Embassy Of Park Avenue
Inspection history, citations, penalties and survey trends for this long-term care facility in Meadville, Pennsylvania.
- Location
- 14714 Park Ave Extension, Meadville, Pennsylvania 16335
- CMS Provider Number
- 395588
- Inspections on file
- 23
- Latest survey
- February 23, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Embassy Of Park Avenue during CMS and state inspections, most recent first.
The facility failed to follow its own policies prohibiting routine use of disposable food service items, resulting in meals being served in Styrofoam containers on multiple evenings and weekends over several weeks. Several residents reported that food served in these containers was cold, did not taste good, and in some cases was not eaten, with one resident choosing to order out instead. Resident council and food committee notes had already documented concerns that food was cold and sometimes hard. Nursing staff, CNAs, and dietary staff acknowledged that Styrofoam containers were used for dinner meals, sometimes due to staffing, and leadership confirmed that this practice had occurred, affecting residents’ perception of meal quality and dignity.
The facility failed to honor resident bathing preferences and follow its own personal care policy by not providing showers or baths as requested or scheduled for multiple residents. One resident with significant neurological and gastrointestinal conditions reported wanting daily showers and at least twice-weekly bathing but had limited documented shower offers and was observed with greasy hair. Another resident with cardiac and metabolic conditions reported missing a scheduled shower that staff attributed to a lack of hot water, while records inaccurately documented the event as a refusal. Several other residents scheduled for showers on the same day received bed baths instead, with staff citing no hot water, although the Maintenance Director confirmed hot water was available. The NHA and DON acknowledged that these residents did not receive showers or baths according to their stated preferences and that required twice-weekly bathing was not consistently provided.
The facility failed to follow its planned menus and did not document or communicate food substitutions to residents and staff. Multiple residents reported receiving foods that did not match the posted menu without prior notice. Staff interviews revealed that substitutions, such as serving cabbage instead of brussels sprouts, mashed potatoes instead of biscuit mix for pot pie, and pears instead of apples, occurred because ordered food items were not delivered or ran out. An LPN noted that nursing staff and residents were not informed of these changes, and required documentation on the menu substitution log and updates to posted menus were not completed.
The facility did not follow its freezer maintenance policy requiring regular cleaning and removal of excess ice in the main kitchen walk-in freezer. Surveyors observed heavy ice accumulation on the ceiling extending from the condenser, on the floor near the entrance, and on frozen food boxes on top shelves, with the condenser coils encased in ice. The Dietary Manager confirmed these conditions and acknowledged that the ice should be removed.
Surveyors found that two nurse station closets used for oxygen storage were not properly designed or constructed for storing over 300 cubic feet of oxygen cylinders, and one cylinder was left unsecured. The maintenance supervisor confirmed these deficiencies during the survey.
Surveyors observed that the first floor therapy exit door was obstructed by ice and snow, preventing it from opening fully and resulting in an unsafe evacuation surface. The maintenance supervisor confirmed the deficiency during the inspection.
The facility did not meet required NA staffing ratios on multiple day, evening, and overnight shifts, as confirmed by staffing records and the Nursing Home Administrator. These deficiencies were identified through review of staffing documents, with actual NA numbers falling below the minimum required based on resident census.
The facility did not provide the required minimum of 3.2 hours of direct nursing care per resident per day on two reviewed days, as confirmed by staffing records and the Nursing Home Administrator.
The facility did not ensure dignified meal service, as residents seated at the same table were not served at the same time, leading to some eating while others waited or finished before their tablemates received food. Meals were often served in Styrofoam containers and were reported to be cold, with staff and residents attributing these issues to dietary staffing shortages.
A resident with a history of NSTEMI, type II diabetes, and muscle weakness experienced slurred speech and appeared off, but the physician and emergency contact were not notified promptly as required by facility policy. The DON and administrator confirmed that notification and documentation should have occurred at the time of the incident.
The facility did not maintain adequate dietary staffing, leading to meals being served in Styrofoam containers and often arriving cold. Residents and a family member reported these issues, and staff confirmed that staffing shortages caused the use of foam containers and inconsistent meal service. The expected staffing levels were not met, impacting meal quality and service.
The facility did not meet the required nurse aide staffing ratios during a day shift, with only 9.38 NAs available for 114 residents, falling short of the mandated 11.40 NAs. This deficiency was confirmed by the Nursing Home Administrator.
A facility failed to notify a resident's representative of a change in treatment and x-ray findings, as required by their policy. The resident, who had multiple health issues, received a new order for Voltaren Gel, but there was no evidence of communication with the representative. Both the resident's representative and the DON confirmed the lack of notification.
The facility failed to provide proper care for two residents with indwelling catheters, as their catheter drainage bags were found uncovered and on the floor, contrary to facility policy. One resident had a recent hospitalization for a UTI, and both residents have medical histories that include conditions affecting bladder function. The DON confirmed the bags should not be uncovered or on the floor due to infection risks.
The facility did not maintain the safe operation of the walk-in freezer in the main kitchen, as required by their policy. Observations revealed significant ice accumulation on the ceiling, floor, and condenser coils, with water and ice dripping onto frozen food boxes. The Dietary Manager confirmed these conditions.
A facility failed to follow its policy requiring two staff members for mechanical lift transfers, as observed when a nurse aide transferred a resident with rheumatoid arthritis and mobility issues without assistance. Interviews with staff and the resident confirmed the usual practice of having two aides, highlighting a deficiency in management and nursing services.
Use of Styrofoam Meal Containers Undermining Resident Dignity
Penalty
Summary
The facility failed to honor resident dignity and self-determination by not implementing dignified feeding practices and by serving meals in Styrofoam containers on multiple occasions over several weeks. Facility policies stated that the environment must be safe, functional, sanitary, and comfortable, and that paper products such as disposable plates, bowls, cups, and utensils were prohibited in dietary operations except in approved emergency situations, in part to support resident dignity. Despite this, residents reported that meals were served in Styrofoam containers at dinner on evenings and weekends, and that the food was often cold and unpalatable when served this way. Resident council and food committee minutes documented prior concerns that food was cold and sometimes hard. Multiple residents reported that they had been receiving meals in Styrofoam containers for the last few weeks, not only during a recent water issue but also at other times without explanation. Several residents stated that when meals were served in disposable containers, the food was cold, did not taste good, and in at least one case was considered not worthy of eating, leading that resident to order food from outside the facility instead. Nursing staff, including LPNs and CNAs, confirmed that evening and weekend meals had been served on Styrofoam quite a few times in recent weeks. Dietary staff reported that Styrofoam was sometimes used for dinner meals mainly due to staffing. The NHA and DON confirmed that Styrofoam containers had been used on occasion for residents’ meals over the past few weeks, contrary to the facility’s stated policy and contributing to resident dissatisfaction and concerns about dignity.
Failure to Honor Resident Bathing Preferences and Accurately Document Care
Penalty
Summary
The deficiency involves the facility’s failure to honor resident choice and provide showers or baths according to resident preference and facility policy for seven of thirteen residents reviewed. The facility’s Personal Care Procedure policy states that baths/showers are to be provided based on individual status and needs, that showers may be given at any time the resident chooses, and that a shower may be necessary 2–3 times per week or more per resident request, with bed baths on non-shower days per resident preference. For one resident with epilepsy, Crohn’s disease, cerebral infarction, and monoplegia of an upper limb, clinical records showed that from 1/21/26 through 2/19/26 the resident was only offered showers/baths on four specific dates. The resident reported wanting a daily shower but being satisfied with twice weekly, stated that a scheduled shower was missed, and was observed with greasy hair. The resident also indicated they could shower independently but were not allowed to do so for safety reasons. Another resident with atrial fibrillation, diabetes mellitus, morbid obesity, and cardiac heart failure was documented as being offered showers/baths on five specific dates during the same review period and reported that showers should occur on Sundays and Wednesdays. This resident stated they did not receive a scheduled shower due to staff citing a lack of hot water, while facility documentation recorded the event as a refusal, which the resident later denied. Further review showed that several other residents scheduled for showers/baths on that same day did not receive them and instead received bed baths, with CNAs and an LPN attributing this to no hot water being available. The Maintenance Director, however, confirmed that hot water was available for those residents’ showers/baths. The NHA and DON confirmed that these residents did not receive showers/baths per their preferences and that there was no evidence that one resident received showers/baths at least twice weekly as preferred.
Failure to Follow Planned Menus and Communicate Undocumented Food Substitutions
Penalty
Summary
The deficiency involves the facility’s failure to ensure that meals were prepared and served according to the planned menus, that menu changes were documented and updated, and that residents were notified of substitutions. The facility’s own menu change policy, dated 8/29/25, required that any change to the posted or planned menu be intentional, documented, and communicated to residents and staff, with substitutions of equal nutritional value that meet resident preferences and dietary restrictions, and that all changes be recorded on a monthly menu substitution log and communicated via pre-meal huddles, nursing staff, and menu boards or general communication. Despite this policy, multiple residents reported recently receiving foods that were not on the posted menu without prior notification of the changes. Interviews with residents and staff, along with confidential interviews, revealed that food substitutions were occurring due to ordered items not being delivered or running out of specific foods, and that these substitutions were not documented or communicated. Examples included cabbage being served to approximately 12–15 residents instead of brussels sprouts, mashed potatoes being served in place of biscuit mix for pot pie, and pears being served instead of apples for dessert, as well as a planned cream of broccoli soup that was not delivered as ordered. An LPN reported noticing food substitutions on resident trays without notification from the kitchen to nursing staff or residents. Follow-up interviews confirmed that the facility failed to follow the planned menus, complete the monthly menu substitution log, update posted menus, or alert residents to menu changes, in violation of the cited state regulatory requirements for management and dietary services.
Failure to Maintain Safe Operation of Walk-In Freezer Equipment
Penalty
Summary
The facility failed to properly maintain safe operation of essential equipment in the main kitchen walk-in freezer as required by its policy. The facility’s freezer policy, last reviewed on 8/29/25, required that all walk-in freezers be cleaned at least every six months, that excess ice buildup be removed, and that any damage or need for repair be reported to the Maintenance Department. During an observation of the main kitchen walk-in freezer on 2/18/26 at 10:30 a.m., surveyors noted an accumulation of ice on the ceiling extending from the condenser to the opposite side of the freezer, as well as multiple areas of ice on the floor near the entrance. Ice accumulation was also observed on frozen food boxes stored on the top shelves to the right and left of the entrance door, and the condenser coils were found frozen in ice. In an interview at the time of the observation, the Dietary Manager confirmed the presence of these ice accumulations and the frozen condenser coils, and acknowledged that the ice should be removed. No residents or specific patient conditions were mentioned in the report, and the deficiency focused solely on the condition and maintenance of the walk-in freezer equipment and surrounding environment in the main kitchen.
Oxygen Cylinder Storage Deficiencies in Nurse Station Closets
Penalty
Summary
Surveyors observed that the facility failed to maintain gas equipment requirements in two of three nurse station closets. Specifically, the north and east oxygen storage closets were not designed and constructed to accommodate storage of over 300 cubic feet of oxygen cylinders, as required by NFPA 101 and NFPA 99 standards. Additionally, in the east oxygen closet, one oxygen cylinder was found unsecured at the time of the survey. These deficiencies were confirmed during an interview with the maintenance supervisor, who acknowledged the issues with the storage closets and the unsecured cylinder. No information was provided regarding any residents directly involved or affected at the time of the deficiency.
Plan Of Correction
At the time of surveyor identification, the unsecured oxygen cylinder was secured and the facility's oxygen cylinders were rearranged in the designed oxygen storage closets throughout the facility to ensure that the East and North oxygen storage closets did not have over 300 cubic feet of oxygen cylinders stored. No further action is needed. All staff will be re-educated that the oxygen cylinders must be secured appropriately and that there cannot be more than 300 cubic feet of oxygen cylinders stored in any of the oxygen storage closets. The Maintenance Director will do weekly monitoring throughout the facility to ensure that all the oxygen cylinders are secured appropriately and that none of the oxygen storage closets have over 300 cubic feet of oxygen cylinders stored. On identification, unsecured oxygen cylinders will be secured and if needed oxygen cylinders will be removed from storage closets to ensure that there is no more than 300 cubic feet of oxygen cylinders stored in any one oxygen storage closet.
Obstructed Exit Due to Ice and Snow Buildup
Penalty
Summary
A deficiency was identified when the first floor therapy exit door was found to have a buildup of ice and snow, which prevented the door from opening to its full width. Additionally, the exit discharge surface was not maintained in a manner that would allow for safe evacuation during an emergency. These conditions were observed during a facility inspection and were confirmed by the maintenance supervisor at the time of the survey. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
At the time of surveyor identification, the buildup of snow and ice was removed from the first floor therapy entrance door and surface in order to permit the exit door to open to its fullest width in order to allow a safe evacuation in the event of an emergency. No further action is required. All staff will be re-educated that all surfaces, exit discharges, exit locations, and entrance accesses must be maintained free of the buildup of ice and snow in order to maintain a continuous means of egress in case of emergency. The Maintenance Director will do weekly monitoring throughout the facility to ensure that all surfaces, exit discharges, exit locations, and entrance accesses are maintained free of the buildup of ice and snow. On identification, any buildup of snow or ice will be removed.
Failure to Meet Minimum Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) staffing ratios as mandated by regulation for several shifts over multiple days. Specifically, on three days, the day shift did not have the minimum required number of NAs per resident, with actual staffing falling short of the calculated requirement based on the resident census. On two days, the evening shift also did not meet the required NA-to-resident ratio, and on three days, the overnight shift was similarly understaffed. These deficiencies were identified through a review of facility nursing staffing documents covering several time periods. During an interview, the Nursing Home Administrator confirmed that the facility did not meet the minimum NA ratios for the specified days and shifts. The report does not mention any specific residents affected or provide details about their medical history or condition at the time of the deficiency. The findings are based solely on staffing records and administrative confirmation.
Plan Of Correction
No residents were found to be negatively affected by the deficient practice of regulation. In an effort to maintain compliance with the regulation, the facility should utilize the following process: 1. In an attempt to achieve appropriate staffing ratios, the facility has created a daily assignment grid for the Scheduler to complete daily that designates the required amount of Certified Nurse Aides per shift that are required to meet the regulatory requirements. The assignment grids will be reviewed during Labor Meetings to be held no less than weekly. Additionally, the Scheduler will be re-educated on the required amount of Certified Nurse Aides per shift that are required to meet the regulatory requirements. This review will be the responsibility of the Director of Nursing or designee. 2. When a call-off is received, the Supervisor will make every effort to replace hours fully. In the event that the Supervisor is unable to fully cover the hours of a staff call-off and the loss of staff might impact the facility's compliance with the regulatory requirement, the RN Supervisor will notify the Director of Nursing and Assistant Director of Nursing so that all administrative clinical staff can be notified of the need so they can assist with coverage. 3. The facility will continue with recruitment efforts and will continue to enforce the attendance policy. 4. The facility shall complete a monitor of staffing ratios weekly utilizing the DOH staffing calculation tool for 1 month, then monthly for 2 months then quarterly until such time it is determined by the Quality Assurance Committee that the facility is maintaining compliance. This shall be the responsibility of the Director of Nursing or designee.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the required minimum of 3.2 hours of direct general nursing care per resident per day for two out of twenty-one days reviewed. Specifically, on two dates, the provided nursing care hours were 3.16 and 3.14 per patient day, which is below the regulatory standard. This was confirmed through a review of facility nursing staffing documents covering several periods and was acknowledged by the Nursing Home Administrator during an interview. No additional details about specific residents or their conditions were provided in the report.
Plan Of Correction
No residents were found to be negatively affected by the deficient practice of regulation. In an effort to maintain compliance with the regulation, the facility shall utilize the following process: 1. In an attempt to achieve general nursing care hours of at least a minimum of 3.2 hours of direct resident care hours per resident in a 24-hour period, the facility has created a daily assignment grid for the Scheduler to complete daily that designates the required amount of direct care staff in relation to Resident census. The assignment grids will be reviewed during Labor Meetings to be held no less than weekly. This review will be the responsibility of the Director of Nursing or designee. 2. When a call-off is received, the Supervisor will make every effort to replace hours fully. 3. The facility will continue with recruitment efforts and will continue to enforce the attendance policy. 4. The facility shall complete a monitor of staffing PPD's on a daily basis utilizing the DOH staffing calculation tool until such time it is determined by the Quality Assurance Committee that the facility is maintaining compliance. This shall be the responsibility of the Director of Nursing or designee. 5. The scheduler and RN Supervisors will be re-educated on the regulatory guidelines for the minimum number of general nursing care hours of 3.2 hours of direct resident care hours per resident in a 24-hour period. This will be the responsibility of the Director of Nursing.
Failure to Provide Dignified and Timely Meal Service
Penalty
Summary
The facility failed to implement dignified feeding practices and maintain resident dignity and respect by not serving meals in a timely manner to individuals seated at the same table in both the North and Haven dining areas. Observations revealed that residents seated together were not served their meals at the same time, resulting in some residents eating while others waited and watched, and in some cases, residents finishing and leaving the table before others had received their meals. Facility policy requires that all residents at the same table be served before moving to another table, but this was not followed during the observed meal service. Additionally, multiple residents and a family member reported that meals were frequently served in Styrofoam containers, which often resulted in cold food. Staff interviews confirmed that the use of Styrofoam containers and delays in meal service were due to inadequate staffing in the dietary department. The dietary manager acknowledged that staffing shortages led to the use of disposable containers and confirmed that residents at the same table should be served simultaneously, as per facility policy.
Failure to Timely Notify Physician and Emergency Contact of Change in Condition
Penalty
Summary
The facility failed to notify a resident's physician and emergency contact in a timely manner following a significant change in the resident's condition. According to facility policy, nursing staff are required to inform the primary care physician and responsible party when there is a notable decline in a resident's clinical status. In this case, a resident with a history of NSTEMI myocardial infarction, type II diabetes, and muscle weakness exhibited slurred speech and appeared 'a little off' during the night. Despite this change, there was no timely notification to the physician or emergency contact, nor was this action documented in the clinical record at the time of the incident. The Director of Nursing and Nursing Home Administrator later confirmed that proper notification and documentation should have occurred.
Insufficient Dietary Staffing Resulting in Cold Meals and Use of Styrofoam Containers
Penalty
Summary
The facility failed to provide sufficient staffing in the dietary department, as evidenced by a review of four weeks of dietary schedules that lacked the appropriate number of trained dietary staff each day. Resident grievances and council meeting minutes documented concerns about meals not being ready for residents going to dialysis and food being served warm or not hot. Multiple residents reported receiving meals in Styrofoam containers several days a week, resulting in food often being cold. These issues were attributed to inadequate dietary staffing, as confirmed by both dietary aides and the dietary manager, who stated that the use of foam containers was due to insufficient staff and that there were shifts with only a cook and one dietary aide present. A family member corroborated that meals were frequently served in Styrofoam containers and were often cold. The dietary manager and aides confirmed that staffing shortages led to the use of these containers and that residents at the same table should be served simultaneously, which was not consistently happening. The Nursing Home Administrator acknowledged that the expected staffing level was one cook and three dietary aides per shift, which was not being met. These findings were supported by facility policy and state regulations regarding the responsibility of the licensee and management.
Nurse Aide Staffing Shortage on Day Shift
Penalty
Summary
The facility failed to meet the required nurse aide (NA) staffing ratios during the day shift on January 12, 2025. Specifically, the regulation mandates a minimum of one NA per 10 residents during the day shift. On the day in question, the facility had a census of 114 residents, necessitating 11.40 NAs to meet the required ratio. However, only 9.38 NAs were available, resulting in a staffing shortage. This deficiency was confirmed during a telephone interview with the Nursing Home Administrator on January 14, 2025, who acknowledged that the NA ratios were not met for the specified day and shift.
Plan Of Correction
Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. In an effort to maintain compliance with the regulation, the facility should utilize the following process: 1. In an attempt to achieve appropriate staffing ratios, the facility has created a daily assignment grid for the Scheduler to complete daily that designates the required amount of Certified Nurse Aides per shift that are required to meet the regulatory requirements. The assignment grids will be reviewed during Labor Meetings to be held no less than weekly. This review will be the responsibility of the Director of Nursing or designee. 2. When a call-off is received, the Supervisor will make every effort to replace hours fully. In the event that the Supervisor is unable to fully cover the hours of a staff call-off and the loss of staff might impact the facility's compliance with the regulatory requirement, the RN Supervisor will notify the Director of Nursing and Assistant Director of Nursing so that all administrative clinical staff can be notified of the need so they can assist with coverage. 3. The facility will continue with recruitment efforts and will continue to enforce the attendance policy. 4. The facility shall complete a monitor of staffing ratios weekly utilizing the DOH staffing calculation tool for 1 month, then monthly for 2 months, then quarterly until such time it is determined by the Quality Assurance Committee that the facility is maintaining compliance. This shall be the responsibility of the Director of Nursing or designee.
Failure to Notify Resident's Representative of Treatment Change
Penalty
Summary
The facility failed to notify a resident's representative of a change in condition and treatment, as required by their policy. Specifically, the clinical record of a resident with multiple diagnoses, including an unstageable pressure ulcer, diabetes mellitus, weakness, and COPD, showed a physician's order for Voltaren External Gel to be applied as needed for pain. However, there was no evidence that the resident's representative was informed of this new order or the x-ray findings that prompted it. An interview with the resident's representative confirmed that the facility did not always update them on new orders or test results. The Director of Nursing also confirmed that the facility did not notify the resident's representative of the new orders and x-ray findings. This lack of communication is a violation of the facility's policy, which mandates notifying the responsible party and physician of changes in a resident's condition or treatment.
Failure to Ensure Proper Catheter Care for Residents
Penalty
Summary
The facility failed to ensure proper care and services for residents with indwelling catheters, leading to potential infection risks. Specifically, two residents with indwelling catheters, identified as R19 and R79, were observed with their catheter drainage bags uncovered and placed on the floor beside their beds. This is contrary to the facility's policy, which mandates that catheter drainage bags should be covered and not placed on unclean surfaces to prevent infections. Resident R19, who has a history of cerebral infarction, aphasia, neuromuscular dysfunction of the bladder, and urinary tract infections, was observed with an uncovered catheter bag on the floor. The resident's representative confirmed a recent hospitalization for a urinary tract infection. Similarly, Resident R79, with diagnoses including encephalopathy, dementia, and a history of urinary tract infections, was also observed with an uncovered catheter bag on the floor. The Director of Nursing confirmed that the catheter bags should not be left uncovered or placed on the floor, acknowledging the risk of infection.
Failure to Maintain Safe Operation of Walk-In Freezer
Penalty
Summary
The facility failed to maintain the safe operation of essential equipment in the main kitchen, specifically the walk-in freezer. The facility's policy, titled 'Cleaning Instructions: Freezer,' with a review date of 10/28/24, mandates defrosting the freezer when frost exceeds 1/4 inch thick and according to a cleaning schedule. However, observations on 11/19/24 revealed significant ice accumulation in the walk-in freezer, including on the ceiling, extending from the condenser to the opposite side, and on the floor near the entrance. Water and ice were observed dripping and freezing on boxes of frozen food items on the top shelves, and the condenser coils were encased in ice. The Dietary Manager confirmed these observations during an interview on 11/20/24.
Failure to Follow Safe Transfer Protocols
Penalty
Summary
The facility failed to adhere to its policy on safe resident handling and transfers, which mandates the use of two staff members when transferring residents with a mechanical lift. This deficiency was observed during the transfer of a resident diagnosed with rheumatoid arthritis, lymphedema, lack of coordination, weakness, and abnormal gait and mobility. The resident's care plan specified the use of a sit-to-stand lift for transfers to a power wheelchair, indicating the resident was non-ambulatory. However, on the observed date, a nurse aide transferred the resident using the mechanical lift without the assistance of a second staff member. Interviews conducted with various staff members, including the nurse aide involved, another nurse aide, a licensed practical nurse, the assistant director of nursing, and the nursing home administrator, confirmed the requirement for two staff members to operate mechanical lifts. The resident also confirmed that typically two staff members assist with the lift, but on this occasion, only one aide was present. This failure to follow the established policy for safe transfers constitutes a deficiency in the facility's management and nursing services, as outlined in the relevant Pennsylvania Code sections.
Latest citations in Pennsylvania
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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