Bryn Mawr Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Bryn Mawr, Pennsylvania.
- Location
- 773 East Haverford Road, Bryn Mawr, Pennsylvania 19010
- CMS Provider Number
- 395095
- Inspections on file
- 28
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Bryn Mawr Village during CMS and state inspections, most recent first.
Two residents reported verbal and physical abuse by nurse's aides, including rough care, yelling, and being left in bed for extended periods. Despite these allegations and facility policy requiring prompt investigation, there was no documented evidence that a thorough investigation was conducted or that findings were recorded by the DON or Social Worker.
A resident with severe protein calorie malnutrition, who was cognitively intact, reported multiple times that a night shift nurse's aide was rough and yelled during care. Despite the resident and a medication nurse submitting written complaints, the facility's grievance log showed no record of these grievances, and staff interviews confirmed that no investigation was conducted as required by facility policy.
The facility did not maintain and inspect its kitchen hood suppression systems, impacting the entire facility. Reports from July 2024 and January 2025 indicated failures in the system, and an interview with the Administrator and Maintenance Director confirmed that corrective actions were not completed.
The facility did not maintain the required testing of its automatic sprinkler system components, affecting the entire facility. A document review revealed that the last full flow trip test for the dry system was conducted in 2019, which was confirmed during an exit interview with the Administrator and Maintenance Director. This testing was out of the required three-year cycle.
The facility was found to be improperly using a 75-foot extension cord to power a sump pump on the front lawn. The cord was wrapped around facade lights and plugged into an external outlet, violating regulations. The Administrator and Maintenance Director confirmed this prohibited use.
The facility failed to maintain proper exit signage, as observed in the East Wing near the nursing station. Multiple illuminated exit signs led to a back courtyard with no egress, and the exterior doors had signs indicating they were not fire exits. This was confirmed in an interview with the Administrator and Maintenance Director.
The facility failed to ensure portable fire extinguishers were accessible, as observed in the multi-purpose room where two wall-mounted extinguishers were blocked by large tables. This was confirmed during an exit interview with the Administrator and Maintenance Director, indicating non-compliance with NFPA 10 standards.
The facility was found to be non-compliant with NFPA 101 standards due to exceeding the maximum allowable story height for its construction type. A two-story, Type III (200) building and a two-story, Type II (000) building, both fully sprinklered, exceeded the permitted story height by one story. These findings were confirmed during an exit interview with the Administrator and Maintenance Director.
The facility failed to maintain emergency generator components, as the generator set location lacked battery back-up emergency lighting, and the 3-year, 4-hour load test report was unavailable. These deficiencies were confirmed during an exit interview with the Administrator and Maintenance Director.
The facility failed to maintain the required fire resistance rating for vertical openings, affecting two levels. The stairway between the Lower Level Kitchen and the First Floor lacked one-hour fire resistive construction. Additionally, the north side exit from the Basement had a staircase with unsheathed walls, lacking the required fire resistance. These deficiencies were confirmed during interviews with the Administrator and Maintenance Director.
The facility was found to lack two acceptable emergency exits in the basement, as the north exit is a communicating stair that does not lead to an exterior exit discharge. This deficiency was confirmed by the Administrator and Maintenance Director.
The facility was found to be non-compliant with NFPA 101 Life Safety Code as the north exit from the second floor requires passage through an intervening dining room, violating the requirement for corridors to provide access to at least two approved exits without passing through other rooms. This was confirmed during a survey and exit conference with the Administrator and Maintenance Director.
Bryn Mawr Village failed to ensure advance directives were in place for two residents, as revealed by clinical record reviews and staff interviews. One resident, admitted with COPD, and another with Acute Respiratory Failure and Multiple Sclerosis, both lacked advance directives on their face sheets and documentation of related discussions. Interviews confirmed the absence of advance directives, and no physician orders were present for either resident.
The facility failed to recognize the placement of beds against the wall as a restraint for three residents, violating their right to be free from unnecessary restraints. Observations and interviews confirmed the bed placements, which were not documented in care plans or assessments as safety measures or preferences, despite the residents' medical conditions and risks.
A facility failed to develop a baseline care plan within 48 hours for a resident admitted with multiple diagnoses, including COPD and Depression. Despite having physician orders for medications, the only care plan addressed an ADL self-care performance deficit, initiated eight days post-admission. This was confirmed by the Unit Manager.
A resident experienced significant weight loss, dropping from 180 lbs to 150.4 lbs, without a comprehensive care plan being developed to address this issue. The facility's policy mandates the creation of such plans to meet residents' needs, but no documentation was found for this resident's weight management.
The facility failed to provide necessary grooming services for two residents requiring assistance with activities of daily living. One resident, with severe cognitive impairment, had an inadequately groomed beard, and family intervention was needed for shaving. Another resident, with intact cognition, had an overgrown beard affecting his ability to eat properly. Staff confirmed the lack of grooming assistance and documentation for both residents.
A resident at risk for pressure ulcers due to immobility and bowel incontinence developed multiple pressure injuries while under care. The facility failed to implement a turning and positioning program, as confirmed by the absence of documentation and staff interviews.
The facility failed to obtain and document weekly weights as ordered by physicians for two residents. One resident, admitted with a femur fracture and muscle weakness, had no documented weekly weights or refusal to be weighed. Another resident, with pleural effusion and dysphagia, showed gaps in weight records exceeding seven days, with no documentation of attempts to weigh or refusal. The Unit Manager confirmed these documentation lapses.
A facility failed to adhere to a Registered Dietitian's recommendations for a resident receiving enteral nutrition. The resident, admitted with conditions like dysphagia, required tube feeding. Despite a recommendation for a specific feeding regimen, the facility did not promptly implement it, and there was no documented rationale for the delay in meeting the resident's caloric needs.
The facility failed to provide appropriate respiratory care for two residents. One resident received oxygen at a higher flow rate than prescribed, while another received oxygen therapy without a physician's order. Both issues were confirmed by the DON and Unit Manager.
A resident with chronic pain syndrome did not receive prescribed Oxycodone for severe pain on two occasions, despite documented pain levels of 10 and 8. The facility's policy on pain management was not followed, as there was no rationale for the non-administration, no physician notification, and no alternative pain management strategies documented.
A resident with documented opioid allergies was prescribed oxycodone and tramadol, despite known allergies. Interviews confirmed the oversight, and the facility lacked a policy addressing allergies, contributing to the medication management failure.
The facility failed to meet the required NA to resident ratios for 21 consecutive days across all shifts. During the day shift, the facility consistently scheduled fewer NA hours than required, with discrepancies ranging from 4.8 to 17.6 hours short. The evening and overnight shifts also experienced significant staffing deficiencies, with shortfalls ranging from 2.18 to 13.09 hours in the evening and 3.2 to 9.53 hours overnight. These consistent staffing inadequacies were confirmed by the facility's administrator.
The facility failed to meet the required LPN staffing levels during day and evening shifts on 9 out of 21 days. The regulation requires one LPN per 25 residents during the day and one per 30 residents in the evening. However, staffing records showed insufficient LPN hours, such as 8 hours for 37 residents when 11.84 were needed. The administrator confirmed the shortfall, indicating a pattern of non-compliance with staffing regulations.
The facility did not meet the required 3.2 hours of direct resident care per resident in a 24-hour period on 12 out of 21 days reviewed. Staffing sheets from February to March 2025 showed several days with insufficient care hours, with the lowest being 2.93 hours. This was confirmed by the facility's administrator.
A resident experienced significant weight loss due to the facility's failure to implement nutritional interventions and notify the physician. Despite recommendations from the dietician to liberalize the diet and add supplements, these were not followed. The facility also did not adhere to the approved vegetarian menu, and meal intake was inadequately monitored.
The facility did not adhere to professional standards for food service safety, as observed during a kitchen tour. The main cook was not wearing a hair net, and food items in the refrigerator were improperly labeled with a single date, indicating the open date, rather than the required use-by date. Interviews with staff confirmed the labeling did not meet professional standards.
The facility did not ensure that five nursing assistants received the required 12 hours of annual training to maintain competence. A review of documentation and interviews revealed that the facility failed to track or complete the necessary in-service training, violating state regulations.
The facility failed to maintain confidentiality and privacy for two residents. A resident's POA received medical records containing another resident's information due to improper review by staff. Additionally, a staff member provided incontinence care with the door open, exposing a resident, which was confirmed by the DON.
A facility failed to follow physician orders for weekly weight monitoring of a resident, resulting in an undocumented significant weight loss of 8% over eleven days. The last recorded weight was 170.5 pounds, and upon reweighing, the resident weighed 157 pounds. This deficiency was confirmed by a Registered Dietitian.
A resident requiring assistance with daily living activities had long and thick toenails, as observed on a specific date. Despite multiple requests from the resident's representative for a podiatrist consultation, no action was taken until the issue was confirmed by the DON. The facility had a podiatry service available, but no appointment was made until after the deficiency was noted.
A resident experienced severe weight loss over several months, but the facility failed to notify the physician or complete an assessment as required by policy. Despite recommendations from the dietician to liberalize the diet and notify the physician, the resident's weight continued to decline significantly without appropriate medical intervention.
The facility did not adhere to professional standards for medication storage. An observation revealed that a medication storage room was left unlocked, and a refrigerator containing medications was missing its lock. A LPN confirmed the unlocked status of both the room and the refrigerator.
A facility failed to follow an approved vegetarian diet for a resident, leading to nutritional inadequacy. Despite having a dietician-approved vegetarian menu extension, the Food Service Director was unaware of how to access it, resulting in undocumented calorie intake and meals for four months. This deficiency highlights a communication and training gap in dietary services.
A resident with a documented lactose allergy and intolerance was provided with fortified cereal containing dairy products, despite physician orders and personal requests for non-dairy alternatives. The resident continued to consume the cereal each morning, highlighting a failure in accommodating dietary needs.
The facility did not provide prescribed dietary items for two residents. One resident did not receive a double portion meal or a mighty shake, while another did not receive a magic cup as ordered. These issues were confirmed by an LPN and a Unit Manager.
A resident experienced significant weight loss due to the failure of the Nursing Home Administrator and DON to manage nutritional needs effectively. Despite the resident's medical conditions and dietary requirements, the facility did not implement timely nutritional interventions or notify the physician of the weight loss. The Registered Dietician's recommendations were not followed, and meal intake was inconsistently documented, leading to an Immediate Jeopardy situation.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to investigate allegations of verbal and physical abuse for two residents, despite both residents being cognitively intact and able to report their concerns. One resident reported that a night shift nurse's aide was rough during care and yelled at him, and stated that he had submitted written complaints twice, including one written by a medication nurse on his behalf. However, the Director of Nursing and the Social Worker both confirmed that they were unaware of any grievances from this resident, and no investigation was conducted into his allegations. Another resident reported that nurse's aides were rough during care, yelled at her, and ignored her call bells, with one incident involving being left in bed for hours in feces. The resident's husband also reported concerns about his wife being manhandled. Although a Resident Concern Report was completed, there was no documented evidence of a thorough investigation, such as staff statements, findings, conclusions, or disciplinary actions. The Social Worker acknowledged interviewing the nurse's aide involved but did not document the interview or include it in the investigation file. Facility policy requires prompt reporting and thorough investigation of all abuse allegations, including interviews with all relevant parties and documentation of findings. In both cases, the facility did not follow its own policies or regulatory requirements, as there was no evidence of a complete investigation or appropriate documentation regarding the residents' allegations of abuse.
Failure to Address Resident Grievances in a Timely Manner
Penalty
Summary
The facility failed to address a resident's grievances in a timely manner, as required by its own grievance policy. The policy states that residents and their representatives have the right to file grievances orally or in writing, and that the Grievance Officer must review and investigate any allegations, submitting a written report to the Administrator within five working days. In this case, a resident with severe protein calorie malnutrition, who was cognitively intact according to the most recent MDS assessment, reported that a night shift nurse's aide was rough during care and yelled at him. The resident stated that he had submitted written complaints twice, and that a medication nurse had also written a complaint on his behalf the previous week. Despite these actions, the facility's grievance log contained no record of grievances from this resident. Interviews with staff revealed that the DON was unaware of any investigation into the resident's complaints, and the social worker, who regularly checks the grievance box, reported not finding any grievance forms related to the resident. The social worker also confirmed that no investigation had been conducted because no grievance was received. The DON further confirmed that no investigation was initiated regarding the resident's complaints about the night shift nurse's aide.
Failure to Maintain Kitchen Hood Suppression Systems
Penalty
Summary
The facility failed to maintain and inspect its kitchen hood suppression systems, which affected the entire facility. During a document review on March 17, 2025, it was found that the kitchen hood suppression system report from July 3, 2024, indicated a failure with the 'Cylinder'. Additionally, a subsequent report dated January 6, 2025, showed a failure of the 'Kitchen System'. An exit interview with the Administrator and Maintenance Director confirmed that corrective actions had not been completed.
Plan Of Correction
The kitchen hood suppression system repair is scheduled for 4/11/2025. Maintenance Director will report completion and compliance to QAPI committee.
Failure to Maintain Sprinkler System Testing
Penalty
Summary
The facility failed to maintain the required testing of automatic sprinkler system components, which affected the entire facility. During a document review on March 17, 2025, it was revealed that the quarterly sprinkler inspection reports for both wet and dry systems, dated January 20, 2025, indicated that the last full flow trip test for the dry system was conducted in 2019. This finding was confirmed during an exit interview with the Administrator and Maintenance Director on the same day, highlighting that the testing was out of the mandated three-year testing cycle.
Plan Of Correction
Full flow trip test is scheduled for 4/28/2025. A task will be entered in TELS work order system to ensure tests are completed timely. Maintenance director will report on the results and compliance to QAPI committee.
Improper Use of Extension Cord for Sump Pump
Penalty
Summary
The facility failed to comply with regulations regarding the use of extension cords, as evidenced by an observation made on March 17, 2025. A 75-foot extension cord was found wrapped around two facade fixed sconce lights above an egress exit door, outside the main entrance. This extension cord was plugged into an external electrical outlet fixed to the building and was being used to power a sump pump on the front lawn. During an interview at the exit conference, both the Administrator and Maintenance Director confirmed the prohibited use of the extension cord, which affected one of the two levels of the facility.
Plan Of Correction
The installation of an exterior outlet for the sump pump is scheduled for 4/21/2025. Maintenance director will report on completion of job to QAPI committee.
Conflicting Exit Signage in East Wing
Penalty
Summary
The facility failed to ensure proper exit signage, which is a requirement for maintaining unobstructed egress. During an observation on March 17, 2025, at 11:50 a.m., it was noted that in the East Wing near the nursing station, there were multiple illuminated exit signs in the corridor leading to a back courtyard that did not provide an egress route. Additionally, the exterior doors leading to the back courtyard had signage indicating that it was not a fire exit and should not be used in case of fire. This conflicting signage was confirmed during an exit interview with the Administrator and Maintenance Director on the same day at 2:00 p.m.
Plan Of Correction
All exit signs were audited and corrected by 4/7/2025. Maintenance director will report on compliance to QAPI committee.
Fire Extinguishers Obstructed by Tables
Penalty
Summary
The facility failed to ensure that portable fire extinguishers were accessible on one of its two levels. During an observation on March 17, 2025, at 12:15 p.m., it was noted that in the multi-purpose room, which was formerly used for Physical Therapy, two wall-mounted fire extinguishers were obstructed by large tables on each side of the room. This obstruction was confirmed during an exit interview with the Administrator and Maintenance Director on the same day at 2:00 p.m., indicating a failure to comply with the requirements for fire extinguisher accessibility as per NFPA 10 standards.
Plan Of Correction
Obstructions were corrected immediately on 3/17/2025, and staff was educated on compliance. Maintenance director will report to QAPI committee on compliance of this regulation.
Building Construction Type Exceeds Allowable Story Height
Penalty
Summary
The facility was found to be non-compliant with building construction requirements as per NFPA 101 standards. During a document review and interview conducted on March 17, 2025, it was discovered that the facility was classified as a two-story, Type III (200), unprotected ordinary construction, which was fully sprinklered. However, this classification exceeded the maximum allowable story height by one story, as the construction type only permits a maximum of two stories when sprinklered. This discrepancy was confirmed during an exit interview with the Administrator and Maintenance Director. Additionally, another component of the facility was identified as a two-story, Type II (000), unprotected noncombustible construction with a basement, which was also fully sprinklered. This component similarly exceeded the maximum allowable story height by one story, as the construction type does not allow for any stories when non-sprinklered and only permits one story when sprinklered. This finding was also confirmed during the exit interview with the facility's Administrator and Maintenance Director.
Plan Of Correction
Bryn Mawr Village would like the Department of Health and Human Services Life Safety Divisions assistance with reapplying for another FSES for two-story type III (200), unprotected ordinary construction which is fully sprinklered. The story height exceeds the maximum allowance for this construction type one story. The facility has previously submitted a waiver for this deficiency. The Administrator or designee is responsible for monitoring this and as part of the Quality Assurance Performance Improvement Program will report on Life Safety requirements and plan of correction to the Committee. Bryn Mawr Village would like the Department of Health and Human Services Life Safety Divisions assistance with reapplying for another FSES for two-story type III (200), unprotected ordinary construction which is fully sprinklered. The story height exceeds the maximum allowance for this construction type one story. The facility has submitted a TLW waiver for this deficiency. The Administrator or designee is responsible for monitoring this and as part of the Quality Assurance Performance Improvement Program will report on Life Safety requirements and plan of correction to the Committee.
Emergency Generator Maintenance Deficiency
Penalty
Summary
The facility failed to maintain required emergency generator components, which affected the entire facility. During an observation on March 17, 2025, it was noted that the emergency generator set location inside the transformer room in the basement lacked battery back-up emergency lighting. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director on the same day. Additionally, a documentation review revealed that the facility did not have the required 3-year, 4-hour load test report available for the generator that supports the emergency electrical system. This lack of documentation was also confirmed during the exit interview with the Administrator and Maintenance Director.
Plan Of Correction
Emergency lighting installation is scheduled for 4/21/2025. A 4-hour load test was completed on 3/31/2025. A task will be entered in TELS work order system to ensure tests are completed timely. The maintenance director will report on results to the QAPI meeting.
Failure to Maintain Fire Resistance Rating for Vertical Openings
Penalty
Summary
The facility failed to maintain the required fire resistance rating for vertical openings, specifically affecting two levels within the building. During a document review and interview conducted on March 17, 2025, it was discovered that the communicating stairway between the Lower Level Kitchen and the First Floor did not have the necessary one-hour fire resistive construction. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director. Additionally, the facility did not maintain the fire resistance rating for stair towers, impacting one of two floors within the building. A document review revealed that the north side exit from the Basement was a communicating staircase with walls not sheathed on the room 2A side, lacking the required one-hour fire resistance rating. This issue was also confirmed during an exit interview with the Administrator and Maintenance Director.
Plan Of Correction
The facility will work with an outside consultant to complete an FSES to cover this deficiency. The Administrator or designee is responsible for monitoring this and, as part of the Quality Assurance Performance Improvement Program, will report on Life Safety requirements and plan of correction to the Committee. The facility will work with an outside consultant to complete an FSES to cover this deficiency. The Administrator or designee is responsible for monitoring this and, as part of the Quality Assurance Performance Improvement Program, will report on Life Safety requirements and plan of correction to the Committee.
Facility Lacks Two Acceptable Exits in Basement
Penalty
Summary
The facility failed to provide two acceptable exits, located remotely from one another, affecting one of two floors of the building. During a document review on March 17, 2025, it was revealed that the basement level of the facility lacked two acceptable emergency exits that are located remotely from each other. Specifically, the north exit from the basement is a communicating stair and does not lead to an exterior exit discharge. This deficiency was confirmed during an interview at the exit conference with the Administrator and Maintenance Director on the same day, where it was acknowledged that the basement level lacked two acceptable exits.
Plan Of Correction
The facility will work with an outside consultant to complete an FSES to cover this deficiency. The Administrator or designee is responsible for monitoring this and, as part of the Quality Assurance Performance Improvement Program, will report on Life Safety requirements and plan of correction to the Committee.
Exiting Deficiency Through Intervening Dining Room
Penalty
Summary
The facility failed to ensure compliance with the NFPA 101 Life Safety Code regarding the number of exits in corridors. Specifically, the deficiency was identified in the north exit from the second floor, which requires passage through an intervening dining room, contrary to the requirement that corridors provide access to at least two approved exits without passing through any intervening rooms or spaces other than corridors or lobbies. This issue was observed and documented during a survey on March 17, 2025, at 11:30 a.m. The deficiency was confirmed during an exit conference with the Administrator and Maintenance Director later that day.
Plan Of Correction
The facility will work with an outside consultant to complete an FSES to cover this deficiency. The Administrator or designee is responsible for monitoring this and, as part of the Quality Assurance Performance Improvement Program, will report on Life Safety requirements and plan of correction to the Committee.
Failure to Ensure Advance Directives for Residents
Penalty
Summary
Bryn Mawr Village was found to be non-compliant with the requirements of 42 CFR part 483, Subpart B, and the 28 PA Code related to the health portion of the survey process. The facility failed to ensure that advance directives were in place for two residents, Resident R149 and Resident R26, as evidenced by clinical record reviews and staff interviews. Resident R149, admitted with a diagnosis of Chronic Obstructive Pulmonary Disease, had no advance directives indicated on the face sheet, nor was there documented evidence of discussions regarding advance directives. Similarly, Resident R26, admitted with Acute Respiratory Failure with Hypoxia and Multiple Sclerosis, also lacked advance directives on the face sheet and documentation of related discussions. Interviews with Unit Manager Employee E3 confirmed the absence of advance directives for both residents. Additionally, there were no physician orders for advance directives for either resident. The facility's policy on advance directives, last revised in 2016, mandates that residents be provided with written information about their rights to accept or refuse treatment and to formulate an advance directive upon admission. The policy also requires that information about advance directives be prominently displayed in the medical record and that the plan of care aligns with the resident's documented treatment preferences.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Residents R26 and R149 are discharged from the facility. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: An audit of the clinical records of current residents will be conducted to ensure that a code status is included, a physician order for code status is included, and the resident's family member is given an advance directive or clarification of the hospital code status to implement the residents wishes after admission to the facility. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Education will be provided by the DON/ and or designee to nursing staff and Social Services regarding the components of this regulation and how to properly document this regulation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Random audits will be conducted weekly by the DON/ or designee of five clinical records to ensure that they include a code status, a physician order for code status and that the family was involved in the wishes. Audits will be conducted weekly x for four weeks and then monthly for six months. Results of these audits will be reported to the monthly Quality Assurance Performance Improvement Committee until monthly and/or substantial compliance is met. Adjustments to the plan of corrections will be made by the Interdisciplinary team as needed.
Failure to Identify Bed Placement as Restraint
Penalty
Summary
The facility failed to identify the placement of beds against the wall as a restraint for three residents, which is a violation of their right to be free from physical restraints not required to treat medical symptoms. The facility's policy defines physical restraints as any device that restricts freedom of movement and cannot be easily removed by the resident. Observations revealed that the beds of Residents R247, R248, and R249 were placed against the wall, which was not documented in their care plans or assessments as a safety measure or preference. Resident R247, diagnosed with Alzheimer's disease and at high risk for falls, had no care plan addressing the bed placement. Resident R248, with intact cognition and a history of respiratory failure and falls, also lacked documentation for the bed's position. Resident R249, with hypertensive urgency and intact cognition, confirmed that the bed's placement was not their preference. Interviews with staff, including an LPN and the Director of Nursing, confirmed the bed placements, indicating a failure to adhere to the facility's restraint policy.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Residents R247, R248, R249 were interviewed by DON and NHA to obtain preferences for the placement of the beds and adjusted as needed. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: Residents with beds near the wall were interviewed by DON and NHA regarding their preferences and beds were adjusted and care plan updated to reflect their request. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Education will be provided by the DON/ and or designee to nursing staff regarding the components of this regulation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Random audits will be conducted weekly by the DON/ and or designee of five residents to ensure that bed placement preferences are in place and the care plan is being followed. Audits will be conducted weekly x for four weeks and then monthly for six months. Results of these audits will be reported to the monthly Quality Assurance Performance Improvement Committee until monthly and/or substantial compliance is met. Adjustments to the plan of corrections will be made by the Interdisciplinary team as needed.
Failure to Develop Timely Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident, identified as R149, within the required 48-hour timeframe following admission. The resident was admitted with multiple diagnoses, including COPD, Centrilobular Emphysema, Generalized Anxiety Disorder, Alcohol Dependence, Depression, Acute Pancreatitis, and Anemia. Despite having physician orders for medications such as Lidocaine Patch, Eliquis, and Gabapentin, the facility did not create a baseline care plan that included these orders or any other necessary healthcare information to properly care for the resident. The only care plan in place for the resident addressed an ADL self-care performance deficit, which was initiated eight days after admission. This delay in developing a comprehensive person-centered care plan was confirmed by the Unit Manager, Employee E3, during an interview. The lack of a timely baseline care plan and comprehensive care plan for Resident R149 represents a failure to meet the regulatory requirements for comprehensive person-centered care planning.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The care plan for Resident R149 was updated to include goals and interventions for the residents specific goals and needs. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: An audit of current residents will be conducted to ensure that a baseline care plan was developed and implemented and that a written summary of the baseline care plan was provided to the resident and/or resident representative. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Education will be provided by the DON/ and or designee to nursing staff and Interdisciplinary Team regarding the components of this regulation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Random audits will be conducted weekly by the DON/ and or designee of five clinical records to ensure that a baseline care plan was developed and that the resident/ resident representative received a copy of the baseline care plan. Audits will be conducted weekly x for four weeks and then monthly for six months. Results of these audits will be reported to the monthly Quality Assurance Performance Improvement Committee until monthly and/or substantial compliance is met. Adjustments to the plan of corrections will be made by the Interdisciplinary team as needed.
Failure to Develop Comprehensive Care Plan for Weight Changes
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, identified as Resident R33, who experienced significant weight changes. The facility's policy requires that a comprehensive person-centered care plan be developed and implemented for each resident, including measurable objectives and timeframes to meet their physical, psychological, and functional needs. However, upon review of Resident R33's clinical record, it was found that there was no documented evidence of a care plan addressing the resident's weight loss. Resident R33 was admitted to the facility with diagnoses including pleural effusion, dysphagia, and cognitive communication deficit. The resident's weight records showed a significant decrease from 180 lbs at admission to 150.4 lbs over a period of approximately two months, indicating a weight loss of 16.4%. Despite this notable weight change, the facility did not develop a care plan to address the resident's nutritional needs, which is a requirement under the facility's policy and federal regulations.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The care plan for Resident R33 was updated to include goals and interventions for the residents specific goals and needs. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: An audit of current residents will be conducted to ensure that a comprehensive care plan was developed and implemented and that a written summary of the comprehensive care plan was provided to the resident and/or resident representative. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Education will be provided by the DON/ and or designee to nursing staff and Interdisciplinary Team regarding the components of this regulation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Random audits will be conducted weekly by the DON/ and or designee of five clinical records to ensure that a comprehensive care plan was developed and that the resident/ resident representative received a copy of the baseline care plan. Audits will be conducted weekly for four weeks and then monthly for six months. Results of these audits will be reported to the monthly Quality Assurance Performance Improvement Committee until monthly and/or substantial compliance is met. Adjustments to the plan of corrections will be made by the Interdisciplinary team as needed.
Failure to Provide Grooming Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide necessary grooming services for two residents who required assistance with activities of daily living. Resident R243, admitted with conditions including chondrocalcinosis, lack of coordination, and severe cognitive impairment, was observed with an inadequately groomed beard. Interviews with the resident and a family member revealed that the facility had not provided grooming assistance since the resident's admission, necessitating family intervention for shaving. A licensed nurse confirmed the absence of documentation or evidence of grooming assistance for this resident. Similarly, Resident R244, who had diagnoses including cirrhosis of the liver, muscle weakness, and intact cognition, was observed with an overgrown beard and hair over the upper lip. The resident reported inadequate grooming since admission, which affected his ability to eat properly. The Director of Nursing confirmed the resident's need for grooming assistance and the overgrown state of his beard. These findings indicate a failure by the facility to maintain adequate grooming for residents requiring assistance.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident R243 and R244 facial hair were trimmed by licensed staff. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: An audit of current residents was conducted by the DON/Designee to ensure that facial hair is groomed based on residents' wishes. Any additional concerns identified during the audit will be corrected immediately. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: DON/Designee will re-educate facility clinical staff on the components of this regulation with an emphasis on ensuring that residents receive appropriate grooming of hair/facial hair and footcare/nail care. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: DON/Designee to conduct random visual audits of 10 residents 1x a week for 4 weeks, 2x a month for 3 months, then monthly for 2 months to ensure that residents are being groomed appropriately and that facial hair is trimmed. The findings of these quality monitoring activities will be reported to the Quality Assurance/Performance Improvement Committee monthly for 6 months.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent and heal pressure ulcers for a resident, as required by professional standards of practice. The resident, admitted with a fracture and muscle weakness, was dependent on staff for mobility and at risk for developing pressure ulcers. Despite this, the facility did not implement a turning and positioning program to prevent pressure ulcers, as confirmed by the absence of documented evidence in the resident's clinical record. The resident, who was at risk for skin breakdown due to immobility and bowel incontinence, developed deep tissue pressure injuries on the sacrum, left heel, and right heel, as well as a Stage 1 pressure injury on the right great toe while under the facility's care. The lack of a documented turning and positioning program was confirmed by the Unit Manager, indicating a failure to adhere to the necessary preventive measures for pressure ulcer development.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Treatment was provided to Residents R1 to address the pressure ulcer and prevent new ulcer from developing. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: An audit will be conducted for all Residents at risk for pressure ulcers to ensure proper treatment is being provided. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Education will be provided by the DON/ and or designee to nursing staff regarding the components of this regulation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Random audits will be conducted weekly by the DON/ and or designee of five residents to ensure that treatment to prevent pressure ulcers is being provided and physician orders are followed. Audits will be conducted weekly for four weeks and then monthly for six months. Results of these audits will be reported to the monthly Quality Assurance Performance Improvement Committee until monthly and/or substantial compliance is met. Adjustments to the plan of corrections will be made by the Interdisciplinary team as needed.
Failure to Obtain and Document Weekly Weights
Penalty
Summary
The facility failed to ensure that weekly weights were obtained as ordered by the physician for two residents. Resident R1 was admitted with diagnoses including a fracture of the lower end of the left femur and muscle weakness. A physician's order dated February 12, 2025, required weekly weights for four weeks, then monthly. However, there was no documented evidence that Resident R1 was weighed weekly as ordered, nor was there any indication of refusal to be weighed. An interview with the Unit Manager confirmed the absence of documentation regarding attempts to obtain weights or any refusal by the resident. Similarly, Resident R33, admitted with conditions such as pleural effusion and dysphagia, had a physician's order for weekly weights. After being discharged to the hospital and readmitted, there was no documented evidence of a weight being taken at readmission. The resident's weight records showed gaps greater than seven days between weighings, contrary to the physician's orders. The Unit Manager confirmed the lack of documentation for attempts to weigh the resident or any refusal. These deficiencies indicate a failure to adhere to physician orders and maintain proper documentation.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The Resident immediately weighed per physicians' orders. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: An audit of current will be conducted to ensure physician orders for obtaining weights are followed. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Education will be provided by the DON/ and or designee to nursing staff and Interdisciplinary Team regarding the components of this regulation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Random audits will be conducted weekly by the DON/ and or designee of five clinical records to ensure that physician orders for weights are being followed. Audits will be conducted weekly x for four weeks and then monthly for six months. Results of these audits will be reported to the monthly Quality Assurance Performance Improvement Committee until monthly and/or substantial compliance is met. Adjustments to the plan of corrections will be made by the Interdisciplinary team as needed.
Failure to Follow Nutritional Recommendations for Enteral Feeding
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for a resident receiving enteral nutrition, as evidenced by a lack of adherence to the recommendations provided by the Registered Dietitian. Resident R33, who was admitted with conditions including pleural effusion, muscle weakness, dysphagia, and cognitive communication deficit, required tube feeding due to difficulty swallowing. The care plan indicated that the Registered Dietitian was to evaluate the resident's nutritional needs quarterly and as needed, making recommendations for changes to the tube feeding regimen. Despite the Registered Dietitian's recommendation on January 2, 2025, for the tube feed to run at 65 ml/hour over 22 hours for a total volume of 1430 ml daily, the facility did not follow this guidance promptly. The clinical record showed a series of physician orders adjusting the tube feed rate, but there was no documented rationale from the physician for the delay in meeting the resident's caloric needs as recommended. This oversight resulted in the facility's failure to ensure the resident received the appropriate treatment and services to maintain nutritional parameters.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident R148 tube feeding orders were reviewed with physician to updated to reflect current needs. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: An audit will be conducted for current Residents to ensure that all tube feeding orders are current and are being followed. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Education will be provided by the DON/ and or designee to nursing staff regarding the components of this regulation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Random audits will be conducted weekly by the DON/ and or designee of five residents to ensure that tube feeding orders updated and are being followed. Audits will be conducted weekly x for four weeks and then monthly for six months. Results of these audits will be reported to the monthly Quality Assurance Performance Improvement Committee until monthly and/or substantial compliance is met. Adjustments to the plan of corrections will be made by the Interdisciplinary team as needed.
Inadequate Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care services for two residents, R146 and R149, as observed during a survey. Resident R146, who was admitted with diagnoses including Acute Respiratory Failure and COPD, had a physician's order for oxygen at 2 liters per minute via nasal cannula. However, during an observation, it was found that the oxygen flow meter was set at 5 liters per minute, contrary to the physician's order. This discrepancy was confirmed by the Director of Nursing, Employee E3, during a follow-up observation. Resident R149, admitted with diagnoses including COPD and Generalized Anxiety Disorder, was observed receiving oxygen therapy without a physician's order. The oxygen concentrator's flow meter was also set at 5 liters per minute, and the oxygen tubing and humidification bottle lacked proper labeling. The resident reported informing the staff about the issue, but no action was taken. The Director of Nursing and Unit Manager confirmed the absence of a physician's order for oxygen therapy for Resident R149.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Residents R146 and R149 were provided with respiratory care and supplemental oxygen as ordered by the physician. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: Residents on oxygen will be audited to ensure they are MD orders are being followed. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Education will be provided by the DON/ and or designee to nursing staff regarding the components of this regulation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Random audits will be conducted weekly by the DON/ and or designee of five clinical records to ensure that pain medications are in place and are being given as ordered. Audits will be conducted weekly x for four weeks and then monthly for six months. Results of these audits will be reported to the monthly Quality Assurance Performance Improvement Committee until monthly and/or substantial compliance is met. Adjustments to the plan of corrections will be made by the Interdisciplinary team as needed.
Failure in Pain Management for a Resident
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as Resident R148, consistent with professional standards of practice. The resident, who was admitted with diagnoses including spinal stenosis, low back pain, and chronic pain syndrome, had documented severe pain levels of 10 and 8 on March 3 and March 4, 2025, respectively. Despite having physician orders for Oxycodone and Tramadol for severe and moderate pain, the resident did not receive the prescribed Oxycodone on these dates. Additionally, there was no documented rationale for not administering the medication, nor was there evidence that the physician was informed of the non-administration or that non-pharmacological pain management techniques were implemented. The facility's policy on pain management emphasizes the importance of assessing and addressing pain based on professional standards and the resident's care plan. However, the review of Resident R148's clinical records revealed a lack of adherence to these guidelines. The resident's allergies to several opioids, including Oxycodone, were noted, yet there was no documentation explaining the decision not to administer the prescribed medication or any alternative strategies employed. This oversight in pain management was further highlighted by the absence of documentation regarding the effectiveness of interventions or modifications to the care plan, as required by the facility's policy.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident R148's pain medication were delivered and she has been receiving it as per Physician orders. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: An audit will be conducted of residents that have an order for pain medications to ensure that they are being given per physician order. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Education will be provided by the DON/ and or designee to nursing staff regarding the components of this regulation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Random audits will be conducted weekly by the DON/ and or designee of five clinical records to ensure that pain medications are in place and are being given as ordered. Audits will be conducted weekly x for four weeks and then monthly for two months. Results of these audits will be reported to the monthly Quality Assurance Performance Improvement Committee until monthly and/or substantial compliance is met. Adjustments to the plan of corrections will be made by the Interdisciplinary team as needed.
Failure to Manage Resident's Opioid Allergies
Penalty
Summary
The facility failed to ensure the safe and effective use of medications for a resident, identified as R148, who had documented allergies to several opioids. The resident was admitted with multiple diagnoses, including spinal stenosis and chronic pain syndrome, and had a known allergy to opioids such as fentanyl, hydrocodone, hydromorphone, morphine, oxycodone, and codeine. Despite these documented allergies, a physician's order included oxycodone, which the resident was allergic to, and tramadol, which the resident suspected might cause a milder allergic reaction. Interviews with the resident and facility staff confirmed the presence of documented opioid allergies in the resident's clinical records. The physician, identified as Employee E5, acknowledged the oversight and stated that oxycodone had been discontinued, leaving the resident on tramadol. Additionally, the facility administrator, identified as Employee E1, admitted that the facility lacked a policy addressing allergies, which contributed to the oversight in medication management for the resident.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident R148 medications were reviewed with physician to identify any allergies and adjusted as needed. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: An audit will be conducted for current Residents to ensure that all medication allergies are being followed. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Education will be provided by the DON/ and or designee to nursing staff regarding the components of this regulation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Random audits will be conducted weekly by the DON/ and or designee of five residents to ensure that medication allergy orders are followed. Audits will be conducted weekly x for four weeks and then monthly for six months. Results of these audits will be reported to the monthly Quality Assurance Performance Improvement Committee until monthly and/or substantial compliance is met. Adjustments to the plan of corrections will be made by the Interdisciplinary team as needed.
Consistent Staffing Deficiencies Across All Shifts
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident ratios across all shifts for 21 consecutive days. During the day shift, the facility consistently scheduled fewer NA hours than required, with discrepancies ranging from 4.8 to 17.6 hours short of the necessary staffing levels based on the resident census. For instance, on February 20, 2025, with a census of 45 residents, only 24 NA hours were scheduled when 36 hours were required. Similar shortfalls were observed on other days, indicating a pattern of understaffing during the day shift. The evening and overnight shifts also experienced significant staffing deficiencies. The evening shift required one NA per 11 residents, yet the facility consistently scheduled fewer hours than needed, with shortfalls ranging from 2.18 to 13.09 hours. On February 23, 2025, for example, 32 NA hours were scheduled for a census of 62 residents, while 45.09 hours were required. The overnight shift, which required one NA per 15 residents, also fell short, with discrepancies ranging from 3.2 to 9.53 hours. These consistent staffing inadequacies were confirmed by the facility's administrator, indicating a systemic issue in meeting the mandated staffing ratios.
Plan Of Correction
Nursing schedules were reviewed to ensure the proper Nurse's Aide ratio on the morning, evening, and overnight shifts. NHA/designee will reeducate the scheduler and Director of Nursing on the correct Nurse's Aide ratio. NHA/designee will audit the nursing schedules in advance daily x4 weeks to ensure Nurse Aids are being staffed at the proper ratio. Results will be shared at QA.
LPN Staffing Deficiency
Penalty
Summary
The facility failed to meet the required minimum staffing levels for Licensed Practical Nurses (LPNs) during both day and evening shifts over a period of 9 out of 21 days reviewed. Specifically, the regulation mandates a minimum of one LPN per 25 residents during the day shift and one LPN per 30 residents during the evening shift. However, the facility's staffing records revealed that on several occasions, the number of LPN hours provided was insufficient to meet these requirements. For instance, on February 14, 2025, the day shift had only 8 LPN hours for a census of 37 residents, whereas 11.84 hours were required. Similarly, on February 23, 2025, the evening shift had 8.50 LPN hours for a census of 62 residents, requiring 16.53 hours. The deficiency was confirmed through a review of nursing staff care hours and an interview with the facility's administrator, who acknowledged the shortfall in meeting the LPN-to-resident ratios. This issue was consistent across multiple days, indicating a pattern of inadequate staffing levels that did not comply with the regulatory requirements. The administrator's confirmation further substantiates the facility's failure to adhere to the mandated staffing ratios, impacting the quality of care provided to the residents.
Plan Of Correction
Nursing schedules were reviewed to ensure the proper LPN ratios on the day and evening shifts. NHA/designee will reeducate the scheduler Director of Nursing on the correct LPN ratio. NHA/designee will audit the nursing schedules in advance daily x4 weeks to ensure LPN's are being staffed at the proper ratio. Results will be shared at QA.
Deficiency in Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident in a 24-hour period. This deficiency was identified during a review of the facility's nursing staffing sheets for the weeks spanning February 13, 2025, to March 5, 2025. On 12 out of 21 days reviewed, the facility's staffing hours fell below the required threshold. Specific days with insufficient staffing hours included February 13, 14, 15, 18, 19, 20, 21, 23, 25, 27, 28, and March 2, 2025, with the lowest recorded at 2.93 hours on February 20, 2025. The deficiency was confirmed by the facility's administrator, Employee E1, on March 6, 2025.
Plan Of Correction
Nursing schedules were reviewed to ensure the total hours of general nursing care for each 24-hour period meets the requirement. NHA/designee will reeducate the scheduler and the Director of Nursing on the total hours of general nursing care for each 24-hour period. NHA/designee will audit the nursing schedules in advance daily x4 weeks to ensure total hours of general nursing care for each 24-hour period are met. Results will be shared at QA.
Failure to Implement Nutritional Interventions Leads to Significant Weight Loss
Penalty
Summary
The facility failed to provide adequate nutritional interventions and timely assessments for Resident R20, who experienced significant unplanned weight loss over several months. The resident, who was on a vegetarian and cardiac diet, lost 33.03% of their body weight from November 2023 to April 2024. Despite the resident's severe weight loss, the facility did not implement necessary dietary recommendations or notify the physician of the resident's condition. The Registered Dietician made multiple recommendations to address the resident's weight loss, including liberalizing the diet, adding nutritional supplements, and conducting weekly weight monitoring. However, these recommendations were not implemented, and the physician was not notified of the resident's significant weight loss. Additionally, the facility failed to follow the approved vegetarian menu, and meal intake was not properly monitored or documented. Interviews with facility staff revealed a lack of communication and follow-through on dietary recommendations. The Food Service Director was unaware of the approved vegetarian menu, and the Registered Dietician, who worked only two days a week, could not track the resident's weight loss effectively. The physician confirmed they were not informed of the resident's weight loss, and there was no evidence of a physician assessment in response to the resident's condition.
Removal Plan
- The facility initiated a comprehensive Quality Assurance/Performance Improvement Plan to ensure that the residents in the facility with concerns regarding weight loss were addressed by the physician/dietician and that recommendations were implemented if applicable; resident food preferences were being honored, to ensure that meal consumption amounts are being properly monitored and documented and to ensure that current policies were reviewed with changes made as indicated.
- Resident 20 was reweighed, and the dietician and physician were notified to implement interventions as needed.
- The resident was reassessed by the physician.
- The resident was re-interviewed by the dietary manager to update preferences related to preferred vegetarian diet.
- Current facility residents were re-weighed. The physician and dietician were notified of any significant changes with interventions implemented if applicable.
- Currently facility residents were interviewed by the Certified Dietary Manager to ensure their diet preferences were up-to-date and to ensure their preferences were being honored. An additional audit of the meal tracker system was completed by the Certified Dietary Manager to ensure that orders accurately reflected residents' current preference.
- Dietary recommendations for the last 30 days were reviewed to ensure that any recommendations made were implemented.
- Facility Licensed Nurses received education from the Director of Nursing regarding the procedures for obtaining resident weights and notifying the physician and dietician of any significant changes, along with implementing dietary recommendations in a timely manner.
- Facility clinical staff received education from Director of Nursing on ensuring that resident meal intake is appropriately monitored and documented.
- Facility Dietary Staff will receive education from the CDM on ensuring that residents are receiving the appropriate diet based on their preferences.
- An Ad Hoc QAPI Meeting was held to discuss the events surrounding the resident's weight loss, to identify the root cause, and to initiate improvements to the facility's processes and procedures regarding obtaining weights, communication with the IDT team when significant changes occur, implementing physician/dietician recommendations in a timely manner and ensuring that resident meal preferences are honored.
- Any staff member that did not receive education related to the above mentioned was notified by the staffing coordinator verbally via phone indicating they may not return to work until the education is received.
- Newly hired staff will receive education in orientation.
- Education for respective facility staff as stated above, weekly weight meetings with the members of the interdisciplinary team to ensure that weights are being obtained and any significant changes are addressed immediately with the appropriate team members to include the physician, verbally while in the facility and via phone call when not present; the dietician will be present in the weekly weight meetings and will provide a paper copy of recommendations made; an additional copy of recommendations will be provided to the facility in the form of an electronic copy via email to the NHA, DON, and CDM; care plans are active and reflect appropriate interventions related to the residents' current nutrition and weight status.
- Audits will be conducted as follows: bi-monthly resident interviews by the CDM to ensure that resident food and diet preferences remain up to date; random audits of 5 residents weekly to ensure that food intake is being appropriately monitored and documented.
- The Quality Improvement Performance Committee will continue to hold weekly meetings to review and discuss the results of the ongoing quality monitoring. The findings of these quality reviews to be reported to the Quality Assurance/Performance Improvement Committee weekly. Quality Review schedule modified based on findings.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to ensure that food was stored in accordance with professional standards for food service safety. During an initial tour of the main kitchen, it was observed that the main cook was not wearing a hair net while cooking. In the main refrigerator, all items were dated with a single date, March 28, 2024, which included defrosted pork loins, cheddar cheese, mozzarella cheese, and yogurt. The kitchen supervisor confirmed that this date indicated the open date. Additionally, pulled ham was dated May 25, 2024, and cheese was dated April 1, 2024, with the assistant supervisor indicating these dates as the use-by dates. Interviews with the kitchen supervisor and the Administrator confirmed that the food items were not labeled according to professional standards and facility procedures.
Failure to Provide Required Annual Training for Nursing Assistants
Penalty
Summary
The facility failed to ensure that five nursing assistants received the required minimum of 12 hours of annual training to maintain their competence. This deficiency was identified during a review of facility documentation, personnel files, and staff interviews. On May 8, 2024, a request was made to the Nursing Home Administrator and Director of Nursing for the annual training records of five nursing assistants, identified as Employees E15, E16, E17, E18, and E19. The facility was unable to provide these records. An interview with the facility Administrator on the same day confirmed that the facility did not track or complete the annual in-service training as mandated by the training requirements for nursing assistants. This lack of compliance with the training requirements was in violation of 28 Pa. Code 201.18(b)(1)(3) Management and 28 Pa. 211.12(c) Nursing services.
Confidentiality Breach and Privacy Violation
Penalty
Summary
The facility failed to maintain the confidentiality of residents' medical records and provide privacy during incontinence care for two residents. An interview with the Power of Attorney (POA) for a resident revealed that she had requested her mother's medical records and received them with another resident's medical information included. This breach was confirmed by the Medical Records Staff, who admitted that the records were not reviewed properly before being released. Additionally, an observation on the nursing unit showed that a staff member provided incontinence care to a resident with the room door fully open, exposing the resident. This was immediately confirmed by the Director of Nursing.
Failure to Monitor Resident's Weight as Ordered
Penalty
Summary
The facility failed to adhere to physician orders regarding the monitoring of a resident's weight. According to the facility's policy, weights should be measured weekly for two weeks upon admission to prevent and monitor undesirable weight loss. A physician's order for a resident, dated April 27, 2024, specified weekly weights for four weeks, to be taken every Friday morning. However, the clinical records showed that the last recorded weight for the resident was 170.5 pounds on April 26, 2024, and no subsequent weights were documented. An interview with the Registered Dietitian confirmed the absence of further documented weights. Upon reweighing the resident on May 7, 2024, the resident's weight was found to be 157 pounds, indicating a significant weight loss of 8% (13.5 pounds) over eleven days. This deficiency was identified under 28 Pa Code 211.12(d)(5) Nursing services.
Failure to Provide Timely Foot Care
Penalty
Summary
The facility failed to provide timely foot care for a resident, identified as Resident R38, who required assistance with Activities of Daily Living. On May 3, 2024, an observation revealed that the resident had long and thick toenails on both feet. The resident's representative reported having requested a podiatrist consultation at least five times without receiving a response. The Director of Nursing confirmed on May 7, 2024, that the resident's toenails were indeed long and that no appointment had been made with a podiatrist, despite the facility having a podiatry service available for emergencies. A progress note from the same day indicated that a request was finally sent to the podiatrist, and no injury or skin breakdown was observed.
Failure to Notify Physician of Severe Weight Loss
Penalty
Summary
The facility failed to ensure that a physician assessment was completed for a resident experiencing significant unplanned weight loss. The facility's policy required nursing staff to measure resident weights on admission, the next day, and weekly for two weeks thereafter, with specific thresholds for significant and severe weight loss. Despite these guidelines, a resident experienced severe weight loss over several months, with no evidence that the physician was notified or that an assessment was completed. The resident's weight decreased from 132.6 pounds to 88.8 pounds over a six-month period, representing a 33.03% weight loss, which is classified as severe. The dietician recommended changes to the resident's diet and suggested notifying the physician about the weight loss, but the clinical records revealed that the physician was not informed. Interviews confirmed that the physician was unaware of the resident's weight loss and that no assessment was conducted. This oversight violated several state codes related to nursing services, physician services, and clinical records, highlighting a deficiency in the facility's adherence to its own policies and regulatory requirements.
Medication Storage Security Lapse
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in accordance with professional standards. During an observation of the east medication storage room, it was found that the room was open despite having a lock, which was left unlocked. Inside the room, a medication refrigerator was observed to have medications stored within it, but the refrigerator's lock was missing, even though it had metal hooks for locks. This was confirmed by an interview with a Licensed Practical Nurse, who acknowledged that both the medication storage room and the refrigerator were unlocked.
Failure to Follow Approved Vegetarian Diet
Penalty
Summary
The facility failed to adhere to an approved vegetarian diet for a resident, leading to a deficiency in ensuring nutritional adequacy. The resident, who was on both a vegetarian and cardiac diet, had specific nutritional needs, including an estimated calorie requirement of 2000-2200 kcal and 63-83 grams of protein. Despite having a vegetarian extension of the cycle menu approved by a dietician, the facility did not follow this menu. The Food Service Director, Employee E13, was aware of the resident's dietary requirements but did not utilize the approved vegetarian menu extension, resulting in a lack of documentation regarding the resident's calorie intake and the specific foods provided over the past four months. Interviews with facility staff revealed a lack of awareness and understanding of the approved vegetarian menu extension. Employee E13 admitted to not knowing how to access the vegetarian extension electronically, which contributed to the failure to follow the approved menu. The Regional Food Service Staff, Employee E14, confirmed the existence of the approved vegetarian menu extension, highlighting a communication and training gap within the facility's dietary services. This deficiency was identified under the regulations 28 Pa. Code 211.6 (a) Dietary services and 28 Pa. Code 201.18 (e)(2)(3) Management.
Failure to Accommodate Resident's Lactose Allergy
Penalty
Summary
The facility failed to provide food that accommodates the allergies and intolerances of a resident, identified as Resident R37. The resident's admission nutrition assessment indicated a lactose allergy and intolerance, which was confirmed by physician orders specifying no milk due to lactose intolerance. Despite this, the resident was ordered fortified foods, including a nutritional supplement called Super Cereal, which contained dairy products such as dry milk, whole milk, and butter. Interviews with the resident and his wife revealed that the resident could not tolerate any dairy products and had requested a non-dairy nutritional supplement, Boost Breeze. However, the resident continued to receive and consume the fortified cereal containing dairy each morning, as confirmed by an interview with the resident and the Registered Dietitian.
Failure to Provide Prescribed Diets
Penalty
Summary
The facility failed to provide food items consistent with the prescribed diet orders for two residents during dining observations. For Resident R25, the physician's orders included a health shake three times a day and double portions, but during dining observations, the resident was not served a double portion lunch meal or the mighty shake supplement as indicated on the meal ticket. Similarly, Resident R14 had a physician's order for a health shake, but during dining, the meal ticket indicated a magic cup, which was not provided on the meal tray. These discrepancies were confirmed through interviews with a Licensed Practical Nurse and a Unit Manager.
Failure to Manage Nutritional Needs Leads to Immediate Jeopardy
Penalty
Summary
The Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility, resulting in a significant deficiency related to the care of a resident, identified as Resident R20. The resident, who was admitted with diagnoses including hemiplegia, hemiparesis, cognitive communication deficit, and dysphagia, experienced unplanned significant weight loss of 43 pounds over five months. The facility did not provide timely nutritional interventions, assessments, or notify the resident's physician about the weight loss. Additionally, the resident was not provided with an appropriate vegetarian diet, contributing to the Immediate Jeopardy situation. The clinical records revealed that the resident's weight decreased from 132.6 pounds in November 2023 to 88.8 pounds by April 2024, indicating severe weight loss. Despite the Registered Dietician's repeated recommendations for re-weights, nutritional supplements, and physician notifications, these interventions were not implemented. The facility failed to document meal intake consistently and did not follow through with the dietician's recommendations, such as liberalizing the diet and providing supplements like Vitamin C and protein shakes. The report highlights the lack of adherence to the facility's policies and procedures, as well as the failure to monitor and address the resident's nutritional needs adequately. The deficiencies identified in the report demonstrate a significant lapse in the responsibilities of the Nursing Home Administrator and the Director of Nursing, leading to the Immediate Jeopardy situation for Resident R20.
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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