Gardens At Stevens, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Stevens, Pennsylvania.
- Location
- 400 Lancaster Avenue, Stevens, Pennsylvania 17578
- CMS Provider Number
- 395575
- Inspections on file
- 30
- Latest survey
- April 28, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Gardens At Stevens, The during CMS and state inspections, most recent first.
Surveyors found that the facility did not consistently provide ordered respiratory care and oxygen tubing changes for three residents requiring oxygen therapy. One resident with CHF and COPD had oxygen tubing labeled with an earlier date than documented on the TAR, and the resident reported the tubing had not been changed since that earlier date. Another resident with COPD and centrilobular emphysema had an illegible date on the oxygen tubing and no physician order specifying when tubing should be changed. A third resident with COPD and obstructive sleep apnea had physician orders for weekly tubing and equipment changes, but the tubing in use was dated earlier than the most recent change documented on the TAR. A licensed nurse confirmed the observed tubing dates, and the NHA confirmed that one resident lacked any tubing-change order.
The facility did not complete or document required annual performance reviews for five nurse aides. Review of personnel files showed no evidence of performance evaluations within a 12‑month period, and the Nursing Home Administrator confirmed that there was no documentation of these reviews, in violation of state personnel policy requirements.
Surveyors found that multiple nurse aides had no documented completion of the required 12 hours of annual in‑service education, including dementia care and abuse prevention content. Review of several personnel files showed an absence of records demonstrating that these staff had met the annual training requirement, and the NHA confirmed that there was no evidence that the mandated in‑service hours had been completed.
Surveyors identified that insulin pens on two medication carts were not managed according to professional standards. On one cart, an open Toujeo insulin pen lacked an expiration date, and an unopened Toujeo pen was not kept refrigerated per manufacturer instructions. On another cart, an open Lantus insulin pen had no open or expiration date, and an unopened Lantus pen was also stored unrefrigerated. The DON confirmed that these insulin pens were not properly labeled or stored.
Surveyors found that the facility did not notify the State LTC Ombudsman when several residents were transferred to the hospital for evaluation or admission, as documented in nursing progress notes and confirmed by the NHA, DON, and Social Services. In addition, for a resident who had a planned discharge to home, the MDS and nursing notes showed the discharge occurred, but the facility did not complete the required discharge summary with a recapitulation of the resident’s stay. These failures were cited under state regulations governing the licensee’s responsibilities.
A resident’s quarterly MDS assessment was inaccurately coded to show use of an anticoagulant in the high-risk drug class section, despite clinical record review of physician orders and the MAR confirming that no anticoagulant had been ordered or administered during the lookback period. An interview with licensed staff confirmed the miscoding of the assessment, resulting in an inaccurate clinical record.
A resident was not invited, nor was the resident’s representative invited, to participate in interdisciplinary care plan meetings. Record review showed no documentation of any invitation to care plan meetings, and the resident reported never being asked to attend such a meeting. The NHA confirmed there was no evidence that the resident or representative had been invited to participate in the care planning process, resulting in a violation of resident rights and nursing services requirements.
Two residents did not receive care according to provider orders and standards. One resident with metastatic lung cancer received decadron as ordered in preparation for a chemotherapy infusion, but the infusion appointment was missed because transportation was not arranged, and the steroid regimen was then discontinued. Another resident with a scheduled cataract surgery had an active NPO order and a diet communication sent to the kitchen, yet still received and ate a breakfast tray, leading to cancellation of the surgery. These events were confirmed by facility leadership, including the NHA and DON.
A resident with chronic pain conditions did not have their Fentanyl transdermal patch changed as ordered by the physician, resulting in unaddressed pain despite notifying nursing staff. Review of medication records confirmed the patch was not removed and reapplied as scheduled, and the NHA acknowledged improper medication administration.
Staff interviews revealed that 1-2 residents are unable to attend scheduled Sunday religious services each week because nursing staff do not assist them out of bed in time. The Activities Director and Assistant reported this occurs every weekend and did not inform the NHA. A resident confirmed missing a service due to not being assisted out of bed before the scheduled time.
A resident diagnosed with scabies was not placed on contact precautions as required by facility policy. There were no physician orders for contact precautions, and no signage was present in the resident's room. The ADON was unaware of the diagnosis and confirmed that precautions should have been implemented.
Surveyors found that several residents, including those with cognitive impairment and those requiring moderate to total assistance, did not receive scheduled showers and were instead given bed baths without documentation that showers were offered. Interviews and observations revealed residents were unkempt, dissatisfied with their hygiene care, and that staff shortages contributed to missed showers. The DON and administrator confirmed the lack of documentation for showers on the scheduled days.
Several residents did not receive scheduled showers over an extended period, despite not refusing care, due to insufficient nursing staff. Residents were observed to be unkempt and reported being told that staff shortages prevented them from receiving showers. Staff interviews confirmed that inadequate staffing led to missed showers and incomplete daily care.
Surveyors identified that clinical records for several residents, including those with cognitive impairments and chronic conditions, were incomplete or inaccurately documented. Multiple shower records were left blank or marked as 'NA,' which the DON confirmed was not acceptable practice. These documentation lapses were found across several months and affected residents who required varying levels of assistance with personal care.
The facility did not have a system in place to track and monitor infectious skin conditions, as confirmed by interviews with the infection prevention nurse, DON, and nurse practitioner. Two residents were observed with rashes, one of whom received permethrin cream after other treatments failed, but no scabies testing was performed. Staff interviews revealed confusion over responsibility for tracking and trending skin conditions.
The facility did not complete required investigations into two separate incidents involving residents—one with cognitive impairment and another who was cognitively intact and dependent on staff—where concerns of possible abuse or neglect arose. In both cases, there was no documentation of an investigation or collection of written statements from those involved, despite policy requirements.
A cognitively impaired resident with Alzheimer's and dementia did not receive a required RN assessment after a male resident was found in her bed. The incident was reported by the resident's daughter, and facility leadership confirmed that no RN assessment was documented as required by policy.
The facility failed to ensure that common wall doors positively latched on both floors within the component. Observations revealed that the doors did not latch properly at specific locations on the upper and lower levels between Components 01 and 02. The Director of Maintenance confirmed this issue.
The facility did not maintain stair tower doors within the allowed gap margins on one of two floors, as observed and confirmed through interviews. This failure to adhere to NFPA 101 standards for stairways and smokeproof enclosures as exits was noted during the survey.
The facility failed to maintain corridor doors, with observations revealing that stairtower doors near a resident room had excessive gaps, and corridor doors to two resident rooms failed to close and latch. These issues were confirmed by the Director of Maintenance, indicating non-compliance with NFPA 101 standards for fire safety and smoke containment.
The facility did not adhere to NFPA 101 standards by storing soiled-linen and trash containers exceeding 32 gallons in the 1st floor corridor outside a resident's room, rather than in a 1-hour fire-rated room. This was confirmed by the Director of Maintenance.
The facility did not ensure that nurse aides completed the required 12 hours of annual inservice training. A review of five employee files showed that none of the aides had completed the necessary training, a fact confirmed by the Nursing Home Administrator.
The facility failed to ensure accurate MDS assessments for several residents, with discrepancies in medication administration and discharge status. For example, a resident's MDS inaccurately indicated anticoagulant use, while another's noted insulin administration without supporting orders. Staff interviews confirmed these inaccuracies.
The facility failed to provide scheduled showers for four residents due to staffing shortages, as revealed by resident interviews and clinical record reviews. Despite the facility's policy requiring weekly showers, residents only received bed baths, with no documentation of shower refusals. The DON confirmed the expectation for twice-weekly showers, highlighting a recurring issue with nursing services.
The facility failed to ensure monthly drug regimen reviews by a pharmacist and timely physician responses to recommendations for several residents. Recommendations for medication changes were not addressed, and some lacked physician rationale for disagreement. Interviews confirmed these deficiencies.
The facility failed to monitor a resident's fluid restriction and complete wound care treatments as ordered by physicians. A resident with congestive heart failure did not have their fluid intake monitored as required, and another resident with a full thickness wound did not receive documented wound care on several occasions. These deficiencies were confirmed by facility staff.
A facility failed to monitor a resident's weight and follow a dietitian's recommendations after a significant weight loss. The resident's weight dropped from 122.8 to 116.2 pounds, indicating a 7.9% loss over 30 days. Despite the dietitian's recommendation for weekly weights, no re-weight was obtained after March 2, and no further weights were recorded by March 14, even after a physician's order was placed.
A resident's lower dentures broke and were not repaired or replaced in a timely manner. Despite the resident's POA requesting dental services, the facility failed to refer the resident for dental care, as confirmed by staff.
The facility failed to provide appropriate PPE and door notifications for two residents on Enhanced Barrier Precautions (EBP). One resident with a Stage II sacral wound and another with a nephrostomy tube did not have EBP in place, as confirmed by the DON. The facility's policy requires PPE for high-contact care activities, which was not followed.
A resident with moderate cognitive impairment, requiring assistance with personal hygiene, was found with long and dirty fingernails. Despite morning care, the nails were not cleaned due to a scheduled doctor's appointment. This deficiency was observed and reported to the Assistant DON.
A resident with severe cognitive impairment and high fall risk fell from a window due to inadequate supervision, resulting in significant injuries. Despite being identified as a moderate elopement risk, the resident exited through an unsecured window without triggering alarms. The facility's failure to provide adequate supervision and secure the environment led to this incident.
Failure to Provide Ordered Respiratory Care and Oxygen Tubing Changes
Penalty
Summary
The facility failed to provide necessary respiratory care and services for three residents who required oxygen therapy and monitoring. For one resident with CHF and COPD, surveyors observed oxygen tubing labeled with a date of April 17, 2026, during an observation on April 28, 2026, despite a physician’s order to change the nasal cannula tubing weekly and TAR documentation indicating changes on April 17 and April 24, 2026. In interview, this resident stated that the oxygen tubing was last changed on April 17, 2026, and that oxygen was used at night or when napping. A licensed employee confirmed on April 28, 2026, that the date on the tubing was April 17, 2026, indicating a discrepancy between the documented tubing change on the TAR and the date on the tubing in use. For a second resident with COPD and centrilobular emphysema, a physician’s order directed staff to apply oxygen at 2 L via nasal cannula to maintain oxygen saturation above 92% every shift, but observation with a licensed employee showed that the date on the oxygen tubing was illegible, and review of the clinical record revealed no physician order for changing the oxygen tubing. For a third resident with COPD and obstructive sleep apnea, physician’s orders required oxygen saturation monitoring every shift and weekly changes of oxygen tubing and humidification equipment on the night shift every Friday. The TAR showed that the oxygen tubing was changed on April 24, 2026, but observation on April 28, 2026, with a licensed employee revealed tubing dated April 17, 2026. The Nursing Home Administrator confirmed that the second resident had no orders for changing oxygen tubing. These findings demonstrated failures in following physician orders, documenting, and implementing appropriate respiratory care and services.
Failure to Complete Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to complete required performance reviews at least once every 12 months for five nurse aides. Review of personnel records for Employees E5 through E9 showed no evidence that any performance evaluations had been conducted within the required annual timeframe. During an interview, the Nursing Home Administrator confirmed that there was no documentation of performance reviews for these five nurse aides, indicating that the facility did not carry out or record the mandated periodic assessments of their job performance, as required by applicable state personnel policies and procedures.
Failure to Ensure Required Annual In‑Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides completed the required 12 hours of annual in‑service training, including education in dementia care and abuse prevention, as required by 42 CFR 483.95 and 28 Pa. Code 201.19(7). During review of personnel files for five nurse aides (Employees E5–E9), surveyors found no documentation that any of these employees had completed the mandated 12 hours of annual in‑service education. An interview with the Nursing Home Administrator confirmed that there was no evidence in the records that these nurse aides had received the required annual training hours.
Improper Labeling and Storage of Insulin Pens on Medication Carts
Penalty
Summary
Surveyors found that the facility failed to ensure proper labeling and storage of insulin pens on two of three medication carts observed. On the Second Floor Back Hall medication cart, one open Toujeo insulin pen was labeled with an open date of January 18, 2026, but had no expiration date documented, and another Toujeo insulin pen was unopened yet not stored in the refrigerator as required by the manufacturer’s directions. On the First Floor medication cart, one opened Lantus insulin pen had no open date or expiration date, and another unopened Lantus insulin pen was not refrigerated as recommended by the manufacturer. During an interview, the DON confirmed that the insulin pens on these carts were not properly identified with open and expiration dates, and that unopened insulin pens were not stored in accordance with manufacturer instructions. The deficiency was cited under 28 Pa. Code 211.12(c)(d)(1)(2)(5) related to nursing services and the requirement that drugs and biologicals be labeled and stored according to accepted professional principles.
Failure to Notify Ombudsman of Hospital Transfers and Complete Required Discharge Summary
Penalty
Summary
Surveyors determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers to the hospital for multiple residents. For one resident, a nursing progress note dated December 12, 2025, documented transfer to a local hospital for evaluation, but documentation provided by the Nursing Home Administrator showed that the Ombudsman was not notified, which was confirmed in an interview with an employee. Another resident’s record contained a nursing progress note dated January 17, 2026, indicating transfer to the hospital for evaluation, yet the Nursing Home Administrator’s documentation and staff interview again confirmed that the Ombudsman was not notified. A third resident was discharged to the hospital and later readmitted, but review of the clinical record did not show evidence that the Ombudsman was notified of the hospital admission, which the DON confirmed. For a closed record, a nursing progress note documented that the resident was admitted to a local hospital and discharged from the facility the same day, and review of the record and an interview with Social Services confirmed that the Ombudsman was not notified. Surveyors also found that the facility failed to complete a required discharge summary, including a recapitulation of the resident’s stay, for one closed record. For this resident, a nursing progress note documented discharge from the facility to home, and the MDS indicated the discharge was planned. However, the Nursing Home Administrator reported that the facility did not complete a discharge summary, including a recapitulation of the stay, for this resident. The Nursing Home Administrator also confirmed that the facility did not notify the Ombudsman of the hospital transfers for two of the residents reviewed. These findings were cited under 28 Pa. Code 201.14(a), Responsibility of licensee.
Inaccurate MDS Coding of Anticoagulant Use
Penalty
Summary
The facility failed to ensure the accuracy of a resident assessment for one resident when the quarterly MDS dated February 2, 2025, indicated in section N0415 (High Risk Drug Classes) that the resident was receiving an anticoagulant. Clinical record review, including the physician’s orders and the Medication Administration Record for the assessment lookback period, showed no evidence that the resident had been ordered or administered an anticoagulant during that time. In an interview on February 27, 2025, at 12:10 p.m., licensed staff member E3 confirmed that the MDS assessment had been coded inaccurately, resulting in an assessment that did not accurately reflect the resident’s actual medication regimen. This deficiency was cited under 42 CFR 483.20 related to the accuracy of assessments and 28 Pa. Code 211.5(f) regarding clinical records, and had been previously cited on multiple prior survey dates.
Failure to Involve Resident in Interdisciplinary Care Plan Process
Penalty
Summary
The facility failed to invite a resident and/or the resident’s representative to participate in the care plan process as required. Resident 37’s clinical record showed that the resident was admitted to the facility on the documented admission date, and review of the record revealed no evidence that the resident or the resident’s representative had been invited to attend or participate in interdisciplinary care plan meetings. During an interview on February 24, 2026, at 11:10 a.m., Resident 37 stated that they had not been invited to participate in an interdisciplinary care plan meeting. An interview with the Nursing Home Administrator on February 27, 2026, at 12:00 p.m. confirmed that there was no documentation or evidence that the resident or the resident’s representative had been invited to an interdisciplinary care plan meeting, resulting in noncompliance with resident rights and nursing services requirements. All findings were based on review of the clinical record and interviews with the resident and the Nursing Home Administrator, and no additional medical history or clinical condition details for the resident were documented in the report.
Failure to Follow Medication and NPO Orders for Two Residents
Penalty
Summary
The facility failed to provide treatment and care in accordance with standards of care for two residents. One resident had a diagnosis that included secondary malignant neoplasm of the lung and was ordered to receive 4 mg of decadron the day before, the day of, and the day after a scheduled cancer infusion. The Medication Administration Record showed that decadron was administered on February 24, 2026, in preparation for an infusion appointment at a cancer center on February 25, 2026. However, the resident did not attend the infusion appointment because transportation had not been arranged, and the appointment had to be rescheduled. A subsequent progress note documented that the CRNP ordered discontinuation of the three days of decadron since the infusion was not given. Another resident had an order to remain NPO after midnight prior to a scheduled cataract surgery. Nursing had sent a Diet Order and Communication slip to the kitchen indicating that this resident was not to receive a breakfast tray on the morning of the scheduled surgery. Despite this written communication and the active NPO order, the resident received a breakfast tray from the kitchen and ate breakfast, resulting in the cancellation of the cataract surgery appointment. The DON confirmed that the resident received a breakfast tray while the NPO order was in place.
Failure to Follow Physician Orders for Pain Management
Penalty
Summary
The facility failed to follow physician orders for a resident with multiple chronic pain diagnoses, including osteoarthritis of the left knee, left hip pain, arthritis in the left hip, and lower back pain. The physician had ordered a Fentanyl transdermal patch to be applied every 72 hours for pain management. Review of the Medication Administration Records (MAR) showed no documentation that the patch was removed and reapplied as ordered between December 1 and December 6, 2025. The resident confirmed that the pain patch was not changed during this period, experienced pain, and reported it to nursing staff, but the patch was still not changed. The Nursing Home Administrator acknowledged that the medication was not administered properly.
Failure to Assist Residents Out of Bed for Scheduled Activities
Penalty
Summary
The facility failed to ensure that residents were assisted out of bed in a timely manner to attend scheduled Sunday religious services. Interviews with the Activities Director and Activities Assistant revealed that this issue occurs every weekend, with 1-2 residents unable to attend services each week because nursing staff do not provide assistance out of bed in time. Both staff members reported that they did not inform the Nursing Home Administrator about the recurring problem. Additionally, a resident confirmed missing a recent Sunday service due to not being assisted out of bed before the scheduled time, despite staff being aware of her need to be up before 9:30 a.m. These findings were confirmed by the Nursing Home Administrator.
Failure to Implement Contact Precautions for Scabies Diagnosis
Penalty
Summary
The facility failed to implement contact precautions for a resident diagnosed with scabies. Review of the resident's clinical record showed a diagnosis of scabies with a start date of October 28, 2025. The facility's policy required affected residents to remain on contact precautions until twenty-four hours after treatment. However, there were no physician orders for contact precautions in the resident's record, and observations of the resident's room revealed no signage indicating that contact precautions were in place. The resident had an order for Permethrin 5% cream, but treatment was to be held until after a dermatology appointment. During interviews, the Assistant Director of Nursing (ADON) stated she was not informed of the resident's recent scabies diagnosis and confirmed that contact precautions should have been implemented upon diagnosis. The ADON also noted that previous dermatology appointments did not indicate scabies. The resident was unavailable for interview due to cognitive impairment. The lack of communication and failure to follow facility policy led to the deficiency in infection prevention and control.
Failure to Provide Scheduled Showers to Multiple Residents
Penalty
Summary
The facility failed to provide scheduled showers to six out of eight residents reviewed, as evidenced by clinical record reviews, staff and family interviews, and direct observations. Multiple residents, including those with cognitive impairments and those requiring moderate to total assistance for activities of daily living, did not receive showers according to their documented preferences and schedules. Instead, these residents were given bed baths on several occasions, with no documentation that showers were offered on the scheduled days. For example, one resident with cognitive impairment and moderate care needs was scheduled for showers twice weekly but only received bed baths on select dates, with no evidence of being offered showers on other scheduled days. Another resident with diabetes mellitus received only a bed bath and was unaware of her shower schedule, expressing a preference for showers over bed baths. Observations noted that this resident appeared unkempt, with greasy hair and dirty fingers. Additional residents, both cognitively impaired and intact, also missed scheduled showers, with records showing only bed baths provided and no documentation of showers being offered. Interviews with these residents revealed dissatisfaction with the lack of showers, with one resident reporting feeling unclean and experiencing a rash, and another stating that showers were missed when there was insufficient staff. The DON and Nursing Home Administrator confirmed the absence of documentation for showers on the specified dates. These findings indicate a failure to provide care and assistance with activities of daily living, specifically bathing, as required by facility policy and resident preference.
Failure to Provide Sufficient Nursing Staff for Resident Showers
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the scheduled bathing and showering needs of residents, as required by policy. Multiple residents, including those with cognitive impairments and those dependent on staff for daily care, did not receive showers according to their preferred or scheduled times. Bathing records showed that several residents received only one or two showers over a period of more than a month, despite not refusing care. Observations and interviews confirmed that residents were left unkempt, with dirty hair, unclean bodies, and in some cases, visible rashes. Residents expressed a preference for showers over bed baths and reported being told that staff shortages were the reason for missed showers. Staff interviews corroborated the lack of adequate staffing, with nurse aides and an LPN stating that they were unable to complete all required showers and daily care tasks due to insufficient personnel. Staff reported having to rotate which residents received showers and being unable to provide quality care, including turning and repositioning. The Nursing Home Administrator and Director of Nursing acknowledged the staffing challenges. These findings were based on a review of facility policies, clinical records, and direct interviews and observations.
Incomplete and Inaccurate Clinical Record Documentation
Penalty
Summary
The facility failed to ensure that clinical records for multiple residents were complete and accurately documented, as required by accepted professional standards. Specifically, for six out of eight residents reviewed, there were missing or incomplete entries in the shower records for various dates. In several instances, documentation was left blank or marked as 'NA,' which was confirmed by the Director of Nursing to be unacceptable. These documentation lapses were identified through clinical record reviews and staff interviews. The residents affected included individuals with cognitive impairments and those requiring moderate to total assistance with personal care, such as showering. The deficiencies were noted across both cognitively impaired and intact residents, with some having significant medical conditions like diabetes mellitus. The lack of proper documentation was observed over multiple months and for multiple residents, indicating a pattern of incomplete record-keeping for essential care activities.
Failure to Implement Surveillance System for Infectious Skin Conditions
Penalty
Summary
The facility failed to implement a system of surveillance to identify, prevent, monitor, and report potential infectious skin conditions. Observations revealed that one resident had a persistent rash on her upper arms, chest, and back, which she described as feeling like bugs crawling on her. Another resident was observed with a rash over his arms, chest, and back, and had recently received permethrin cream for treatment after other interventions were unsuccessful; he reported relief from itching following this treatment. Clinical records confirmed the administration of permethrin cream, but there was no testing for scabies as the presentation was considered atypical, and a dermatology follow-up was pending. Interviews with the infection prevention nurse and the DON confirmed that there was no system in place to track and trend skin conditions, with each believing the other was responsible for this task. The nurse practitioner also indicated that tracking and trending of skin conditions was the responsibility of the infection prevention nurse.
Failure to Investigate Alleged Abuse and Neglect Incidents
Penalty
Summary
The facility failed to conduct thorough investigations into incidents involving two residents, as required by its abuse policy and state regulations. For one resident with Alzheimer's Disease and dementia, a grievance was filed by her daughter after a male resident was found in her bed and was only removed after the roommate called for staff assistance for several minutes. There was no documentation of the incident in the resident's medical records, nor any evidence that an investigation was completed to determine if neglect or abuse had occurred. In a separate incident, another resident who was cognitively intact and dependent on staff for care sustained a skin tear. Although the Director of Nursing heard a noise and checked on the resident, there was no documented investigation to rule out neglect or abuse. Interviews with facility leadership confirmed that written statements were not obtained from staff or residents involved, and no formal investigation was conducted for either incident.
Failure to Complete RN Assessment After Resident Incident
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) completed an assessment after an incident in which a male resident was found in the bed of a female resident. According to the Pennsylvania Nursing Practice Act and the facility's own risk management policy, an RN assessment should be documented in the clinical record following such incidents. However, review of the clinical record for the affected resident revealed no evidence that an RN assessment was performed after the event. The resident involved was cognitively impaired, with diagnoses including Alzheimer's Disease and dementia, and required moderate assistance from staff. The incident was brought to attention through a grievance filed by the resident's daughter, who reported that the male resident was only removed after the roommate called for staff for several minutes. Interviews with the Director of Nursing and the Nursing Home Administrator confirmed that no RN assessment was completed at the time of the incident.
Failure to Maintain Common Wall Doors
Penalty
Summary
The facility failed to maintain the common wall doors to positively latch on two of two floors within the component. During an observation conducted on March 31, 2025, between 12:00 PM and 2:00 PM, it was noted that the common wall doors did not positively latch at specific locations. At 12:00 PM, the issue was observed on the upper level at the common wall between Components 01 and 02. Similarly, at 2:00 PM, the same issue was noted on the lower level at the common wall between Components 01 and 02. An interview with the Director of Maintenance at 2:20 PM on the same day confirmed the failure of the common wall doors to positively latch.
Plan Of Correction
1. The common wall doors between Components 01 and 02 have been adjusted to positively latch. 2. The corrective action was completed on 4/1/2025. 3. The Maintenance Director or Designee will conduct audits of the common wall doors between Components 01 and 02 quarterly for 1 year. 4. Findings of Audits will be submitted to QAPI for review.
Stair Tower Door Gap Deficiency
Penalty
Summary
The facility failed to maintain stair tower doors within the allowed gap margins on one of two floors. This deficiency was identified through observation and interview, indicating a lapse in maintaining the required standards for stairways and smokeproof enclosures as exits, as per NFPA 101 standards.
Plan Of Correction
1. The 1st floor stairtower doors by Resident Room 215 have been adjusted to have gaps less than 3/16 inch. 2. The corrective action was completed on 4/10/2025. 3. The Maintenance Director or Designee will conduct audits of all facility stairtower doors to have gaps less than 3/16-inch quarterly for 1 year. 4. Findings of Audits will be submitted to QAPI for review.
Deficiencies in Corridor Door Maintenance
Penalty
Summary
The facility was found to have deficiencies related to the maintenance of corridor doors, which are crucial for fire safety and smoke containment. On March 31, 2025, an observation revealed that the stairtower doors on the 1st floor, near Resident Room 215, had gaps greater than the allowed 3/16 inch. This was confirmed by an interview with the Director of Maintenance, indicating that the doors exceeded the permissible gap margins, thus failing to meet the National Fire Protection Association (NFPA) 101 standards for corridor doors. Additionally, further observations on the same day revealed that the corridor doors to Resident Rooms 215 and 205 failed to close and latch properly. These findings were also confirmed through interviews with the Director of Maintenance. The inability of these doors to close and latch compromises their effectiveness in resisting the passage of smoke, which is a critical safety requirement, especially in fully sprinklered smoke compartments. These deficiencies highlight a failure in maintaining the required safety standards for corridor doors within the facility.
Plan Of Correction
1. The corridor doors to Resident Rooms 205 and 215 have been adjusted to close and latch. 2. The corrective action was completed on 4/1/2025. 3. The Maintenance Director or Designee will conduct a facility wide audit of all facility corridor doors for closure and latch then random door checks monthly. 4. Findings of Audits will be submitted to QAPI for review.
Improper Storage of Soiled-Linen and Trash Containers
Penalty
Summary
The facility failed to comply with NFPA 101 standards regarding the storage of soiled-linen and trash containers. During an observation on March 31, 2025, at 12:50 PM, it was noted that soiled-linen and trash containers exceeding 32 gallons were stored in the 1st floor corridor outside Resident Room 221. These containers were not placed in a 1-hour fire-rated room as required. An interview with the Director of Maintenance at the same time confirmed that the containers were not stored in a rated assembly, indicating a lapse in adherence to safety protocols for hazardous areas.
Plan Of Correction
1. The soiled linen and trash containers were removed from outside resident room 221. 2. The corrective action was completed on 4/1/2025. 3. The Maintenance Director or Designee will conduct audits of the 1st and 2nd floor corridors for soiled linen and trash containers daily until compliance is achieved, then weekly on all 3 shifts x 4 and then randomly for 2 months. 4. Findings of Audits will be submitted to QAPI for review.
Failure to Complete Required Annual Inservice Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides completed the required 12 hours of annual inservice training. A review of five nurse aide employee files revealed that none of the aides had completed the necessary training. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the five nurse aides did not fulfill the annual training requirement.
Inaccurate Resident Assessments in MDS Documentation
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' status for five of the 24 residents reviewed. Specifically, the Minimum Data Set (MDS) assessments for several residents contained inaccuracies regarding medication administration and discharge status. For instance, Resident 1's quarterly MDS inaccurately indicated that the resident was receiving anticoagulant medication, despite the absence of such an order or administration in the Medication Administration Record (MAR). Similarly, Resident 39's MDS incorrectly noted insulin administration, which was not supported by physician orders or the MAR. Further discrepancies were noted with Resident 45 and Resident 58, whose MDS assessments inaccurately reflected the administration of anticoagulants, contrary to their physician orders and MAR records. Additionally, Resident 78's discharge MDS inaccurately documented the discharge destination as a short-term general hospital, while records indicated the resident was discharged home. These inaccuracies were confirmed through staff interviews, highlighting a failure in the facility's assessment processes.
Failure to Provide Scheduled Showers Due to Staffing Shortages
Penalty
Summary
The facility failed to provide necessary services to maintain personal hygiene for residents unable to carry out activities of daily living. This deficiency was identified for four residents who were reviewed during the survey. The facility's policy, revised in August 2018, mandates that residents should receive showers or baths at least weekly, considering their preferences. However, interviews with residents revealed that they did not receive showers as scheduled due to staffing shortages. Specifically, Residents 2, 6, 14, and 25 reported not receiving showers, and there was no documentation indicating that they refused showers. Clinical record reviews showed that Residents 2, 6, and 14, who had moderate cognitive impairment and required assistance for bathing, did not receive showers from February 26 to March 13, 2025, but only received bed baths. Similarly, Resident 25, who was cognitively intact and required partial assistance, also did not receive a shower during the same period. The Director of Nursing confirmed that residents are supposed to receive showers twice a week and should be offered a bed bath if a shower is refused. The facility was previously cited for similar deficiencies, indicating a recurring issue with maintaining adequate nursing services and clinical records.
Failure to Address Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a monthly drug regimen review for each resident and that the physician addressed all pharmacy recommendations in a timely manner. This deficiency was identified for four out of five residents reviewed. For Resident 5, the pharmacist made recommendations on multiple occasions, but the physician did not respond to the recommendations made in March and September 2024. Additionally, a recommendation made in June 2024 lacked a rationale for the physician's disagreement, and a recommendation from February 2025 was not reviewed until March 2025. Similarly, for Resident 28, the pharmacist made several recommendations throughout 2024, but there was no evidence of the physician's response. Resident 34's record showed that recommendations made in March, September, and October 2024 were not reviewed by the physician, and no changes were made. For Resident 59, recommendations made in March and September 2024 were also not addressed by the physician. Interviews with the Nursing Home Administrator and Director of Nursing confirmed these findings.
Failure to Monitor Fluid Restriction and Complete Wound Care
Penalty
Summary
The facility failed to monitor a resident's fluid restriction and complete treatments according to physician orders for two residents. Resident 4, diagnosed with congestive heart failure, had a physician's order for a daily fluid restriction of 1500 ml. The order specified the distribution of fluids between the Dietary and Nursing departments. However, a review of Resident 4's clinical records from January to March 2025 revealed no evidence that the nursing staff was monitoring the resident's total daily fluid intake in conjunction with the Dietary department. This was confirmed during an interview with the Nursing Home Administrator and Director of Nursing. Resident 45 had a full thickness wound with 100% eschar on the right heel and foot. Physician's orders required daily cleansing and dressing of the wound. However, the February and March 2025 Medication Administration Records (MAR) showed that the treatment was not documented as completed on multiple occasions. This lack of documentation was confirmed by the Director of Nursing during an interview. These deficiencies were previously cited in February 2024 under the Quality of Care and Nursing Services regulations.
Failure to Monitor Resident's Weight and Follow Dietitian's Recommendations
Penalty
Summary
The facility failed to ensure routine nutrition monitoring for a resident, identified as Resident 66, by not obtaining re-weights and not following the recommendations made by a registered dietitian. According to the facility's policy titled 'Weight Assessment and Intervention,' any weight change of 5 pounds or more should be retaken for confirmation, and significant unplanned weight loss should be reported to the physician and dietitian. Resident 66 experienced a weight loss from 122.8 pounds to 116.2 pounds within a short period, which was noted by the dietitian as a 7.9% weight loss over 30 days. Despite this significant weight loss, there was no evidence of a re-weight being obtained after March 2, 2025, as required by the facility's policy. The clinical record review also revealed that the dietitian recommended weekly weights for three weeks, but there was no order for these weekly weights until March 10, 2025. Even after the order was placed, no further weights were obtained by March 14, 2025. An interview with the Director of Nursing and the Nursing Home Administrator confirmed that no re-weight was obtained after the significant weight loss was identified, and no further weights were taken in accordance with the physician's order. This failure to monitor the resident's weight and follow the dietitian's recommendations constitutes a deficiency in the facility's nutritional monitoring practices.
Failure to Timely Provide Dental Services
Penalty
Summary
The facility failed to timely provide dental services for a resident, identified as Resident 19, whose lower dentures broke after falling on the floor on January 6, 2025. The dentures were placed at the nursing station, but no immediate action was taken to repair or replace them. On March 13, 2025, the resident's power of attorney requested that the process for obtaining new dentures be initiated, and the resident was added to the dentist list. However, a review of the clinical record showed no evidence that the resident was referred for dental services. This was confirmed in an interview with Employee E4 on March 14, 2025, who acknowledged that the resident had not been referred for dental services.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure appropriate personal protective equipment (PPE) was available and proper door notifications were in place for residents on Enhanced Barrier Precautions (EBP). This deficiency was identified for two residents during the survey. Resident 4, who had a Stage II sacral wound, did not have any evidence of EBP being utilized in their room, doorway, or hallway area. The Director of Nursing confirmed that no EBPs were being used for the treatment of Resident 4's wound. Similarly, Resident 63, who had a nephrostomy tube, also lacked evidence of EBP in their room throughout the survey. The Director of Nursing confirmed that enhanced barrier precautions were not in place for Resident 63. The facility's policy on EBPs requires the use of gown and gloves for high-contact resident care activities and mandates that PPE be available at the resident's room, which was not adhered to in these cases.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to provide adequate nail care for a resident with moderate cognitive impairment who required partial/moderate assistance with personal hygiene. During an observation, the resident was found with long and dirty fingernails, with a dried brown stain or substance underneath. Despite morning care being provided, the non-licensed staff member did not clean the resident's fingernails because the resident had a doctor's appointment. This deficiency was noted during an interview with the staff member and was later communicated to the Assistant Director of Nursing.
Resident Falls from Window Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision of a resident, leading to a fall from a window and subsequent hospitalization. The resident, who had a history of left side hemiplegia, vascular dementia, and severe cognitive impairment, was identified as a high fall risk and moderate elopement risk. Despite these risks, the resident was able to exit the building through a window, resulting in significant injuries including facial fractures, rib fractures, a pneumothorax, and a subarachnoid hemorrhage. The resident's care plan included interventions for fall risk and elopement, such as assisting with transfers and ambulation, providing orientation and diversional activities, and checking the function of a wanderguard. However, on the night of the incident, the resident was last seen in a wheelchair near their room and was later found outside the building without the wheelchair. The wheelchair was discovered near an open window in the activity room, indicating the resident had exited through the window without triggering any alarms. Interviews and observations revealed that no staff were present in the activity room at the time of the incident, and the window had stop brackets that were not effective in preventing the resident's exit. The facility's failure to provide adequate supervision and secure the environment contributed to the resident's fall and subsequent injuries, highlighting deficiencies in management and nursing services as previously cited in past surveys.
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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