decline or increased supervision needs. The resident was care planned for fall risk and a decline in mobility, with therapy services initiated, but interventions such as encouraging wheelchair use, therapy referrals, and a pharmacy consult were minimal and were not revised after subsequent falls. After readmission from the hospital, there was no evidence that the interdisciplinary team updated the care plan to include enhanced safety measures, increased monitoring, or alternative interventions, and no formal neurological assessments were implemented. Staff interviews confirmed that, aside from keeping the bed in a low position and performing routine safety checks and general nursing assessments, no additional individualized interventions or care plan updates were put in place following the resident’s recurrent falls and hospitalization for subdural hematoma.
Inaccurate Clinical Records for Falls and Psychotropic Medication Use
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate clinical records for one resident, as required by accepted professional standards. Nursing documentation showed that the resident experienced multiple falls in January 2026, including a fall from a chair in the dining room with minor bleeding to the left hand and a separate incident in which the resident stumbled and fell to the knees without injury. The resident was later hospitalized and diagnosed with a hemoglobin of 6.6 and a subdural hematoma, and was readmitted to the facility on February 6, 2026. On readmission, the nursing assessment completed February 6, 2026, inaccurately documented that the resident was alert and oriented x3, had normal gait and balance, and had no falls in the prior three months, despite the earlier documented falls. Additionally, the February 2026 medication review inaccurately indicated that the resident had not received psychotropic medications within the prior seven days, even though physician orders for that month included multiple psychotropic medications: Seroquel, Fluphenazine, Divalproex sodium, Benztropine, and Clonazepam.
Failure to Submit Required PB-22 Forms for Abuse and Neglect Allegations
Penalty
Summary
The facility failed to submit completed PB-22 forms to the Department as required for six separate reported events involving allegations of abuse, neglect, or misappropriation of property. Each event involved a resident making an allegation against staff, including nurse aides, a van driver, the Director of Nursing, and a licensed nurse. The allegations included failure to provide proper care after a bowel movement, not providing care overnight resulting in a resident being found wet with urine, verbal altercations with staff, failure to provide proper care during a bath, not providing drinking water, and inappropriate response to requests for pain medication. Despite multiple notifications and reminders sent electronically to the Nursing Home Administrator and the Director of Nursing over several months, the required PB-22 forms for these events were not completed or submitted. Interviews with facility leadership confirmed the ongoing failure to complete the forms, and documentation reviews on several occasions showed that the deficiency persisted. The lack of submission of these forms was confirmed repeatedly by both the Nursing Home Administrator and the Director of Nursing.
Plan Of Correction
Submitted all outstanding PB22's to event report portal. Re-education for NHA and DON on timely submission of PB22's. Audit weekly x4 and monthly x3 to be completed by corporate team to determine timely submission of all PB22's. Results of audits will be submitted to monthly QAPI meeting. I Certify This Document to be a True and Correct Statement of Deficiencies and Approved Facility Plan of Correction for the Above-Identified Facility Survey.
Failure to Serve Palatable Food and Drink at Safe Temperatures
Penalty
Summary
The facility failed to provide food and drink that were palatable and served at the proper temperature, as required by policy. Facility documentation review and interviews revealed that foods sent to units were not consistently maintained at or below 41°F for cold foods, as specified. During interviews, one resident stated that the food was not good, and another reported that food temperatures were often cold. Observations during a test tray with the Food Service Director showed that milk, tangerines, and apple juice were all served at temperatures significantly above the required threshold for cold foods, with milk at 59.9°F, tangerines at 70.8°F, and apple juice at 58.6°F. The Food Service Director confirmed that these items were too warm to be palatable.
Uncovered Ready-to-Eat Food Served During Meal Transport
Penalty
Summary
During a lunch meal delivery observation on the first-floor unit, a dietary staff member was seen transporting meal trays in a mobile tray cart with doors. Each tray contained servings of canned fruit, specifically pears and tangerines, placed in small bowls that were not covered with lids. An interview with the Food Service Manager confirmed that coverings for these bowls were not available for all nursing units. As a result, moist, ready-to-eat food items were served uncovered, which did not comply with professional standards for food protection during transportation and placed the food at risk of contamination.
Incomplete Discharge Notice Lacking Transfer Location
Penalty
Summary
The facility failed to provide a complete written discharge notice for one resident, as required by regulation. Specifically, the discharge notice issued to the resident on June 19, 2025, did not include the location to which the resident was being transferred or discharged. Review of the clinical record confirmed the omission, and an interview with the facility Social Worker further verified that the discharge notification lacked this required information. The Social Worker also acknowledged that the facility was unaware of the requirement to include the discharge location in the notice.
Failure to Provide Competent Staff for Behavioral Health Needs Resulting in Resident Elopement
Penalty
Summary
The facility failed to ensure that there were sufficient staff members with the appropriate competencies and skills to meet the behavioral health needs of residents, specifically those with mental and psychosocial disorders. On the date in question, all staff assigned to the dementia unit were new agency staff who lacked prior knowledge of the residents and the unit. Review of training records for these staff members revealed no evidence of facility training or competency in dementia care or in caring for residents with behavioral health needs. During the shift, three nurse aides were observed sitting in the common area with limited interaction with residents, and one was using a cell phone. A resident, who was alert and oriented only to self and identified as being at risk for elopement due to impaired safety awareness, was able to leave the unit through a staff-access-only exit door. The resident was missing for approximately 30 minutes before being returned to the facility by local police, having been found at a neighbor's house. The care plan for this resident included interventions such as distraction, structured activities, and reorientation strategies, but these were not implemented by the staff on duty. The incident was attributed to the lack of staff training and familiarity with the residents' needs.
Failure to Provide Appropriate Supervision and Services for Resident with Dementia Resulting in Elopement
Penalty
Summary
A resident with a diagnosis of dementia, psychotic disturbance, gait abnormalities, and anxiety was housed in a secured, locked unit designed to prevent elopement. Despite being identified as at risk for elopement and having a care plan that included interventions such as distraction, structured activities, and reorientation strategies, the resident was able to leave the unit unsupervised. Facility documentation and camera footage revealed that the resident wandered aimlessly in the unit while three agency nurse aides, unfamiliar with the resident and the unit, were sitting in the common area with limited interaction and one using a cell phone. The resident ultimately exited the facility through a back door, which required a staff code to open and did not trigger an alarm, likely by following a staff member who opened the door. The resident was found by local police at a neighbor's house and returned to the facility after being out for approximately 30 minutes. The facility's investigation confirmed that all staff on duty during the incident were new agency staff who lacked prior knowledge of the resident and the unit. The care plan interventions for supervision and redirection were not implemented, as staff failed to provide appropriate monitoring and engagement. The facility's policy required staff to prevent elopement and maintain resident safety, but these measures were not followed, resulting in the resident's unsupervised exit from the secured unit.
Failure to Timely Administer PRN Pain Medication
Penalty
Summary
A deficiency occurred when a resident with a history of chronic pain, hidradenitis suppurativa, muscle weakness, and mobility issues did not receive prescribed pain medication in a timely manner. The resident had a physician's order for Oxycodone 15 mg every 4 hours as needed for pain. On the day in question, the resident last received the medication at 3:09 p.m. and was eligible for the next dose after 7:09 p.m. The resident requested the medication at approximately 8:00 p.m., but it was not administered until 9:58 p.m., resulting in a delay of 1 hour and 58 minutes. Facility policy requires that medications be administered safely, timely, and as prescribed, and that frequent PRN use be evaluated by the care team. Staff interviews and facility investigation revealed that the nurse on duty did not provide the medication promptly after the resident's request, citing personal safety concerns and workflow interruptions. The delay was confirmed by the Director of Nursing and the Administrator, who acknowledged that the nurse failed to administer the pain medication according to the physician's order. The incident involved multiple staff interactions and documentation of the resident's repeated requests and escalating distress prior to receiving the medication.
Failure to Conduct Timely and Thorough Investigation After Resident Fall
Penalty
Summary
The facility failed to ensure a complete and thorough investigation was conducted to rule out neglect following a resident's unwitnessed fall. According to the facility's policy, investigations must include timely review of documentation, interviews with all relevant staff across shifts, and comprehensive documentation. In this case, the resident, who had severe cognitive impairment due to dementia, was found face down on the floor in front of her bed by a nurse aide. The incident was not immediately or thoroughly investigated, as key staff statements were delayed by up to thirteen days, and not all relevant staff, such as the overnight nurse and nurse aide, were interviewed promptly or at all regarding the resident's condition after the fall. Additionally, there was a lack of documentation in the resident's clinical record between the time of the fall and her subsequent transfer to the emergency room the following day. The investigation did not include statements from staff who provided care during the overnight and morning shifts, nor was there documentation of the resident's condition during this period. The Director of Nursing confirmed that the investigation was neither complete, thorough, nor timely, and that the facility did not follow its own policy for investigating alleged neglect.
Failure to Provide Neurological Assessment and Monitoring After Unwitnessed Fall
Penalty
Summary
The facility failed to provide necessary care and services to a resident following an unwitnessed fall with a head injury. According to the facility's Falls - Clinical Protocol, nurses are required to assess and document vital signs, injuries, musculoskeletal function, changes in cognition or consciousness, neurological status, and pain after a fall. However, after the resident was found face down on the floor by staff, there was no documented evidence of neurological assessments or monitoring for changes in condition from the time of the fall through the following morning. Nursing notes and incident reports did not reflect any neuro checks or assessments for potential head injury, despite the resident having severe cognitive impairment and being at increased risk for complications. The resident's daughter discovered significant bruising on the resident's forehead and a swollen, sore right foot the morning after the fall. She reported that staff were unaware of the fall and that there was no documentation in the clinical record regarding the incident or the injuries observed. The daughter had to request that the resident be sent to the emergency room, where hospital records later confirmed a large scalp hematoma and a nondisplaced fracture of the toe. Interviews with staff and review of the clinical record confirmed the absence of required neurological monitoring and documentation following the unwitnessed fall. The deficiency was further substantiated by interviews with the resident's physician and the Director of Nursing, both of whom confirmed that no neuro checks or systematic assessments were performed or documented after the fall. The lack of timely and appropriate assessment and documentation following the unwitnessed fall with head injury constituted a failure to follow facility policy and provide necessary care and services as required by regulation.
Failure to Maintain Clean, Comfortable, and Homelike Resident Care Areas
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment in resident care areas across both the first and second floor nursing units. Observations included black food debris scattered in hallways, dirty and soiled toilets, shower stalls containing paper trash and soiled linens, and dresser drawers with mouse droppings. Additional findings included pill fragments and residue on furniture and floors, soiled bed linens with food stains, and food debris on and around beds. Trash cans were found without liners and were nearly full, with some containing used latex gloves and food debris. These conditions were confirmed by staff during the survey. Further issues were identified such as broken or missing furniture, including headboards and bedside dressers, leaving residents without proper storage for personal items like telephones, which were found on the floor. Some rooms had strong odors of urine, holes behind toilets, and resident belongings such as boxes of cleaning supplies and hygiene items stored on the floor. These deficiencies were corroborated by interviews with residents and staff, including the scheduler and the Director of Nursing, who confirmed the unsanitary and disorganized state of the resident care areas.
Failure to Permit Timely Return of Hospitalized Resident
Penalty
Summary
The facility failed to permit a resident to return after hospitalization, resulting in a five-day delay despite the resident being medically cleared for discharge. The resident, who had a history of schizoaffective disorder, depression, bipolar disorder, and PTSD, was initially transferred to a hospital due to physical and verbal aggression, refusal of medication, and unpredictable behavior. The transfer was conducted via involuntary admission with police presence, and documentation indicated that the resident was expected to return to the facility after hospitalization. Hospital staff notified the facility on the second day after transfer that the resident was cleared for return, as psychiatric evaluation determined that inpatient psychiatric admission was not required. Despite this, the facility did not allow the resident to return immediately. Instead, the facility requested the hospital to continue holding the resident for several more days, citing the need to make staffing arrangements and to seek alternative placement, as the resident had expressed a preference for transfer to another facility while hospitalized. However, there was no documentation that the resident refused to return to the facility. During this period, hospital staff communicated with the facility multiple times, and the facility's operator and regional director confirmed the refusal to accept the resident back, requesting additional time before readmission. The resident was ultimately permitted to return five days after being medically cleared. The facility's actions were not in accordance with their own bed-hold and return policy, which requires timely readmission of residents who are eligible and cleared to return.
Failure to Provide Resident-Preferred Food and Beverages Due to Supply Shortages
Penalty
Summary
The facility failed to honor resident food and drink preferences by not providing requested and acceptable food and beverages to several residents. During the survey, it was observed that breakfast trays delivered to residents did not include hot beverages, specifically coffee, despite residents' preferences. Multiple residents reported not receiving coffee with their breakfast, and staff confirmed that there were not enough hot beverage cups available to serve all residents. Additionally, omelets served to residents were burned, and when a resident requested a replacement, staff stated that all omelets were burned and no new plate would be provided. One resident did not receive breakfast in a timely manner due to a broken bed, resulting in a cold meal, and another resident had their tray removed before finishing their prescribed dietary supplements. Further investigation revealed that the kitchen had a significant shortage of hot beverage cups, with only about 20 available for a census of 120 residents. Staff and dietary aides confirmed the lack of adequate supplies and that requests for additional cups had been made but not fulfilled. The administrator acknowledged the shortage and stated that an order had been placed, but no documentation was provided to verify this. These actions and inactions resulted in residents not receiving food and beverages according to their preferences and needs, as required by regulations.
Failure to Implement Enhanced Barrier Precautions for Resident with PICC Line and Wounds
Penalty
Summary
The facility failed to implement enhanced barrier precautions for a resident who had a peripherally inserted central catheter (PICC) line and multiple wounds. According to the facility's policy, transmission-based precautions should be initiated for residents with signs or symptoms of infection, laboratory-confirmed infection, or those at risk of transmitting infection. The policy also requires appropriate signage on the resident's door and chart to inform staff and visitors of the necessary precautions, as well as instructions for the use of personal protective equipment (PPE). A review of the resident's clinical record showed the presence of a PICC line and multiple wounds, with a care plan in place for enhanced barrier precautions. However, during an interview and observation with the Director of Nursing, it was confirmed that there was no enhanced barrier precaution signage on the resident's door, and gowns were not readily available outside the room. This failure to follow established infection prevention protocols was identified during the survey.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program in one of two nursing units and the kitchen area. During a tour of a resident's room, surveyors observed a broken nightstand drawer containing opened food items such as cookies and nuts, as well as mouse droppings in the top two drawers of a dresser near the window. The resident, who was admitted with dementia, anxiety disorder, and major depressive disorder, was assessed as severely impaired in decision-making. A licensed nurse confirmed the presence of food and droppings, noting that family members sometimes bring in food without staff knowledge. A grievance was filed by the resident's spouse regarding mouse droppings and chewed food bags in the resident's drawer, which was confirmed by housekeeping, but documentation of resolution was incomplete. Pest control reports from April and May indicated ongoing issues with roaches and mice, particularly in the kitchen and second floor nursing unit. The pest control company recommended deep cleaning and additional services due to poor sanitation and excessive roach activity, but service logs were incomplete, with missing details on pesticide application and locations treated. The facility's pest control schedule was unclear, and the last documented service was on May 19, despite continued pest concerns. Additionally, the dumpster area was found to have trash and food debris, contributing to the pest problem.
Failure to Provide Timely and Adequate Meal Service Due to Kitchen Shutdown
Penalty
Summary
The facility failed to provide meals at regular and scheduled times due to a sewage backup in the kitchen, which resulted in the County Health Department shutting down the kitchen and requiring all prepared food to be discarded. As a result, staff had to arrange for outside food, leading to significant delays in meal service. Lunch was not delivered until late in the afternoon, with residents receiving hoagies from a local fast food place around 3:45 p.m. or later. Breakfast was also delayed, with some residents still waiting for their morning meal well past the scheduled time. Observations confirmed that food deliveries were late, and meals were not served within the facility's established meal schedule. Multiple residents reported waiting extended periods for meals, with some receiving inadequate or incomplete food, such as cold cereal without milk or juice. One resident, who is diabetic, was at risk due to the delay in receiving meals, and her roommate had to obtain a sandwich from a nurse to prevent low blood sugar. Staff interviews corroborated the delays and confirmed that meals were being prepared offsite and transported to the facility, further contributing to the late service. Documentation review showed that the facility did not serve meals within the scheduled times on the days in question.
Failure to Notify Responsible Party After Resident Fall
Penalty
Summary
The facility failed to ensure timely notification of a resident's responsible party following a fall with injury. Clinical records showed that a resident, admitted for short-term rehabilitation after a previous fall, was found on the floor and required assistance with a Hoyer lift and two nurse aides to return to bed. Although a nursing note indicated that the registered nurse supervisor would contact the physician and the resident's responsible party, there was no documentation that the resident's daughter, who is the responsible party, was notified of the incident. The Director of Nursing confirmed the absence of such documentation, and the resident's daughter reported being upset about not being informed of the fall and subsequent injury.
Failure to Maintain Clean, Safe, and Homelike Environment on Two Nursing Floors
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean, safe, comfortable, and homelike environment on both the first and second nursing floors. On the first floor near the nurse's station and a specific resident room, there was a strong odor of urine, which was confirmed by both the DON and the NHA during their walkthroughs. Additionally, the door handle on the inside of the stairwell door was missing, leaving a sharp opening that required individuals to reach into the hole to open the door from the inside, presenting a safety hazard. Further observations in a resident bathroom revealed that the sink was detached from the wall and placed on the floor, and the walk-in shower floor was very dirty. A soiled incontinent brief was found in a wash basin on the shower floor, contributing to a strong odor in the bathroom. These findings were confirmed by the nurse aide assigned to the room and the Environmental Services Director, who also noted that the walk-in shower should be closed off due to the confusion of residents on the floor and their inability to use the shower unsupervised.
Missed Wound Care Treatments During Staff Absence
Penalty
Summary
A deficiency was identified when a resident with diagnoses including generalized weakness and gait abnormalities did not receive wound care as ordered by the physician. The resident's orders included cleansing the buttocks and groin with a special wound cleanser and applying medicated dressings. Review of the Treatment Administration Report (TAR) for April revealed that on six specific dates, there was no documented evidence that the prescribed wound care was performed. Interviews with the resident, the wound nurse, and the Director of Nursing confirmed that wound care was not completed on these dates, which coincided with the wound nurse being on vacation. The resident reported that when the regular wound nurse was absent, wound care was typically not provided, particularly by agency staff. The absence of documentation and staff confirmation indicated that the required wound care treatments were missed.
Environmental Hazards and Unattended Syringe Identified on Two Nursing Units
Penalty
Summary
Surveyors identified multiple deficiencies related to environmental safety and supervision on two of four nursing units. On the first floor, the inside door handle to the stairwell was missing, leaving a sharp-edged opening that required individuals to reach into the hole to open the door, creating a potential hazard. In a resident room, the walk-in shower had a lower floor that posed a fall risk for confused residents, and the shower drain was missing its cover, exposing a sharp edge and open pipe that residents were filling with debris. Additionally, the bathroom sink in the same room was detached from the wall and placed on the floor, creating a tripping hazard for ambulatory, confused residents. Further observations revealed a hypodermic syringe left unattended on top of a medication cart in the main hallway between the nurse's station and the stairwell, with no nurse in sight. The DON was present nearby but not attending to the cart, and upon being questioned, confirmed that the insulin syringe should not have been left unattended. Facility policy requires that medication carts be closed and locked when out of the nurse's sight and that no medications be left on top of the cart. These findings were confirmed through staff interviews and direct observation.
Non-Compliance with Food Safety Standards
Penalty
Summary
Accela Rehabilitation and Care Center at Springfield was found to be non-compliant with food safety requirements as per 42 CFR Part 483, Subpart B, and the 28 Pa. Code. During an abbreviated survey conducted in response to two complaints, it was observed that the facility failed to store food in accordance with professional standards for food service safety. Specifically, during a kitchen tour, it was noted that several food items, including hamburger buns, loaves of bread, and hot dog buns, were not labeled as required by the facility's policy. The Dietary Director confirmed that these items were received on a recent shipment, and the weekend staff had neglected to label them. Further inspection of the main walk-in refrigerator revealed additional issues with food labeling and storage. A large salad bowl containing lettuce with visibly discolored, pink edges was found unlabeled, along with containers of chopped vegetables such as tomatoes and green peppers. Additionally, a bowl of watermelon and opened packages of salami and ham were also observed without labels. These findings indicate a failure to adhere to the facility's policy on food receiving and storage, which mandates that dry foods be labeled and dated, and that a first-in-first-out system be used for food rotation.
Plan Of Correction
Corrective action All items in dry storage and fridges reviewed. All discolored and old foods removed. Proper labeling added. Potentially affecting all residents. All dietary staff reeducated on policy of delivery, labeling and dating. FSD will review all foods bi-weekly x4 weeks to ensure labeling policy is being followed. Followed by monthly audit x3. Results of audits will be reported to QAPI.
Failure to Ensure Privacy and Dignity in Shared Bathroom Arrangement
Penalty
Summary
A deficiency was identified when a female resident, admitted for skilled nursing care, was observed sharing a common bathroom with two male residents in adjacent rooms. The shared bathroom did not have a locking mechanism on the entry doors, which failed to ensure privacy for the residents using it. During the observation, a licensed nurse confirmed that the bathroom was shared between the female and male residents. The facility administrator also acknowledged that it was not facility policy to have female and male residents share a bathroom, indicating a lapse in adherence to resident care policies and privacy standards.
Failure to Maintain Functional Overbed Lighting for Resident
Penalty
Summary
The facility failed to ensure that essential equipment, specifically overbed lighting, was maintained in safe working order for one of eight residents reviewed. On March 27, 2025, observations on the second floor nursing care unit revealed that the overbed light above the bed occupied by Resident R2 was not functioning. This was confirmed during an interview with a licensed nurse, Employee E5, who acknowledged that the overbed light was not operational at the time of the observation. The deficiency was cited under multiple sections of the Pennsylvania Code related to facility management and resident rights, as the facility did not provide adequate overbed lighting for the affected resident.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as evidenced by multiple observations, resident reports, and pest control documentation. During a resident council meeting, 19 alert and oriented residents reported seeing mice within the facility and stated that they had informed staff for pest control documentation and treatment. Review of pest control operator reports for several months showed that both the main kitchen and certain resident rooms were being treated for common household pests and rodents. The pest control operator also documented the presence of voids in the main kitchen and adjacent areas that needed to be addressed to prevent pest entry. Environmental observations revealed that a door adjacent to the main kitchen, which opens onto the loading dock and receiving area near the facility's garbage dumpster, was not properly sealed. There was a visible gap at the threshold of the metal door, measuring two inches by two inches, which allowed easy access for pests and rodents into the building. The nursing home administrator confirmed the existence of this gap and acknowledged the pest control operator's findings and treatments for mice that had entered the building during the previous months.
Failure to Maintain Effective QAPI Program and Documentation
Penalty
Summary
The facility failed to maintain an effective, comprehensive, and data-driven Quality Assurance and Performance Improvement (QAPI) program as required. Review of the facility's QAPI policy indicated that the program should be ongoing, facility-wide, and focused on indicators of care outcomes and quality of life. The policy outlined processes for identifying and correcting quality deficiencies, including tracking performance, setting goals, analyzing causes, implementing corrective actions, and monitoring effectiveness. However, documentation review revealed no evidence that the QAPI process was used to address or resolve quality deficiencies identified during previous State surveys. Additionally, there was no documentation available to demonstrate the implementation or evaluation of corrective actions or performance improvement activities related to previously identified deficiencies. The current Nursing Home Administrator was unable to locate any QAPI documentation from the previous administrator, and there were no meeting minutes available for the previous months. This lack of documentation and follow-through indicated that the facility did not adhere to its own QAPI policy or regulatory requirements.
Failure to Offer or Document Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer or provide influenza and pneumococcal vaccinations to four out of five residents reviewed during the survey. Clinical record reviews for these residents showed no evidence that they had received the influenza or pneumococcal vaccines, nor was there documentation that the facility had offered these immunizations. The residents involved had various diagnoses, including heart failure, asthma, malnutrition, cerebral vascular incident, depression, anemia, renal insufficiency, and hypertension. Each resident's immunization record lacked any indication of vaccine administration or offer. An interview with the Director of Nursing confirmed the absence of documentation regarding the administration or offer of these vaccines to the affected residents. The findings were cited under relevant Pennsylvania Codes related to the responsibility of the licensee, management, and nursing services.
Survey Results Not Readily Accessible and Outdated
Penalty
Summary
The facility failed to ensure that the most recent Department of Health survey results were readily accessible to residents and visitors on two nursing units. During an observation with the Nursing Home Administrator, it was found that the survey results binder was kept behind the main lobby desk, making it inaccessible without requesting assistance. Additionally, the information in the binders was outdated, with the most recent entries ranging from April 2023 to September 2022, depending on the location within the facility. The Administrator acknowledged that this issue had been identified but had not yet been addressed.
Grievance Forms Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that grievance forms were available and accessible to residents on the nursing units, as required by facility policy and state regulations. During a resident council meeting attended by 19 alert and oriented residents, it was revealed that none of the residents knew where to find grievance forms or where to submit anonymous grievances. This lack of awareness indicated that the forms and submission boxes were not readily accessible or visible to residents. A subsequent facility tour with the Nursing Home Administrator confirmed that grievance forms were not present on the first and second-floor main and pavilion nursing units. Nurses at the stations stated that the forms were typically kept in a filing cabinet behind the nursing station, but when asked, they were unable to locate any forms, confirming their inaccessibility to residents. The facility's policy stated that grievances could be filed orally or in writing, including anonymously, but the lack of accessible forms and submission boxes prevented residents from exercising this right.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent during observed medication administration, resulting in a calculated error rate of 14.81%. Multiple instances were documented where licensed nursing staff did not follow physician orders for medication administration. One resident was given two puffs of Fluticasone Propionate HFA Inhalation Aerosol instead of the ordered one puff, and was not instructed to rinse their mouth after use as required. Another resident received Advair Diskus Inhalation without rinsing their mouth post-administration, contrary to the physician's order. In both cases, the nurses confirmed the deviations from the prescribed orders during interviews. Additionally, a resident with an order for subcutaneous insulin was not administered the medication because it was unavailable on the medication cart, and the nurse stated she would need to notify the unit manager. Another resident, who had physician orders for medications to be administered via G-tube, received those medications orally instead. The nurse administering the medications stated that the resident was on a trial for oral ingestion, but the physician orders had not been updated to reflect this change. The Director of Nursing confirmed that the orders needed to be updated to match the resident's current needs.
Resident Left in Urine-Soaked Linens Due to Lack of Overnight Incontinence Care
Penalty
Summary
A deficiency was identified when a nursing aide was observed providing routine care to a resident who was found lying in bed on linens saturated with urine. The observation revealed that all bed linens were soaked through and required changing. The resident reported that overnight aides did not provide care and that they were left in urine-soaked briefs. The nursing aide confirmed that she discovered the resident in this condition during her morning tasks and stated that overnight aides are responsible for providing care throughout the night and before the end of their shift. The Director of Nursing confirmed that the resident had not been attended to during the evening and was unaware of the situation until it was reported that morning.
Failure to Provide Appropriately Sized Gowns and Linens for Bariatric Residents
Penalty
Summary
The facility failed to maintain resident dignity by not providing appropriately sized gowns and linens for three residents with significant bariatric needs. Observations revealed that one resident, weighing 618 pounds and dependent on staff for activities of daily living, was transported through the corridor minimally covered by only a top sheet after bathing, as no suitable gown was available. This resident also reported a lack of properly fitting sheets for her mattress, resulting in periods without sheets. Another resident, weighing 401 pounds and also dependent on staff for care, was observed lying on a plastic mattress without sheets and covered only by a blanket, expressing discomfort and itching due to direct contact with the plastic. The resident stated that available gowns did not fit properly, leading her to prefer not wearing them. A third resident, weighing 353 pounds, was found in bed without clothes and reported that the gowns provided were too small and uncomfortable, but indicated willingness to wear a properly fitted gown if available. Staff interviews confirmed the lack of adequate supplies, with a nursing aide stating there were no gowns to fit one resident and an environmental services employee acknowledging a limited supply of bariatric gowns, despite an increase in the bariatric population. The employee also noted that gowns were not readily available on nursing units and had to be specifically requested. Facility policies reviewed indicated a requirement to provide individualized care and ensure necessary supplies are available prior to admission, but these were not followed, resulting in residents being left without appropriate linens and gowns, compromising their dignity and comfort.
Unauthorized Use of Personal Device to Access PHI
Penalty
Summary
A deficiency occurred when a licensed nurse was observed using a personal iPad, which lacked technical safeguards, to access resident protected health information (PHI) during a medication pass on the first-floor nursing unit. The nurse stated that she found it easier to use her personal device to log into the facility's electronic health record system (PCC) between residents. This action was in direct violation of the facility's policies, which prohibit the use of personal handheld electronic devices for accessing PHI without prior approval from the Administrator and require all staff to use only facility-provided, secured devices for such purposes. The facility's policies, as outlined in the employee handbook and specific PHI safeguarding documents, emphasize the importance of protecting resident information through administrative, technical, and physical safeguards. Interviews with the Human Resources Director and Assistant Nursing Home Administrator confirmed that all employees are informed of these rules and that the facility's official computer systems have multiple layers of security to protect resident information. The nurse's use of a personal device bypassed these safeguards, resulting in a failure to ensure the confidentiality and security of resident medical records.
Failure to Update PASRR Applications and Refer for Mental Health Services
Penalty
Summary
The facility failed to ensure that Pre-Admission Screening and Resident Review (PASRR) applications were updated to reflect current mental health diagnoses for three out of twenty-one residents reviewed. Specifically, one resident's PASRR did not document a diagnosis of post-traumatic stress disorder that was identified after admission, and this omission was confirmed by the facility's social worker. Another resident, who had diagnoses including major depressive disorder, post-traumatic stress disorder, anxiety disorder, and a history of substance abuse, had a PASRR indicating a positive screen for serious mental illness, but there was no documentation that this resident was referred for a Level II PASRR review to determine eligibility for mental health services. Interviews with the facility social worker confirmed the lack of documentation and appropriate referral for the required PASRR Level II process for residents with mental health conditions. The facility's policy requires all new admissions and readmissions to be screened for mental disorders, intellectual disability, or related disorders, and to complete a Level I PASRR for all potential admissions. However, the facility did not follow its own policy or regulatory requirements in these cases, resulting in incomplete or missing PASRR documentation and failure to refer residents for further mental health evaluation as needed.
Failure to Develop Comprehensive Care Plans for Physician-Ordered Treatments
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for two residents as required. For one resident with diagnoses including cerebral palsy, acute respiratory failure with hypoxia, and COPD, the clinical record showed a physician's order for oxygen administration to maintain oxygen saturation above 93%. However, review of the care plan revealed that there were no documented focus areas, interventions, or measurable outcomes related to oxygen administration. This omission was confirmed by the Director of Nursing during an interview. For another resident with a laceration on the right foot, peripheral vascular disease, and a non-pressure chronic ulcer of the left heel and midfoot, the clinical record included a physician's order for specific wound care on the right dorsal foot. Despite this, the care plan did not include any focus, interventions, or outcomes for the prescribed wound treatment. This deficiency was also confirmed by the Director of Nursing. The lack of care plan documentation for these physician-ordered treatments constituted a failure to meet regulatory requirements for comprehensive care planning.
Failure to Provide Adequate Grooming and Hygiene for Dependent Residents
Penalty
Summary
The facility failed to provide necessary services to maintain adequate grooming and personal hygiene for two dependent residents. One resident, admitted with a history of stroke, muscle weakness, and an open wound, was assessed as requiring assistance with personal hygiene and was totally dependent on staff for bathing, dressing, and eating. Observations revealed that this resident had long fingernails on a contracted right hand and reported not having had a shower in a month, only receiving bed baths. Staff confirmed the long nails and the resident's shower schedule, but the nails remained untrimmed over several days. Another resident, who was cognitively intact but had upper extremity functional limitations and was dependent on staff for bathing, grooming, and transfers, was observed with disheveled, greasy hair and untrimmed, dirty fingernails. This resident reported not being assisted out of bed, lacking a wheelchair for transfers, and only receiving a bed bath once a week. Staff interviews confirmed the resident's grooming needs were not being met and that plans were being made to address hair and nail care. Additionally, the resident's lower extremities were observed to be extremely dry with peeling skin.
Failure to Follow Physician Orders for Medication Administration and Monitoring
Penalty
Summary
The facility failed to provide treatment and care in accordance with physician orders and professional standards for two residents. For one resident with diagnoses including atherosclerotic heart disease, dementia, and epilepsy, there was a physician order for weekly weights to be obtained every Tuesday for four weeks. However, documentation showed that weights were not recorded for two of the required weeks, and this was confirmed by both the unit manager and the dietician. The dietician also noted a 4.01% weight loss during the period in question. For another resident with diagnoses including aphasia, cerebrovascular accident, hemiplegia, malnutrition, anxiety, and depression, and who required nutrition via a feeding tube, physician orders specified that certain medications be administered via the g-tube. During observation, a licensed nurse administered these medications orally instead of via the g-tube, as per the current physician orders. The nurse stated that the resident was now taking medications orally, and the DON confirmed that the resident was on a trial for oral ingestion, but acknowledged that the physician orders had not been updated to reflect this change.
Failure to Assess and Provide Hearing Services for Resident with Hearing Deficit
Penalty
Summary
Facility staff and physician failed to adequately assess and monitor a resident identified with a hearing deficit. The facility's policy required staff and the physician to identify residents with hearing impairment and for the physician to order a consultation with an audiologist to determine causes and treatment options. Despite the nursing admission assessment documenting a hearing deficit for the resident, there was no evidence in the clinical record of an evaluation by a professional specializing in hearing assistive devices. Throughout the survey, the resident was observed to have moderate difficulty hearing, requiring others to speak loudly and distinctly for comprehension, and preferring the television volume to be turned up high. Staff interviews confirmed the resident's moderate hearing impairment and the need to adjust communication methods. The lack of follow-through on the facility's policy and absence of a professional evaluation for hearing assistive devices led to the deficiency.
Failure to Follow Physician Order for Catheter Size
Penalty
Summary
A review of the clinical record and staff interview revealed that the facility failed to implement appropriate treatment and services for incontinence management for one resident. Specifically, a physician's order dated January 29, 2025, directed the use of a 16 French (FR) supra pubic catheter with a 10 CC balloon for the resident. However, on March 4, 2025, it was observed that the resident had a 22 FR/10 CC balloon supra pubic catheter in place, which did not match the physician's order. This discrepancy was confirmed at the time of observation with a licensed nurse.
Failure to Follow Physician's Order for Oxygen Administration
Penalty
Summary
A deficiency was identified when a resident with diagnoses including cerebral palsy, acute respiratory failure with hypoxia, and chronic obstructive pulmonary disease was not provided respiratory care in accordance with physician orders. The resident had a physician's order for oxygen to be administered at 2 liters per minute via nasal cannula, as needed, to maintain oxygen saturation above 93%. However, during an observation, the resident was found to be receiving oxygen at 3 liters per minute via nasal cannula, which was not consistent with the prescribed order. This finding was confirmed by a licensed nurse at the time of observation. The failure to follow the physician's order for oxygen administration constituted a lack of appropriate respiratory care and services for the resident, as required by facility policy and regulatory standards.
Failure to Provide Behavioral Health Services and Psychiatric Evaluation
Penalty
Summary
The facility failed to provide appropriate treatment and services for two residents with mental health diagnoses and psychosocial adjustment difficulties. One resident, with diagnoses including PTSD, major depressive disorder, anxiety disorder, and a history of substance abuse, had not received a psychiatric evaluation for over six months despite being prescribed multiple psychotropic medications. This resident expressed ongoing symptoms such as trouble sleeping, anxiety, nightmares, and flashbacks, and had requested to resume psychological services. Additionally, the resident had requested a transfer to another facility, but there was no documentation indicating that this request was being addressed. The resident was also found smoking in his room, with documentation noting that family members had provided the smoking materials. Another resident, diagnosed with schizophrenia, bipolar disorder, depression, and anxiety disorder, was identified as eligible for mental health services following a positive PASRR II evaluation. Although a referral for mental health services was made, the resident had not received any behavioral health programs since the referral due to the absence of qualified personnel to provide care. Observations during the survey period showed that this resident was not participating in social activities and was making aggressive and derogatory comments to staff, visitors, and other residents. The facility's policies required behavioral health services to be provided by qualified staff, but these services were not delivered as needed for these residents.
Delayed Insulin Administration Due to Miscommunication
Penalty
Summary
A deficiency occurred when a resident with diabetes, renal insufficiency, and viral hepatitis did not receive their prescribed insulin in a timely manner. The resident had a physician's order for Humalog insulin to be administered with meals. During a medication pass after breakfast, a licensed nurse discovered that the resident's insulin was not available in the medication cart. The nurse reported the missing medication to the unit manager and was informed that it would be ordered, resulting in a delay in administration. The nurse was unaware that additional insulin was available in storage, leading to further delay. Facility policy requires that only licensed personnel administer medications and that insulin pens be clearly labeled and verified before use. The policy also mandates that medications be stored properly and that nursing staff maintain medication storage areas. The delay in insulin administration was attributed to miscommunication between staff regarding the availability of the medication, which resulted in the resident not receiving their insulin as ordered with meals.
Failure to Properly Label and Discard Opened Insulin Vials
Penalty
Summary
Surveyors observed that the medication cart on the second floor, front hall, contained two opened vials of insulin—Humalog Insulin Lispro and Insulin Aspart—each with a valid manufacturer expiration date but lacking a marked date of opening. The absence of an opened date on these vials is not in accordance with professional standards for medication labeling. During the observation, a licensed nurse confirmed that the insulin vials should have been discarded, indicating that the facility failed to ensure proper labeling and timely disposal of medications as required by professional standards.
Failure to Provide Prompt Dental Services
Penalty
Summary
The facility failed to provide prompt routine dental services to a resident who was cognitively intact and had requested dental care. According to the facility's policy, it is responsible for ensuring that each resident is examined and assessed by a dentist and receives dental services as needed. Clinical records showed that the resident complained of a broken tooth and requested a dental cleaning. Nursing staff notified the consulting dental service, which confirmed the resident required extractions and fillings, and scheduled an appointment. Despite these actions, the resident had not received any dental care since the initial request. This was confirmed by the Director of Nursing during an interview. The deficiency was identified through clinical record review, staff interviews, and policy review, which demonstrated that the facility did not ensure timely provision of dental services as required by its own policies and state regulations.
Failure to Ensure Safe Storage and Handling of Outside Food Items
Penalty
Summary
The facility failed to ensure the safe and sanitary storage and handling of personal food items brought in by family members or visitors for three residents. Observations revealed that one resident had two unlabeled Ziplock bags containing different types of bread, as well as opened soy sauce, blueberry jam, and pancake syrup that were not stored or refrigerated appropriately. These findings were confirmed by a licensed nurse during a room tour. Another resident was found with two opened containers of mayonnaise, a large opened coffee creamer, and three milk containers standing on the floor by his shoes. Additionally, his roommate had chicken salad on his bedside that had been brought by a family member, opened the previous day, and left unrefrigerated, with most of it remaining. The same resident also had potatoes brought by a family member that were not labeled or refrigerated. The unit manager confirmed that these foods were not appropriately stored, which was inconsistent with the facility's policy requiring labeling and proper storage of outside food items.
Failure to Report Investigation Outcomes
Penalty
Summary
Accela Rehab and Care Center at Springfield was found to be non-compliant with the requirements of 42 CFR Part 483, Subpart B, specifically regarding the reporting of alleged violations. The facility failed to report the results of investigations into allegations of abuse, neglect, and misappropriation to the State Survey Agency within the required five working days. This deficiency was identified during an abbreviated survey conducted in response to two complaints. The facility's policy, "Abuse and Neglect - Clinical Protocol," mandates timely reporting of such incidents, but the facility did not adhere to this policy. The survey revealed that four residents were involved in incidents that required investigation. One resident reported money missing from their personal bag, another alleged a verbal altercation with a facility van driver, a third resident claimed neglect due to not receiving showers or snacks, and a family member of a fourth resident alleged rough treatment by nurse aides. Despite initiating internal investigations for each incident, the facility did not document evidence of reporting the outcomes to the State Survey Agency as required, leading to the cited deficiency.
Plan Of Correction
NHA will submit outcome of internal investigations identified in observation #0609 to SSA via Event Reporting System. NHA to review and submit outcome and findings of investigations that remain incomplete in Event Reporting System. NHA, DON to be reeducated on timely submission of event investigation findings to Event Reporting System. Event Reporting System to be audited weekly x4 weeks by a member of regional team to ensure compliance with completing submission of events. After 4 weeks above said audits will be done monthly x3 months. Results of said audits will be reported to QAPI.
Environmental Deficiencies in Nursing Units
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents and staff across three of four nursing units. Observations and interviews revealed that a clogged sink in room 126 caused repeated flooding into room 124, affecting the residents in these rooms. The issue was confirmed by both residents and staff, with a nurse inadvertently causing the overflow by leaving the sink running. Additionally, the tour of the facility uncovered various maintenance issues, including a broken bed enabler, missing cabinet doors, and visibly soiled furniture. Further observations during the facility tour revealed additional deficiencies, such as a missing sink handle and toilet paper holder in room 136, a broken footboard in room 207-D, and a missing sink in room 206, leaving a hole in the wall. These issues were confirmed by the Assistant Administrator, indicating a broader problem with maintaining the facility's environment in a safe and sanitary condition.
Plan Of Correction
NHA or designee will oversee the identified areas mentioned in observation #0921 are corrected. Additionally, weekly rounds of a few rooms per week will be conducted by NHA or designee with maintenance, housekeeping and nursing team member auditing environment to identify concerns related to safe sanitary and comfortable conditions of living spaces. Weekly rounds will be conducted for x4 weeks. Subsequently, monthly audit of the above will be conducted. Findings to be reported to QAPI.
Failure to Conduct PASARR Screening for Resident with Mental Disorders
Penalty
Summary
The facility failed to provide evidence of a Level 1 pre-screening for mental disorders or intellectual disabilities for a resident, identified as Resident R1. According to the facility's policy "Admission Criteria," all new admissions and readmissions are required to be screened for mental disorders, intellectual disabilities, or related disorders as part of the Medicaid Pre-Admission Screening and Resident Review (PASARR) process. However, upon review of Resident R1's clinical records, there was no documented evidence that such a screening was conducted. This oversight was confirmed during an interview with the Nursing Home Administrator. Resident R1 was admitted to the facility on May 12, 2023, and was noted to be cognitively intact. The resident's Minimum Data Set (MDS) dated January 5, 2025, indicated diagnoses of post-traumatic stress disorder, schizophrenia, and depression. Additionally, the resident had physician orders for medications including Duloxetine for depression and Seroquel for bipolar disorder. Despite these significant mental health diagnoses, the facility did not have a Level 1 PASARR screen on record for Resident R1, which is a requirement for ensuring appropriate care and services are provided to residents with mental disorders or intellectual disabilities.
Plan Of Correction
NHA or designee to review PASSAR Level II screening to ensure resident is receiving appropriate care services based on criteria for MD, ID, and RD. Admission team and SW to be reeducated on PASSAR Level I requirement prior to admission. Random audit of admissions to be conducted by NHA, or designee, looking back at the past 3 months of admissions, to see if PASSAR Level I were obtained when appropriate. Weekly audit x4 weeks of admissions to be conducted by NHA or designee to review if PASSAR was obtained prior to admission when appropriate. After 4 weeks, monthly random audit to be conducted by NHA or designee to check for PASSAR's if appropriate. Findings of all above mentioned audits to be reported to QAPI.
Deficiency in Maintaining Transport Agreements
Penalty
Summary
The facility failed to maintain proper agreements for services furnished by outside resources, specifically regarding transportation services for residents. Resident R1, who is cognitively intact and has diagnoses of PTSD, schizophrenia, and depression, expressed concerns about the use of Uber for transportation to and from appointments. The resident reported issues with being dropped off and picked up at incorrect locations, requiring them to walk short distances, and experiencing long wait times for Uber to arrive after appointments. The facility has its own van and staffed drivers for resident transportation and an agreement with a contracted transport company for residents requiring stretcher use. However, the agreement with the contracted ambulance service was not fully executed, as it was signed by the facility administration but not by the contracted service. Additionally, the facility did not have a formal transport agreement with Uber, which was used for Resident R1's transportation, leading to the deficiency in maintaining proper agreements for outside services.
Plan Of Correction
R1 will be offered transportation through safe and contracted providers. All residents will be offered transportation through safe and contracted providers. NHA to educate scheduler and assistant admin on requirement to offer safe and contracted service providers for all services. Review of means of transportation will be audited weekly x4. Then subsequently random audit will be conducted monthly. Results of audits will be reported to QAPI.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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