Canterbury Place
Inspection history, citations, penalties and survey trends for this long-term care facility in Pittsburgh, Pennsylvania.
- Location
- 310 Fisk Street, Pittsburgh, Pennsylvania 15201
- CMS Provider Number
- 395146
- Inspections on file
- 30
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 20 (1 serious)
Citation history
Health deficiencies cited at Canterbury Place during CMS and state inspections, most recent first.
A cognitively intact resident with cancer and malnutrition was left without an accessible, functioning call bell after an RN unplugged the call system from the wall in an attempt to stop persistent TV sound. The call bell was left on the floor and no alternative call method was provided, despite facility policy requiring call lights to be plugged in and functioning at all times. Staff statements indicated awareness that the call light was not working and that no one ensured the resident had another way to summon help, even as the resident later experienced emesis and could not call for assistance. Documentation also showed a gap in MAR entries during the overnight hours, and the NHA confirmed the failure to provide a fully functioning call bell system, which was cited as immediate jeopardy.
Staff disconnected a malfunctioning call bell for a trach‑dependent, cognitively intact resident and left it on the floor, out of reach, without providing any alternative means to summon help. The resident, who could not speak due to a tracheostomy and had diagnoses including cancer and malnutrition, later experienced emesis and was unable to call for assistance, ultimately walking to the nurse’s station to obtain help. Facility documentation and interviews confirmed that the call bell was unplugged and no backup system or checks were implemented, resulting in the resident being left without a functional way to contact staff.
A resident with spinal stenosis, obesity, and muscle weakness who required a Hoyer lift for transfers developed significant left thigh pain and bruising during care, after reporting that staff held her legs open to clean her. She was transferred to the hospital, where imaging showed a large hematoma of the left medial thigh with active bleeding. Facility records indicated that an incorrect Hoyer pad had been used, and surveyors determined that inadequate supervision and improper use of mechanical lift equipment led to the injury.
The facility failed to ensure that a resident had access to a fully functioning call bell system, resulting in an immediate jeopardy situation. The NHA, whose role includes overseeing overall operations and resident safety, and the DON, responsible for directing nursing services and coordinating care to maintain quality, did not effectively manage the facility to provide this essential safety measure. Consequently, the facility did not uphold fundamental principles of treatment and care or ensure that care was delivered in accordance with professional standards of practice and facility policy.
Two residents did not receive treatment and care in accordance with professional standards due to inaccurate transcription of physician orders on admission. One resident received Hydroxyurea at twice the prescribed frequency, and another received Omeprazole at a lower frequency than ordered, with both errors confirmed by facility leadership.
A resident with diabetes experienced multiple episodes of blood glucose levels above 400 mg/dL, which required physician notification according to orders. Facility staff did not notify the physician as required, despite repeated abnormal readings, as confirmed by review of records and staff interview.
A resident with chronic respiratory conditions did not receive Bipap therapy as ordered due to repeated device malfunctions and lack of timely staff response. Staff noted the Bipap would turn off or stop working, but did not always notify the physician or family. The resident experienced respiratory distress and was ultimately hospitalized with elevated CO2 levels, requiring ICU care.
A resident with severe cognitive impairment and multiple medical conditions was recorded by a nurse aide, who then posted the video on social media while laughing at the resident's comments. The resident's identity was partially obscured but still recognizable, and the video was shared among staff. This incident was reported by another staff member, and facility leadership confirmed the failure to protect the resident from mental abuse facilitated by technology.
Surveyors found that two residents did not receive proper respiratory care, including undated and unchanged oxygen tubing, and respiratory equipment such as BiPAP masks and nebulizer masks not being stored in bags as required by facility policy and physician orders. An LPN and the DON confirmed these deficiencies during interviews.
The facility failed to maintain its automatic sprinkler system, as the sprinkler gauges were dated 2019 and lacked documentation of replacement or testing within the last five years. This deficiency was confirmed by the Facility Administrator and Maintenance Director, affecting the entire facility.
The facility did not perform required criminal history background checks before hiring five staff members, including RNs, NAs, and an LPN, as per their policy. This failure was confirmed by the Nursing Home Administrator and identified through personnel records and deployment documents.
The facility failed to include necessary details in physician orders for urinary catheters for three residents and did not cover catheter bags as required for two residents, impacting their care and dignity. This was confirmed through staff interviews and observations.
The facility failed to maintain consistent communication with the dialysis provider and accurate care plans for residents requiring dialysis. Incomplete communication forms were found for four residents, and two residents had care plans lacking necessary monitoring instructions for dialysis access sites. Staff interviews confirmed these deficiencies, violating facility policy and state regulations.
The facility did not complete annual performance evaluations for three nurse aides as required by federal regulations. The personnel records for these aides lacked the necessary evaluations based on their hire dates, which was confirmed by the Nursing Home Administrator.
A resident with renal insufficiency and diabetes was found with two cups of medication at their bedside, but the facility failed to conduct a thorough investigation. The Director of Nursing confirmed the investigation was incomplete, lacking documentation and staff interviews to determine the origin and nature of the medications.
The facility failed to update care plans for two residents, omitting necessary interventions for a Continuous Glucose Monitoring system and a Wound Vac. This was confirmed by the DON, indicating a lack of adherence to policy and state regulations.
A facility failed to notify a physician of abnormal glucose readings for a resident with diabetes, as per the physician's order. The resident had multiple glucose readings above the threshold requiring physician notification, yet no documentation of such notification was found. The Director of Nursing confirmed the oversight, which violated facility protocols and state regulations.
The facility failed to prevent and treat pressure ulcers for two residents. One resident with a Stage 3 pressure injury lacked a care plan for injury management and preventative measures. Another resident had an injury on the toe with no documented follow-up. Staff confirmed the lack of care plans and preventative measures.
A facility failed to provide appropriate care for a resident with an enteral feeding tube, as observed when the resident's feeding and water flush bags were found undated. The resident, with diagnoses including cerebral infarction and aphasia, had specific physician orders for enteral feeding and water flushes, which were not properly managed, potentially leading to complications.
A facility failed to coordinate hospice services for a resident with heart failure, dysphagia, and high blood pressure. The facility's policy requires collaboration with hospice representatives, but the resident's records lacked appropriate physician orders and a comprehensive care plan for hospice services. Interviews confirmed the facility's failure to ensure proper coordination of hospice care.
The facility failed to follow enhanced barrier precautions for two residents and did not implement proper interventions for a Covid-positive resident. A resident with renal failure did not have EBP orders for indwelling devices, and a nurse improperly donned a gown. Another resident under isolation-contact and droplet precautions was assisted by a nurse aide without proper PPE, and the signage was incorrect. A Covid-positive resident's room was left open, and a nurse aide was observed without appropriate PPE.
A facility failed to provide mandatory training on Abuse, Neglect, and Exploitation to a newly hired nurse aide on the date of orientation, as required by policy. The nurse aide began working without this training and only received it two months after her hire date. This deficiency was confirmed by the NHA.
The facility's Infection Control Committee meetings in 2024 lacked required multidisciplinary members, specifically laboratory personnel, for two quarters. This non-compliance with the MCARE Act was confirmed through attendance logs and an administrative assistant's interview, which also noted the absence of pharmacy staff in a previous quarter.
The facility failed to maintain complete personnel records for an RN, missing documentation such as job description, educational background, employment history, and reference checks. Despite the facility's policy requiring these documents before employment, the RN began working without them, as confirmed by the NHA.
The facility failed to conduct pre-employment TB screening for a newly hired RN, Employee E2, as required by their TB infection control program policy. The RN's pre-employment health questionnaire had an unanswered TB section, yet the RN was hired and began working without the necessary screening. This was confirmed by the Nursing Home Administrator during an interview.
The facility failed to notify the State Ombudsman Office of resident transfers and discharges for 30 months, from April 2022 through September 2024. This was confirmed through a review of facility documents, an audit by the State Ombudsman Office, and an interview with the DON. The facility did not provide evidence of compliance with the notification requirement, as required by PA Code: 201.29(f)(g) on resident rights.
Resident Left Without Functioning Call Bell After RN Unplugs System
Penalty
Summary
The deficiency involves the facility’s failure to ensure a fully functioning and accessible call bell system for a cognitively intact resident, resulting in the resident being without an active call system in the room and bathroom/bathing area for an extended period. The resident had diagnoses including cancer, malnutrition, and malignant neoplasm of the larynx, and was assessed as cognitively intact with a BIMS score of 15. Facility policy required that call lights be plugged in and functioning at all times and that residents unable to use call lights be checked frequently. Despite this policy, the resident’s call bell was disconnected from the wall and left inaccessible on the floor, leaving the resident unable to summon assistance. According to facility documentation and witness statements, during a night shift an RN attempted to address a problem with the television sound that was controlled through the call system remote. The resident requested that the TV sound be turned off, and when the RN could not silence the sound using the available controls, the RN removed the call system cord from the wall to stop the noise. The RN acknowledged that this action disconnected the call system and that no alternative call method (such as a hand bell or backup cord) was provided to the resident. The resident later reported that the call bell was left on the floor and was not accessible, and that she experienced an episode of emesis and was unable to call for assistance because the call bell had been disconnected. Additional staff statements indicated that other staff were aware the call light was not working and did not ensure that the resident had an alternative means to call for help. A nurse aide reported being told by the RN that the call light was not working and that she did not know how to fix it. Another undated/unsigned witness statement described a staff member seeing the call light going off at 2 a.m., being told by the assigned nurse that the light had been broken that shift and that it was fine with no need to enter the room, and therefore not checking on the resident. Facility documentation also showed a gap in the resident’s MAR documentation between 1:25 a.m. and 4:00 a.m. The Nursing Home Administrator later confirmed that the facility failed to provide a fully functioning call bell system for this resident, which was determined to be an immediate jeopardy situation.
Removal Plan
- Tested Resident R1's call bell to ensure proper functioning and verified the resident had access to a functioning call system positioned appropriately to meet the resident's needs.
- Completed an assessment of Resident R1 to ensure no adverse outcomes occurred as a result of the call bell being unplugged; no injuries found.
- Educated staff from all departments on call bell accessibility and what to do if the call bell stops working.
- Inspected and tested all resident rooms and common areas with call bell access for functionality and accessibility; no issues identified.
- Had an outside vendor examine the nurse call system and test all activation points; all found in good working condition.
- Conducted a root cause analysis regarding the call bell issue and performed an audit of the call bell system in all resident rooms and common areas where residents may initiate a call.
- Implemented a preventative maintenance schedule for ongoing monitoring of the call bell system.
- Re-educated staff on daily visual checks of call bell accessibility and reporting procedures for any identified functionality issues.
- Implemented Maintenance Director/designee audits of call bell functionality and maintained documentation, reviewed results at QAPI, and corrected and reported any deficiencies immediately.
- Updated the TELS maintenance tracking system to include conducting a test of the nurse call system.
- Completed immediate corrective action for Resident R1 and completed facility-wide call bell testing, with ongoing preventative maintenance and monitoring to continue.
Resident Left Without Functional Call System After Call Bell Disconnected
Penalty
Summary
Facility staff failed to ensure that a cognitively intact, trach‑dependent resident had a functional means to contact staff after the resident’s call bell system malfunctioned. The resident, who had diagnoses including cancer, malnutrition, and malignant neoplasm of the larynx and was unable to speak due to a tracheostomy, reported that during the night shift a nurse removed the call bell from the wall because of a technical issue and left it on the floor, out of the resident’s reach. Facility documentation and staff statements indicated that the call system’s TV volume function was malfunctioning, and the RN disconnected the call bell from the wall to stop the noise. At that time, there were no alternative call systems, backup cords, or other devices provided to the resident to summon assistance. The resident stated that after the call bell was disconnected and left inaccessible, she experienced an episode of emesis and was unable to call for help. She reported that staff did not come in to check on her and that, without a working call bell, she had to walk out to the nurse’s station to obtain assistance. Facility documentation confirmed that the resident’s call bell was unplugged and that no other way to contact staff was provided, despite the resident’s trach dependence and inability to speak. This sequence of actions and inactions resulted in the resident being left without necessary means and services to request help, constituting neglect as defined in the facility’s abuse and neglect policy.
Improper Hoyer Lift Pad Use and Inadequate Supervision Resulting in Hematoma
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and safe use of mechanical lift equipment during care for one resident, resulting in a significant injury. The resident had diagnoses including spinal stenosis, obesity due to excess calories, and muscle weakness, and required the use of a Hoyer lift for transfers. During care, the resident complained of left leg pain while care was being performed, cried out, and reported tightness in her legs and a loose stool overnight. She stated that no one hit her but that her legs had been held open to clean her, after which her left leg developed a bruise and became painful. Vital signs were within normal limits and respirations were easy at the time, but the resident’s daughter requested hospital transfer. Hospital documentation later identified a 9 x 7 x 16.6 cm hematoma within the soft tissue of the left medial thigh with a small spot of active bleeding. Facility documentation indicated that the resident required a Hoyer lift and that an incorrect Hoyer pad had been used during the incident. Based on policy review, clinical and facility record review, hospital records, and staff and resident interviews, surveyors determined that the facility did not ensure the area was free from accident hazards and did not provide adequate supervision and proper use of assistive devices for this resident, leading to the hematoma and transfer to the hospital.
Failure to Ensure Functioning Call Bell System Resulting in Immediate Jeopardy
Penalty
Summary
The deficiency involves the failure of the Nursing Home Administrator (NHA) and the Director of Nursing (DON) to effectively manage the facility so that it provided a fully functioning call bell system for one resident (R1), resulting in an immediate jeopardy situation. The NHA’s job description specified responsibility for overseeing overall operations, including resident care, customer service, and the welfare and safety of residents, while the DON’s job description specified responsibility for planning, organizing, developing, and directing the overall operation of the nursing services department and coordinating nursing services with other departments to maintain quality of care. Despite these defined responsibilities, the facility did not ensure that one resident had access to a fully functioning call bell system. As a result, the facility failed to provide fundamental principles that apply to treatment and care, and failed to ensure that residents receive treatment and care in accordance with professional standards of practice and facility policy.
Failure to Accurately Transcribe Physician Orders on Admission
Penalty
Summary
The facility failed to ensure that physician orders were transcribed accurately upon admission for two residents. For one resident with diagnoses including encephalopathy, COPD, and dementia, the medication Hydroxyurea was ordered at 1000 mg by mouth daily, but was incorrectly transcribed and administered as 1000 mg by mouth twice daily throughout the resident's stay and included in discharge instructions. This error was identified after the resident was hospitalized, and the facility administrator confirmed the transcription failure. For another resident admitted with a history of elbow fracture, benign prostatic hyperplasia, and heart disease, the medication Omeprazole was ordered at 20 mg by mouth twice daily per hospital discharge summary, but was initially transcribed and administered as 20 mg by mouth once daily. The discrepancy was noted in physician progress notes, and the order was later adjusted to match the hospital discharge instructions. Both the Nursing Home Administrator and Director of Nursing confirmed the failure to accurately transcribe physician orders on admission for these two residents.
Failure to Notify Physician of Abnormal Glucose Readings
Penalty
Summary
The facility failed to notify a physician of abnormal blood glucose readings for a resident with diabetes, as required by physician orders and facility policy. The resident had multiple documented blood glucose levels exceeding 400 mg/dL, which, according to the physician's sliding scale insulin order, required immediate notification of the physician or CRNP. Despite these elevated readings occurring on several occasions, there was no evidence in the resident's progress notes that the physician was notified as directed. The resident in question had a medical history including diabetes, anemia, and hypertension, and was receiving insulin therapy with specific parameters for monitoring and reporting abnormal glucose levels. The facility's policy and the resident's care plan both emphasized the importance of maintaining blood glucose within the desired range and following physician orders for reporting. Staff interviews confirmed that the required notifications were not made, resulting in a failure to provide care and treatment according to orders and the resident's clinical needs.
Failure to Follow Physician Order and Address Malfunctioning Bipap Device
Penalty
Summary
The facility failed to follow a physician's order for the use of a Bipap device and did not act in a timely manner when the device was reported as malfunctioning for a resident with significant respiratory conditions. The resident had diagnoses including COPD, acute and chronic respiratory failure, and heart failure, and was ordered to use Bipap nightly with specific settings. Documentation and staff interviews revealed that the Bipap device was not consistently functioning as ordered, with multiple staff noting that the machine would turn off or stop blowing air, and that these issues were not always communicated to the physician or the resident's family. Progress notes indicated that the resident experienced episodes of shortness of breath and complaints of discomfort, with staff at times substituting oxygen via nasal cannula when the Bipap was not working. Despite ongoing issues with the Bipap, there was a lack of timely escalation to the physician or respiratory company, and the care plan did not specify steps to follow in the event of equipment malfunction. The resident's family ultimately provided a backup Bipap device, but the resident continued to exhibit symptoms consistent with hypercapnia and respiratory distress. The resident was eventually transferred to the hospital in respiratory distress, where elevated carbon dioxide levels were confirmed, and ICU admission for Bipap was required. Staff interviews confirmed that the Bipap malfunction was known but not always reported or addressed promptly. The facility's failure to follow the physician's order for Bipap use and to respond appropriately to equipment malfunction resulted in actual harm to the resident, including dyspnea, hypoxemia, and hypercapnia.
Failure to Prevent Mental Abuse via Social Media
Penalty
Summary
The facility failed to protect a resident from mental abuse, specifically abuse facilitated through the use of technology. A nurse aide recorded a video of a resident, who had severe cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of six, and posted it on a social media platform. The video showed the resident in bed, making inappropriate comments, while the staff member recording the video laughed at her. The resident's face was partially obscured by an emoji, but at one point, the face became recognizable. The video was shared within a group of staff members on social media, and another staff member reported the incident to nursing management after viewing the video. The resident involved had multiple medical diagnoses, including dementia, atrial fibrillation, and diabetes, and was dependent on staff for care. The facility's own policy emphasized the importance of maintaining a culture of compassion and caring, especially for residents with behavioral, cognitive, or emotional problems. Despite this, the actions of the staff member who recorded and shared the video constituted a failure to ensure the resident was free from mental abuse, as confirmed by the facility's administration during interviews.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents who required oxygen therapy and respiratory equipment. For one resident with diagnoses including heart failure, COPD, and respiratory failure, surveyors observed that the oxygen nasal cannula in use was not dated, and two BiPAP masks were left on the bedside nightstand without being stored in a bag as required by facility policy. The LPN confirmed these deficiencies during an interview. Physician orders specified that oxygen tubing should be changed weekly, and the facility policy required proper storage and dating of respiratory equipment. For another resident with heart failure, hypertension, and dementia, surveyors found that the oxygen tubing in use was dated beyond the weekly change interval specified in physician orders, and the nebulizer tubing was not dated. Additionally, the nebulizer mask was not stored in a bag when not in use, contrary to facility policy. The LPN confirmed that the oxygen tubing was not changed as ordered and that the nebulizer was not properly stored. The DON also confirmed the facility's failure to provide appropriate respiratory care for both residents.
Failure to Maintain Automatic Sprinkler System
Penalty
Summary
The facility failed to maintain its automatic sprinkler system, as evidenced by an observation on January 13, 2025. The sprinkler gauges were found to be dated 2019, and the facility was unable to provide documentation that these gauges had been replaced or tested against a calibrated gauge within the last five years. This deficiency was confirmed during an interview with the Facility Administrator and Maintenance Director, indicating a lapse in the required maintenance and testing of the sprinkler system, which affects the entire facility.
Plan Of Correction
The automatic sprinkler gauges dated 2019 were replaced by an outside vendor on January 20, 2025. The Director of Maintenance and the maintenance staff were educated by the Administrator on the importance of ensuring that the fire sprinkler gauges need to be tested or replaced every five years. The Director of Maintenance or designee will pre-schedule with the outside vendor to ensure the five-year test and/or replace regulation.
Failure to Conduct Background Checks Before Hiring
Penalty
Summary
The facility failed to implement its written procedures to prohibit and prevent abuse, neglect, and exploitation of residents by not performing criminal history background checks prior to the date of hire for five employees. These employees included two Registered Nurses (RNs), two Nurse Aides (NAs), and one Licensed Practical Nurse (LPN). The facility's policy, dated May 1, 2022, and last reviewed on January 3, 2024, required obtaining criminal and FBI background checks before an employee's first day of employment. However, the personnel records for these employees did not include the required State background checks. The deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the failure to adhere to the facility's procedures. The employees in question were already working and no longer on orientation, indicating that the background checks were not completed in a timely manner as per the facility's policy. This oversight was identified through a review of personnel records and nurse deployment documents, which showed that the employees continued to work without the necessary background checks being documented.
Plan Of Correction
The facility obtained satisfactory criminal records checks (state background checks, PATCH) on new employees hired in the last four months including employees E-2, E-17, E-18, E-19, and E-20. Human Resources and the In-service coordinator have been re-educated on the importance of securing a satisfactory criminal records check (state background checks, PATCH) on all new employees prior to the employees' first day at the facility. All new hire paperwork including the satisfactory criminal records check (state background checks, PATCH) will be audited by the administrator or designee every two weeks for two months prior to the start of orientation to ensure that all new employees have a satisfactory criminal records check (state background checks, PATCH). Any deficient practice will be immediately corrected. All data will be forwarded to the QAPI committee and the need for additional monitoring will be determined by the committee.
Deficiencies in Catheter Management and Resident Dignity
Penalty
Summary
The facility failed to ensure that physician orders for urinary catheters included necessary details such as the size of the suprapubic catheter, balloon sizing, and the amount of fluid needed for balloon inflation for three residents. This omission was confirmed through staff interviews and a review of clinical records. Specifically, the orders for Residents R53, R58, and R316 lacked these critical details, which are essential for proper catheter management and resident care. Additionally, the facility did not adhere to its policy on maintaining resident dignity by failing to cover catheter bags as required. Observations revealed that the catheter drainage bags for Residents R58 and R316 were not covered with dignity bags and were positioned facing the door entrance, contrary to the facility's dignity policy. This was confirmed by interviews with registered nurses who acknowledged the oversight. The deficiencies were identified during a review of facility policies, clinical records, and staff interviews. The Director of Nursing confirmed the facility's failure to include necessary catheter details in physician orders and to ensure catheter bags were covered, impacting the care and dignity of the residents involved.
Plan Of Correction
The size of the suprapubic catheter, the balloon size and the proper fluid amount were obtained for residents R53, R58, and R316. Also, the catheter drainage bags were covered for residents R58 and R316. RNs, and LPNs, will be educated by the Director of Nursing, In-Service Director and/or designee on adding the size of the suprapubic catheter, the balloon size and the proper fluid amount urinary catheter type and size when entering a suprapubic order. RNs, and LPNs, and CNAs will be educated by the Director of Nursing, In-Service Director and/or designee on covering all the urinary drainage bags with dignity bags. An audit of all residents with a suprapubic catheter will be conducted by the Director of Nursing or designee to ensure the order contains the size of the catheter, the balloon size and the fluid requirements weekly for three weeks and then biweekly for three weeks. An audit of all residents with a foley will be conducted by the Director of Nursing or designee to ensure that their catheter drainage bags are covered will be conducted weekly for three weeks and then biweekly for three weeks. Any deficient practice will be immediately corrected. All data will be forwarded to the QAPI committee and the need for additional monitoring will be determined by the committee.
Deficiencies in Dialysis Communication and Care Planning
Penalty
Summary
The facility failed to ensure consistent communication between the dialysis provider and facility staff for four out of five residents requiring dialysis services. Specifically, the clinical records for these residents lacked complete communication forms, which are essential for maintaining continuity of care. For Resident R14, there were nine incomplete communication sheets and four missing sheets for December 2024. Similarly, Resident R22's records showed multiple instances of incomplete communication forms over several months. Resident R58 also had incomplete communication forms for several dates, and Resident R314's record was missing a communication sheet for a specific date. Additionally, the facility did not maintain accurate care plans for dialysis access sites for two residents. Resident R22's care plan failed to include monitoring instructions for the AV fistula, which is crucial for ensuring the fistula's functionality and preventing complications. Resident R314's care plan lacked a nursing plan of care for dialysis monitoring of the access device and communication with the dialysis center, only noting the days the resident attended dialysis. Interviews with facility staff, including registered nurses and the Director of Nursing, confirmed the deficiencies in maintaining complete dialysis communication forms and accurate care plans. These lapses in documentation and care planning are in violation of the facility's policy and state regulations, which require comprehensive care plans and consistent communication for residents undergoing dialysis.
Plan Of Correction
The facility cannot go backward and re-create documentation (i.e. blood pressures) from the past. Therefore, all RNs and LPNs will be educated by the Director of Nursing and/or designee on completely completing the dialysis communication log (example: vital signs, medical changes, status of access site including possible thrill and bruit, and nurse sign off) and having a care plan for the access site/fistula. The facility will audit all dialysis communication logs for all residents for completeness by both the facility and the dialysis center. Additionally, the care plans of the dialysis residents will be audited to ensure the access site/fistula is addressed. This will be completed weekly for three weeks and then three random dialysis residents weekly for three weeks. If a deficient practice is noted in the bottom half of the form completed by the dialysis center, it will be returned to them for completion. Any deficient practice will be immediately corrected. All data will be forwarded to the QAPI committee and the need for additional monitoring will be determined by the committee.
Failure to Conduct Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance evaluations for three out of four nurse aides, specifically NA Employee E10, NA Employee E11, and NA Employee E12. According to the Code of Federal Regulations S483.35(d)(7), the facility is required to conduct a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on these reviews. However, a review of the personnel records for these employees showed that the facility did not conduct the required annual performance evaluations based on their respective dates of hire. During an interview on January 10, 2025, the Nursing Home Administrator confirmed the facility's failure to complete these evaluations. This deficiency is in violation of the federal regulation and the Pennsylvania Code, which outlines the responsibility of the licensee and management requirements.
Plan Of Correction
The facility will complete annual performance evaluation for all those nurse aide staff employed at the facility for a year. This includes nurse aides E10, E11 and E12. The Administrator will re-educate the Director of Nursing and Human Resources that evaluations are a requirement annually for nurse aide staff. A master list of current nurse aide employees will be viewed weekly for six weeks to determine who qualifies for this annual performance review. The Director of Nursing or designee will complete these evaluations. The evaluation period for all employees will be June 2025.
Incomplete Investigation of Medication Found at Resident's Bedside
Penalty
Summary
The facility failed to conduct a thorough investigation regarding an incident involving a resident, identified as Resident R77, who was found with two cups of medication at their bedside. The facility's policy on abuse, neglect, and exploitation requires thorough investigation and reporting of such incidents, but the investigation was incomplete. The clinical record of Resident R77, who has diagnoses of renal insufficiency and diabetes mellitus, indicated that the medications were found on an unspecified date, and the facility's documentation did not include necessary details such as the identification of the pills, their origin, or whether they were documented as taken by the resident. The Director of Nursing confirmed that the investigation was incomplete, acknowledging the lack of documentation and interviews with staff from various shifts. The facility did not determine what the medications were, where they came from, or if they were part of the resident's prescribed regimen. This failure to conduct a thorough investigation is a violation of the facility's responsibility to ensure resident safety and comply with regulatory requirements.
Plan Of Correction
An incident report will be filed in our internal risk master system regarding the medications being found at the bedside for resident R-77. The resident's provider was also made aware. If possible, it will be determined if the medications were facility based or were previously in the possession of the resident. The Medication administration record will be reviewed for accuracy and staff interviews conducted to possibly learn the origin of these medications. No untoward effects were demonstrated by the resident at the time of discovery. All incidents will be reviewed on an at least weekly basis by the DON and/or NHA to ensure timely and complete submission of all pertinent facts. Incidents will be reviewed more immediately if the situation is more acute. Nursing staff (RNs, LPNs and Unit Managers) will be educated by the Director of Nursing, Staff Educator or designee on the gathering of all pertinent information as part of the investigation of incidents including complete and accurate documentation of medication administration, and that nursing staff are not permitted to leave medication at the bedside unless directed by the provider and included as part of the care plan. Seven rooms will be checked for medications left in the resident's rooms per week for three weeks and then seven rooms will be checked every two weeks for a period of three weeks. Any deficient practice will be immediately corrected. All data will be forwarded to the QAPI committee and the need for additional monitoring will be determined by the committee.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update the care plans for two residents, resulting in deficiencies in accurately reflecting their current status and care needs. Resident R8, who was admitted with diagnoses of heart failure, mild cognitive impairment, and anxiety disorder, had a physician order for the use of a FreeStyle Libre 3 Continuous Glucose Monitoring system. However, the care plan did not include the use, care, and service interventions related to this device. This omission was confirmed by the Director of Nursing (DON) during an interview. Similarly, Resident R316, who was admitted with high blood pressure, Multiple Sclerosis, and diabetes, had a physician order for a Wound Vac to be applied to a sacral wound. The care plan for this resident also failed to include the necessary interventions for the Wound Vac, as confirmed by the DON. These deficiencies indicate that the facility did not update the care plans to reflect the residents' current medical needs and interventions as required by their policy and state regulations.
Plan Of Correction
The care plans of the affected residents (R8 and R316) were updated during survey to include the continuous glucose monitoring device and the wound vac. All the care plans of residents having either a continuous glucose monitoring device and/or a wound vac were reviewed and/or updated to ensure compliance. RNs, and LPNs, will be educated by the Director of Nursing, In-Service Director and/or designee that care plans should be created and/or updated timely to reflect the current condition of the resident including their use of a continuous glucose monitoring device and/or a wound vac. The facility will audit the care plans of all residents with continuous blood glucose monitoring devices and/or wound vacs weekly for three weeks and then biweekly for three weeks to ensure that the care plans reflect the current needs of the residents utilizing these devices. Any deficient practice will be immediately corrected. All data will be forwarded to the QAPI committee and the need for additional monitoring will be determined by the committee.
Failure to Notify Physician of Abnormal Glucose Levels
Penalty
Summary
The facility failed to notify a physician of abnormal glucose readings for a resident, identified as Resident R108, as per the physician's order. The facility's policy on diabetes management required staff to incorporate physician-ordered parameters for monitoring and reporting blood sugar levels into the Medication Administration Record (MAR). Resident R108, who was admitted with diagnoses including diabetes, had specific physician orders for insulin administration based on a sliding scale, with instructions to notify the physician if glucose levels exceeded 340. However, the review of Resident R108's glucose log revealed multiple instances where glucose levels were significantly above 340, yet there was no documentation of physician notification in the progress notes. The Director of Nursing confirmed during an interview that the facility did not notify the physician of the abnormal glucose readings as required. The resident's care plan emphasized the importance of monitoring and reporting symptoms of hyperglycemia, yet the facility failed to adhere to these protocols. This deficiency was identified under the regulations 28 Pa. Code: 201.14(a) and 28 Pa. Code 211.12(d)(1)(2)(3)(5), which pertain to the responsibility of the licensee and nursing services, respectively.
Plan Of Correction
The resident has been discharged from the facility so provider notification was not accomplished. RNs, LPNs, and Unit Managers will be educated by the Director of Nursing, In-Service Director or designee on the necessity of timely provider notification of the resident's blood glucose level pursuant to the provider's order. The facility will audit five random residents' blood glucose levels weekly for three weeks and compare these levels with the provider's order to ensure compliance. Subsequently, the facility will audit five random residents' blood glucose levels for three weeks bi-weekly. Any deficient practice will be immediately corrected. All data will be forwarded to the QAPI committee and the need for additional monitoring will be determined by the committee.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary services to prevent and treat pressure ulcers for two residents. Resident R317, who was admitted with a Stage 3 pressure injury, did not have a care plan that included management of the injury or the use of a low air loss mattress, despite being totally dependent on staff for repositioning. The resident's physician orders also lacked preventative measures such as a low air loss mattress and assistance with turning and repositioning. The facility's policy on pressure injury prevention was not followed, as the care plan did not address the resident's specific needs for pressure ulcer management. Resident R51, diagnosed with dementia and depression, had a noted injury on the right big toe, which was not adequately followed up. Progress notes indicated a red/purple area on the toe, but there was no documentation of the progression, cause, or resolution of the injury. Interviews with staff confirmed the lack of follow-up and the failure to develop a pressure ulcer care plan. The facility did not implement preventative measures or ensure that residents received necessary services to prevent and treat pressure ulcers, as confirmed by the Director of Nursing.
Plan Of Correction
The care plans of the affected residents (R51 and R317) were updated to reflect preventive measures for a stage III wound and a right great toe injury. RNs and LPNs will be educated by the Director of Nursing, In-Service Director, or designee on the importance of including in the clinical record how an injury occurred, its progression, treatment, and healing. The facility will audit the care plans of five random residents with wounds and skin issues weekly for three weeks and then bi-weekly for three weeks to ensure that documentation in the clinical record is complete and comprehensive (how the injury occurred, its progression, treatment, and healing). Any deficient practice will be immediately corrected. All data will be forwarded to the QAPI committee, and the need for additional monitoring will be determined by the committee.
Failure to Ensure Appropriate Enteral Feeding Tube Care
Penalty
Summary
The facility failed to ensure that a resident with an enteral feeding tube received appropriate treatment and services to prevent potential complications. The facility's policy on Enteral Nutrition, dated 1/2/25, mandates that adequate nutritional support through enteral nutrition is provided to residents as ordered, based on a comprehensive nutritional assessment and consistent with current standards of practice. However, during an observation on 1/7/25, it was noted that Resident R14's enteral feeding and water flush bag were hanging undated on a pole at the bedside. This was confirmed by Registered Nurse Employee E6, indicating a lapse in the facility's adherence to its policy and the provision of appropriate care. Resident R14, who was admitted to the facility with diagnoses including cerebral infarction, dependence on renal dialysis, and aphasia, had a Minimum Data Set indicating the presence of a feeding tube. The current physician orders specified a continuous enteral feed order with Nepro at 85 ml/hr for 19 hours, along with a 60 ml water flush every 4 hours. The failure to date the feeding and water flush bags could lead to potential complications, as the facility did not ensure the resident received the necessary treatment and services as per the physician's orders and facility policy.
Plan Of Correction
The tube feeding and water flush bag for resident R14 have been dated. RNs and LPNs will be educated by the Director of Nursing, In-Service director or designee on the importance of placing the date hung on both the tube feeding and water flush bag. An audit of all residents having a tube feeding will be conducted weekly for three weeks by the Director of Nursing or designee. Then the audit will be conducted biweekly of all residents receiving a tube feeding. Any deficient practice will be immediately corrected. All data will be forwarded to the QAPI committee and the need for additional monitoring will be determined by the committee.
Failure to Coordinate Hospice Services for a Resident
Penalty
Summary
The facility failed to ensure the coordination of hospice services with facility services to meet the needs of a resident, identified as Resident R59, for end-of-life care. The facility's policy on hospice services, dated 1/2/25, requires collaboration with hospice representatives and coordination of facility staff participation in the hospice care planning process. However, a review of Resident R59's clinical records revealed that the facility did not provide appropriate physician orders for hospice care, which should have included the hospice diagnosis, the hospice provider, and contact information. Additionally, the current care plan for Resident R59 did not include a plan of care for hospice services by the facility. Resident R59 was admitted to the facility with diagnoses of heart failure, dysphagia, and high blood pressure. The MDS assessment indicated that hospice services were required, but the facility failed to document the necessary hospice information in the physician orders. Interviews with the Registered Nurse Assessment Coordinator and the Nursing Home Administrator confirmed these deficiencies, highlighting the facility's failure to coordinate hospice services effectively for Resident R59.
Plan Of Correction
The care plan and physician orders for R59 have been updated to include a diagnosis for hospice care, the provider and their contact information. Additionally, the care plan was reviewed/updated to ensure it was comprehensive to include hospice services. Staff including RNs, LPNs, and Unit Managers as well as providers will receive additional training on the needed components of hospice orders and the need for comprehensive care plans. Four residents receiving hospice care with a focus on those most recently admitted to hospice will be reviewed weekly for three weeks to ensure they have the proper provider order as well as a comprehensive care plan. Then two residents receiving hospice services will be reviewed weekly for three weeks to ensure complete hospice orders and comprehensive care plans. Any deficient practice will be immediately corrected. All data will be forwarded to the QAPI committee and the need for additional monitoring will be determined by the committee.
Failure to Follow Infection Control Precautions
Penalty
Summary
The facility failed to adhere to enhanced barrier precautions (EBP) for two residents, R22 and R315, and did not implement proper interventions for a Covid-positive resident, R34. Resident R22, who had renal failure and required dialysis, did not have EBP orders for indwelling medical devices as required. During an observation, a registered nurse failed to properly don a gown when checking the resident's AV fistula, indicating a lack of familiarity with the gowning procedure. Resident R315, diagnosed with breast cancer and secondary bone cancer, was placed under isolation-contact and droplet precautions due to respiratory symptoms. However, the care plan did not include necessary interventions for these precautions. An observation revealed that a nurse aide assisted the resident without wearing a gown or N95 respirator, as required by the physician's orders, and the signage on the resident's door was incorrect. Resident R34, who tested positive for Covid-19, was supposed to be under airborne contact isolation. However, the resident's door was left open, and a nurse aide was observed inside the room without the appropriate personal protective equipment (PPE), including an N95 mask, gloves, or gown. The signage on the door only indicated airborne precautions, and the infection preventionist confirmed the facility's failure to follow the required precautions for these residents.
Plan Of Correction
Residents R-22, R315, and R34 have all experienced resolution of their condition and are now not needing any precautions. All nursing staff (RNs, LPNs, CNAs, and Unit Managers) will receive additional training on the types and reasons for transmission-based precautions as well as the PPE required from the In-Service Director or designee. Additionally, staff will demonstrate their ability to effectively don and doff a gown. The Director of Nursing, In-Service Director, or designee will observe 10 random resident staff encounters weekly for three weeks to ensure proper PPE. This includes donning of gowns. Additionally, 5 random encounters will be observed for three weeks. Any deficient practice will be immediately corrected. All data will be forwarded to the QAPI committee and the need for additional monitoring will be determined by the committee.
Failure to Provide Timely Training on Abuse, Neglect, and Exploitation
Penalty
Summary
The facility failed to provide mandatory training on Abuse, Neglect, and Exploitation to a newly hired nurse aide, Employee E3, on the date of her orientation as required by the facility's policy. The policy, last reviewed on January 3, 2024, mandates that all employees receive education on these topics upon orientation, annually, and as needed. Employee E3 was hired on October 2, 2024, and began working on the floor on October 7, 2024, after completing her orientation. However, her personnel record indicated that she did not receive the required training until December 6, 2024, two months after her hire date. This deficiency was confirmed by the Nursing Home Administrator during an interview on January 10, 2025.
Plan Of Correction
Nurse Aide (e-3) completed the educational material on abuse, neglect and exploitation. All new employees will be educated by Human Resources or the In-Service Director or designee during orientation on abuse, neglect and exploitation prior to starting their employment in the clinical areas. Human Resources and the In-Service Director were re-educated on the importance of completing all educational material while in orientation and prior to their employment in the clinical areas. The administrator or designee will review all employee training records after orientation but prior to the employee entering the clinical areas to ensure that abuse, neglect and exploitation education is complete. Audits will be conducted for each orientation class for two months. Any deficient practice will be immediately corrected. All data will be forwarded to the QAPI committee and the need for additional monitoring will be determined by the committee.
Infection Control Committee Lacks Required Members
Penalty
Summary
The facility failed to meet the minimum standards for infection control as required by the Medical Care Availability and Reduction of Error (MCARE) Act. Specifically, the facility's Infection Control Committee did not include the required multidisciplinary members, such as laboratory personnel, during meetings for two of the four quarters in 2024. This deficiency was identified through a review of the facility's Infection Control Committee Attendance Log, which showed the absence of laboratory personnel in Quarters Three and Four of 2024. Additionally, during an interview, an administrative assistant confirmed the absence of both laboratory personnel and pharmacy staff in the attendance log for Quarter Four of 2023, further highlighting the facility's non-compliance with the infection control plan requirements.
Plan Of Correction
The laboratory member of the QAPI committee has been re-educated on attending the QAPI meetings at least quarterly. Email invitations are provided and a zoom option offered. The administrator will note if attendance is by zoom. Laboratory personnel did attend the QAPI meeting on January 16, 2025. On 1/28, all personnel sign in for the QAPI meetings including laboratory personnel. This sign in sheet serves to monitor attendance for all required personnel.
Personnel Record Deficiency for RN Employee
Penalty
Summary
The facility failed to ensure that personnel records for Registered Nurse (RN) Employee E2 included essential documentation such as a job description, educational background, employment history, and a reference check. This deficiency was identified during a review of the facility's policy, employee personnel records, and staff interviews. The facility's policy, "Safety-01 Abuse, Neglect, Exploitation general policy," mandates that reasonable efforts be made to obtain personal and professional reference information before an employee's first day of employment, with documentation of these attempts. However, RN Employee E2, who was hired on 9/3/24 and began working independently by 9/17/24, did not have the required documentation in her personnel file. The Nursing Home Administrator confirmed this oversight during an interview.
Plan Of Correction
The personnel record for registered nurse (E-2) has been updated to include the employee's job description, educational background, employment history and a reference check. Human Resources and the In-service director have been re-educated on the importance of ensuring that all pre-employment documentation including but not limited to the employee's job description, educational background, employment history and a reference check must be obtained prior to the first day of employment. All new hire paperwork including the employee's job description, educational background, employment history and a reference check will be audited every two weeks for two months by the administrator or designee to ensure all documentation is completed prior to their first day of employment. Any deficient practice will be immediately corrected. All data will be forwarded to the QAPI committee and the need for additional monitoring will be determined by the committee.
Failure to Conduct Pre-Employment TB Screening for RN
Penalty
Summary
The facility failed to implement pre-employment screening procedures for Tuberculosis (TB) for a newly hired Registered Nurse (RN), identified as Employee E2. The facility's TB infection control program policy, reviewed on January 3, 2024, mandates screening of employees for latent TB infection and active TB as appropriate. However, upon review of RN Employee E2's pre-employment health questionnaire dated August 19, 2024, it was found that the TB section was unanswered. Despite this, RN Employee E2 was hired on September 3, 2024, and began working without the required TB screening. The nurse deployment documents confirmed that RN Employee E2 was no longer on orientation by September 17, 2024, and continued to work at the facility. The Nursing Home Administrator confirmed during an interview on January 10, 2025, that the facility did not conduct the necessary pre-employment TB screening for RN Employee E2 as required by their policy.
Plan Of Correction
Registered Nurse (E-2) has obtained a pre-employment screening test for Tuberculosis. The negative results are noted on the pre-employment health questionnaire. Human Resources and the In-service coordinator have been re-educated on the importance of securing a negative pre-employment screening test for Tuberculosis prior to the employees' first day at the facility. All new hire paperwork, including the pre-employment test for Tuberculosis, will be audited every two weeks for two months prior to orientation by the administrator or designee to ensure they have a recorded negative pre-employment screening for Tuberculosis. Any deficient practice will be immediately corrected. All data will be forwarded to the QAPI committee, and the need for additional monitoring will be determined by the committee.
Failure to Notify Ombudsman of Transfers and Discharges
Penalty
Summary
The facility failed to notify the State Ombudsman Office of resident transfers and discharges for a period of 30 months, from April 2022 through September 2024. This deficiency was identified based on a review of facility documents, an audit conducted by the State Ombudsman Office, and staff interviews. The facility was unable to provide documented evidence of compliance with the notification requirement during this time frame. An audit conducted by the State Ombudsman Office on August 1, 2024, confirmed the lack of notifications since March 2022. During an interview on October 25, 2024, the Director of Nursing confirmed the facility's failure to report these transfers and discharges as required by the Pennsylvania Code: 201.29(f)(g) regarding resident rights.
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.
Trusted data from CMS and state health departments
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.
Trusted by long-term care providers and associations.
