Crosslands
Inspection history, citations, penalties and survey trends for this long-term care facility in Kennett Square, Pennsylvania.
- Location
- 1660 East Street Road, Kennett Square, Pennsylvania 19348
- CMS Provider Number
- 395388
- Inspections on file
- 18
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Crosslands during CMS and state inspections, most recent first.
The facility did not follow its own Criminal Record/FBI Check Policy when hiring a staff member who had not been a state resident for the required two-year period. Policy required an FBI national criminal background check for such individuals upon hire, but review of the employee’s personnel file showed no evidence that an FBI check was initiated or completed. The NHA confirmed that the employee did not meet the two-year residency requirement and that the FBI check had not been done, resulting in a failure to properly screen the individual for findings of abuse, neglect, exploitation, or theft before employment.
A resident discharged to independent living did not have proper documentation of medication disposition completed at discharge. Facility policy required the licensed nurse to remove all medications from the med cart, count remaining quantities, and document the amounts and disposition on a printed eMAR or in an ID note, then ensure it was entered into the EHR. For this resident, the nurse discharge summary only stated that all medications were given to the resident, without recording the quantities of medications. The DON later confirmed that the required documentation of medication disposition was not completed, resulting in a failure to follow the facility’s clinical records policy.
A resident's care plan for continence was not followed, leading to a fall and injury. The resident, who was supposed to be toileted at specific intervals, was last toileted at 9:00 a.m. and later found on the floor with a hematoma. The facility's documentation and staff interviews confirmed the care plan was not adhered to, resulting in the fall.
A resident fell from a Broda chair, sustaining a hematoma and other symptoms, due to the facility's failure to follow the resident's toileting care plan. Despite the incident and the facility's policy requiring investigation of suspected abuse or neglect, no investigation was conducted.
A facility failed to ensure accurate assessments for a resident, as the discharge MDS indicated an incorrect discharge location. The resident was marked as discharged to an acute hospital, but records showed they were discharged home. This error was confirmed by the RNAC during an interview.
The facility failed to notify physicians in a timely manner of multiple medication errors experienced by 15 residents. The errors, originating from the contracted pharmacy, were identified through internal audits. Despite the findings, attending physicians were not informed until much later, as confirmed by the DON and NHA.
The facility failed to address pharmacy delivery errors, resulting in 70 medication errors for 15 residents. These errors were due to late deliveries from the contracted pharmacy, leading to missed doses of critical medications for conditions such as pain, glaucoma, calcium deficiency, insomnia, and more. The facility is now seeking a new pharmacy to meet residents' needs.
Failure to Obtain Required FBI Background Check Prior to Hiring Staff
Penalty
Summary
The facility failed to thoroughly screen an individual prior to hire by not obtaining a required FBI criminal background check for one of five employee records reviewed (Employee E3). The facility’s Criminal Record/FBI Check Policy, revised March 14, 2022, required that a criminal record check and, when applicable, an FBI national check be processed for all staff members upon hire, specifying that an FBI check is required if the staff member is not a current Pennsylvania resident or has not been a state resident for the two years preceding the application. Review of Employee E3’s personnel record showed that this employee was hired on December 18, 2025, with no evidence that an FBI check had been initiated or completed. In an interview on February 20, 2026, at 12:43 p.m., the Nursing Home Administrator confirmed that Employee E3 had not been a Pennsylvania resident for the required two-year period and that the FBI check had not been completed, resulting in noncompliance with the facility’s policy and regulatory requirements related to screening for abuse, neglect, exploitation, or theft findings.
Failure to Document Medication Disposition at Discharge
Penalty
Summary
The facility failed to ensure accurate documentation of the disposition of medications upon discharge for one discharged resident. Facility policy on disposition of noncontrolled medications, revised in December 2025, required the licensed nurse to remove all of a discharged resident’s medications from the medication cart, count the remaining quantities, and document the disposition by printing the resident’s eMAR, recording the amounts of medications returned to the pharmacy on the printout, dating and initialing it, and scanning it into the EHR; alternatively, the nurse could document in an ID note the medication names, dosages, amounts remaining, and disposition. Clinical record review for Resident 51, who was discharged to independent living on December 19, 2025, showed that the nurse discharge summary stated all medications were given to the resident, but did not record or document the quantity of medications. In an interview on February 20, 2026 at 1300, the Director of Nursing confirmed that the required documentation of medication disposition was not completed for this resident, constituting noncompliance with 28 Pa. Code 211.5(d)(f) regarding clinical records.
Failure to Follow Care Plan Results in Resident Fall and Injury
Penalty
Summary
The facility failed to adhere to a resident's care plan, resulting in a fall and subsequent harm. Resident 52, who had a care plan for continence management, was not toileted according to the specified schedule. The care plan required checks and changes upon waking, before bed, before and after meals, and at specific times during the night. However, the resident was last toileted at 9:00 a.m., and the fall occurred later that morning. The resident was found on the floor with a large hematoma on the forehead, complaining of dizziness and an upset stomach, and was subsequently transported to the emergency room for evaluation. The facility's documentation and staff interviews revealed that Resident 52 had been repositioned in a Broda chair multiple times before the fall, indicating attempts to move forward in the chair. Despite these observations, the care plan was not followed, as the resident was not toileted as required. The post-fall investigation confirmed that the root cause of the fall was the failure to follow the toileting care plan, leading to the resident's fall and injury.
Plan Of Correction
In accordance with Facility Policy-Comprehensive Person-Centered Care Plan (#11.01), the Interdisciplinary Team will meet each resident's goals, based on a comprehensive assessment of the resident's physical, psychological, social and spiritual needs. In addition, in accordance with Facility Policy - Minimum Data Set (MDS) Completion (#11.02), residents residing in skilled nursing will be assessed by the Interdisciplinary Team upon admission, annually, quarterly and with significant change in condition. A review of Resident #52 indicated the facility completed assessments for reference periods 5-14-24 to 5-20-24 (Comprehensive Admission Assessment); 8-14-24 to 8-20-24 (Quarterly Assessment) and 11-13-24 to 11-29-24 (Quarterly Assessment). A comprehensive review of Resident #52 Care Plans was completed January 23, 2025 by the Interdisciplinary Team and found to be current. All resident care plans are reviewed annually, quarterly and with significant change in condition. In accordance with the Facility Policy 5.13 - Resident Info SNAP Sheet, the Facility will conduct an audit using the Care Plan Audit Form of all current resident Care Plans, covering Activities of Daily Living, Continence and Falls Prevention Care Plans to ensure Care Plans are current no later than March 7, 2025. Findings will be reported at the next quarterly Quality Assurance Committee meeting. Utilizing a Care Plan Monitoring Tool, beginning February 17th, 2025, a Facility staff member/designee shall monitor 10% of current residents weekly for the first four weeks to ensure care plans of current residents are being followed. Thereafter, monitoring of 10% of current residents will occur on a monthly basis up to 90 days. Findings will be reported at the next quarterly Quality Assurance Committee meeting. All staff will be educated on the definition, importance, and process for the comprehensive plan of care of residents no later than 2/21/2025.
Failure to Investigate Possible Abuse/Neglect Incident
Penalty
Summary
The facility failed to investigate an incident involving possible abuse or neglect of a resident. The incident involved a resident who fell from a Broda chair and sustained a large hematoma on the forehead, along with other symptoms such as dizziness and an upset stomach. The resident was sent to an acute care facility to rule out a head bleed, and upon return, was found to have bruising and fecal smearing. The facility's policy requires immediate reporting and investigation of suspected abuse or neglect, but this was not followed in this case. The resident's care plan included a specific toileting program, which was not adhered to, leading to the fall. The resident had been observed earlier attempting to move forward in the Broda chair and was repositioned by staff. Despite these observations and the fall, the facility did not conduct an investigation into potential abuse or neglect, as confirmed by an interview with a licensed employee. The failure to follow the care plan and the lack of investigation into the incident constitute the deficiency.
Plan Of Correction
The Facility will conduct a review of all current residents in similar situations for which an Electronic Event Report was submitted to the Pennsylvania Department of Health during the period January 9, 2024 to January 9, 2025. The Neglect Screening Tool will be utilized to conduct this review by the Interdisciplinary Team to ensure there were no other instances that required further investigation to determine neglect. Review will be completed no later than 2/28/25. Findings of this audit will be shared with the Facility Quality Assurance Committee at the next quarterly meeting. All staff will be re-educated on Facility Policy and Procedure titled Resident Abuse/Neglect/Misappropriation of Property Prevention (12/23) no later than 2/21/25. The training referenced above will also include discussion of the procedures to follow where, in different situations than this, "neglect" is found, and the subsequent investigations and reporting that must accompany such a finding. A follow-up review of incident and resident 52's medical record was conducted on January 20 -23, 2025 by Administrator, Director of Nursing, Medical Director and members of the Interdisciplinary Team. A Preventative Abuse Incident Monitor will be conducted by NHA or designee to include: Missing Property, Skin Incidents of Unknown Origin and Events Reported to Department of Health involving Abuse, Neglect, Misappropriation. This monitor will include any similar situations involving Event Reports submitted reported to the Pennsylvania Department of Health in which the checklist was utilized. Findings will be reported at the Quarterly QA Committee Meeting.
Inaccurate Resident Discharge Assessment
Penalty
Summary
The facility failed to ensure that assessments accurately reflected the resident's status for one of the 24 residents reviewed. Specifically, for Resident 58, the discharge Minimum Data Set (MDS) assessment inaccurately indicated that the resident was discharged to an acute hospital. However, a review of the clinical record, including the discharge/transfer summary dated December 5, 2024, revealed that the resident was actually discharged home on that date. This discrepancy was confirmed during an interview with the RNAC, Employee E4, on January 9, 2025, at 11:50 a.m., who acknowledged that the MDS assessment was marked incorrectly.
Plan Of Correction
Upon review of MDS assessment for Resident 58, discharge location was marked in error on Discharge MDS Assessment of Resident 58. Correction was immediately made ("hospital to home") and resubmitted on January 9, 2025, while the surveyor was onsite. RNAC will run "Discharge Register" from EMR on a monthly basis to conduct an audit of discharge MDS and death trackers to confirm accuracy of discharge location. Findings of the audit will be included in the monthly Quality Assurance Documentation Committee report and reported at the quarterly Quality Assurance Committee meeting.
Failure to Timely Notify Physicians of Medication Errors
Penalty
Summary
The facility failed to notify the physician in a timely manner of multiple medication errors experienced by 15 residents. The errors, which were due to inaccuracies from the contracted pharmacy, were identified through internal audits and investigations conducted by the facility. From September 1, 2023, through October 22, 2023, 15 residents experienced 70 medication errors. Despite these findings, the attending physicians were not informed of the errors until December 14 and 15, 2023. This delay in notification was confirmed by the Director of Nursing and the Nursing Home Administrator during interviews on January 22, 2024.
Failure to Address Pharmacy Delivery Errors
Penalty
Summary
The facility failed to identify and address pharmacy delivery errors, resulting in multiple medication errors for 15 residents. These errors were due to the pharmacy delivering medications late, which led to the residents not receiving their prescribed medications on time. The errors included missed doses of critical medications such as Gabapentin, Remeron, Combigan, Latanoprost, Travatan, Saline Nasal Spray, Cosopt, Restasis, Vitamin C, Oyster Shell, Vitamin D3, Vitamin B Complex, Melatonin, Guafenesin, Ferrous Sulfate, Clonazepam, Albuterol, Rytary, Famotidine, Beano, Allegra, Centrum, and Senna. These medications are used to treat various conditions, including pain, appetite stimulation, glaucoma, calcium deficiency, insomnia, iron deficiency, restless leg syndrome, asthma, Parkinson's, nausea, allergies, and constipation. The facility conducted internal audits and investigations, revealing that from September 1, 2023, through October 22, 2023, 15 residents experienced 70 medication errors due to late deliveries from the contracted pharmacy. Interviews with the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed the frequency and impact of these errors. Specific instances included multiple missed doses for individual residents, such as R1 not receiving Gabapentin on September 20, 2023, and R2 missing doses of Remeron on three separate occasions. The facility's failure to ensure timely delivery of medications from the pharmacy led to significant medication errors, affecting the health and well-being of the residents. The DON and NHA acknowledged the issue and confirmed that the facility is in the process of finding a new pharmacy to meet the residents' needs. The facility also provided education to nursing staff on medication error policies and conducted pharmacy and medication audits in November and December 2023.
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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