Communities At Indian Haven,
Inspection history, citations, penalties and survey trends for this long-term care facility in Indiana, Pennsylvania.
- Location
- 1675 Saltsburg Avenue, Indiana, Pennsylvania 15701
- CMS Provider Number
- 395778
- Inspections on file
- 22
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Communities At Indian Haven, during CMS and state inspections, most recent first.
A resident, who was cognitively intact and required assistance for daily care, experienced neglect when a nurse aide repeatedly removed his call bell, leaving it out of reach. This action, observed by a housekeeper, was not reported immediately, allowing the nurse aide to continue working with the resident and others. The delay in addressing the neglect resulted in Immediate Jeopardy to the resident's health and safety.
A resident's call bell was removed by a nurse aide, placing it out of reach, and the incident was not reported immediately by a housekeeper who witnessed it. The resident, who was cognitively intact and required assistance for daily care, expressed a preference to have the call bell within reach. The delay in reporting violated the facility's policy for immediate notification of neglect allegations.
The NHA and DON at The Communities at Indian Haven failed to manage the facility effectively, leading to an environment where residents were not protected from neglect and abuse. Deficiencies were identified under federal regulations, indicating that the NHA and DON did not fulfill their duties to maintain a safe environment and ensure timely reporting of abuse. This resulted in violations of specific regulatory codes related to resident protection and management responsibilities.
The facility failed to maintain electrical safety standards as an extension cord was found plugged into a power strip in the 300-wing mechanical room. This was confirmed by the maintenance supervisor.
The facility failed to maintain an emergency exit discharge near the laundry area with a hard-packed, all-weather travel surface leading to a public way. This deficiency was confirmed by the maintenance supervisor.
The facility did not maintain a self-closing door in the corridor from the 300 wing to the dining room area, as one of the two leaves failed to positively latch in the frame. This deficiency was confirmed by the maintenance supervisor.
The facility failed to maintain the sprinkler system, as two sprinkler heads in the laundry room were covered with dust and lint. This accumulation can affect the sprinkler's activation and spray coverage. The maintenance supervisor confirmed the deficiency.
The facility failed to complete Quarterly MDS assessments within the required timeframe for several residents, as mandated by the RAI User's Manual. The assessments were completed late, ranging from one to eighteen days past the due date. This deficiency was confirmed through clinical records and staff interviews, with the Nursing Home Administrator acknowledging the oversight.
The facility did not follow its planned menu, substituting a hamburger bun for a croissant without informing residents, as required by policy. A resident confirmed they were not notified of the change, and the Dietary Aide acknowledged the mistake.
The facility failed to individualize care plans for two residents receiving IV antibiotics and anticoagulants. One resident's care plan did not document a PICC line or Vancomycin treatment, while another's lacked documentation of Xarelto administration. The Assistant Director of Nursing confirmed these omissions.
A resident with high blood pressure was supposed to switch from amlodipine to lisinopril as per physician's orders. However, an LPN administered amlodipine instead, after dropping the tablet and picking it up with bare hands. The error was confirmed, and the Medical Director was notified.
A facility failed to obtain a vancomycin trough as ordered by a physician for a resident. The facility's policy requires staff to process test requisitions and arrange for tests as ordered by physicians. However, a nursing note indicated that the vancomycin trough was missed, and new orders were issued to have the test drawn. The Nursing Home Administrator confirmed the oversight.
A facility failed to maintain complete and accurate clinical records for a resident, as required by their medication administration policy. Despite the resident confirming no missed medications, documentation was missing for several prescribed medications over multiple months. The Nursing Home Administrator acknowledged the incomplete records.
The facility's QAPI committee failed to address recurring deficiencies related to timely and accurate MDS assessments, comprehensive care plans, and quality of care. Despite developing plans of correction involving audits and committee reviews, the facility did not maintain compliance with regulations, as evidenced by repeated issues identified in multiple surveys.
An LPN at the facility failed to follow proper infection control practices by administering a dropped amlodipine tablet to a resident with her bare hands. This incident occurred despite the facility's protocols against such actions, as confirmed by the Nursing Home Administrator.
The facility failed to accurately complete MDS assessments for two residents. One resident's assessment incorrectly indicated they had not received prescribed medications, while another resident's discharge status was inaccurately recorded. These discrepancies were confirmed by the Nursing Home Administrator.
The facility failed to meet the required NA-to-resident staffing ratios on multiple occasions, as evidenced by a review of nursing schedules and staff interviews. On specific days, the facility was understaffed during day, evening, and overnight shifts, with the Nursing Home Administrator confirming these deficiencies. No additional higher-level staff were available to compensate for the shortfall, leading to non-compliance with staffing regulations.
The facility did not meet the required 3.2 hours of direct resident care per resident in a 24-hour period, providing only 3.11 hours on one occasion. This was confirmed by reviewing nursing time schedules and an interview with the Nursing Home Administrator.
The facility failed to complete timely admission MDS assessments for two residents. One resident's assessment was completed 29 days post-admission, exceeding the 13-day requirement. Another resident, admitted with malignant neoplasm, lacked documented evidence of a completed assessment. The Nursing Home Administrator confirmed these deficiencies.
A facility failed to develop a comprehensive care plan for a resident admitted to hospice care. Despite physician's orders and nursing notes indicating the resident's hospice status, there was no documented care plan addressing the resident's individualized needs. This deficiency was confirmed by the Nursing Home Administrator.
A facility failed to complete a quarterly MDS assessment for a resident within the required timeframe. The assessment, which should have been completed within 14 days of the ARD, was delayed and completed 32 days after the ARD. This was confirmed by the Nursing Home Administrator.
The facility failed to update care plans for three residents to reflect changes in care needs. A resident's care plan did not include new blood pressure parameters for diuretics, another resident's care plan did not reflect her preference for more frequent showers, and a third resident's care plan was not updated to include a fall mat after a fall. These deficiencies were confirmed by the Nursing Home Administrator.
A facility failed to maintain complete clinical records and accurately document medication administration for a resident with heart failure, hypertension, and COPD. Orthostatic blood pressure results were missing from the records, and a diuretic medication was incorrectly documented as administered despite low blood pressure readings. The Nursing Home Administrator confirmed these documentation errors.
The facility failed to ensure that baseline care plans included necessary information for four residents within 48 hours of admission. The plans lacked details on treatments with medications and care for specific conditions, as confirmed by the Nursing Home Administrator.
The facility failed to update care plans for four residents to reflect changes in their care needs, including the use of hearing aids, glucose monitoring methods, nephrostomy tube care, and the discontinuation of a urinary catheter and intravenous medication. These deficiencies were confirmed through observations, clinical record reviews, and staff interviews.
Monitoring of restorative nursing programs for two residents did not reflect progress toward program goals. The facility's policy requires periodic evaluation and documentation by a licensed staff member at least quarterly, but there was no documented evidence of such evaluations for a resident with dementia and Parkinson's disease and another with Cerebral Vascular Accident and hemiplegia. The deficiency was confirmed by the Nursing Home Administrator.
The facility failed to administer pain medications as ordered by the physician for two residents. One resident received hydrocodone-acetaminophen for pain ratings less than six on three occasions, while another received oxycodone for pain ratings less than six on six occasions. The Nursing Home Administrator confirmed the discrepancies.
The facility failed to maintain accountability for controlled medications for a resident. The MAR indicated doses of Oxycodone were signed out, but there was no documented evidence in the clinical record confirming administration. The DON confirmed the lack of documentation.
The facility failed to ensure that it was free from significant medication errors for a resident. The resident's insulin Aspart was not administered within the required five to ten minutes of meal times as per the manufacturer's instructions. The Medication Administration Records showed discrepancies between the insulin administration times and the actual meal times. The Director of Nursing confirmed the error.
The facility failed to discard expired medications in one of two medication rooms reviewed. A Forteo injection pen and five 100 cc bags of outdated IV stock solution were found expired and not discarded, as confirmed by staff interviews and observations.
The facility failed to notify the State Long-Term Care Ombudsman about the hospitalizations of three residents, despite the facility's policy requiring such notifications. The Nursing Home Administrator confirmed the lack of written notifications for the hospitalizations, which involved residents with conditions such as congestive heart failure, hypertension, and kidney failure.
The facility failed to complete accurate MDS assessments for five residents, with multiple sections left unassessed or inaccurately coded. The RNAC confirmed these deficiencies, noting the use of a remote RNAC who does not physically assess the residents.
The facility failed to develop and implement comprehensive care plans for three residents, including one with an anticoagulant, one with a cardiac pacemaker, and one receiving multiple medications. These omissions were confirmed by the Nursing Home Administrator and Assistant Director of Nursing.
The facility failed to follow physician's orders for two residents. One resident with a nephrostomy tube did not have the tube's patency checked as required, leading to complications and hospitalization. Another resident with Type 2 Diabetes had significantly elevated blood sugar levels without the physician being notified, as confirmed by the DON.
The facility failed to complete the annual performance evaluation for a nurse aide as required. The evaluation for the nurse aide was due in February, but as of March, there was no documented evidence of its completion. This was confirmed by the Human Resource Director, violating several facility management regulations.
The facility failed to complete the Care Area Assessment Process of comprehensive MDS assessments within the required time frame for three residents. The assessments for these residents were completed one to three days late, as confirmed by the RNAC.
The facility failed to complete a quarterly MDS assessment within the required time frame for a resident. The assessment, which had an ARD of February 24, 2024, was completed two days late, as confirmed by the RNAC.
Neglect of Resident Due to Call Bell Removal
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in Immediate Jeopardy to the resident's physical and mental health and safety. The incident involved a resident who was cognitively intact and required staff assistance for daily care needs. A housekeeper observed a nurse aide removing the resident's call bell and placing it out of reach, which was against the facility's abuse policy. The resident confirmed that the same staff member had taken his call bell on multiple occasions, leaving him unable to call for assistance when needed. The nurse aide continued to work with the resident and others for several days after the incident, as the housekeeper did not report the neglect immediately. The Director of Nursing was informed of the situation several days later, leading to the suspension and eventual termination of the nurse aide. The delay in reporting and addressing the neglect placed the resident in Immediate Jeopardy, as the resident was dependent on staff for most of his care needs.
Removal Plan
- The nurse aide was suspended and is no longer employed at the facility.
- An in-house audit was performed on residents, and assessments were completed along with interviews to confirm no other residents were identified.
- In-house re-education was provided to staff on abuse and reporting of abuse. The facility will not allow an employee to work unless this education has been completed prior to returning to work.
- Re-education regarding abuse to staff was completed.
- Audits will be conducted weekly and monthly to verify compliance and understanding of reporting abuse.
Failure to Timely Report Allegation of Neglect
Penalty
Summary
The facility failed to ensure timely reporting of an allegation of neglect involving a resident who was cognitively intact and required assistance for daily care needs. The incident involved a nurse aide who removed the resident's call bell, placing it out of reach, and instructed a housekeeper not to return it. The resident, who relied on staff for most care needs, expressed a preference to have the call bell within reach, as he could not perform tasks independently except for feeding himself. The housekeeper, who observed the incident, did not report it immediately, delaying notification to the Director of Nursing until several days later. During this period, the nurse aide continued to work with the resident and others. The facility's policy required immediate reporting of such incidents to supervisory staff, which was not adhered to in this case, leading to a delay in addressing the neglect allegation.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The Nursing Home Administrator (NHA) and the Director of Nursing (DON) at The Communities at Indian Haven failed to effectively manage the facility, resulting in an environment where residents were not adequately protected from neglect and abuse. The job descriptions for both positions outlined responsibilities for maintaining compliance with regulatory requirements and ensuring the well-being of residents. However, during the survey, deficiencies were identified under the Code of Federal Regulatory Groups for Long-Term Care, specifically 483.12, which pertains to Freedom from Abuse, Neglect, and Exploitation (F600). These deficiencies indicated that the NHA and DON did not fulfill their essential duties to maintain a safe environment for residents. Additionally, the survey revealed that the NHA and DON did not ensure timely reporting of abuse by staff and allowed staff to return to residents after incidents of abuse or neglect. This was in violation of 483.12(b)(1) and 483.12(b)(5)(iii), which prohibit and prevent abuse, neglect, and exploitation of residents, as well as retaliation. The report also cited state codes, including 28 Pa. Code 201.14(a), 28 Pa. Code 201.18(b)(1)(e)(1), and 28 Pa. Code 211.12(d)(1)(5), which emphasize the responsibility of the licensee and management to ensure proper nursing services and resident protection.
Electrical Safety Deficiency in Mechanical Room
Penalty
Summary
The facility failed to maintain electrical wiring and equipment in accordance with NFPA 99 Chapter 10 requirements. During an observation on February 11, 2025, at 11:50 a.m., it was noted that the 300-wing mechanical room had an extension cord plugged into a power strip. This setup is not compliant with the electrical safety standards. The maintenance supervisor confirmed the presence of this electrical deficiency during an interview conducted at the same time.
Plan Of Correction
1. Extension cord has been removed. 2. House audit to check for other extension cords has been conducted. 3. During weekly rounds, extension cords will be removed if found. 4. Random monthly check x3 by Administrator or designee will watch for extension cords. QAPI's Safety Committee will monitor for action or review. Administrator to monitor.
Emergency Exit Discharge Deficiency
Penalty
Summary
The facility failed to maintain one of its six emergency exits in compliance with NFPA 101 standards. During an observation on February 11, 2025, at 11:52 a.m., it was noted that the emergency exit discharge near the laundry area did not have a hard-packed, all-weather travel surface leading to a public way. This deficiency was confirmed through an interview with the maintenance supervisor at the same time, indicating a lapse in maintaining the required exit discharge conditions.
Plan Of Correction
1. A wheel-chair width hard packed surface will be installed at the laundry exit. This exit is not used for resident egress. 2. The other emergency exits have been audited and meet requirements. 3. A monthly check of hard packed surfaces from exit doors will be performed by the maintenance supervisor or designee to ensure that they are in good repair. 4. QAPI's Safety Committee will oversee building services for action or review. Administrator to monitor.
Failure to Maintain Self-Closing Door Latch
Penalty
Summary
The facility failed to maintain doors with self-closing devices as required by NFPA 101 standards. During an observation, it was noted that one of the two leaves of the self-closing doors in the corridor from the 300 wing to the dining room area did not positively latch in the frame. This deficiency was confirmed through an interview with the maintenance supervisor, who acknowledged the issue with the self-closing door.
Plan Of Correction
This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because Communities at Indian Haven agrees with the allegations and citations listed on the statement of deficiencies. Communities at Indian Haven maintains that the alleged deficiencies do not, individually, and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as Communities at Indian Haven's written credible allegation of compliance. By submitting this plan of correction, Communities at Indian Haven does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Communities at Indian Haven reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action. K0023 1. Door on 300 wing has been adjusted. Both leaves positively latch. 2. House audit shows other doors positively latch as required. 3. Weekly checks of self closing doors will be documented by maintenance supervisor or designee ongoing. 4. A monthly random door audit will be conducted by administrator or designee for 3 months. Reviews submitted to QAPI's Safety Committee for review. Administrator to monitor for compliance.
Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the sprinkler system adequately, as evidenced by the condition of two sprinkler heads in the laundry room. During an observation, it was noted that the sprinkler heads behind the dryers were covered with a layer of dust and lint. This accumulation of material can insulate the sprinkler's thermal element, potentially affecting the temperature activation and response time of the sprinkler, and may also lead to inadequate spray coverage. The maintenance supervisor confirmed the deficiency during an interview conducted at the time of the observation.
Plan Of Correction
1. Sprinkler heads behind dryers have been cleaned. 2. House audit was done and documented to check the other sprinkler heads for cleanliness. 3. A weekly check of sprinkler heads in laundry and a monthly check of sprinkler heads will be documented by maintenance supervisor or designee. 4. QAPI's Safety Committee will oversee for action or review. Administrator to monitor.
Failure to Complete Quarterly MDS Assessments on Time
Penalty
Summary
The facility failed to ensure that Quarterly Minimum Data Set (MDS) assessments were completed within the required timeframe for seven residents. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, a quarterly assessment is due every 92 days, with the completion date being the Assessment Reference Date (ARD) plus 14 days. However, the facility did not adhere to these guidelines, resulting in late assessments for several residents. For instance, Resident 19's assessment was completed 18 days late, while Resident 54's assessment was 17 days late. The deficiency was confirmed through a review of the Resident Assessment Instrument User's Manual, clinical records, and staff interviews. The Nursing Home Administrator acknowledged that the quarterly MDS assessments for the identified residents were not completed within the required timeframes. This non-compliance with the 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities, and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations, highlights a lapse in the facility's adherence to mandated assessment schedules.
Plan Of Correction
This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because Communities at Indian Haven agrees with the allegations and citations listed on the statement of deficiencies. Communities at Indian Haven maintains that the alleged deficiencies do not, individually, and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as Communities at Indian Haven's written credible allegation of compliance. By submitting this plan of correction, Communities at Indian Haven does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Communities at Indian Haven reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action. F638 1. The dates of submission for residents 19, 33, 35, 38, 43, 54, and 62 cannot be altered. The residents suffered no harm from this action. 2. Any other Minimum Data Set submission has potential to be submitted late. 3. An evaluation of the scheduling and planning process was conducted to determine measures that could be implemented to prevent this deficient practice from recurring. The scheduling target was shortened to fall within required parameters. Education was done with the interdisciplinary team, and dates are being reviewed weekly. 4. A Performance Improvement Plan was started to review timely submissions for 3 months until new process is secured. An audit of submission dates will be done weekly x 4 and then monthly x 2 and reported to the quality assessment team for review. Administrator or designee will monitor.
Failure to Communicate Menu Substitution
Penalty
Summary
The facility failed to adhere to its planned menu, as evidenced by the substitution of a hamburger bun for a croissant during the dinner meal on February 4, 2025. The facility's policy, dated January 15, 2024, required that any food menu substitutions due to unplanned situations be communicated to residents prior to meal service. However, this communication did not occur. Observations during the dinner meal confirmed the substitution, and an interview with Dietary Aide 2 acknowledged the mistake, indicating that the Dietary Manager was responsible for updating staff and residents about such changes. Further interviews revealed that the residents were not informed of the menu change. The Resident Council President confirmed that he was not notified of the substitution. The Nursing Home Administrator also confirmed the substitution and acknowledged that residents were not informed prior to the meal. This lack of communication and failure to follow the established menu policy led to the deficiency noted in the report.
Plan Of Correction
1. No individual resident was named or harmed. 2. No residents were harmed by substituting a nutritionally equivalent bread type for lunch. Any resident has potential to be harmed by menu substitution. 3. Re-education of the individual cook and other cooks regarding the menu substitution policy and procedure has been given by the kitchen operator. 4. Random tray audits will be conducted weekly x 4 and then monthly x 2 to ensure that meal is served as posted. These audits will be reported to the Quality Assurance team for review. Dietary manager to monitor.
Failure to Individualize Care Plans for Residents on IV Antibiotics and Anticoagulants
Penalty
Summary
The facility failed to develop comprehensive care plans that included specific and individualized treatment for two residents who were receiving intravenous antibiotics and anticoagulants. For one resident, admission orders included a PICC line for administering Vancomycin for a left hip infection. Observations confirmed the presence of the PICC line, and the Medication Administration Record (MAR) showed regular administration of the antibiotic and IV flushes. However, there was no documented evidence in the care plan regarding the PICC line or the antibiotic treatment. An interview with the Assistant Director of Nursing confirmed the omission and acknowledged that the care plan should have been individualized to include these treatments. Similarly, another resident was receiving Xarelto, an anticoagulant, as per admission orders. The MAR confirmed daily administration of the medication, but the care plan did not document the anticoagulant treatment. The Assistant Director of Nursing confirmed that the care plan was not individualized to include the resident's anticoagulant medication, which was a necessary component of the resident's care plan.
Plan Of Correction
1. Residents 37 and 293 have been discharged from the facility. 2. Any newly admitted resident has the potential to have an incorrect care plan. 3. The clinical team will review new admissions, including the initial care plan the next business day after admission to ensure no medications are missed on the admission care plan. Clinical team has been educated on this altered process. 4. Random audits of new admissions will be done weekly x 4 and then monthly x2 to ensure that medications are included in the initial care plan. These audits will be reported to the Quality Assurance team for review. Director of Nursing or designee will monitor.
Medication Administration Error for a Resident
Penalty
Summary
The facility failed to provide medications as ordered by the physician for a resident, identified as Resident 41. The resident, who was cognitively intact and required moderate assistance for daily care, had a diagnosis of high blood pressure. According to the physician's orders dated February 4, 2025, the resident was to discontinue taking 5 mg of amlodipine and start taking 5 mg of lisinopril. However, during a medication administration observation on February 5, 2025, an LPN administered 5 mg of amlodipine instead of the prescribed lisinopril. The LPN was observed dropping the amlodipine tablet on the cart, picking it up with bare hands, and then administering it to the resident. The LPN confirmed the error and acknowledged that medications should not be handled with bare hands. The Medical Director was notified of the medication error, and new orders were issued to hold the lisinopril for one day. The Nursing Home Administrator was informed of the incident and confirmed the improper handling of the medication.
Plan Of Correction
1. Resident 41 meds were reviewed for accuracy. 2. A house audit was conducted to review and reconcile resident medications for discontinued discrepancies. None were found. 3. The process was changed, and nurses were educated so that the person taking the discontinued order goes to the cart and removes the discontinued medication. During clinical review each morning, a list of discontinued medications will be reviewed and given to the RN supervisor to verify accuracy of cart medications. 4. An audit of discontinued medications against cart accuracy will be done weekly x 4 and then monthly x2 and reported to the Quality Assurance team for review. The Director of Nursing or designee will monitor.
Failure to Obtain Ordered Laboratory Specimen
Penalty
Summary
The facility failed to ensure that laboratory specimens were obtained as ordered by the physician for one resident. According to the facility's policy for lab and diagnostic testing, the physician orders diagnostic tests, and the staff is responsible for processing test requisitions and arranging for tests. For one resident, a physician's order was placed for a vancomycin trough to be drawn 30 minutes prior to the administration of vancomycin on a specific date. However, a nursing note revealed that the vancomycin trough was missed on the following day, and new orders were subsequently received to have the test drawn. An interview with the Nursing Home Administrator confirmed that the vancomycin trough was not obtained as per the physician's order on the specified date.
Plan Of Correction
1. Resident 37 has been discharged home. 2. A house audit was conducted to review labs ordered and the last draw date to ensure compliance. 3. The lab procurement process was simplified and streamlined to ensure labs have less chance of being missed. Nurses were educated on the revised process. A report will be run each evening for the next day's labs. The clinical team will review in the morning meeting for accuracy. 4. An audit of ordered labs will be done weekly x 4 and then monthly x 2 and reported to the Quality Assurance team for review. The Director of Nursing or designee will monitor.
Incomplete and Inaccurate Clinical Documentation
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented for a resident, identified as Resident 37. The facility's policy for medication administration required maintaining a medication administration record to document all medications administered. However, there was no documented evidence in Resident 37's Medication Administration Records (MAR) for several dates in December 2024, January 2025, and February 2025, indicating that the resident received prescribed medications, including vancomycin HCL, normal saline solution (NSS) flushes, Heparin Porcine, levothyroxine sodium, lithium carbonate, olanzapine, and omeprazole. Despite the lack of documentation, an interview with Resident 37 confirmed that she had not missed any medications since arriving at the facility. The Nursing Home Administrator also confirmed that Resident 37's clinical record was not complete and accurately documented on the specified dates. This deficiency was identified based on a review of facility policies, clinical records, and staff interviews.
Plan Of Correction
1. Resident 37 has been discharged home. 2. Any resident has the potential to be affected by this deficient practice. 3. The process for reviewing medications was amplified and nurses were educated. At the end of each shift, the nurse will review the medication administration record for any medications not given, and document after administration. If not given, a note of explanation will be placed in chart and physician notified as needed. Each morning the Director of Nursing or designated supervisor will run a list of missed medications from the previous day and rectify per procedure. 4. An audit of missed medications will be done weekly x 4 and then monthly x2 and reported to the Quality Assurance team for review. Director of Nursing or designee will monitor.
QAPI Committee Fails to Address Recurring Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address recurring deficiencies effectively, as evidenced by repeated issues identified in multiple surveys. The deficiencies were related to timely quarterly Minimum Data Set (MDS) assessments, accurate MDS assessments, comprehensive care plans, and overall quality of care. Despite developing plans of correction that included quality assurance systems, the facility did not maintain compliance with the cited nursing home regulations. The facility's plan of correction for the deficiency regarding quarterly assessments, cited in previous surveys, involved completing audits and reporting the results to the QAPI committee. However, the current survey revealed that the QAPI committee did not successfully implement their plan to ensure ongoing compliance with regulations regarding quarterly assessments. This failure was cited under F638. Similarly, the facility's plan of correction for deficiencies related to accurate resident assessments, comprehensive resident care plans, and quality of care also involved audits and QAPI committee reviews. Yet, the current survey found that the QAPI committee failed to implement these plans effectively, resulting in ongoing non-compliance with regulations. These failures were cited under F641, F656, and F684, respectively.
Plan Of Correction
1. No individual resident was named or harmed. 2. Any resident has potential to be harmed by failure to correct systems in the facility. 3. Re-evaluation of the Quality Assurance process has resulted in a reorganization of the current Performance Improvement Plans. Regular quarterly meeting in February finalized new Performance Improvement Plans to be monitored and reevaluated in 3 months. 4. Administrator to monitor for compliance.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to adhere to proper infection control practices during medication administration for one resident. Specifically, a Licensed Practical Nurse (LPN) was observed administering a 5 mg tablet of amlodipine, a medication used to treat high blood pressure, to a resident after it had been dropped on the medication cart. The LPN picked up the tablet with her bare hands and proceeded to give it to the resident, which is against the facility's infection control protocols. The incident occurred on February 5, 2025, and involved Resident 41, who had a physician's order for amlodipine that had been discontinued the previous day. The LPN confirmed during an interview that she should not have handled the medication with her bare hands. The Nursing Home Administrator also confirmed that staff are instructed not to touch residents' medications with their bare hands, indicating a breach in the facility's infection prevention and control program.
Plan Of Correction
1. Resident 41 was assessed and no harm suffered from ingesting the touched pill. 2. Any resident has the potential to be affected by this deficient practice. 3. Nurses have been re-educated on the policy of not touching medication with bare hands. Three nurses will be observed each week doing a medication pass for one resident each. This audit will be done weekly x 4 and then monthly x2 and reported to the Quality Assurance team for review. Director of Nursing or designee will monitor.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in the documentation of their medical status. For one resident, the MDS assessment inaccurately indicated that the resident had not received several medications, including an anti-anxiety medication, an antidepressant, an anticoagulant, and an antibiotic, despite physician's orders confirming their administration. This discrepancy was confirmed during an interview with the Nursing Home Administrator, who acknowledged the incorrect coding of the resident's MDS assessment. Another resident's MDS assessment was also inaccurately coded regarding their discharge status. The assessment indicated that the resident was discharged to the hospital, while nursing notes documented that the resident was discharged home with his brother. This error was similarly confirmed by the Nursing Home Administrator during an interview, highlighting a failure in accurately reflecting the resident's discharge status in the MDS assessment.
Plan Of Correction
1. Resident 63 significant change assessment, assessment reference date of 11/29/2024 was corrected and resubmitted to include the following medications: N0415B, N0415C, N0415E and N0415F. Resident 78 discharge assessment was corrected and resubmitted on 2/4/2025. 2. Any resident has potential to be affected by this deficient practice. 3. Staff have been reeducated on section N for medication listing and section A for discharge disposition. 4. Six random assessments a week will be audited times 4 weeks. These audits will verify that medications are properly coded and/or discharge disposition was correct. Audits will be submitted to Quality Assessment Team for review and to determine if audits should continue. Director of Nursing or designee will monitor.
Staffing Ratio Deficiency
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident staffing ratios on several occasions, as evidenced by a review of nursing schedules, staffing information, and staff interviews. On November 28, 2024, the facility had a census of 75 residents, necessitating 7.50 NAs during the day shift, but only 7.03 NAs were available. On November 29, 2024, the evening shift required 6.82 NAs, but only 5.83 NAs were present. Additionally, the overnight shift on the same day required 5.00 NAs, but only 4.40 NAs were available. Further deficiencies were noted on December 8, 2024, and February 2, 2025, where the overnight shifts were understaffed with 4.60 and 4.90 NAs, respectively, against the required numbers. The Nursing Home Administrator confirmed these staffing deficiencies during an interview on February 6, 2025. The report indicates that no additional higher-level staff were available to compensate for the shortfall in nurse aides, leading to non-compliance with the staffing regulations effective from July 1, 2024. The facility's inability to meet the mandated staffing ratios on these specific days highlights a failure to adhere to the regulatory requirements for adequate resident care.
Plan Of Correction
1. No individual resident was named or harmed. 2. Any resident has potential to be harmed by failure to have adequate staffing. 3. Facility has contracted with temporary agencies to fill upcoming vacancies. In the case of call-offs, there is not often adequate time to find another coverage. Two upcoming nurse aide training classes will yield newly trained aides to fill vacancies on a permanent basis. Facility continues to advertise openings and opportunities. 4. Review of the daily schedule with nursing administration and Administrator continue. Weekly audits to ensure compliance of staffing ratios will be done x 4 weeks, then monthly x 2. Reviews submitted to the Quality Assurance team for review. Administrator to monitor for compliance.
Deficiency in Meeting Required Direct Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident in a 24-hour period. This deficiency was identified during a review of nursing time schedules for specific periods, including November 23 through 29, 2024; December 5 through 11, 2024; and January 30 through February 5, 2025. It was found that on November 29, 2024, the facility provided only 3.11 hours of direct care per resident. This shortfall was confirmed during an interview with the Nursing Home Administrator on February 6, 2025.
Plan Of Correction
1. No individual resident was named or harmed. 2. Any resident has potential to be harmed by failure to have adequate staffing. 3. Facility has contracted with temporary agencies to fill upcoming vacancies. In the case of call-offs, there is not often adequate time to find another coverage. Two upcoming nurse aide training classes will yield newly trained aides to fill vacancies on a permanent basis. Facility continues to advertise openings and opportunities. 4. Review of the daily schedule with Nursing Administration and Administrator continue. Weekly audits to ensure compliance with required direct resident care hours will be done x 4 weeks, then monthly x 2. Reviews submitted to Quality Assurance team for review. Administrator to monitor for compliance.
Failure to Complete Timely Admission MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive admission Minimum Data Set (MDS) assessments within the required timeframe for two residents. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, admission MDS assessments must be completed no later than 13 calendar days after a resident's admission. However, for Resident 2, the MDS assessment was completed 29 days after admission, as confirmed by the Nursing Home Administrator. This delay in assessment completion was a clear deviation from the required guidelines. Additionally, for Resident 4, there was no documented evidence that the admission MDS assessment was completed within the required timeframe. Resident 4 was admitted with a diagnosis of malignant neoplasm, yet the necessary assessment documentation was missing as of the survey date. The Nursing Home Administrator confirmed the absence of this documentation, indicating a failure to adhere to the mandated assessment schedule for this resident as well.
Failure to Develop Hospice Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for one of the residents, specifically Resident 4, who was admitted to hospice care. According to the facility's policy, care plans should include measurable objectives and timetables to meet the resident's needs and should be revised as the resident's condition changes. Despite the physician's orders and nursing notes indicating that Resident 4 was on hospice care, there was no documented evidence of a care plan addressing the resident's individualized needs related to hospice care as of October 2, 2024. This deficiency was confirmed during an interview with the Nursing Home Administrator.
Failure to Timely Complete Quarterly MDS Assessment
Penalty
Summary
The facility failed to complete a quarterly Minimum Data Set (MDS) assessment for a resident within the required timeframe. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, a quarterly assessment must be completed no later than 14 calendar days after the assessment reference date (ARD). For one resident, the ARD was August 2, 2024, but the MDS assessment was not completed until September 3, 2024, which was 32 days after the ARD. This delay was confirmed during an interview with the Nursing Home Administrator.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update care plans to reflect changes in residents' care needs for three residents. For Resident 1, the care plan was not revised to include new blood pressure parameters for diuretic medications, despite new physician orders being issued due to concerns about low blood pressure and syncopal episodes. The care plan, dated January 10, 2023, did not reflect these changes, and this was confirmed by the Nursing Home Administrator. Resident 2's care plan was not updated to reflect her preference for showers and her family's request for more frequent showers. Although the resident was cognitively intact and had a preference for showers, the care plan did not document this preference or the family's request, as confirmed by the Nursing Home Administrator. For Resident 4, the care plan was not updated to include the use of a fall mat after a fall from bed, despite a nursing note indicating the addition of this intervention. Observations showed the fall mat was not in use, and the care plan did not reflect this change, which was confirmed by the Nursing Home Administrator.
Incomplete Clinical Records and Medication Administration Errors
Penalty
Summary
The facility failed to maintain complete and accurately documented clinical records for a resident, as evidenced by missing documentation of orthostatic blood pressure results. The resident, who had diagnoses including congestive heart failure, hypertension, and COPD, was ordered to have orthostatic blood pressures monitored daily for a week. However, there was no documented evidence of the results for specific dates, despite nursing staff indicating that the measurements were obtained. This lack of documentation was confirmed by the Nursing Home Administrator. Additionally, there was a discrepancy in the Medication Administration Record (MAR) for the resident. The resident was prescribed diuretic medications with specific instructions to hold the medication if blood pressure readings were below certain thresholds. On one occasion, the resident's blood pressure was documented as below the threshold, yet a dose of Spironolactone was administered according to the MAR. The Nursing Home Administrator confirmed that the nurse had intended to hold the medication but documented it incorrectly, leading to an inaccurate MAR.
Failure to Include Necessary Information in Baseline Care Plans
Penalty
Summary
The facility failed to ensure that baseline care plans included the necessary information and instructions to provide person-centered care for four residents within 48 hours of their admission. Resident 77's baseline care plan did not include information regarding the care or services required for the treatment with an anticoagulant, diuretic, or antibiotic medication. Similarly, Resident 78's baseline care plan lacked details about the care or services required for the treatment with a sleeping pill for insomnia and the use of oxygen. These omissions were confirmed by the Nursing Home Administrator during interviews on March 20 and 21, 2024. Resident 79's baseline care plan did not include information regarding the care or services required for the treatment with an anti-anxiety or antidepressant medication. Additionally, Resident 82's baseline care plan failed to include information regarding the care or services required for the treatment with an anticoagulant medication or the care needed for a skin tear. These deficiencies were also confirmed by the Nursing Home Administrator during interviews on March 20, 2024. The facility's policy, dated January 15, 2024, mandates that a baseline care plan be developed within 48 hours of admission to meet the resident's immediate needs, which was not adhered to in these cases.
Failure to Update Care Plans
Penalty
Summary
The facility failed to ensure that care plans were updated to reflect changes in care needs for four residents. For Resident 6, the care plan did not include instructions for the use of hearing aids, specifically the collection and re-insertion of the aids, despite a Medication Administration Record Note indicating this practice. Observations and interviews confirmed that the care plan was not revised to include these details. Similarly, Resident 25's care plan was not updated to reflect that the resident did not use a Dexcom glucose monitor, as the facility did not accept the device, and instead, staff performed accuchecks four times a day. This discrepancy was confirmed through interviews with the resident and the Nursing Home Administrator. Resident 57's care plan did not include physician's orders to flush the nephrostomy tubing and change the nephrostomy collection bag, despite these orders being documented. This omission was confirmed through interviews. Lastly, Resident 67's care plan was not updated to reflect the discontinuation of a urinary catheter and intravenous medication, as per physician's orders. This was also confirmed through interviews with the Nursing Home Administrator. These deficiencies indicate a failure to update care plans in accordance with changes in residents' care needs, as required by the facility's policy and regulatory standards.
Failure to Document Periodic Evaluations in Restorative Nursing Programs
Penalty
Summary
Monitoring of the resident's restorative nursing programs for range of motion and transferring did not reflect the resident's progress toward program goals for two residents. The facility's policy on restorative nursing, dated January 15, 2024, requires periodic evaluation and documentation of the resident's progress by a licensed staff member at least quarterly. However, for Resident 3, who has dementia and Parkinson's disease, there was no documented evidence of a periodic evaluation of progress or lack of progress toward meeting the resident's goals for transferring from bed to a power chair with assistance. Similarly, for Resident 14, who has a diagnosis of Cerebral Vascular Accident with hemiplegia, there was no documented evidence of a periodic evaluation of progress or lack of progress toward meeting the resident's goals for passive range of motion exercises to her upper and lower extremities to prevent contracture and skin injury. The deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the lack of documented evidence in the clinical records of both residents. The absence of periodic evaluations by a licensed staff member at least quarterly, as required by the facility's policy, indicates a failure to monitor and document the residents' progress in their restorative nursing programs. This failure affects the ability to assess and adjust the care plans to ensure the residents achieve and maintain an optimal level of self-care and independence.
Failure to Administer Pain Medications as Ordered
Penalty
Summary
The facility failed to administer pain medications as ordered by the physician for two residents. For Resident 78, the physician's orders specified hydrocodone-acetaminophen to be given every twelve hours as needed for a pain rating of 6 to 10. However, the Medication Administration Record (MAR) showed that the medication was administered for pain ratings less than six on three occasions in March 2024. Similarly, for Resident 82, the physician's orders specified oxycodone to be given every four hours as needed for a pain rating of 6 to 10. The MAR revealed that the medication was administered for pain ratings less than six on six occasions in March 2024. The Nursing Home Administrator confirmed that the medications were not administered as ordered by the physician.
Failure to Maintain Accountability for Controlled Medications
Penalty
Summary
The facility failed to maintain accountability for controlled medications for one of the 36 residents reviewed. The facility's policy required accurate accountability of all controlled drugs, including documentation of administration details on the accountability record and Medication Administration Record (MAR). However, for Resident 63, who was cognitively intact and required assistance for daily care needs, there was no documented evidence that the signed-out doses of Oxycodone were actually administered on several dates in February 2024. The MAR indicated doses were signed out, but the clinical record, including the MAR controlled drug record and nursing notes, did not contain documentation confirming administration. An interview with the Director of Nursing confirmed the lack of documented evidence for the administration of the signed-out doses of Oxycodone to Resident 63. This deficiency was identified based on the review of policies, clinical records, and staff interviews, indicating a failure to adhere to the facility's policy on controlled substances and maintain accurate accountability for the medications administered to the resident.
Failure to Administer Insulin Aspart as Prescribed
Penalty
Summary
The facility failed to ensure that it was free from significant medication errors for one of 20 residents reviewed. The facility's medication administration policy required medications to be administered as prescribed. Manufacturer's instructions for Aspart indicated that the medication should be administered within five or ten minutes of a meal. Physician's orders for Resident 20 included orders for the resident to receive 10 units of insulin Aspart before breakfast, lunch, and dinner. However, the Medication Administration Records for January, February, and March 2024 revealed that Resident 20 received his insulin at times that did not align with his meal times. Specifically, insulin was administered at 9:00 a.m., 10:00 a.m., and 3:00 p.m., while meal times were 8:10 a.m., 11:40 a.m., and 4:40 p.m. An interview with the Director of Nursing confirmed that Resident 20 was not receiving his insulin per the manufacturer's instructions.
Failure to Discard Expired Medications
Penalty
Summary
The facility failed to discard expired medication in one of two medication rooms reviewed. Specifically, in Medication room [ROOM NUMBER], a Forteo injection pen was found with an expiration date of [DATE], and five 100 cc bags of outdated IV stock solution were discovered, with two bags expired in [DATE] and three in [DATE]. This was confirmed through observations and staff interviews. The facility's policy, dated [DATE], stated that outdated drugs or biologicals would not be used, yet these expired items were not discarded as required. Interviews with a Registered Nurse and the Nursing Home Administrator confirmed the oversight.
Failure to Notify Ombudsman of Resident Hospitalizations
Penalty
Summary
The facility failed to notify the State Long-Term Care Ombudsman about the hospitalizations of three residents. Resident 24, who had congestive heart failure and coronary artery disease, was transferred to the hospital for a cardiac evaluation. Resident 49, who had hypertension, was sent to the emergency room for low blood pressure and admitted to the medical intensive care unit with a diagnosis of hypotension. Resident 57, who had kidney failure and hydronephrosis, was transferred to the hospital due to issues with her nephrostomy tube. In all three cases, there was no documented evidence that a written notice of the transfer was provided to the Ombudsman as required by the facility's policy and state regulations. The Nursing Home Administrator confirmed during an interview that there was no written notification to the State Long-Term Care Ombudsman for the hospitalizations of Residents 24, 49, and 57, despite the facility's policy mandating such notifications. This failure to notify the Ombudsman was identified during a review of policies, clinical records, and staff interviews, and it was determined that the facility did not comply with the required notification procedures for resident transfers to the hospital.
Inaccurate MDS Assessments
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for five residents. The deficiencies were identified through a review of the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews. Specifically, the assessments for Residents 20, 27, 31, 58, and 72 were found to be incomplete or inaccurately coded. For instance, Resident 20's quarterly MDS assessment indicated clear speech and understanding, yet Sections C, D, and K were not assessed. Similarly, Resident 27's assessment had multiple sections left unassessed, and Resident 58's assessment also had several sections marked with dashes, indicating they were not completed. The RN Assessment Coordinator (RNAC) confirmed these omissions and noted that the facility uses a remote RNAC who does not physically assess the residents, contributing to the inaccuracies and omissions in the MDS assessments. Further discrepancies were found in the assessments for Residents 31 and 72. Resident 31's annual MDS assessment showed inconsistencies between the sections, with Section B0700 indicating the resident was understood by others, while Section C0100 suggested the resident was rarely/never understood, leading to incomplete cognitive status assessments. Additionally, Sections F0300 and F0400, which pertain to daily and activity preferences, were not assessed. Resident 72's admission MDS assessment also showed that while the resident could understand and be understood by others, the sections related to daily preferences were not completed. The RNAC confirmed these coding inaccuracies during an interview. The report highlights that the facility's failure to accurately complete MDS assessments is a significant deficiency. The RAI User's Manual provides clear instructions for coding various sections of the MDS, yet these were not followed, leading to incomplete and inaccurate assessments. This failure was confirmed by the RNAC, who acknowledged the inaccuracies and the role of the remote RNAC in contributing to these issues. The facility's non-compliance with the RAI Manual's guidelines resulted in incomplete documentation of residents' abilities and care needs, which is critical for providing appropriate care.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that included specific and individualized interventions to address the care needs of three residents. Resident 20, who was alert and oriented, had a physician's order to receive 2.5 mg of Xarelto twice a day, but his care plan did not include any information or interventions related to the anticoagulant. Similarly, Resident 27, who had a cardiac pacemaker and was cognitively intact, had a physician's order for a pacemaker check, but his care plan did not include any information or interventions related to the pacemaker. These omissions were confirmed by the Nursing Home Administrator during an interview on March 19, 2024. Resident 72, who was cognitively intact and received multiple medications including an anti-depressant, diuretic, anti-platelet, antibiotic, and hypoglycemic, also did not have a care plan in place for these medications. This was confirmed during an interview with the Nursing Home Administrator and Assistant Director of Nursing on March 20, 2024. The facility's policy, dated January 15, 2024, indicated that care plans should be developed based on residents' needs, but this was not adhered to for the three residents reviewed.
Failure to Follow Physician's Orders for Two Residents
Penalty
Summary
The facility failed to follow physician's orders for two residents. For Resident 57, who had chronic kidney disease and a nephrostomy tube, the physician's orders required staff to check the patency of the nephrostomy tube every eight hours. However, the clinical record revealed that this was not done for several eight-hour periods in February and March 2024. This failure was confirmed by an LPN and the Nursing Home Administrator, who acknowledged the importance of these checks due to the resident's history of suture issues and potential complications with the nephrostomy tube. The resident experienced complications, including the tube being out of place and blood in the drainage bag, leading to hospitalization for tube replacement. For Resident 63, who had Type 2 Diabetes Mellitus, the physician's orders required blood sugar checks before meals. The resident's MAR showed significantly elevated blood sugar levels on multiple occasions in February 2024, but there was no documented evidence that the physician was notified of these elevated levels. This oversight was confirmed by the Director of Nursing. The lack of communication with the physician regarding the resident's elevated blood sugars represents a failure to follow the prescribed care plan and ensure appropriate medical intervention.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to ensure that annual performance evaluations for nurse aides were completed as required. Specifically, for one of the three nurse aides reviewed, Nurse Aide 3, the annual performance evaluation was due on February 13, 2024, but as of March 21, 2024, there was no documented evidence that this evaluation had been completed. This deficiency was confirmed during an interview with the Human Resource Director, who could not provide evidence of the completed evaluation. This failure is a violation of the facility's responsibility and management regulations as outlined in 28 Pa. Code 201.14(a), 28 Pa. Code 201.18(b)(1)(3)(e)(1), and 28 Pa. Code 201.20(a)(c).
Failure to Complete MDS Assessments on Time
Penalty
Summary
The facility failed to ensure that the Care Area Assessment Process of comprehensive Minimum Data Set (MDS) assessments and comprehensive assessments were completed within the required time frame for three residents. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, admission MDS assessments must be completed no later than 13 calendar days after admission, and there must be an MDS every 92 days. However, the comprehensive MDS assessments for three residents were completed late. Specifically, Resident 17's assessment was one day late, Resident 68's assessment was three days late, and Resident 71's assessment was one day late. These delays were confirmed by the Registered Nurse Assessment Coordinator (RNAC) during an interview on March 18, 2024, at 1:35 p.m. The deficiencies were identified based on a review of the Resident Assessment Instrument User's Manual, clinical records, the CMS Minimum Data Set validation report, and staff interviews. The facility's failure to complete the comprehensive MDS assessments within the required time frames for the three residents reviewed indicates non-compliance with the regulatory requirements. This non-compliance was documented under 28 Pa. Code 211.5(f) Clinical Records.
Failure to Complete Quarterly MDS Assessment on Time
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed within the required time frame for one of the 36 residents reviewed. Specifically, a quarterly MDS assessment for Resident 16 had an Assessment Reference Date (ARD) of February 24, 2024, but was not completed until March 11, 2024, which was two days late. This was confirmed during an interview with the Registered Nurse Assessment Coordinator (RNAC) on March 18, 2024. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual mandates that the ARD of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment, and the assessment must be completed no later than 14 calendar days after the ARD.
Latest citations in Pennsylvania
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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