Cole Place
Inspection history, citations, penalties and survey trends for this long-term care facility in Coudersport, Pennsylvania.
- Location
- 1001 East Second Street, Coudersport, Pennsylvania 16915
- CMS Provider Number
- 395228
- Inspections on file
- 14
- Latest survey
- April 23, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Cole Place during CMS and state inspections, most recent first.
The facility failed to maintain proper infection control practices, as staff used non-leak-resistant mesh bags for soiled laundry, risking contamination. Additionally, a nurse aide returned to work prematurely after testing positive for COVID-19, without following CDC guidelines for testing and isolation. The facility lacked evidence of staffing shortages or mitigation measures to justify early return to work.
The facility failed to document that residents were offered influenza and pneumococcal immunizations and did not provide education on the benefits and side effects of these vaccines. This deficiency was identified in five residents, whose records lacked evidence of vaccine administration or education. The issue was discussed with the Nursing Home Administrator and the DON.
The facility failed to offer the COVID-19 vaccine and provide education to three residents, with missing documentation of vaccine administration or refusal. Additionally, the facility did not maintain proper records of a staff member's vaccination status, violating federal regulations.
Two residents were observed wearing hospital gowns due to delays in the return of their personal laundry, impacting their dignity. The facility sends laundry out to a contracted company without a specific return timeframe, and there is no protocol to ensure residents have enough clothing. The environmental services manager and operations manager confirmed these practices, and the Nursing Home Administrator and DON acknowledged the issue.
A facility failed to ensure consistent documentation of a resident's advance directives. The resident's POLST indicated a desire for CPR but refusal of intubation, while the electronic medical record instructed Full Code treatment without limitations. Interviews with RNs confirmed reliance on the EMR, which did not reflect the resident's refusal of intubation.
A resident with range of motion impairment did not consistently receive a physician-ordered splint for their right hand. Observations and staff interviews revealed the splint was not applied as scheduled, and it was in poor condition due to the resident chewing on it. Recommendations to use a tubi-grip sock were not followed, and staff documented the splint's application even when it was not in use.
A resident with severe cognitive impairment did not receive necessary routine dental services, despite having significant dental issues such as decay and heavy plaque buildup. The facility's documentation showed that the resident had previously refused treatment, but her cognitive status prevented effective participation in care planning. The facility failed to assist in making appointments or arranging transportation for dental services.
The facility failed to comply with the Act 52 Infection Control Plan by not providing evidence of infection control committee meetings and attendance. Despite repeated requests from the surveyor, the facility did not demonstrate adherence to the plan's requirements, which include having a multidisciplinary committee with representatives from various departments.
The facility failed to hold infection control committee meetings since February 2024 and did not document the disposition of a resident's personal belongings after their death. A resident admitted in early 2025 passed away, and their personal items, including glasses and a cell phone, were not accounted for, as confirmed by the Nursing Home Administrator and DON.
The facility did not comply with the required NA-to-resident ratios during the overnight shift on five occasions. For instance, with a census of 18 residents, only 1.00 NA was scheduled instead of the required 1.20 NAs. This deficiency was confirmed by the Nursing Home Administrator and DON.
The facility did not meet the required LPN-to-resident ratio during the overnight shift, as evidenced by a review of staffing hours. On a specific night, the facility had a census of 17 residents but no LPNs scheduled, failing to comply with the regulation of one LPN per 40 residents. This was confirmed by the Nursing Home Administrator and the DON.
The facility's laundry area was found to have a significant build-up of lint in the dryer vent and piping, with additional lint on the ground, posing a potential fire hazard. This was confirmed by the environmental services manager and supervisor during an inspection.
The facility failed to assess all required zones for bed rail entrapment risk for five residents, only evaluating zones two, three, and four. Despite high-risk assessments for two residents, enabler bars were used without complete documentation or informed consent, indicating a systemic issue in managing accident hazards.
The facility failed to implement enhanced barrier precautions for three residents, including one with a chronic wound and another with a Foley catheter, due to lack of signage and PPE. Additionally, the laundry area lacked gowns and handwashing facilities, increasing the risk of infection spread.
The facility did not adhere to its abuse prohibition policy by failing to investigate the employment history of two newly hired employees. The policy requires obtaining personal and/or professional references before employment, but records for an Activities Assistant and a Service Assistant showed no evidence of such attempts. This was confirmed by the NHA and HR.
A resident with multiple diagnoses, including cerebral palsy and major depressive disorder, was inaccurately assessed in the MDS as not requiring specialized services, despite a PASRR indicating otherwise. The Nursing Home Administrator confirmed the error in coding, highlighting a failure in accurate assessment and documentation.
The facility failed to prevent or treat UTIs for residents with indwelling catheters. A resident's catheter care policy was contradictory and not aligned with CDC guidelines, leading to improper catheter maintenance. Another resident experienced acute dysuria, but the facility failed to follow protocol, resulting in no urinalysis or antibiotic treatment. The facility's policies lacked professional standards, contributing to deficiencies in care.
The facility failed to properly store CPAP equipment for a resident with obstructive sleep apnea, leaving the mask unprotected from contaminants. Additionally, a resident using a flutter valve for a cough was not given clear instructions on usage frequency, and staff did not document follow-up to ensure proper use.
A facility's medication error rate exceeded the acceptable threshold, with errors involving two residents. An LPN failed to administer the correct number of tablets to one resident and did not follow timing instructions for another resident's medication. These errors were confirmed and discussed with facility leadership.
Infection Control and COVID-19 Work Exclusion Deficiencies
Penalty
Summary
The facility failed to ensure a safe environment free from the potential spread of infection related to the processing of resident personal laundry. Observations revealed that staff collected soiled personal laundry in mesh bags, which were not leak-resistant, potentially exposing staff to contamination during transport. The mesh bags were placed in a large, open bin in the nursing unit's soiled utility room, which lacked a lid, increasing the risk of contamination. Staff were instructed to rinse heavily soiled garments in the soiled utility hopper without the availability of isolation gowns, potentially contaminating the air, surfaces, and staff in the room. Additionally, the facility did not adhere to CDC guidelines for COVID-19 work exclusions. Employee 3, a nurse aide, returned to work five days after testing positive for COVID-19 on two separate occasions without undergoing subsequent testing to confirm a negative result. The facility's policy required adherence to CDC guidance, which stipulates a return to work after at least seven days with a negative test or ten days without testing. The facility did not provide evidence of any additional COVID-19 cases or staffing shortages that would justify early return to work under contingency or crisis staffing criteria. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed the lack of evidence for additional COVID-19 cases or measures to mitigate staffing shortages. The facility did not progress through measures from conventional to contingent nurse staffing, nor did it communicate with local healthcare coalitions to identify additional healthcare personnel. This resulted in Employee 3 returning to work outside of CDC's conventional strategy parameters, potentially increasing the risk of COVID-19 transmission within the facility.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. No individual residents were identified as impacted. At the time of the finding, environmental staff was verbally reminded about the importance of keeping laundry in sealed bags and the use of PPE during laundry processing. 2. The Director of Nursing and/or designee will educate all environmental service staff and nursing assistants on the need to place resident personal laundry that is in a mesh bag in a plastic bag before removing it from the residents' room and the importance of using PPE when working in the soiled laundry area to prevent the potential spread of infection related to resident personal laundry processing. 3. The Administrator and/or designee will educate the Director of Nursing and Human Resources on the updates to the facility policy COVID-19 Testing and Exposure Management. Specifically, but not limited to the need to consider the continuum of options for addressing staffing shortages, and that contingency strategies followed by crisis strategies are provided to augment conventional strategies and are meant to be considered and implemented sequentially. As per the CDC, "when staffing shortages are anticipated, healthcare facilities and employers, in collaboration with human resources and occupational health services, should use capacity strategies to plan and prepare for mitigating this problem." The Director of Nursing will also be educated on the need to consider the PA DOH staffing Ratios and Hours Per Patient Day (HPPD) requirements while balancing strategies to mitigate staffing shortages, safe staffing to meet resident needs, and providing evidence of measures considered. 4. The Director of Nursing and/or designee will conduct 5 visual audits per week for 2 months to ensure the environmental service staff and/or nursing assistants place resident personal laundry that is in a mesh bag in a plastic bag for transport and storage and the importance of using PPE when working in the soiled laundry area to prevent the potential spread of infection related to resident personal laundry processing. The NHA and/or designee will conduct an audit on the return to work for any employee who is off due to COVID-19 and what was considered to support a return to work outside of the conventional strategies to mitigate staffing shortages. The audit will be completed for 2 months or until substantial compliance is achieved. Audit findings will be reviewed at the QAPI meeting.
Deficiency in Immunization Documentation and Education
Penalty
Summary
The facility failed to comply with the regulatory requirements for influenza and pneumococcal immunizations as outlined in §483.80(d). The deficiency was identified through a review of facility policies, CDC guidelines, clinical records, and staff interviews. The facility did not document that residents were offered influenza and pneumococcal immunizations, nor did they provide education regarding the benefits and potential side effects of these immunizations. This failure was observed in five residents who were reviewed for immunization concerns. Resident 2's clinical record lacked documentation of a pneumococcal vaccine administration and did not show evidence that the resident or their representative received education about the vaccine's risks and benefits. Similarly, Resident 7's record showed previous vaccinations but no documentation of education or decision-making regarding newer vaccines as per current CDC guidelines. Resident 10's record included a refusal of consent for yearly immunizations but lacked evidence of education provided about the vaccines. Residents 12 and 14 also had no documented history of pneumococcal vaccine administration or evidence of education provided to them or their representatives. These findings were discussed with the Nursing Home Administrator and the Director of Nursing, highlighting the facility's failure to meet the regulatory requirements for immunization documentation and education.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. The Pneumococcal immunization status for residents 2, 7, 10, 12, and 14 was reviewed. The influenza immunization status of resident 10 was reviewed. Residents' and/or resident representatives' 2, 7, 10, 12, and 14 were provided education regarding the benefits and potential side effects of the pneumonia vaccine. Resident/Responsible party 10 was provided education regarding the potential risks and benefits of the influenza vaccine and declination revisited. The clinical record has been updated to reflect the administration of the pneumococcal vaccine as indicated for residents 2, 7, 10, 12, and 14. 2. All current residents' pneumococcal and influenza immunization statuses will be reviewed. Residents/Resident representatives will be provided education on the potential risks and benefits of the pneumococcal and influenza vaccine. Residents/resident representatives will be offered the pneumococcal and influenza vaccines as indicated and the clinical record will be updated to reflect the administration of pneumococcal and influenza vaccines. 3. The pneumococcal and influenza immunization statuses will be reviewed for all new admissions. Residents/resident representatives will be provided education on the potential risks and benefits of the pneumococcal and influenza vaccines as part of the admission packet. Residents/residents representatives will be offered the pneumococcal and influenza vaccines as indicated and the clinical record will be updated to reflect the administration of pneumococcal and influenza vaccines. The Administrator will educate RNs, LPNs, and social worker on this system alteration. 4. The Director of Nursing and/or designee will audit the pneumococcal and influenza immunization clinical documentation for all new admissions for 3 months or until substantial compliance is achieved to ensure Residents/Resident representatives were provided education on the potential risks and benefits of the pneumococcal and influenza vaccines, to ensure Residents/residents representatives were offered the pneumococcal and influenza vaccines as indicated and that the clinical record was updated to reflect the administration of pneumococcal and influenza vaccines. Results will be reviewed at the QAPI meeting.
Deficiencies in COVID-19 Vaccine Offer and Documentation
Penalty
Summary
The facility failed to ensure that each resident was offered the COVID-19 vaccine and provided with education regarding its benefits and risks. Specifically, for three residents reviewed for immunization concerns, there were deficiencies in documentation and education. Resident 2 had a consent form signed for the 2024/2025 COVID-19 vaccine, but there was no evidence of the vaccine being administered. Resident 7's record showed a refusal of the vaccine in 2021, but there was no documentation of any subsequent offer or education about the 2024/2025 vaccine. Resident 10's record lacked any evidence of receiving or refusing the vaccine, as well as any education provided about it. The facility's policy required that residents and their representatives receive education about the COVID-19 vaccine and have the opportunity to accept or refuse it. However, the survey found that the facility did not adhere to these policies for the residents reviewed. The medical records did not include necessary documentation of education provided or the vaccine's administration or refusal, which is a requirement under the facility's policy and federal regulations. Additionally, the facility failed to maintain proper documentation of staff COVID-19 vaccination status as required. Specifically, there was no information provided regarding the vaccination status of Employee 3, a nurse aide, despite requests from the surveyor. This lack of documentation is a violation of the requirement to maintain records of staff vaccination status and related information as indicated by the Centers for Disease Control and Prevention's National Healthcare Safety Network.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. Residents 2, 7, and 10 were provided with education on the benefits and risks associated to the covid vaccine and offered vaccine if desired. The clinical record has been updated to reflect the administration of the COVID vaccine as indicated for residents 2, 7, and 10. Employee 3 was provided education on the benefits and risks associated with the covid vaccination and where she can get the vaccination if desired. 2. All residents' covid vaccine statuses for the 2024-2025 vaccine will be reviewed and vaccine offered with education on risks and benefits. All current employee files reviewed for vaccine education acknowledgement. 3. Covid vaccine review with new residents incorporated into admission process including education on risks and benefits. Covid vaccine education given to new staff upon hire with acknowledgement form. 4. DON or designee will complete audits for new resident covid vaccination education and offer and new hires for covid vaccine education weekly x4 then monthly x2 with results reported to QAPI.
Failure to Ensure Resident Dignity Due to Laundry Delays
Penalty
Summary
The facility failed to ensure that care and services were provided in a manner that enhanced resident dignity for two residents. Observations revealed that both residents were in bed wearing hospital gowns due to not having their personal clothes returned from the laundry service in a timely manner. Resident 3 reported not having any clothes to wear and stated that her laundry was sent out but not returned promptly. Observations of her closet confirmed the lack of clothing, with only one shirt present and no pants. Similarly, Resident 11 was observed in a hospital gown and reported frequently running out of clothes due to delays in the return of her laundered items. Her closet was also found to be empty. Interviews with the environmental services manager and operations manager confirmed that residents' personal laundry is sent out to a contracted company four times a week, but there is no specific timeframe for its return. They also acknowledged that there is no facility protocol to ensure residents have enough clothes, expecting residents to have 14 days' worth of clothing. The Nursing Home Administrator and Director of Nursing confirmed these findings.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. Resident 3's care plan reflects her preference to occasionally wear hospital gowns depending on her preference each day. Resident 3 and resident 11 had their clean laundry returned to them. 2. All residents using facility laundry services will have closets checked for clothing that allows for seven outfits or per resident's preference. 3. Social Worker and CNAs will be educated to report concerns with availability of clean clothes for residents. 4. Social Worker or designee will complete random audits on 5 residents per week to ensure the resident has the availability of resident's clean clothes. Audits will be completed weekly x4 then monthly x2 with results reported to QAPI.
Inconsistent Advance Directive Documentation
Penalty
Summary
The facility failed to establish clear and consistent resident wishes regarding advance directives for a resident reviewed for advance directive concerns. The clinical record review of the resident's physical chart revealed a POLST signed by a physician and the resident, indicating the resident desired CPR but refused intubation. However, the active physician orders in the resident's electronic medical record instructed staff to implement Full Code treatment without any limitations. Interviews with two registered nurses revealed that they would refer to the electronic medical record, which did not indicate a DNR status, and would initiate CPR without limitations. The nurses confirmed that the electronic medical record did not reflect the resident's wish to refuse intubation as indicated in the POLST. The surveyor reviewed the omission with the Director of Nursing, highlighting the inconsistency between the resident's POLST and the electronic physician orders.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. Resident 118's physician order and banner notification were updated to reflect resident 118's desire for CPR and refusal of intubation (i.e. DNI). There was no harm to resident 118. 2. All current resident records will be reviewed to ensure that the Banner Bar and the physician order, which may also reflect any limited interventions (such as intubation) match the residents code preferences noted on the POLST and/or the Advanced Directive as indicated. 3. The DON or Designee will educate all RNs, LPNs, and Social Workers on the need to ensure that the Banner Bar and the physician order, which may also reflect any limited interventions (such as intubation) match the residents code preferences noted on the POLST and/or the Advanced Directive as indicated. 4. Social worker or designee will audit to ensure that the Banner Bar and the physician order, which may also reflect any limited interventions (such as intubation) match the residents code preferences noted on the POLST and/or the Advanced Directive as indicated. 5 resident charts will be audited weekly x4 then 5 resident charts will be audited monthly x2 or until substantial compliance is achieved. Results will be reported at the QAPI meeting.
Failure to Implement Physician-Ordered Splint for Resident
Penalty
Summary
The facility failed to ensure the proper implementation of a physician-ordered positioning device for a resident with range of motion impairment in the bilateral upper extremities. The resident had an active physician's order for a splint to be applied to the right hand at specific times throughout the day. However, observations and staff interviews revealed that the splint was not consistently applied as ordered. The resident was observed without the splint on multiple occasions, and staff confirmed that the splint was not applied after lunch as required. Further investigation showed that the splint was in poor condition, with worn-out Velcro and missing foam spacers due to the resident chewing on it. Despite recommendations from occupational therapy to use a tubi-grip sock over the splint to prevent chewing and extend its longevity, this was not implemented. The staff documented the application of the splint even when it was not in use, indicating a failure to adhere to the care plan and physician's orders. The deficiency was discussed with the Nursing Home Administrator and the Director of Nursing.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. Resident 12's new right-hand splint arrived before the exit conference. Staff on duty at the time were verbally re-educated on the splint schedule (which specifies when to apply and remove the hand splint) for this resident. Resident was wearing splint as directed without difficulty. The plan of care was reviewed and updated as indicated. 2. All residents with hand splints were reviewed to ensure the splint was present and in good repair. Staff also reviewed the current hand splint schedule (which specifies when to apply and remove the hand splint). The plan of care was reviewed and updated as indicated. 3. The Director of Nursing and/or designee will educate the RNs, LPNs, and CNAs on the need to ensure splints are present and in good repair and where to note the current hand splint schedule. 4. DON or designee will audit residents with hand splints to ensure splints are on as per the plan of care and in good repair weekly x4 then monthly x2 or until substantial compliance is achieved. Results will be reviewed at the QAPI meeting.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to obtain routine dental services for a resident, as evidenced by clinical record reviews, observations, and interviews. The resident, who had severe cognitive impairment, was observed to have several missing and discolored teeth. Documentation from the facility's consultant dental provider indicated that the resident had significant dental issues, including decay, a fractured tooth, and heavy plaque and calculus buildup. Despite these findings, there was no evidence of professional dental cleaning or treatment to address these issues. The resident's cognitive status, as recorded in her MDS assessments, showed severe impairment, which prevented her from effectively participating in her care planning decisions. The facility's documentation noted that the resident had previously refused dental treatment due to a lack of pain and progressing cancer. However, the facility did not ensure that the resident received necessary dental care, such as extractions recommended by the dental provider, and failed to assist her in making appointments or arranging transportation for dental services.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. Resident 1 was seen by dentist on 4/22/25. Reviewed dentist recommendations for resident and follow-up as indicated with resident/resident representative; follow-up will be completed as indicated and the plan of care will be updated. 2. A retrospective review of all residents' most recent dental consult will be completed to ensure recommendations for oral specialists were reviewed with the resident/resident responsible party and scheduled follow-up is coordinated as indicated. 3. The Administrator and/or designee will educate all RNs, LPNs, and Social worker regarding the need to ensure recommendations for oral specialists were reviewed with the resident/resident responsible party and scheduled follow-up is coordinated as indicated. 4. The Social Worker and/or designee will audit all new dental consult notes to ensure recommendations for oral specialists were reviewed with the resident/resident responsible party and scheduled follow-up is coordinated as indicated. Audits will be completed bi-weekly for 2 months, or until substantial compliance is achieved. Results will be reviewed at the QAPI meeting.
Non-Compliance with Infection Control Committee Requirements
Penalty
Summary
The facility failed to comply with the multidisciplinary committee requirements of the Act 52 Infection Control Plan. This plan mandates that a health care facility develop and implement an internal infection control plan aimed at improving the health and safety of residents and health care workers. The plan should include a multidisciplinary committee with representatives from various departments, such as medical staff, administration, laboratory personnel, nursing staff, pharmacy staff, physical plant personnel, a patient safety officer, members from the infection control team, and community representatives. However, the facility was unable to provide evidence of the infection control committee meetings and attendance records since the last standard survey. During interviews with the Nursing Home Administrator and the Director of Nursing, who also serves as the facility's infection preventionist, the surveyor requested documentation of the infection control committee meetings. Despite repeated requests, the facility did not provide the necessary evidence, indicating a failure to adhere to the infection control plan's requirements. This deficiency highlights the facility's non-compliance with the established standards for infection control, as outlined in the Act 52 Infection Control Plan.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. No individual resident was identified as impacted. 2. A multidisciplinary committee is being assembled that meets the requirements of Act 52, and a meeting will be scheduled to be held at least quarterly. 3. The Regional Director of Operations will educate the current NHA on the need to assemble a multidisciplinary committee that meets the requirements of Act 52, and that a meeting is to be scheduled and held on a quarterly basis. 4. The Regional Director of Operations will audit to ensure that a multidisciplinary committee that meets the requirements of Act 52 is in place, and that a meeting was scheduled and held on a quarterly basis. Audit findings will be reviewed at the QAPI meeting.
Deficiencies in Infection Control and Personal Property Management
Penalty
Summary
The facility was found to have deficiencies in infection control and management of residents' personal property. There was no evidence of infection control committee meetings after February 2024, indicating a lapse in ongoing infection control oversight. Additionally, a review of closed clinical records revealed that the facility failed to document the disposition of a resident's personal belongings following their discharge. Specifically, Resident 16, who was admitted on February 8, 2025, and passed away on March 5, 2025, had personal items such as prescription glasses, clothes, shoes, a cell phone, and a charger listed in their inventory. However, there was no documentation indicating what happened to these belongings after the resident's death. This was confirmed during an interview with the Nursing Home Administrator and the Director of Nursing.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. Resident 16 personal belonging inventory disposition was completed and reviewed with the resident's representative. 2. A retrospective review of the last 3 months of discharges was reviewed for the presence of a personal belonging inventory disposition and completed as indicated. 3. The Director of Nursing and/or designee will educate RNs, LPNs, and Housekeeping to ensure that the personal belongings inventory disposition is completed and reviewed with the resident/resident representative as indicated. 4. The Director of Nursing and/or designee will audit all closed records to ensure that the personal belongings inventory disposition is completed and reviewed with the resident/resident representative as indicated. The audit will be completed for 3 months or until substantial compliance is achieved. Results will be reviewed at the quarterly QA meeting.
Non-Compliance with Overnight NA Staffing Ratios
Penalty
Summary
The facility failed to meet the regulatory requirement of maintaining a minimum of one nurse aide (NA) per 15 residents during the overnight shift for five out of the 21 days reviewed. Specifically, on February 9, 2025, with a census of 18 residents, only 1.00 NA was scheduled, whereas 1.20 NAs were required. On February 11, 2025, with a census of 20 residents, 1.00 NA was scheduled, but 1.33 NAs were needed. Similarly, on April 11, 12, and 13, 2025, with a census of 17 residents each night, only 1.00 NA was scheduled, while 1.13 NAs were required. This deficiency was confirmed through an interview with the Nursing Home Administrator and Director of Nursing on April 16, 2025.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. At the time of the finding, the ratios and total nursing hours for the current working schedule were reviewed and staffing was sufficient to meet the needs of the residents or there was sufficient time to coordinate sufficient staffing. 2. The RNs and LPNs will be re-educated on the nursing assistant ratio requirements, and the importance of monitoring staffing as the day and/or shift progress. Education will be completed by the Director of Nursing and/or designee. 3. The Director of Nursing and/or designee will audit the current working schedule, and the deployment sheets prior to the day and after the day is complete to ensure nursing assistant ratios have been met. 4. Audits will be completed 3 times per week for 1 month, and weekly for 1 month thereafter or until substantial compliance is achieved. Results will be reviewed at the QAPI meeting.
Failure to Meet LPN Staffing Requirements Overnight
Penalty
Summary
The facility failed to meet the regulatory requirement of having a minimum of one licensed practical nurse (LPN) per 40 residents during the overnight shift. This deficiency was identified during a review of nursing staffing hours and confirmed through staff interviews. Specifically, on April 13, 2025, the facility had a resident census of 17 but did not have any LPNs scheduled for the night shift, thereby not meeting the required LPN-to-resident ratio. This finding was confirmed in an interview with the Nursing Home Administrator and the Director of Nursing on April 16, 2025.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. At the time of the finding, the LPN ratios for the current working schedule were reviewed, and no issues were noted. 2. The Director of Nursing and/or designee will educate the RNs and LPNs on the LPN ratios and the importance of monitoring staffing as the day and/or shift progress as well as the ability to substitute an RN for an LPN; the designated RN charge nurse may take on an assignment and be counted in ratios. A facility such as Cole Place with a census of 59 or under may substitute an LPN for an RN on the overnight shift only if an RN is on call and located within a 30-minute drive of the facility. 3. The Director of Nursing and/or designee will audit the current working schedule, and the deployment sheets prior to the day and after the day is complete to ensure compliance. 4. Audits will be completed 3 times per week for 1 month, and weekly thereafter for 1 month or until substantial compliance is achieved. Results will be reviewed at the QAPI meeting.
Laundry Area Fire Hazard Due to Lint Build-Up
Penalty
Summary
The facility failed to prevent potential accident hazards in the laundry area, as observed by surveyors. During an inspection, it was noted that the dryer vent and piping had a significant build-up of lint inside the vent/pipe area, with additional white lint observed on the ground below the vent. This condition poses a potential fire hazard. The observation was confirmed during an interview with the manager and supervisor of environmental services. The issue was further discussed with the Nursing Home Administrator and Director of Nursing Home.
Incomplete Bed Rail Risk Assessment
Penalty
Summary
The facility failed to properly assess the risk of side rail entrapment for five residents, as required by their own policy. The policy mandates the assessment of seven potential zones of bed entrapment, but the facility only evaluated zones two, three, and four. This incomplete assessment was documented in the Bed System Measurement Device Test Results Worksheet for Residents 3, 4, 6, 7, and 11. The facility's oversight in not assessing zones one, six, and seven was a significant lapse in ensuring resident safety. For Residents 3 and 4, the facility's documentation indicated that they were assessed as high risk for enabler bar use, which should have prompted a halt in their use. However, the facility proceeded with the installation of enabler bars despite the high-risk assessment. Additionally, the documentation lacked signatures, making it impossible to determine who completed the assessments. This lack of accountability and adherence to the facility's own policy contributed to the deficiency. Observations of Residents 6, 7, and 11 revealed that they were using enabler bars without a complete assessment of all entrapment zones. The facility's failure to conduct a comprehensive risk assessment for these residents, as well as the lack of informed consent and proper documentation, highlights a systemic issue in the facility's approach to managing accident hazards related to bed rails.
Inadequate Infection Control Measures in LTC Facility
Penalty
Summary
The facility failed to implement appropriate enhanced barrier transmission-based precautions for three residents, leading to potential infection control issues. Resident 14, who was on enhanced barrier precautions due to a chronic coccyx wound and a history of MRSA, was observed receiving wound care from an LPN who did not wear a gown, only gloves, during the procedure. The LPN was unsure about the requirement to wear a gown and confirmed with a registered nurse that the resident was indeed on enhanced barrier precautions. Resident 120, who had a physician-ordered Foley catheter, did not have enhanced barrier precaution signage or personal protective equipment available outside her room. Similarly, Resident 3, who had an indwelling urinary catheter and was receiving treatment for a urinary tract infection and bloodstream infection, also lacked signage and PPE outside his room. Staff confirmed that enhanced barrier precautions were not in place for Resident 3 at the time of the surveyor's observation. Additionally, the facility's laundry area was found to be lacking in infection control measures. There were no gowns available for staff to use when handling soiled items, and there was no handwashing sink or hand sanitizer available for staff to clean their hands after processing soiled laundry. This lack of infection control measures in the laundry area further contributed to the potential spread of infection within the facility.
Failure to Implement Abuse Prohibition Policy
Penalty
Summary
The facility failed to implement its abuse prohibition policy effectively, as evidenced by the lack of thorough investigation into the employment history of two newly hired employees. The policy, titled 'Abuse, Neglect, Exploitation General Policy,' mandates that the facility make reasonable efforts to obtain personal and/or professional reference information before an employee's first day of work. However, upon review, it was found that the personnel records for Employee 4, an Activities Assistant hired on April 22, 2024, and Employee 5, a Service Assistant hired on March 16, 2024, contained no evidence of attempts to obtain such reference information. This deficiency was confirmed by the Nursing Home Administrator and a Human Resources representative on May 9, 2024.
Inaccurate MDS Assessment for Resident with PASRR Needs
Penalty
Summary
The facility failed to ensure the accuracy of MDS assessments for one of the eight residents reviewed. Specifically, Resident 2's clinical record indicated several diagnoses, including cerebral palsy, major depressive disorder, generalized anxiety, dementia, and unspecified psychosis. A PASRR assessment from 2003 confirmed that Resident 2 required specialized services due to these conditions. However, the annual MDS assessment inaccurately recorded that Resident 2 was not considered by the state level II PASRR process to have a serious mental illness or intellectual disability, which was incorrect. The Nursing Home Administrator confirmed during an interview that the coding on the annual MDS was an error, acknowledging that Resident 2 did indeed meet the criteria for specialized services as per the level II PASRR process. This discrepancy highlights a failure in accurately assessing and documenting the resident's needs, which is crucial for ensuring appropriate care and services are provided.
Deficiencies in Catheter Care and UTI Prevention
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent or treat urinary tract infections (UTIs) for residents with indwelling catheters. Specifically, for Resident 3, the facility's policy on urinary catheters was found to be contradictory and not aligned with current CDC guidelines. The policy recommended maintaining a closed sterile drainage system but also suggested using an intermittent method for irrigation, which would break the closed system. Resident 3 had active physician orders for two different catheter sizes and instructions to change the collection bag as needed, which also disrupted the closed system. Despite discovering a hole in the catheter bag and bloody drainage, staff changed only the collection bag and not the catheter, failing to document the change in the MAR/TAR. The facility also lacked evidence of urologist consultations for Resident 3. For Resident 5, the facility failed to appropriately address a suspected UTI. Documentation indicated that Resident 5 experienced acute dysuria, but the registered nurse incorrectly completed the Suspected UTI SBAR form, reporting to the physician that the nursing home protocol was not met. As a result, Resident 5 did not receive a urinalysis or antibiotic treatment. The facility had no evidence of any new interventions implemented in response to Resident 5's complaint. The facility's policies and procedures were found to be lacking in professional standards and not in compliance with current guidelines. Interviews with the Director of Nursing confirmed the contradictions in the facility's indwelling catheter policy and the absence of clear instructions for catheter changes. The facility's failure to adhere to proper catheter maintenance and UTI prevention protocols resulted in deficiencies in the care provided to Residents 3 and 5.
Deficiencies in Respiratory Care and Equipment Storage
Penalty
Summary
The facility failed to adhere to professional standards of practice in storing CPAP equipment for a resident with obstructive sleep apnea. The resident's CPAP mask was observed on multiple occasions to be unprotected from environmental contaminants, as it was placed on top of the CPAP machine on a dresser next to the bed. Interviews with the Nursing Home Administrator and a licensed practical nurse revealed that the facility's policy required CPAP masks to be bagged to prevent contamination, but this practice was not being followed. Additionally, the facility's policy on CPAP cleaning and disinfection did not address proper storage of the mask to prevent contamination. Another deficiency was identified in the care of a resident using a flutter valve to manage a dry, non-productive cough. The resident had a physician's order for the device but was not provided with a specified frequency for its use. The resident expressed uncertainty about how often to use the flutter valve and mentioned that staff had only instructed her once, which she had since forgotten. There was no documentation in the clinical records to indicate that staff ensured the resident was using the device correctly or followed up to clarify usage frequency.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 7.14 percent based on 28 medication opportunities with two errors. During a medication administration pass, an LPN prepared medications for a resident but omitted one of the two required calcium citrate tablets, resulting in only eight and one-half tablets instead of the prescribed nine and one-half. This error was confirmed by the LPN after recounting the tablets and reviewing the medication labels. In another instance, the same LPN administered medications to a second resident without adhering to the specific timing instructions. The resident received Gemfibrozil, which should be taken 30 minutes before a meal, after they had already finished breakfast. Additionally, the schedule for the resident's medications included conflicting instructions, with some medications requiring administration with food. The active physician order for Gemfibrozil was discontinued later that day. These issues were discussed with the Nursing Home Administrator and the Director of Nursing.
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Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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