Gino J Merli Veterans Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Scranton, Pennsylvania.
- Location
- 401 Penn Avenue, Scranton, Pennsylvania 18503
- CMS Provider Number
- 39A433
- Inspections on file
- 24
- Latest survey
- April 10, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Gino J Merli Veterans Center during CMS and state inspections, most recent first.
Surveyors found that a corridor door to a resident room on one floor failed to latch into the frame when tested, meaning it did not meet NFPA 101 requirements for positive latching of corridor doors. The Facilities Manager and Facility Life Safety staff confirmed during interview that this corridor door did not latch properly.
The facility failed to fully screen four of five newly hired employees, including LPNs and nurse aides, to determine eligibility for employment. Personnel files showed applications listing prior employers, but there was no documentation that former employers were contacted, and the DON could not provide evidence that past work history was verified for these staff members.
A resident with Parkinson’s disease and moderate cognitive impairment had lower dentures go missing during care. Staff searched the room, wheelchair, clean utility room, and outside laundry service, but the dentures were not found. Although the care plan addressed denture use and listed several behaviors, it did not include individualized interventions for the resident’s habit of placing personal items in tissues or food containers, and there was no evidence the IDT reviewed or revised the care plan after the investigation; the DON confirmed it had not been updated.
A resident with CHF, B12 deficiency anemia, and severe cognitive impairment had a significant weight loss that was identified by the facility, but the RD did not complete the nutrition evaluation and document interventions until 7 days later. The resident's record showed a 13.6-lb loss in 1 month, with additional losses over 90 days and 6 months, and the RD noted variable meal intake, congestion, and lethargy. The DON and RD confirmed the findings and could not explain the delay in addressing the weight loss.
Two residents received duplicate antipsychotic therapy without documented clinical justification, and gradual dose reductions were not attempted as required. One resident with schizophrenia and Parkinson's disease was prescribed both Seroquel and Haldol without individualized rationale, while another resident with dementia and on hospice care received escalating doses of Seroquel and Haldol for behavioral symptoms without evidence of psychosis or trial of nonpharmacological interventions. The facility lacked documentation supporting the necessity of these regimens, and the DON confirmed the absence of required physician documentation.
A resident with a history of falls and lower limb amputation was not properly assessed or provided with individualized safety measures upon return from a hospital stay. Staff transferred the resident from a personal wheelchair with leg rests to a weight chair lacking safety features, and did not use the ADA-compliant wheelchair scale as intended. During the weighing process, the resident fell, sustaining multiple abrasions and a cervical spine fracture, due to the facility's failure to reassess fall risk, use appropriate equipment, and supervise the procedure safely.
The facility failed to include discharge planning in the care plans for four residents. Despite MDS assessments indicating their discharge goals, the care plans did not reflect these intentions. The Director of Nursing confirmed the absence of discharge planning for these residents.
Failure of Corridor Door to Latch Properly
Penalty
Summary
Surveyors identified a deficiency involving a corridor door that did not meet NFPA 101 requirements for positive latching. During observation on the second floor B-Hall, the door to Resident Room 209 was tested and found to fail to latch into the door frame. This condition was noted as a failure to maintain a corridor opening in accordance with the requirement that corridor doors resist the passage of smoke and have positive latching hardware. The issue was observed on one of four floors in the building and specifically involved the corridor door to a resident room. At the time of the survey, the door did not properly engage with the frame when tested, meaning it did not latch as required. During the exit interview, the Facilities Manager and Facility Life Safety staff confirmed that the corridor door to Resident Room 209 failed to latch.
Plan Of Correction
Room 209 door was immediately adjusted to insure proper closure. Resident room doors were inspected and adjusted. Random audits of resident room door closure will be conducted on 5 doors on each nursing unit weekly for 8 weeks. Corridor doors will be inspected semi-annually for proper closure. Any doors found to be not closing properly are adjusted or replaced.
Failure to Verify Prior Employment for Newly Hired Staff
Penalty
Summary
The facility failed to fully screen four of five newly hired employees to determine whether they were eligible for employment in a long term care nursing facility. The report states that the facility’s abuse prohibition policy required screening potential employees, including obtaining references from previous and current employers, and that regulatory requirements call for review of employment history, contact with former employers, and documentation of licensure status and disciplinary actions from licensing or registration boards and other registries. A review of personnel files showed that Employee 1, an LPN hired on March 16, 2026; Employee 2, a nurse aide hired on March 16, 2026; Employee 3, an LPN hired on March 30, 2026; and Employee 4, a nurse aide hired on March 30, 2026, all had employment applications listing previous employers, but there was no documentation that the facility contacted any former employer to screen them. During an interview on April 9, 2026, at 1:15 PM, the DON was unable to provide evidence that prior employers were contacted to verify past work history for four of five newly hired employees.
Care Plan Not Revised After Denture Loss Investigation
Penalty
Summary
The facility failed to ensure that Resident 25’s comprehensive care plan was reviewed and revised to reflect current needs and services after staff identified that the resident’s lower dentures were missing during care. Resident 25 was admitted with Parkinson’s disease and had a quarterly MDS showing moderate cognitive impairment with a BIMS score of 9 and verbal behavioral symptoms directed toward others during the look-back period. Facility investigative documentation dated January 13, 2026, stated that nursing and social services searched the resident’s room and wheelchair, checked the clean utility room, and contacted the outside laundry service, but the dentures were not found. The investigative documentation also noted that Resident 25 had a history of placing personal items in tissues and discarding them, and placing items on the lunch tray and in food containers such as cereal or milk cartons. The resident’s care plan included an ADL focus area documenting that the resident was edentulous and used upper and lower dentures, with interventions for removing dentures in the evening, applying them in the morning, and cleansing and storing them according to preference. The behavior care plan listed behaviors such as poor impulse control, throwing objects, activating alarms, kicking staff, grabbing staff hands, attempting to strike staff, and interfering with care, but it did not include individualized interventions for the documented behavior related to placing personal items in tissues or food containers. The record contained no evidence that the interdisciplinary team reviewed or revised the care plan after the denture-loss investigation, and the DON confirmed the care plan had not been revised to address that behavior.
Delayed response to significant weight loss and inconsistent weight monitoring
Penalty
Summary
The facility failed to monitor resident weights consistently and accurately to timely identify changes in nutritional parameters and implement nutritional interventions for one resident. The facility policy stated monthly weights were to be obtained during the first 5 business days of the month, residents with significant weight changes were to be re-weighed the same day for verification, and the RD was to document significant monthly weight changes, update care plans, and convey significant changes to the provider. Resident 63 was admitted with chronic heart failure, vitamin B12 deficiency anemia, and adjustment disorder with depressed mood, and the annual MDS dated February 4, 2026 documented severe cognitive impairment with a BIMS score of 6 and a weight of 173 pounds. The MDS also documented significant weight loss of 5% or more in one month or 10% or more in six months that was not physician prescribed. The resident's weight record showed 186.4 pounds on January 3, 2026 and 172.8 pounds on February 3, 2026, a 13.6-pound loss, or 7.3%, in one month. The RD's comprehensive nutrition evaluation completed on February 10, 2026, seven days after the significant weight loss was identified, documented the resident had lost 13.6 pounds in 30 days, 15.2 pounds in 90 days, and 20.8 pounds in six months. The RD noted variable meal intake ranging from 0% to 100%, slight congestion, and increased lethargy, and recommended liberalizing the diet, discontinuing the consistent carbohydrate diet, starting Boost Glucose Control twice daily, and implementing weekly weights. During interviews, the Food Service Director/RD and the DON confirmed the findings and the DON could not explain the seven-day delay in implementing nutritional interventions after the significant weight loss was identified.
Failure to Ensure Drug Regimens Free from Unnecessary Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary medications by administering duplicate antipsychotic therapy without documented clinical justification and by not attempting gradual dose reductions (GDR) where appropriate. For one resident with schizophrenia and Parkinson's disease, the clinical record showed concurrent prescriptions for two antipsychotic medications, Seroquel and Haldol, in addition to other psychoactive drugs. The antipsychotic medication review indicated that dose reduction was contraindicated, but there was no resident-specific documentation or individualized clinical rationale to support this assertion. The facility was unable to provide evidence that the physician had documented a justification for continued antipsychotic use at current dosages or for the necessity of prescribing both antipsychotics concurrently, and no GDR had been attempted. Another resident with Alzheimer's disease, anxiety, and on hospice care was prescribed Seroquel for dementia and later Haldol for behavioral symptoms. The clinical record documented persistent behavioral symptoms and repeated increases in antipsychotic dosages, resulting in duplicate antipsychotic therapy. Despite these medication changes, there was no evidence of hallucinations, delusions, or other psychotic symptoms that would warrant antipsychotic use. The record also lacked documentation of nonpharmacological interventions being attempted or considered prior to initiating or escalating pharmacologic treatment. Observations revealed extrapyramidal symptoms, but there was no evidence that the medication regimen was reassessed in response. Interviews with the DON confirmed the absence of physician documentation supporting the clinical need for duplicate antipsychotic therapy or repeated dosage increases for both residents. The facility's actions did not align with its own policy requiring ongoing evaluation and documentation of psychotropic medication use, including the use of nonpharmacological interventions and individualized clinical rationales for medication decisions.
Failure to Assess and Implement Fall Prevention Measures During Weighing Procedure
Penalty
Summary
A deficiency occurred when the facility failed to adequately assess and implement safety measures for a resident identified as at risk for falls, resulting in actual harm. The resident, who had chronic kidney disease, was dependent on renal dialysis, and had an acquired absence of the right leg below the knee, returned from a hospital stay with instructions indicating an increased risk for falls. Upon readmission, there was no documented evidence that the facility performed a comprehensive assessment of the resident’s care needs, including fall risk or the need to update the care plan, despite facility policy requiring such assessments upon readmission. On the day of the incident, staff transferred the resident from his personal wheelchair, which had leg rests, into a facility weight chair that lacked leg rests or other individualized safety features. The weighing procedure was not conducted using the ADA-compliant wheelchair platform scale as intended, which would have allowed the resident to remain in his own wheelchair with proper supports. During the transfer and weighing process, the resident leaned forward and fell from the weight chair, sustaining multiple abrasions and a cervical spine fracture. Staff interviews confirmed that safety devices were not transferred to the weight chair and that the facility did not routinely use individualized safety equipment during weighing procedures. Post-incident documentation and interviews revealed that the resident experienced significant pain and required further medical evaluation, which confirmed a cervical spine fracture. The facility’s failure to reassess the resident after a significant change in condition, ensure the use of appropriate assistive equipment, and supervise the weighing procedure according to safe practices and the intended use of the scale directly resulted in the resident’s fall and injury.
Failure to Include Discharge Planning in Care Plans
Penalty
Summary
The facility failed to include discharge planning in the comprehensive care plans for four residents, as identified during a clinical record review and staff interview. Resident 6, admitted with Parkinson's disease, diabetes, and a right leg amputation, had a quarterly MDS assessment indicating the resident's goal to remain in the facility. However, the care plan did not address this discharge plan. Similarly, Resident 150, with atherosclerotic heart disease and chronic obstructive pulmonary disease, also had a care plan lacking a discharge plan, despite the MDS indicating the resident's intention to stay long-term. Resident 11, diagnosed with neurocognitive disorder with Lewy bodies, Parkinson's disease, and schizophrenia, expressed a goal to be discharged to the community, but this was not reflected in the care plan. Resident 107, with bipolar disorder and atherosclerotic heart disease, also had a care plan that failed to include a discharge plan for long-term placement, despite the MDS indicating the resident's intention to remain in the facility. The Director of Nursing confirmed the absence of discharge planning in the care plans for these residents.
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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