Grandview Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Danville, Pennsylvania.
- Location
- 78 Woodbine Lane, Danville, Pennsylvania 17821
- CMS Provider Number
- 395623
- Inspections on file
- 57
- Latest survey
- April 17, 2026
- Citations (last 12 mo.)
- 37 (1 serious)
Citation history
Health deficiencies cited at Grandview Nursing And Rehabilitation during CMS and state inspections, most recent first.
Lack of Behavioral Health Training Program: The facility failed to provide an effective behavioral health care and services training program for staff across the review period. The facility assessment identified a resident population receiving psychiatric and psychological services and noted staff education was key to quality care, but the annual training modules showed no evidence of training on behavioral symptoms, non-pharmacological interventions, or appropriate responses to residents with psychiatric or psychological needs. The DON and NHA could not provide documentation of such training and confirmed the facility cared for residents with complex behavioral health needs.
MDS assessments for multiple residents did not match the clinical record. Section GG entries for eating, personal hygiene, toileting hygiene, bathing, bed mobility, and wheelchair mobility often showed less assistance than the documentation reflected, including residents with cerebral infarction, Alzheimer’s disease, dementia, amputations, ESRD, diabetes, and hemiplegia. One resident’s MDS also failed to report a documented fall that resulted in an acute hip fracture. The RN Assessment Coordinator acknowledged the discrepancies.
Failure to Monitor Significant Weight Loss and Nutritional Status The facility failed to consistently reweigh residents after significant wt changes, notify the RD and MD, and document timely nutritional assessment/interventions for 3 residents. One resident with dysphagia and malnutrition had a rapid wt loss with no required reweigh or further nutrition monitoring documented, while two other residents also had significant wt loss without timely follow-up, aggressive wt monitoring, or documented notification of clinical staff.
Two residents received PRN oxycodone HCl without consistent documentation that non-pharmacological pain measures were attempted first, despite physician orders directing staff to try interventions such as repositioning, toileting, food, fluids, back rubs, and dimmed lights. One resident had peripheral vascular disease and chronic hip pain, and the other had a left femur fracture; the DON confirmed the missing documentation during interview.
A medication room refrigerator on one unit was found at 30 degrees Fahrenheit, below the facility’s stated range, and records showed repeated temperatures below acceptable limits over several months. The refrigerator stored injectable meds for 10 residents, and an opened multi-dose tuberculin vial was not dated when opened. The DON confirmed the required temperature range and that opened meds must be dated.
Failure to communicate required transfer information for three residents. Three residents were transferred to outside care settings, but their records lacked documentation that the facility sent required clinical details to the receiving provider, including physician contact information, resident representative contact information, advance directive information, special instructions or precautions, care plan goals, and other necessary information. During interview, the DON and NHA could not provide evidence that the information had been communicated.
Pressure injury monitoring and support surface settings were not maintained for two residents. One resident with diabetes and hemiplegia had a Stage 3 heel PI, but the wound was not documented as monitored or measured for over two weeks, and the low air loss mattress was observed set above the resident's current weight. Another resident with osteomyelitis and impaired skin integrity had a right buttock wound and a left heel wound, but the air mattress pump was set for a much higher weight than the resident's actual weight, contrary to the manufacturer instructions and the DON's confirmation.
Failure to provide appropriate wheelchair equipment for mobility. A resident with an acquired leg amputation and limited core strength had OT recommendations for a high-back reclining wheelchair with elevating leg rests, a foot buddy, and a cushion, and could propel that chair independently. After the wheelchair broke, the resident was left waiting for repair or replacement, reported inability to sit upright in a standard chair, and OT documented that the available replacement wheelchairs did not meet the resident’s needs. The OTR and DON could not provide evidence that the resident’s needed equipment had been provided or actively pursued.
Failure to Monitor PICC and Midline Catheters: A resident with osteomyelitis and severe cognitive impairment had a PICC line placed for IV antibiotics, then required two midline catheters after pulling out the prior lines. Physician orders required routine documentation of catheter external length, arm circumference, and site monitoring, but the record showed no consistent documentation that nursing staff completed the ordered measurements or assessments, and the DON confirmed the lack of documentation.
Failure to honor documented food allergies, intolerances, and preferences: Two residents were served foods listed as allergies or dislikes, including raw tomatoes, milk, tomatoes, and cucumbers. One resident’s chart also failed to include a documented raw tomato allergy, and lactose-free milk was not available on the unit drink cart despite being in the kitchen. The NHA and DON confirmed the transcription and meal service failures.
A resident with muscle weakness, dizziness, vertigo, and impaired ambulation was ordered weighted utensils and a two-handled cup with all meals, and the care plan and meal ticket both reflected those needs. During lunch observation, the resident was not provided the ordered weighted utensils, and the RD confirmed the adaptive dining equipment was not provided as ordered.
Inadequate Training and Inaccurate MDS Assessments: The facility failed to ensure staff assisting with the MDS process were adequately trained and competent to complete assigned duties. MDS reviews for several residents contained inaccurate Section GG Functional Abilities data that did not match the clinical record or the level of assistance documented during the look-back period. The RNAC confirmed the errors, and an LPN assisting with data collection stated she had not received sufficient training for her role; the DON and NHA could not provide documentation of training in MDS policies and procedures.
Multiple cognitively intact residents reported ongoing delays in call bell response times, with waits exceeding 30 minutes and sometimes up to two hours. Despite documented grievances and interviews, the facility did not demonstrate effective resolution or follow-up regarding these complaints, impacting residents' timely access to assistance.
Insufficient staffing in the dietary department resulted in delayed meal service and meals not served at palatable temperatures for residents. Multiple residents and staff reported frequent late and cold meals, with one visitor expressing concern for a resident's insulin management. Observation confirmed significant delays in meal delivery and suboptimal food temperatures, and review of staffing schedules showed unfilled dietary aide positions and the dietary manager covering cooking duties.
The facility did not ensure meals were served at palatable temperatures and flavors, with delayed meal cart delivery resulting in food being served cold and unappetizing. Multiple residents reported receiving cold, bland, or inedible food, and observations confirmed that hot food items were below the required temperature standard.
A resident with multiple medical conditions was observed with numerous medications and a prepared respiratory treatment at the bedside, with staff sometimes leaving medications for independent administration. Staff could not confirm that the required self-administration assessment, physician order, or care plan was completed, resulting in a deficiency for not following facility policy and regulatory requirements regarding medication self-administration.
A resident with severe cognitive impairment and multiple medical conditions experienced a fall, persistent pain, increased confusion, and refusal of medications and food. Despite ongoing decline and documentation of symptoms, the attending physician was not notified of these significant changes prior to the resident's hospital transfer, in violation of facility policy.
A resident with severe dementia and a known history of forgetting to use her walker did not have individualized fall-prevention interventions included in her care plan. Despite staff awareness of her impulsivity and cognitive deficits, the care plan failed to specify actions to keep her walker within reach or address her behavior, resulting in a fall that caused injury and required hospitalization.
A resident with severe cognitive impairment and multiple health issues developed a pressure ulcer that worsened after staff failed to perform weekly skin assessments, did not implement wound care consultant recommendations to remove the resident's brief while in bed, and did not update the care plan to reflect the worsening wound. Documentation was lacking for both the required interventions and regular skin checks, leading to the progression of the wound from an abrasion to an unstageable pressure ulcer.
A resident with multiple mental health and medical diagnoses did not receive several prescribed medications as ordered due to delays in obtaining medications from the pharmacy and lack of timely administration by staff. Facility records showed missed or delayed doses for medications including Lamotrigine, Olanzapine, Clonazepam, Lithium, Simethicone, and Cefepime, with documentation indicating medications were not available or were administered late. This occurred despite facility policy requiring timely medication administration.
A deficiency occurred when a hazardous sanitizing chemical was mistakenly served as a beverage to ten residents after a cook, lacking documented training, used a drink pitcher to mix the chemical and left it unlabeled in the kitchen. The solution was then served by another staff member, who assumed it was pink lemonade. Several residents with chronic illnesses and cognitive impairment were affected, and required monitoring and assessment were not documented as completed. Staff interviews and personnel file reviews revealed a lack of formal training and orientation regarding chemical safety and labeling procedures.
A resident with a history of falls, cervical fracture, and on anticoagulation experienced multiple falls, including an unwitnessed fall with possible head impact. Despite physician orders for 15-minute safety checks and neurological assessments, these were not consistently performed or communicated to staff. The resident was not promptly evaluated or transferred for diagnostic imaging, and was later found unresponsive with a large subdural hematoma, resulting in death. The facility failed to provide care in accordance with professional standards, including post-fall monitoring and timely assessment.
Surveyors identified multiple sanitation failures in the dietary department, including improper use of the three-compartment sink, lack of sanitizer test strips, dirty kitchen and storage areas, and widespread issues with unlabeled and undated food items. Additional deficiencies were found in resident dining and pantry areas, with dirty equipment, food debris, and improper storage of cleaning chemicals. Facility leadership confirmed these conditions as food safety and sanitation issues.
Surveyors found that the facility did not maintain a clean and sanitary environment in one care unit, with soiled floors, dirty equipment, and a resident left in a soiled condition for over fifteen minutes after a bowel incontinence episode. Staff shortages contributed to delays in care, and multiple rooms were observed with visible dirt and stains.
Facility administration failed to ensure resident safety when the dietary department served a hazardous cleaning chemical during meal service, resulting in ten residents ingesting the substance and placing all residents in the affected wing at risk. Staff interviews revealed that dietary personnel had not received effective training or competency evaluation on safe handling, storage, and labeling of hazardous chemicals, and administrative oversight was lacking in monitoring departmental operations and implementing facility policies.
A resident with multiple joint replacements and chronic conditions, who required two-person assistance with a Hoyer lift for transfers, was transferred by a single nurse aide who was aware of but did not follow the care plan and physician's orders. During the transfer, the resident sustained a left tibial periprosthetic fracture, resulting in pain, immobilization, and the need for frequent pain medication.
Surveyors found that the facility failed to maintain sanitary food storage and service practices, including unlidded trash near food prep areas, dishware and paper products stored directly on the floor with open packaging, and supplies stored close to the ceiling, all of which increased the risk of contamination in the dietary department.
Surveyors identified that the facility did not develop or implement individualized care plans for two residents: one requiring oxygen therapy and another dependent on staff for hydration. The care plan and Kardex for a resident with chronic respiratory failure did not match the physician’s order for oxygen administration, while another resident’s care plan failed to address full staff dependence for hydration, resulting in delays in fluid provision.
Licensed nursing staff administered Novolog insulin to a resident with type 2 diabetes on several occasions when the resident's blood glucose levels were below the physician-ordered threshold, contrary to the prescribed parameters. The DON confirmed that these administrations did not follow the physician's orders.
A resident with Alzheimer's disease and muscle atrophy, who required significant assistance with mobility, was discharged from physical therapy with recommendations for a ROM Restorative Nursing Program. The program was not included in the care plan or implemented as recommended, and there was no documentation or staff awareness of the omission.
A resident dependent on hemodialysis did not have the required emergency kit at the bedside, despite physician orders and care plan interventions mandating its presence. Observation and interviews confirmed the absence of emergency supplies for the resident's AV fistula site, and staff acknowledged the supplies were not available as required.
Nursing staff did not consistently follow established procedures for counting and verifying controlled substances on a medication cart, as required by facility policy. Required signatures from both on-coming and off-going nurses were missing on several occasions, and this was confirmed through record review, observation, and staff interviews.
A resident with moderately impaired cognition and a history of hypertension and muscle weakness was given multiple medications not prescribed to him after an LPN, unfamiliar with the unit, failed to verify the resident's identity. The medications administered belonged to the resident's roommate, and the error was discovered after the resident exhibited low blood pressure and was sent to the emergency room for evaluation.
Surveyors found that expired and improperly labeled medications and supplements were present in a medication storage room, including items such as Multi-Vitamin with Iron, Aspirin, and Glucosamine and Chondroitin. An LPN confirmed the presence of these items, which had not been removed in accordance with facility policy and manufacturer guidelines.
A resident refused the pneumococcal vaccine, but there was no documented evidence that the resident or their representative received education about the vaccine's benefits and side effects, as required by facility policy. This lack of documentation was confirmed by the Infection Preventionist.
A resident with quadriplegia and COPD, assessed as cognitively intact and able to smoke independently, was found keeping smoking materials in their room, contrary to facility policy requiring all smoking supplies to be secured by staff. The facility was unable to provide evidence of staff monitoring or securing the resident's smoking materials, resulting in noncompliance with established procedures.
A resident with severe cognitive impairment and a history of falls experienced an unwitnessed fall from bed due to the left-side bed wedge not being in place and a nonfunctional bed alarm, despite care plan interventions requiring these safety measures. The facility's investigation determined that the fall resulted from failure to follow the individualized plan of care.
A resident with severe cognitive impairment and chronic medical conditions was not provided with an individualized incontinence management plan, despite being always incontinent of urine and frequently incontinent of bowel. The care plan lacked a structured toileting schedule or specific interventions, and documentation showed the resident was not on a toileting program. The resident was consistently found incontinent, and a family grievance reported the resident was soaked with urine. The DON confirmed there was no documented plan for incontinence management.
Multiple residents reported that their meals were frequently served cold or lukewarm, and a test tray analysis confirmed that hot foods were below the required temperature and cold foods were above the safe limit. The Dietary Manager and NHA acknowledged that meals were not consistently served at palatable temperatures or in line with resident preferences, in violation of facility policy and federal regulations.
Multiple residents experienced significant delays in staff response to call bells due to a malfunctioning notification system on one unit. Visual indicators were present, but without audible alerts or fully functioning pagers, staff were often unaware of active calls unless physically present in the hallway. In contrast, another unit with an upgraded system had faster response times.
The facility failed to follow its planned menus, resulting in food omissions for four residents during breakfast. The Dietary Manager confirmed that biscuits were not served due to being overbaked, but no substitutions were made. The facility could not provide required Meal Substitution Records and lacked a system to monitor food omissions or substitutions, leading to non-compliance with its policies.
The facility failed to serve meals at safe and appetizing temperatures, affecting three residents. Meals were consistently cold, with a test tray evaluation confirming food temperatures below required standards. The dietary manager acknowledged the deficiency, which impacted resident satisfaction and increased the risk of foodborne illness.
The facility failed to provide adaptive dining equipment for two residents, one with cerebral infarction and dysphagia, and another with dementia and polyosteoarthritis. Despite physician orders for specific adaptive cups to prevent dehydration and address nutritional deficits, the dietary staff did not provide the required equipment during breakfast, as confirmed by staff interviews.
Two residents in the facility, both with severe cognitive impairments, did not receive scheduled showers over a three-month period. Despite being dependent on staff for assistance with activities of daily living, the facility failed to provide or document the showers as planned. The Nursing Home Administrator and DON confirmed the oversight but could not explain the lack of compliance.
The facility failed to provide meals accommodating the dietary needs and allergies of two residents. A resident with a dairy allergy was served yogurt containing milk, and both residents did not receive the prescribed honey-thickened juice. Staff interviews and observations revealed systemic issues in dietary service, with aides needing to retrieve missing items from the kitchen.
The facility failed to provide timely responses to residents' requests for assistance, impacting their quality of life and dignity. Several residents reported long wait times for care, with one resident waiting over an hour and a half for staff to respond to her call bell. Another resident, dependent on staff due to Parkinson's disease, was left exposed in bed for 20 minutes. The Nursing Home Administrator and DON acknowledged the issue but could not explain the delays.
A resident with Parkinson's disease was left exposed in bed with pants pulled down and no privacy curtains drawn, visible from the hallway for twenty minutes. The resident, who is cognitively intact and dependent on staff for personal care, expressed anger and frustration over the situation. The DON confirmed the lapse in maintaining the resident's dignity and the need for proper personal care.
A resident with chronic kidney disease and traumatic brain injury was discharged from an LTC facility without a safe discharge plan, particularly regarding medication administration. Despite recommendations for significant supervision due to cognitive impairment, the facility did not document the availability of necessary support or provide self-medication training. The resident was hospitalized shortly after discharge due to the lack of a safe plan.
A facility failed to ensure proper nursing practices for IV medication administration via a central venous catheter. A resident with bacterial meningitis required IV antibiotics through a PICC line, but LPNs administering the medication lacked the necessary education and supervision. The facility did not have a policy for LPNs providing care through central catheter lines, as confirmed by the DON.
A facility failed to document the administration of an antibiotic for a resident with bacterial meningitis. The resident had a PICC line and was prescribed Penicillin G Potassium in Dextrose intravenously every four hours. The Medication Administration Record showed missing documentation on multiple occasions, and the DON confirmed the uncertainty of administration.
Lack of Behavioral Health Training Program
Penalty
Summary
The facility failed to ensure an effective behavioral health care and services training program was provided for employees for 12 out of 12 months reviewed, covering May 2025 through April 2026. The facility assessment, last reviewed on January 29, 2026, stated that the facility manages medical conditions and medication-related issues causing psychiatric symptoms and behaviors and identifies and implements interventions to support individuals with anxiety, cognitive impairment, depression, trauma, post-traumatic stress disorder, other psychiatric diagnoses, and intellectual or developmental disabilities. The assessment also indicated that, on average, 90 residents receive psychiatric services and 99 residents receive psychological services each month, and that staff education is a key component to assuring residents receive quality care. Despite those findings, the facility assessment did not identify or include a structured or ongoing staff training program specific to behavioral health care and services. A review of the facility's annual staff training modules for the review period did not show evidence that staff received training related to behavioral health care and services, including identifying behavioral symptoms, using non-pharmacological interventions, or responding appropriately to residents with psychiatric or psychological needs. During an interview on April 17, 2026, the DON and NHA were unable to provide documentation showing staff received behavioral health care and services training during the review period, and both confirmed the facility cared for residents with varying and complex behavioral health needs, including residents requiring psychiatric and psychological services.
MDS assessments did not match residents’ documented functional status
Penalty
Summary
The facility failed to ensure that MDS assessments accurately reflected residents’ functional status for six of eight residents reviewed for MDS accuracy. The report states that the RAI User’s Manual requires the MDS to reflect the resident’s usual performance based on direct observation, communication with the resident, and communication with direct care staff across shifts, and that Section GG must match the resident’s actual performance during the assessment period associated with the ARD. For Resident 2, who was admitted with cerebral infarction, the Annual MDS indicated partial or moderate assistance for personal hygiene and bed mobility, but the clinical record during the assessment period showed the resident was dependent for personal hygiene on five of nine occasions and required substantial or maximal assistance on three of nine occasions, and was dependent for bed mobility on three of nine occasions with substantial or maximal assistance on five of nine occasions. For Resident 14, admitted with Alzheimer’s disease, the Quarterly MDS indicated partial or moderate assistance with eating and substantial or maximal assistance with personal hygiene and bed mobility, while documentation showed dependence for eating on five of six occasions, dependence for personal hygiene on nine of nine occasions, and dependence for bed mobility on nine of nine occasions. For Resident 6, admitted with dementia, the Annual MDS indicated substantial or maximal assistance with toileting hygiene and bathing, but the record showed dependence for toileting hygiene on nine of nine occasions and dependence for bathing on two of two occasions. For Resident 4, admitted with acquired absence of the left leg below the knee and right hip joint, the Quarterly MDS indicated substantial or maximal assistance with bathing and partial or moderate assistance with personal hygiene and bed mobility, while documentation showed dependence for bathing on four of four occasions, dependence for personal hygiene on five of seven occasions with substantial or maximal assistance on two of seven occasions, and dependence for bed mobility on five of eight occasions with substantial or maximal assistance on three of eight occasions. For Resident 39, admitted with end-stage renal disease, the Quarterly MDS indicated substantial or maximal assistance with bathing, partial or moderate assistance with personal hygiene, and supervision or touching assistance with wheelchair mobility, but the record showed dependence for bathing on one of one occasion, dependence for personal hygiene on four of four occasions, and dependence for wheelchair mobility on two of two occasions; the same resident’s Quarterly MDS also indicated no falls in the prior month or prior two to six months, although the clinical record showed a fall at the facility resulting in an acute right femoral intertrochanteric fracture. For Resident 7, admitted with diabetes and hemiplegia, the admission MDS indicated partial or moderate assistance with personal hygiene, while documentation showed dependence on staff for personal hygiene on five of seven occasions and substantial or maximal assistance on two of seven occasions. The RN Assessment Coordinator acknowledged that the MDS assessments for Residents 2, 4, 6, 7, 14, and 39 did not accurately reflect the residents’ status documented in the clinical record.
Failure to Monitor Significant Weight Loss and Nutritional Status
Penalty
Summary
The facility failed to monitor resident weights consistently and accurately to timely identify changes in nutritional status and implement nutritional interventions for 3 of 33 residents reviewed. Facility policy required residents with a weight change of 5 percent or more to be reweighed for confirmation and, if verified, for nursing to immediately notify the Registered Dietitian. The policy also identified 5 percent weight loss in 1 month, 7.5 percent in 3 months, and 10 percent in 6 months as significant, and required nutritional assessment when a resident had a change in condition placing them at risk for impaired nutrition. Resident 146 was readmitted with dysphagia, major depressive disorder, and muscle wasting with atrophy. The Registered Dietitian documented the resident was underweight, met criteria for malnutrition, and had a downward weight trend from 96 pounds to 91.2 pounds, with Med Pass 2.0 ordered and weight monitoring recommended. The resident’s record showed a weight of 91.2 pounds and then 82.2 pounds about 1 week later, a 9.8 percent loss, but the record did not show a required reweigh after the significant loss. The record also did not show timely identification of the significant weight loss or timely development and implementation of additional nutritional interventions, and no further nutrition monitoring was documented after the later nutrition note. Resident 84 was admitted with major depressive disorder and cerebral infarction. The weight record showed a decrease from 105 pounds to 94 pounds in less than 1 month, an 11-pound loss or 10.5 percent, but the facility did not immediately reweigh the resident. The record also did not show documentation that the Registered Dietitian, physician, or resident representative was notified of the significant weight loss. Resident 161, admitted with major infection, major depression, and diabetes, lost 7.6 pounds over 24 days, from 133.6 pounds to 126 pounds. Dietary assessment and intervention were not completed until 10 days after the weight loss was identified, when a supplement was added, and the record did not show more aggressive monitoring, weekly weights, or timely reassessment before the next documented weight. The DON was unable to provide documentation of re-evaluation of dietary goals, care plan revisions, or ongoing aggressive weight monitoring after the dietary note.
Failure to Document Non-Pharmacological Interventions Before PRN Opioid Administration
Penalty
Summary
Safe, appropriate pain management was not provided for two residents because licensed nursing staff did not consistently attempt or document non-pharmacological interventions before giving PRN oxycodone HCl. Facility policy on pain assessment and management stated that non-pharmacological interventions such as repositioning, toileting, back rubs, dimming lights, food, fluids, and other measures may be used before or with medications, and the physician orders for both residents specifically directed staff to attempt such measures first. Resident 3 had diagnoses including peripheral vascular disease and chronic left hip pain, and was ordered oxycodone HCl 5 mg by mouth every 6 hours as needed for pain rated 4 through 10. The MAR showed the medication was administered multiple times across November 2025 through March 2026, but the facility could not provide consistent documented evidence that non-pharmacological interventions were attempted before administration. Resident 78 had diagnoses including a left femur fracture and was ordered oxycodone HCl 5 mg, one-half tablet by mouth every 4 hours as needed for pain rated 4 through 7, with instructions to attempt non-pharmacological interventions first. The MAR showed multiple administrations from March 12, 2026 through survey end on April 17, 2026, and the facility again could not provide consistent documented evidence that non-pharmacological interventions were attempted before giving the PRN opioid. The DON confirmed these findings during interview.
Medication Refrigerator Temperature and Labeling Deficiencies
Penalty
Summary
The facility failed to follow acceptable storage and labeling practices for medications on the West nursing unit. During observation of the medication room, a refrigerator containing injectable blood glucose-lowering medications had an internal temperature of 30 degrees Fahrenheit, and the posted temperature log had not yet been completed for that day. The posted acceptable range on the unit was 36 to 40 degrees Fahrenheit, which did not match the facility policy range of 36 to 46 degrees Fahrenheit. Review of the refrigerator temperature records from January 1, 2026 through April 14, 2026 showed repeated temperatures below the acceptable range, including multiple readings of 35 degrees Fahrenheit and two readings of 34 degrees Fahrenheit. The refrigerator contained injectable medications for 10 residents, including Lantus, Novolog, Glargine, Lispro, and Trulicity. The same observation also found an opened multi-dose vial of tuberculin that was not dated when opened. The DON confirmed that injectable blood glucose-lowering medications are to be stored between 36 and 46 degrees Fahrenheit and that medications are to be dated when opened, and confirmed that an opened tuberculin vial should be discarded 28 days after opening. The report states there was no evidence the facility implemented or sustained corrective actions to ensure refrigerated medications were consistently maintained within manufacturer-recommended temperature parameters.
Failure to Communicate Required Transfer Information
Penalty
Summary
The facility failed to ensure that required resident information was communicated to the receiving health care provider for three residents who were transferred out of the facility. Resident 7 was admitted to the facility and later transferred to the emergency department on February 4, 2026. Resident 39 was admitted to the facility and later transferred to the community hospital on March 9, 2026. Resident 108 was admitted to the facility and later transferred to the community hospital on February 10, 2026. For each of these residents, the clinical record contained no documented evidence that the facility communicated the required information to the receiving health care provider. The missing information included the contact information of the physician responsible for the resident’s care, resident representative information and contact information, advance directive information, special instructions or precautions for ongoing care as appropriate, comprehensive care plan goals, and other necessary information. During an interview on April 17, 2026, at 11:30 AM, the DON and NHA were unable to provide documented evidence that this required clinical information had been communicated for any of the three residents.
Pressure injury monitoring and support surface settings were not maintained
Penalty
Summary
The facility failed to ensure necessary treatment and services were provided to promote healing of pressure injuries for two residents. Resident 7 had diagnoses including diabetes and hemiplegia, and was identified on admission as being at risk for altered skin integrity related to impaired mobility. A care plan addressed impaired skin integrity with interventions including a pressure reduction mattress, wound monitoring and measurement, and treatments as ordered. An external wound clinic report documented a Stage 3 left heel pressure injury measuring 3.5 cm by 1.8 cm by 0.3 cm with yellow slough and red granulation tissue, mild serous drainage, and no odor, and recommended a low air loss mattress. Clinical record review showed no documented evidence that Resident 7's Stage 3 left heel pressure injury was monitored or measured between March 31, 2026, and April 17, 2026. On April 9, 2026, the resident weighed 222 lbs., and on April 17, 2026, the resident was observed resting on a low air loss mattress set to 275 lbs. The regional nurse consultant confirmed during the observation that the mattress setting had not been adjusted to the resident's current weight. At that same observation, the wound measured 3.0 cm by 1.5 cm by 0.2 cm and had 20 percent slough, 80 percent granulation, and moderate serosanguineous drainage. Resident 75 had diagnoses including osteomyelitis of the vertebra, sacral, and sacrococcygeal region, and was identified as having impaired skin integrity related to inadequate nutrition and immobility. The care plan included use of a pressure reduction mattress with staff checking placement and function every shift, repositioning with two staff assistance while in bed, weekly skin audits, and treatments as ordered. A physician order directed staff to apply an air mattress and check placement and function every shift. A wound care consultant documented a right buttock end-of-life skin failure wound and a left heel end-of-life skin failure wound, with treatment recommendations including use of an air mattress. However, the air mattress pump was observed set for a resident weighing 148 lbs. even though the resident weighed 97.8 lbs., and the DON confirmed the mattress was not set for the resident's current weight.
Failure to Provide Appropriate Wheelchair Equipment for Mobility
Penalty
Summary
The facility failed to ensure a resident with limited mobility received appropriate equipment necessary to maintain or improve mobility with the maximum practicable independence. Resident 4 was admitted with diagnoses including acquired absence of the left leg below the knee and the right hip joint, and the care plan identified a self-care deficit related to decreased mobility. Occupational therapy discharge recommendations called for a high-back reclining wheelchair with elevating leg rests, a foot buddy, and a cushion, and the resident was able to maintain upright positioning in that wheelchair for four hours and propel it independently within the facility. After the resident’s reclining wheelchair broke in January 2026, the resident reported waiting for the facility to repair or replace it so he could independently move throughout the facility. A progress note documented that he was awaiting a new wheelchair in order to get out of bed and reported weak abdominal muscles and inability to sit upright in a standard wheelchair. An OT note later stated the newly ordered high-back wheelchairs were not able to recline and no available high-back wheelchair appropriately met the resident’s needs. The OTR and the DON/NHA were unable to provide documented evidence that the facility had provided or was actively attempting to provide a wheelchair that met the resident’s clinical needs before surveyor inquiry.
Failure to Monitor and Document PICC and Midline Catheter Measurements
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards and physician orders for the management and monitoring of a PICC line and subsequent midline catheters for Resident 75. The resident was admitted with diagnoses including osteomyelitis of the vertebra, sacral, and sacrococcygeal region and had severe cognitive impairment with a BIMS score of 6. A hospital discharge summary indicated the resident had a PICC line placed for IV antibiotics related to the sacral osteomyelitis. On readmission, the facility documented the presence of a PICC line in the upper left arm, but there was no documentation of the external catheter length or arm circumference at that time. Physician orders required arm circumference measurements on admission and every 72 hours, PICC external length measurements on admission and every 7 days, and documentation of all measurements in the progress note. The resident later removed the PICC line, and a midline catheter was inserted in the left upper arm with documentation of an external length of 0 cm and a mid-arm circumference of 25 cm. The resident then pulled out that catheter as well, and another midline catheter was inserted in the right upper arm with documentation of an external length of 0 cm and a mid-arm circumference of 21 cm. A subsequent physician order required the midline external catheter length to be measured and documented on admission and weekly, and another order required the midline site to be monitored every shift for infection, line fracture, breakage, dislodgement, pain, or swelling, with findings documented in the progress notes. Review of the nursing admission evaluation, MAR/TAR, and nursing progress notes from March 19 through April 17, 2026, found no documented evidence that nursing staff consistently completed or recorded the required PICC length, midline length, or arm circumference measurements as ordered. The DON confirmed during interview that there was no documentation showing nursing staff consistently followed the physician orders for monitoring and documenting catheter length and arm circumference for Resident 75.
Failure to Honor Documented Food Allergies, Intolerances, and Preferences
Penalty
Summary
The facility failed to provide food and beverages in accordance with residents’ documented allergies, intolerances, and stated food preferences for two residents. Resident 188’s lunch meal ticket identified a lactose allergy and dislikes for pineapple and raw tomatoes, but during lunch the resident was served a side salad containing raw tomatoes and a cup of white whole milk. At the time of the meal, the resident stated she was allergic to raw tomatoes, pineapple, and milk. Staff confirmed the resident was served raw tomatoes despite the meal ticket identifying tomatoes as a dislike, and the unit drink cart did not have lactose-free milk available even though an unopened half-gallon was present in the kitchen walk-in refrigerator. Clinical record review showed a CRNP progress note documented dietary allergies to chocolate, raw tomatoes, pineapple, and lactose intolerance, but the allergy list in the medical record included pineapple and lactose and did not include raw tomatoes. Resident 167’s lunch meal ticket documented dislikes of tomatoes and cucumbers, yet the resident was served a side salad containing both items. The resident stated he frequently receives foods identified on his dislike list. The NHA and DON confirmed the facility failed to accurately transcribe dietary allergies in the medical record and failed to ensure residents received meals consistent with their documented allergies, intolerances, and preferences.
Failure to Provide Ordered Adaptive Dining Equipment
Penalty
Summary
The facility failed to provide required adaptive dining equipment for one resident out of 33 reviewed, Resident 188. The resident was admitted with diagnoses including muscle weakness and need for assistance with personal care. The comprehensive care plan dated April 3, 2026 identified ADL deficits related to weakness, dizziness, vertigo, and impaired ambulation, and included interventions for weighted utensils and a two-handled cup at all meals. Physician orders dated April 3, 2026 also directed that the resident receive weighted utensils and a two-handled cup with all meals. Review of the resident’s lunch meal ticket showed the same adaptive equipment was required. However, during observation of the resident’s lunch meal on April 15, 2026 at 1:18 PM, the resident was not provided the physician-ordered weighted utensils. During interview on April 15, 2025 at 1:25 PM, Employee 4, the Regional Dietary Director, confirmed the facility failed to provide the required adaptive dining equipment as ordered by the physician.
Inadequate Training and Inaccurate MDS Assessments
Penalty
Summary
The facility failed to ensure staff responsible for participation in the MDS assessment process were adequately trained and competent to perform assigned duties in accordance with federal requirements and professional standards of practice. A review of the facility job description for the MDS Coordinator RN showed the role was responsible for coordinating completion of the resident assessment process and verifying interdisciplinary team members completed, dated, and signed assessments according to federal regulations. The report also noted that while an LPN may contribute to data collection and observation, the comprehensive nursing assessment and certification of the MDS require RN judgment and RNAC sign-off. Review of MDS assessments for six residents showed inaccuracies, with 14 of 15 identified errors involving Section GG Functional Abilities. The facility failed to accurately document the level of assistance residents required during the assessment look-back period, and the clinical record information did not match the MDS submissions. During interviews, the RNAC confirmed the assessments were not accurate, and an LPN assisting with the MDS process stated she was responsible for collecting data and observations for RNAC review but could not explain the discrepancies and reported she had not received sufficient training for her assigned duties. The RNAC stated the LPN had been identified as needing additional training, and the DON and NHA were unable to provide documentation showing the LPN had been trained in facility policies and procedures related to completion of the MDS assessment process.
Failure to Resolve Resident Complaints About Delayed Call Bell Response
Penalty
Summary
The facility failed to resolve ongoing resident complaints regarding delayed call bell response times, as evidenced by multiple grievances and interviews with residents who were cognitively intact. Four residents reported waiting more than 30 minutes, and in some cases up to two hours, for staff to respond to their call bells. These concerns were documented both in written grievances and during interviews, with residents consistently stating that delays occurred on all shifts and affected their ability to receive timely assistance with basic needs such as toileting, mobility, and safety. Despite the facility's grievance policy, which requires prompt and adequate follow-up on resident concerns, there was no evidence that the facility effectively addressed or resolved these repeated complaints. The Nursing Home Administrator was unable to provide documentation showing that corrective actions taken in response to the grievances were successful or that follow-up with residents occurred to ensure their concerns were resolved.
Insufficient Dietary Staffing Leads to Delayed and Unpalatable Meal Service
Penalty
Summary
The facility failed to maintain sufficient staffing in the dietary department, resulting in delayed meal service and meals not served at palatable temperatures for residents on the East unit. Multiple residents reported that meals were often late by thirty minutes to over an hour and were served cold and unpalatable. One resident's visitor expressed concern for timely nutritional intake due to the resident's insulin use, noting that delays in meal service could impact blood sugar management. Nursing staff also reported that meal carts were consistently delivered late to the units. Observation of the lunch tray pass confirmed that the meal cart arrived fifty-three minutes past the scheduled time, and test tray temperatures for hot foods were below expected levels, resulting in lukewarm and bland meals. A review of the dietary department's staffing schedule revealed that two dietary aides were not replaced during their scheduled shifts, and the dietary manager was covering as the PM cook. The facility census was 168 residents at the time, and the administrator acknowledged ongoing staffing shortages in the dietary department.
Failure to Serve Palatable and Timely Meals at Safe Temperatures
Penalty
Summary
The facility failed to serve meals that were palatable, attractive, and at safe and appetizing temperatures during a lunch meal service on the East Unit. Observations revealed that the meal cart, scheduled to arrive at 11:30 AM, was delayed and did not reach the unit until 12:23 PM, resulting in meal trays being distributed significantly later than planned. A test tray obtained after the last resident was served showed that hot food items, including beef tips, garden rice, and mixed vegetables, were served at temperatures below the facility's standard of 120 degrees Fahrenheit, with recorded temperatures ranging from 108.5 to 118.2 degrees Fahrenheit. The food was described as lukewarm, unpalatable in temperature and flavor, with the rice being hard and bland, and the vegetables unseasoned and bland. Only the brownie was found to be palatable. Resident and staff interviews, as well as a review of food committee meeting minutes and grievance forms, indicated ongoing concerns about meals being served cold and unpalatable, with residents attributing these issues to dietary department staffing shortages and delayed meal cart deliveries. One cognitively intact resident specifically reported receiving burnt and inedible food, and others consistently noted that meals arrived late and were frequently cold. The facility's own documentation and interviews confirmed that meals were not served at the expected times or at palatable temperatures and flavors.
Failure to Assess Resident's Capability for Self-Administration of Medications
Penalty
Summary
The facility failed to assess and determine a resident's capability to self-administer medications as required by its own policy. The policy mandates that residents who wish to self-administer medications must undergo an assessment by the interdisciplinary team to determine their ability to do so safely, including evaluating their understanding of medication labels, dosages, administration times, and safe storage. In this case, a resident with multiple diagnoses, including aftercare following abdominal surgery, asthma, anxiety, and depression, was observed with a medication cup containing 22 pills and a prepared nebulizer treatment at the bedside. The resident reported that nursing staff sometimes left medications at the bedside and sometimes stayed during administration. Interviews with staff revealed that medications and respiratory treatments were left at the resident's bedside without confirmation of a completed or approved self-administration assessment. The staff member involved considered the resident cognitively intact but could not verify that the required assessment had been performed. Further review by the Director of Nursing confirmed that the clinical record lacked a current physician order for self-administration, a self-administration assessment, and a care plan documenting self-administration. This failure to follow policy and regulatory requirements resulted in a deficiency related to pharmacy services, resident care policies, and nursing services.
Failure to Notify Physician of Significant Change in Resident Condition
Penalty
Summary
The facility failed to notify the attending physician of a significant change in condition for one resident, as required by facility policy. The policy mandates prompt identification, assessment, intervention, and communication with the resident, family, and healthcare providers when there is a sudden or significant deterioration in a resident's baseline health status. In this case, the clinical record review showed that the resident, who was severely cognitively impaired and had multiple complex diagnoses, experienced an unwitnessed fall with head injury, followed by persistent head and neck pain, increased confusion, and changes in mental status. Despite ongoing documentation of the resident's worsening symptoms—including repeated complaints of pain, increased confusion, refusal of medications and food, and elevated blood glucose—there was no evidence that the attending physician was notified of these changes prior to the resident's transfer to the hospital. While a physician assistant and a certified registered nurse practitioner were involved at various points, and the resident's responsible party was contacted, the attending physician was not informed as required by policy. The resident's condition continued to decline, ultimately resulting in hospital admission for trauma. Interviews with facility leadership confirmed that there was no documentation verifying physician notification before the hospital transfer. The deficiency was cited under state regulations for nursing services and resident care policies, as the facility did not follow its own protocols for managing and communicating significant changes in a resident's condition.
Failure to Individualize Fall-Prevention Care Plan for Cognitively Impaired Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with individualized fall-prevention interventions for a resident with severe cognitive impairment and a history of forgetting to use her walker. The resident, diagnosed with dementia and requiring supervision and assistance for transfers and ambulation, was known to be impulsive and easily distracted, with a BIMS score of 00 indicating severe cognitive deficits. Despite these documented needs and behavior patterns, the care plan did not include specific interventions to ensure the resident's walker was kept within reach or address her tendency to ambulate without it. As a result of this omission, the resident was left unattended without her walker after being assisted to her room, during which time she attempted to follow her cousin and fell. This incident led to the resident sustaining a head laceration and a right hip fracture, requiring hospitalization and surgery. Staff interviews confirmed awareness of the resident's impulsivity and forgetfulness regarding her walker, yet the care plan lacked tailored strategies to mitigate these risks.
Failure to Implement and Document Pressure Ulcer Interventions
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and multiple medical conditions, including polyosteoarthritis and osteomyelitis, developed a pressure ulcer that worsened due to the facility's failure to implement and document required interventions. The resident was assessed as being at high risk for pressure injuries and had a care plan in place that included frequent repositioning, use of specialized support surfaces, and regular skin assessments. However, between mid-July and mid-August, there was no documentation of weekly skin assessments, during which time the resident developed an open area in the left gluteal fold. Despite recommendations from the wound care consultant to remove the resident's brief while in bed to relieve pressure on the wound, facility records, including Treatment Administration Records and nurse aide documentation, did not show evidence that this intervention was implemented. The wound progressed from an abrasion to an unstageable pressure ulcer, with the wound consultant repeatedly noting that pressure from the brief contributed to the worsening condition. The care plan was not updated to reflect the new wound or the consultant's recommendations, and the facility did not follow its own pressure ulcer prevention and treatment policy. Interviews with facility leadership confirmed the absence of documentation verifying implementation of the recommended interventions and weekly skin checks. The lack of timely assessment, failure to update the care plan, and non-implementation of wound care recommendations directly contributed to the deterioration of the resident's pressure ulcer.
Failure to Ensure Timely Acquisition and Administration of Prescribed Medications
Penalty
Summary
The facility failed to implement procedures to ensure the timely acquisition and administration of prescribed medications for one of twelve sampled residents. Facility policy required medications to be administered in a safe and timely manner, specifically within one hour of the prescribed time unless otherwise specified. For a resident admitted with diagnoses including bipolar disorder and major depressive disorder, multiple physician orders for medications such as Lamotrigine, Olanzapine, Clonazepam, Lithium, Simethicone, and Cefepime were not followed as prescribed. Medication Administration Records (MAR) showed blank entries or notes indicating medications were not available and were awaiting pharmacy delivery on several occasions. There were also instances of delayed administration, such as a four-hour delay in administering Cefepime. The resident involved was cognitively intact, as indicated by a BIMS score of 13, and had several mental health and medical conditions requiring consistent medication management. Interviews and record reviews confirmed that the facility did not ensure medications were obtained and administered as ordered, due to misunderstandings between nursing staff and the pharmacy regarding medication availability. This resulted in missed or delayed doses for multiple prescribed medications, in violation of facility policy and state regulations.
Improper Chemical Labeling and Storage Leads to Residents Being Served Sanitizer
Penalty
Summary
A deficiency occurred when the facility failed to implement safe and sanitary food handling practices in the kitchen, specifically by not ensuring that hazardous chemical cleaning and sanitizing solutions were properly labeled, stored, and used according to manufacturer instructions and facility policy. A cook, who had not received any documented orientation or training, used a clear plastic drink pitcher to mix a red sanitizing chemical solution due to a lack of available sanitation buckets. After cleaning, the cook left the pitcher containing the chemical in the sink, and it was later mistaken for pink lemonade by another staff member, who then served it to residents on the East unit. Ten residents were served the chemical solution, and the facility could not determine how much was consumed by each individual. The affected residents included individuals with chronic kidney disease, dementia, cerebral infarction, COPD, and cerebral palsy, with varying levels of cognitive impairment. One resident experienced vomiting after lunch, and all affected residents were assessed for symptoms, with physicians and poison control notified. However, clinical record reviews revealed that the ordered monitoring, fluid administration, and oral assessments were not documented as completed at the time of the incident for any of the residents involved. Interviews with dietary staff and review of personnel files showed that most kitchen staff were newly hired and had not received formal education or training regarding their job responsibilities, chemical safety, or labeling procedures. The contracted dietary company did not provide written job descriptions or documented orientation for the staff. The lack of proper labeling, storage, and staff training directly led to the accidental serving of a hazardous chemical to residents, resulting in Immediate Jeopardy to resident health and safety.
Plan Of Correction
Investigation was completed on 9/22/2025. Root cause determined to be isolated staff member improperly using a drink pitcher to store a cleaning sanitizer. Medical team made aware. Poison Control Center consulted. East Unit residents were assessed, and additional orders were implemented for the 10 residents found to have ingested some of the diluted sanitizer. These orders included vital sign monitoring, additional fluids, and oral assessments. Resident Representatives notified. Completed on 9/22/2025. DON/designee to complete follow-up clinical needs determined by post-incident evaluations of affected residents. Completed on 9/23/2025. The chemicals in the kitchen were reviewed for proper storage and labeling; sanitizing solutions were secured. Dietary staff are to store drink pitchers on the shelf under the beverage preparation station. Open chemicals that are in current use are to be stored under the 3-compartment sink. All other chemicals are to be stored in a remote storage area. Dietary staff are to complete pH testing on diluted 3-compartment sink chemicals and keep a log. Chemicals are only to be used for intended purposes and in labeled containers. Completed on 10/3/2025. DON/designee to complete chemical safety education for nursing staff for specifics on chemical storage and container labeling. Date of completion 10/3/2025. Dietary policies for labeling and storing of chemicals were reviewed and updated. Dietary Manager/designee to complete chemical safety training for dietary staff to include Food and Chemical Storage (NO chemicals can be in food storage containers), Sanitation Bucket Use, Labeling and Dating, Hazardous Chemicals, Food Storage, SDS, and Hazard Communications. Chemicals that are in current use are to be stored under the 3-compartment sink. All other chemicals are to be stored in a remote storage area. Dietary staff are to complete pH testing on diluted 3-compartment sink chemicals and keep a log. Chemicals are only to be used for intended purposes and in labeled containers. Completed on 10/3/2025. DON/designee to complete chemical safety education for nursing staff for specifics on chemical storage and container labeling. Date of completion 10/3/2025. Dietary policies for labeling and storing of chemicals were reviewed and updated. Dietary Manager/designee to complete chemical safety training for dietary staff to include Food and Chemical Storage (NO chemicals can be in food storage containers), Sanitation Bucket Use, Labeling and Dating, Hazardous Chemicals, Food Storage, SDS, and Hazard Communications. Chemicals that are in current use are to be stored under the 3-compartment sink. All other chemicals are to be stored in a remote storage area. Dietary staff are to complete pH testing on diluted 3-compartment sink chemicals and keep a log. Chemicals are only to be used for intended purposes and in labeled containers. Completed on 10/3/2025. DON/designee to complete chemical safety education for nursing staff for specifics on chemical storage and container labeling. Date of completion 10/3/2025. Dietary policies for labeling and storing of chemicals were reviewed and updated. Dietary Manager/designee to complete chemical safety training for dietary staff to include Food and Chemical Storage (NO chemicals can be in food storage containers), Sanitation Bucket Use, Labeling and Dating, Hazardous Chemicals, Food Storage, SDS, and Hazard Communications. Dietary Manager/designee to complete post-education audits to ensure compliance with remediation. Audits to be completed 5 times weekly for 4 weeks. Audit findings to be reviewed at the facility QAPI. Audits initiated on 10/3/2025 and continue. DON/designee to complete post-education audits to ensure compliance with remediation. Audits to be completed 5 times weekly for 4 weeks. Audit findings to be reviewed at the facility QAPI. Audits initiated on 10/3/2025 and continue.
Removal Plan
- A root-cause analysis determined that a staff member had improperly used a drink pitcher to mix and store a sanitizing chemical in the kitchen.
- All residents on the East Unit were reassessed for injury or adverse effects, and physician orders were implemented for care and monitoring.
- All chemicals in the kitchen were reviewed for proper labeling and storage.
- Education was provided to all dietary and nursing staff regarding chemical safety, labeling, and segregation of food and cleaning supplies.
- All chemicals not in active use were removed from the kitchen area and placed in a secure, designated chemical-storage area.
- Facility dietary policies regarding chemical labeling, storage, and use were reviewed and revised.
- Post-education audits were initiated to verify continued staff compliance with labeling and storage procedures.
Failure to Provide Post-Fall Monitoring and Timely Assessment for Anticoagulated Resident
Penalty
Summary
A resident with a history of falls, cervical fracture, and on anticoagulation therapy was admitted to the facility and identified as a high fall risk. The care plan included interventions such as keeping the call bell within reach, ensuring non-skid footwear, and encouraging the resident to request assistance for mobility. Despite these interventions, the resident experienced multiple falls during their stay, including unwitnessed incidents and falls resulting in injury. After each fall, documentation shows that only minor or previously implemented interventions were added, and there was no evidence of significant revision to the care plan to address the ongoing pattern of falls. Following an unwitnessed fall with possible head impact, the resident, who was on anticoagulation therapy, was not transferred for immediate medical evaluation or diagnostic imaging as recommended by professional standards and facility policy. Although a physician ordered 15-minute safety checks and neurological assessments after the fall, documentation revealed that these were not consistently performed or communicated to all staff. The neurological assessment flow sheet showed gaps in monitoring, and the facility could not provide evidence that the required 15-minute safety checks were completed. The DON confirmed that staff were unaware of the order for increased monitoring due to a lack of communication. Subsequently, the resident was found unresponsive approximately 13 hours after the fall, with no documented neurological assessments in the five hours prior. Emergency services were called, and the resident was transferred to the hospital, where diagnostic imaging revealed a large subdural hematoma and multiple areas of brain bleeding. The resident was pronounced deceased following further evaluation. The facility failed to ensure that treatment and care were provided in accordance with professional standards of practice, including prompt evaluation and monitoring after a fall in an anticoagulated resident, as well as proper implementation and documentation of physician-ordered interventions.
Plan Of Correction
1. Unable to retro correct deficient practice for Resident CR1. 2. Facility will review residents on anticoagulation therapy who have had a fall in the past 48 hours. Physician will be contacted with post fall assessment findings including neurological evaluation to determine whether residents need to be transferred to the hospital for evaluation. 3. Nursing Educator/ designee will provide education to licensed staff facility on post fall protocols including MD notification to include anticoagulant use and neurological evaluation. 4. Director of Nursing / designee to complete audits on 5 falls weekly to ensure that interventions are initiated to address risk for falls and interventions to prevent reoccurrence. Audits will also include neurological evaluations on unwitnessed falls and q 15-minute checks if applicable, and MD notification if the resident is on anticoagulation therapy. Audits will continue x 8 weeks and findings will be reviewed by the facility QAPI committee. F 0684
Widespread Food Service Sanitation Failures in Dietary and Resident Areas
Penalty
Summary
The facility failed to maintain food service sanitation practices in accordance with professional standards for safe preparation, handling, and service of food. During a tour of the kitchen, surveyors observed multiple sanitation concerns, including improper use and maintenance of the three-compartment sink system. All three sink compartments contained food debris, and no sanitizer test strips were available to verify sanitizer concentration. The surrounding area was dirty, with paper debris, liquid stains, and a sticky residue on the floor. A mop bucket filled with dirty water and cleaning equipment was stored adjacent to the sink, creating a risk of contamination. The Corporate Dietary Manager confirmed that sanitizer test strips could not be located and that there was no documentation verifying that sanitizer concentrations were checked as required by facility policy. He also stated that most dietary staff were recently hired and had not been trained on proper three-compartment sink use. Additional environmental observations revealed widespread sanitation issues throughout the kitchen, maintenance, storage, and service areas. Unlabeled drink pitchers were stored upside-down on a dirty windowsill, and an unlabeled bucket containing a rag in chemical solution was stored next to food items. The kitchen maintenance room contained unidentified machines, an open bottle of degreaser, and electrical extension cords strewn across the machines and floor. A metal cart was visibly soiled, and the floor had visible dirt, paper, and a black sticky substance. In the storage room, uncovered shelving held pans and utensils with standing water and water stains, and the area was cluttered with dust, dirt, cobwebs, and open containers of paper dining products. The kitchen's meal tray delivery cart and open food carts in resident hallways had visible food and liquid stains. Further deficiencies were noted in the Pavilion resident dining area and pantry. Clean coffee cups had a white film inside, and there were open, undated, and unlabeled food items in both the refrigerator and freezer. The refrigerator and pantry areas were dirty, with food debris, paper waste, and dirt accumulation. Dirty dishes, a microwave with dried food residue, and sticky countertops were observed. The cabinet under the sink contained dirty trays and an unlocked bag of dishwasher pods. The Corporate Dietary Manager confirmed that dietary staff were responsible for cleaning and maintaining these areas, and the Nursing Home Administrator acknowledged that the observed conditions constituted food safety and sanitation issues.
Plan Of Correction
1. Three compartment sinks were emptied, cleaned, and sanitizer test strips were obtained. Area around the 3-compartment sink was cleaned, and the dirty mop bucket was emptied and cleaned. Cleaning equipment stored by the 3-compartment sink was moved to avoid possible contamination of food-contact areas. Log obtained for documentation of sanitizer concentrations. Unlabeled drink pitchers were removed from the window sill and cleaned. The window sill was cleaned of dirt and lint. The cleaning bucket was moved away from the spice shelf with cooking products. The kitchen maintenance room was checked for contamination and hazards, and all equipment and cleaning products were removed and/or relocated. The floor of the maintenance storage room was cleaned, and detergent was stored. The 3-tier metal shelving unit in the storage room was cleaned. The floor of the storage room was cleaned of dirt and debris. All meal delivery carts have been cleaned. Kitchen refrigerator fans have been cleaned, as well as the ceiling. Unlabeled and use-by date deli meat has been discarded. Coffee cups with white film in Pavillon dining room have been discarded, as well as an open cereal bag in a box. Metal banquet pans have been cleaned. The refrigerator has been cleaned, and outdated sandwiches and unmarked peaches have been discarded. Resident Pavillon pantry has been cleaned; all outdated, outdated, or opened food items have been discarded. Dirty dishes have been removed for cleaning. The refrigerator and freezer have been cleaned. 2. Corporate Dietary Service manager will complete a detailed and thorough audit of the main kitchen, maintenance storage area, food storage area, walk-in refrigerator and freezer areas, as well as all pantries on nursing units, and ensure areas are compliant. 3. Dietary Manager/designee will educate dietary staff on regulation requirements for food procurement, storage, preparation, serving, and maintaining a sanitary environment. 4. Corporate Dietary Service manager or designee will complete visual inspections and audits of kitchen areas as well as pantries twice a week for eight weeks. Results of audits will be reviewed by the QAPI committee.
Failure to Maintain Clean and Sanitary Resident Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean and sanitary environment in the West Resident Unit. In Room W-16, a large amount of a white substance from an incontinent brief was found strewn under and around a bed, with the floor showing liquid stains, visible dirt, and paper debris. A fall mat was propped against the bathroom door frame and was visibly soiled with dark liquid stains and dirt. Additional rooms, W-9 and W-11, were also noted to have dried liquid stains and dirt on the floors. A resident was observed seated in a wheelchair outside her room with a brown liquid substance on her clothing, wheelchair seat, and tires. Multiple large puddles of the same brown liquid were present under the wheelchair and extended along the floor. The resident reported having a bowel incontinence episode, activating her call bell, and waiting more than fifteen minutes for assistance. Staff interviews revealed that the nurse aide assigned to the resident had to leave due to an emergency, and other aides were occupied with their assigned tasks. The DON confirmed that all resident care and common areas are required to be kept clean and sanitary.
Plan Of Correction
1. Rooms W 8, 9, 11, & 16 including floors and any fall mats, were deep cleaned. Incontinence care was provided to Resident # 12 on 10/4/25. Resident # 12 w/c seat and wheels were cleaned. 2. EVS supervisor to complete an initial audit of all resident rooms, fall mats, and wheelchairs to ensure cleanliness. Any items identified as not clean will be cleaned. 3. EVS supervisor with provide education to housekeeping staff on room cleanliness standards. 4. EVS Supervisor or designee will complete room audits 3 x week for cleanliness of flooring, fall mats and chairs. Audits will be completed 3 x week x 4 weeks, then weekly x 4 weeks. Results of audits will be reviewed at facility QAPI committee.
Immediate Jeopardy: Hazardous Chemical Served to Residents Due to Administrative Oversight
Penalty
Summary
The facility's administration failed to effectively use its resources to promote resident safety and maintain the highest practicable physical and mental well-being of residents. Specifically, the administration did not ensure resident safety when the dietary department served a hazardous cleaning chemical to residents during meal service. As a result, ten out of fifty-seven residents ingested the chemical, placing all residents in the East Wing at risk of consuming a hazardous substance and resulting in an immediate jeopardy to resident health and safety. A review of the job descriptions for the Nursing Home Administrator (NHA) and Director of Nursing (DON) revealed that their responsibilities include overseeing the safety and cleanliness of the facility, ensuring hazardous conditions are addressed, and monitoring departmental operations. The facility failed to carry out these administrative responsibilities, as evidenced by the lack of effective oversight in the safe handling, storage, and labeling of hazardous chemicals within the dietary department. Interviews with staff confirmed that dietary personnel had not received effective training or competency evaluation regarding the safe handling, storage, and labeling of hazardous chemicals in accordance with facility policy and procedure. This lack of oversight and resource utilization by the Administrator and DON contributed to the immediate jeopardy situation, as they did not monitor departmental operations, identify systemic risks, or ensure the implementation of facility policies to maintain resident safety.
Plan Of Correction
Unable to retro correct deficient practice. 2. NHA/ designee will direct and lead and direct the overall operations of the facility and ensure that the Corporate Dietary Service manager provided education to all dietary staff on proper use and storage of kitchen chemicals. NHA will ensure that Corporate Dietary Service manager/ designee is present in the facility to inspect, direct and oversee the dietary personnel to ensure regulatory compliance. In the absence of the NHA, DON will assume these responsibilities. 3. Regional Director of Operations/ designee will provide education to the NHA and DON on Administrative Duties and responsibilities. 4. Regional Director of Operations/designee will follow-up weekly by reviewing audits to ensure the NHA and DON are providing effective and efficient administrative oversight. Audit findings will be reviewed at facility QAPI meeting.
Failure to Follow Care Plan for Safe Transfer Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a resident with chronic heart failure and polyosteoarthritis, who required assistance with activities of daily living, was not provided the required level of staff support during a transfer. The resident's care plan and physician's orders specifically mandated the use of a Hoyer lift with two staff members for all transfers. Despite this, a nurse aide performed a transfer alone, citing the absence of available staff at the time. During the transfer, the nurse aide attempted to reposition the resident's legs and heard a crack. The resident, who was cognitively intact, later reported pain and swelling in her left knee. Subsequent assessment and hospital evaluation confirmed a left tibial periprosthetic fracture, requiring immobilization and pain management. The resident experienced significant pain, necessitating frequent administration of oxycodone for relief. The incident was corroborated by witness statements, clinical documentation, and interviews with the resident and staff. The nurse aide admitted to being aware of the two-person requirement for Hoyer lift transfers but proceeded alone due to staffing constraints. This failure to follow the individualized care plan and physician's orders resulted in actual harm to the resident in the form of a serious fracture.
Improper Food Storage and Sanitation in Dietary Department
Penalty
Summary
Surveyors observed that the facility failed to maintain proper food storage and service practices in the dietary department, leading to unsanitary conditions. Specifically, unlidded garbage cans containing trash were found near the tray line and cook's preparation areas, which increased the risk of contamination in food preparation zones. In both the First Floor East and Ground Floor dry storage areas, multiple cases of disposable dishware and paper products were stored directly on the floor, with some packaging open and unsealed, exposing the contents to potential contamination from floor debris, cleaning solutions, and pests. Additionally, in the Ground Floor dry storage/equipment area, cases of dishware, supplies, and dietary-related materials were stored close to the ceiling, which limited air circulation and increased the risk of contamination from overhead surfaces, dust, or ceiling-based hazards. A review of the facility's policy on food receiving and storage indicated that all foods and goods should be stored in a manner that maintains the integrity of the packaging until use, and bulk food should be removed from original packaging, placed in bins, and labeled with a use-by date. These practices were not followed as observed during the survey. During an interview, the Nursing Home Administrator acknowledged that the dietary department should be maintained in a sanitary condition to prevent contamination and reduce the risk of foodborne illness.
Failure to Develop and Implement Individualized Care Plans for Oxygen Therapy and Hydration
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with specific and individualized interventions for two residents. For one resident with chronic respiratory failure, quadriplegia, and a tracheostomy, there was a discrepancy between the physician’s order for oxygen therapy and the interventions listed in the care plan and Kardex. The physician’s order specified oxygen at 10 liters per minute via nasal cannula or tracheostomy collar, but the care plan and Kardex indicated oxygen at only 2 liters per minute. Observation confirmed the resident was receiving oxygen at 10 liters per minute, but the care plan and Kardex had not been updated to reflect this, resulting in a lack of alignment between the physician’s order and the documented plan of care. For another resident with Parkinson’s disease, hemiplegia, and hemiparesis following a stroke, the care plan addressed several nutritional concerns and included general interventions for monitoring hydration. However, the care plan did not identify that the resident was fully dependent on staff for hydration or include individualized interventions to ensure the resident’s fluid needs were proactively assessed and met. The resident, who was cognitively intact but required total staff assistance with eating and drinking, reported that fluids were only offered at meals and that he had to use the call bell to request drinks at other times, often experiencing long delays due to his inability to provide himself with fluids. These deficiencies were confirmed through clinical record reviews, staff interviews, and resident interviews, which revealed that the care plans did not contain specific, individualized interventions to address the residents’ needs for oxygen therapy and hydration, as required by regulatory standards.
Failure to Follow Physician Orders for Insulin Administration
Penalty
Summary
Licensed nursing staff failed to follow physician orders for the administration of insulin to a resident with type 2 diabetes mellitus and a long-term insulin regimen. The facility's policy required verification of a physician's medication order, including specific parameters for administration. The physician's order specified that Novolog insulin should be administered subcutaneously with meals, but only if the resident's blood glucose level was 100 mg/dl or higher. Despite these instructions, the resident's Medication Administration Records showed that nursing staff administered Novolog insulin on multiple occasions when the resident's blood glucose levels were below the prescribed threshold. Specifically, insulin was given when blood glucose readings were 78 mg/dl, 92 mg/dl, and 96 mg/dl, all of which were below the physician's specified parameter. The Director of Nursing confirmed that these administrations were outside the prescribed parameters.
Failure to Implement Restorative Nursing Program for Resident with Limited Mobility
Penalty
Summary
The facility failed to consistently provide restorative nursing services as planned for a resident with Alzheimer's disease and muscle atrophy. The resident was admitted with significant cognitive impairment and required substantial to maximal assistance for mobility. After a period of physical therapy, the resident was discharged with recommendations for a Range of Motion (ROM) Restorative Nursing Program (RNP) to reduce contractures in the lower extremities. However, there was no evidence that the RNP was included in the resident's care plan or that the program was implemented as recommended. A review of the resident's clinical record, care plan, and nursing documentation revealed no documentation of the restorative program being carried out. Additionally, there was no indication that licensed staff were aware that the RNP was not being implemented as planned. During an interview, the Nursing Home Administrator was unable to provide evidence that the facility had consistently implemented the restorative nursing program to maintain the resident's functional abilities and prevent decline.
Failure to Provide Required Emergency Dialysis Supplies at Bedside
Penalty
Summary
The facility failed to ensure the availability of necessary emergency supplies for a resident who required hemodialysis. The resident, who had end-stage renal disease and was dependent on hemodialysis, had a physician's order and care plan intervention requiring an emergency kit to be present at the bedside. This kit, intended to address complications such as bleeding from the arteriovenous (AV) fistula site, was not found at the resident's bedside during an observation, despite documentation on the Medication Administration Record indicating it was present. The resident, who was cognitively intact, confirmed the absence of the emergency supplies after returning from dialysis. Staff interviews further confirmed that the emergency supplies were not available in the resident's room as required. An LPN acknowledged that the supplies should have been at the bedside and typically are kept on the back of the resident's headboard. The Nursing Home Administrator also confirmed the failure to ensure the emergency dialysis access supplies were available as ordered and required by the resident's care plan. This deficiency was identified through observation, record review, and staff and resident interviews.
Failure to Follow Controlled Substance Reconciliation Procedures
Penalty
Summary
The facility failed to implement its established pharmacy procedures for the reconciliation of controlled substances on one of five medication carts reviewed. According to facility policy, nursing staff are required to count controlled medications at the end of each shift, with both the on-coming and off-going nurses participating in the count and signing the verification sheet. A review of the controlled medication count sheet for Pavilion cart #2 revealed that on several occasions, the required signatures were missing during shift changes, specifically on multiple dates in July 2025. Observation of the medication cart and interviews with staff confirmed that licensed nurses did not consistently sign the count verification at the change of shift as required by policy. This failure to follow established procedures prevented timely identification of any discrepancies in controlled substance counts. The deficiency was identified through review of facility policy, controlled substance records, direct observation, and staff interviews.
Failure to Verify Resident Identity Results in Significant Medication Error
Penalty
Summary
A significant medication error occurred when a nurse administered medications to the wrong resident. The facility's policy required staff to verify resident identity using methods such as checking identification bands, photographs, or confirming with other personnel before administering medications. However, a Licensed Practical Nurse (LPN) who was unfamiliar with the unit and the residents failed to verify the identity of a resident before giving medications. As a result, the resident received multiple medications, including Keppra, Remeron, Lyrica, Trazodone, and Warfarin, which were not prescribed to him but were intended for his roommate. The resident was not scheduled to receive any nighttime medications at that time and did not have diagnoses requiring those medications. The affected resident had a history of hypertension, muscle weakness, and moderately impaired cognition, as indicated by a BIMS score of 11. After receiving the incorrect medications, the resident's blood pressure was recorded as low, and the physician was notified. The resident was sent to the emergency room for evaluation due to the medication error and a recent unwitnessed fall earlier that day. Upon return from the hospital, the resident was noted to be lethargic. Interviews with facility leadership confirmed that the LPN failed to follow proper identification procedures, resulting in the administration of another resident's medications.
Expired and Improperly Labeled Medications Found in Storage Room
Penalty
Summary
Surveyors identified that the facility failed to store medications and pharmaceutical products in accordance with expiration date guidelines in one of three medication storage areas, specifically the Pavilion medication storage room. During an observation, ten medication and supplement items were found to be either expired or had illegible expiration dates. These included bottles of Multi-Vitamin with Iron, Aspirin, Sodium Bicarbonate, Glucosamine and Chondroitin, Meclizine, Vitamin E, Guaifenesin Liquid, and Copper Glycinate. The expiration dates on these items ranged from February 2024 to June 2025, with one item having an illegible expiration date. A review of the facility's policy on Storage of Medications indicated that all medications should be stored according to manufacturer recommendations and regularly inspected for expiration and labeling by the consultant pharmacist. However, the presence of expired and improperly labeled medications was confirmed by an LPN during an interview, demonstrating that the facility did not ensure the timely removal of these items as required by both policy and regulatory standards.
Failure to Document Vaccine Education for Pneumococcal Immunization
Penalty
Summary
The facility failed to provide required education to a resident or the resident's representative regarding the benefits and potential side effects of the pneumococcal immunization. According to the facility's policy, all residents must be offered the pneumococcal vaccine and have the right to refuse, with documentation of both the offer and any refusal, including education provided. A review of the clinical record for one resident showed that the pneumococcal vaccine was refused, but there was no documented evidence that education about the vaccine's benefits and side effects was given to the resident or their representative. This was confirmed by the Infection Preventionist during an interview, who acknowledged the lack of documentation in the resident's medical record.
Failure to Secure Smoking Materials per Facility Policy
Penalty
Summary
The facility failed to follow its established policy and procedures regarding safe smoking practices for one resident. According to the facility's Resident Smoking Policy, all smoking supplies for both supervised and independent smokers are to be kept in a locked nursing medication room, and residents are not permitted to keep smoking supplies in their possession. A review of the clinical record for a resident with quadriplegia and chronic obstructive pulmonary disease showed that the resident was assessed as cognitively intact and able to smoke independently, with the understanding that smoking materials must be returned to staff when not in use. During an observation, the resident was found in their room with smoking materials, including two lighters and a pack of cigarettes, which were not secured by staff as required by policy. The resident stated that they kept their smoking supplies in a locked drawer in their bedside cabinet. The Nursing Home Administrator confirmed that the facility policy requires all smoking supplies to be secured by staff, regardless of independent smoking status, and was unable to provide evidence that staff were monitoring the resident's storage of smoking materials. This failure to follow policy was identified through review of records, interviews, and direct observation.
Failure to Consistently Implement Fall Prevention Measures
Penalty
Summary
A resident with severe cognitive impairment, generalized muscle weakness, difficulty walking, and a history of falls was identified as being at high risk for falls. The resident's care plan included specific fall prevention interventions such as bilateral fall mats, triangular wedges on both sides of the bed, a tab alarm while in bed, and maintaining the bed in a low position. Physician's orders also required triangular wedges to be positioned at the upper bilateral bed rails while the resident was in bed. Despite these interventions, the resident experienced an unwitnessed fall from bed, resulting in a minor injury. Review of the incident revealed that at the time of the fall, the left-side bed wedge was not in place as required and was found on the window frame, while the right-side wedge was in place. Additionally, the bed alarm was nonfunctional, and it was noted that the resident had a known history of disabling the alarm. The facility's investigation concluded that the fall occurred due to failure to follow the resident's plan of care, specifically the improper placement of the bed wedge and the nonfunctional bed alarm.
Failure to Implement Individualized Incontinence Management Plan
Penalty
Summary
The facility failed to develop and implement an individualized plan to meet the toileting needs of a resident with severe cognitive impairment, dementia, and chronic kidney disease. Despite the resident's care plan identifying issues such as overactive bladder, frequent urinary and bowel incontinence, hemorrhoid pain, urinary pain, recurrent UTIs, and atrophic vaginitis, the plan did not include a structured toileting schedule or individualized incontinence program. The resident required substantial assistance for bed mobility, transfers, and toileting, and was always incontinent of urine and frequently incontinent of bowel. Documentation showed the resident was not on a toileting program, and the nursing information system lacked instructions for timely toileting or incontinence care. A quarterly toileting review noted a decline in continence and the need for extensive assistance, but did not specify individualized interventions such as scheduled toileting. The resident was documented as being incontinent of urine 100% of the time during every shift, and a family grievance reported the resident was found soaked with urine. The Director of Nursing confirmed there was no documented evidence of a planned incontinence management program for the resident, indicating a failure to provide timely and individualized care as required by facility policy and state regulations.
Failure to Serve Meals at Palatable and Safe Temperatures
Penalty
Summary
The facility failed to ensure that meals were served at palatable and safe temperatures, as required by both federal regulations and the facility's own policy. Observations and interviews revealed that five out of nine residents interviewed reported their meals were often served cold, lukewarm, or unappetizing. A review of a resident concern form and direct interviews confirmed that multiple residents experienced meals that were not at a palatable temperature. During a lunch service observation, the last tray delivered to a resident was found to have hot food items below the required 135°F, with temperatures ranging from 113°F to 126.1°F, and cold items above the required 41°F, with a fruit drink at 59.9°F. A taste analysis confirmed the food was lukewarm and unappetizing. The facility's policy, last reviewed in January 2025, required hot foods to be held and served at or above 135°F and cold foods at or below 41°F. Despite this, the Dietary Manager incorrectly stated that a hot food temperature of 126.1°F was acceptable, which contradicted both policy and regulatory requirements. The Nursing Home Administrator acknowledged that the facility had not ensured meals were consistently served at palatable temperatures or in accordance with resident preferences. These findings were based on direct observation, resident and staff interviews, and review of facility documentation.
Delayed Response Due to Malfunctioning Call Bell System
Penalty
Summary
The facility failed to maintain a fully functioning resident call bell system that ensured direct and timely communication between residents and caregivers for three of nine sampled residents. According to the facility's policy, all staff are responsible for responding to call bells, and nurse aides, charge nurses, and RN supervisors are required to carry pagers to receive notifications. However, interviews with residents revealed that staff response to call bells could take up to an hour, with multiple reports of delays exceeding 30 minutes. Observations on the second floor showed that while visual call bell indicators were present above hallway doors, there was no audible alert to notify staff unless they were physically present in the hallway. This resulted in active call bell requests going unnoticed for extended periods. Further investigation found that some pagers used by staff were malfunctioning, with issues such as non-working screens that prevented identification of which resident had activated their call bell. Staff confirmed that when pagers were not functioning, the only way to identify an active call bell was by visually checking the hallway indicators, as there was no alternative notification system. In contrast, another unit in the facility had an upgraded call bell system with both visual and audible alerts, leading to faster response times. The Nursing Home Administrator confirmed that the second floor call bell system was not functioning as intended, resulting in delayed responses to resident calls.
Failure to Follow Planned Menus and Document Substitutions
Penalty
Summary
The facility failed to adhere to its written planned menus, resulting in food omissions for four residents during a breakfast meal. The planned menu included hot cereal, an egg, cheese and ham biscuit, banana, milk, and coffee or tea. However, observations revealed that the meal trays for four residents were missing hot cereal and biscuits. One resident expressed that such omissions occurred frequently, and the Dietary Manager confirmed that biscuits were not served due to being overbaked, but no substitutions were made. The facility's policy required that any menu substitutions be discussed with the director of food and nutrition services and documented, but the facility was unable to provide the Meal Substitution Records for the months of December 2024, January 2025, and February 2025. Interviews with the Nursing Home Administrator and the Dietary Manager confirmed the absence of these records and the failure to follow the planned menus. The facility did not have a system in place to monitor food omissions or substitutions, nor did it ensure the required documentation of menu changes, leading to non-compliance with its own policies regarding meal service.
Failure to Maintain Safe and Appetizing Food Temperatures
Penalty
Summary
The facility failed to serve meals that were palatable and maintained at a safe and appetizing temperature for three residents. Observations and interviews revealed that meals were consistently served cold, with residents expressing dissatisfaction with the temperature and palatability of their food. Resident 3 reported never receiving a hot meal and lacking condiments, while Resident 4 and Resident 5 also complained about the cold temperature of their meals, specifically mentioning cold eggs and insufficient food portions. A test tray evaluation conducted on the East Wing Nursing Unit confirmed these concerns, with food temperatures recorded below the required standards. The ziti with meat sauce and Italian blend vegetables were served at temperatures significantly below the required 135 degrees Fahrenheit, and the vanilla pudding was served above the required 41 degrees Fahrenheit. The dietary manager acknowledged that the test tray results did not meet the facility's policy or regulatory requirements, confirming the deficiency in maintaining appropriate food temperatures, which affected resident satisfaction and increased the risk of foodborne illness.
Failure to Provide Adaptive Dining Equipment
Penalty
Summary
The facility failed to provide adaptive dining equipment as required and prescribed for two residents. Resident 7, who was admitted with cerebral infarction and dysphagia, had a care plan indicating the use of a two-handled adapted cup with a lid for beverages at all meals to prevent dehydration and malnutrition. Despite this, an observation on February 26, 2025, revealed that the dietary staff did not provide the adaptive cup during breakfast, as ordered by the physician. Similarly, Resident 8, diagnosed with dementia with behavioral disturbance and polyosteoarthritis, was prescribed a Kennedy cup for all meals and bedside use to address a nutritional deficit. However, during the same breakfast observation, the dietary staff failed to provide the Kennedy cup. Interviews with a nurse aide and the Dietary Manager confirmed that the dietary staff frequently forget to include the necessary adaptive equipment on meal trays, causing interruptions in care as nursing staff must retrieve the equipment from the kitchen.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to ensure that residents who were dependent on staff for assistance with activities of daily living were consistently provided showers as planned. Resident 1, who was admitted with diagnoses including hypertension and atrial fibrillation, required substantial assistance for showering due to severe cognitive impairment, as indicated by a BIMS score of 00. Despite being scheduled for showers on Mondays and Thursdays, Resident 1 missed multiple showers from December 2024 through February 2025, with no documentation of the showers being provided or refused. Similarly, Resident 2, admitted with osteoarthritis and dementia, also required assistance for showering and was scheduled for showers on Tuesdays and Fridays. However, Resident 2 missed several scheduled showers from December 2024 through February 2025, again with no documentation of the showers being provided or refused. During an interview, the Nursing Home Administrator and Director of Nursing confirmed the residents should have received their showers as scheduled but could not explain the failure to provide or document the showers.
Failure to Accommodate Dietary Needs and Allergies
Penalty
Summary
The facility failed to provide meals that accommodated the dietary needs and allergies of two residents. Resident 7, who has a documented allergy to dairy/milk, was served a Yoplait original harvest peach yogurt, which contains milk, during breakfast. Additionally, Resident 7 was supposed to receive 4 ounces of honey-thickened juice due to swallowing difficulties, but this was not provided on the breakfast tray. Similarly, Resident 9 was supposed to receive 8 ounces of honey-thickened juice with lunch, but this was also missing from the tray. Interviews and observations revealed systemic issues in the dietary service. A nurse aide reported that dietary staff consistently failed to include thickened liquids on residents' trays, requiring aides to interrupt meal service to retrieve them from the kitchen. The dietary manager confirmed the failure to provide meals that met residents' dietary orders. Observations of the kitchen and storeroom showed a lack of honey-thick juice in the kitchen, although it was available in the storeroom, indicating a failure in the distribution process.
Facility Fails to Respond Timely to Residents' Requests for Assistance
Penalty
Summary
The facility failed to provide timely responses to residents' requests for assistance, impacting their quality of life and dignity. Resident 5, who is cognitively intact, reported waiting over an hour and a half for staff to respond to her call bell. Similarly, Resident 1, also cognitively intact, experienced wait times of about 20 minutes, with instances extending over 40 minutes. Both residents expressed concerns about the lack of staff to provide timely care. Resident 2, who is cognitively intact and suffers from osteomyelitis, reported waiting up to an hour and thirty minutes for assistance, often resulting in sitting soiled due to incontinence. Resident 4, with COPD, experienced similar delays, waiting an hour for care after being incontinent. These residents highlighted the facility's staffing shortages as a reason for the delays, which they had communicated to the staff without resolution. Resident 3, who has Parkinson's disease and is dependent on staff for care, was observed lying in bed with his pants down, exposed to the hallway, for 20 minutes before receiving assistance. He expressed feelings of frustration and neglect due to the long wait times for care. The Nursing Home Administrator and Director of Nursing acknowledged the importance of treating residents with dignity and respect but could not explain the untimely responses to residents' needs.
Plan Of Correction
1. Facility staff unable to retroactively correct past call bell and dignity issues mentioned for R 1,2,3,4, & 5. 2. DON/designee to perform an audit of cognitively intact residents to determine if they feel as if they are treated with respect and dignity and that their call bells are answered timely. 3. ADON educator/designee to provide education to staff on resident rights and dignity to include not leaving residents exposed in view of others and timely answering of call bells. 4. Department Heads/designee to perform call bell audits for 10 cognitively intact residents 5X per week X 2 weeks then 3X per week X 2 weeks, then weekly X 2 weeks to ensure call bells answered timely. Department Heads/designee to perform observation audits for 10 residents 5X per week X 2 weeks then 3X per week X 2 weeks, then weekly X 2 weeks to ensure dignity and respect is maintained by not leaving them exposed in view of others. 5. Audit findings to be reported and reviewed at facility QAPI monthly X 3 to evaluate process improvement.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to provide care and services in a manner respectful of each resident's personal dignity, as evidenced by the situation involving a resident with Parkinson's disease. This resident, who is cognitively intact and dependent on staff for assistance with personal care, was observed lying in bed with his pants pulled down to his thighs and his stomach exposed. The privacy curtains were not drawn, leaving the resident visible from the hallway. This situation persisted for twenty minutes while other residents and staff walked past the room. The resident expressed feelings of anger and frustration, describing himself as feeling like a piece of furniture due to the lack of assistance from the staff. The Director of Nursing confirmed that the resident should not have been left in such a state without privacy curtains drawn and acknowledged the facility's responsibility to ensure residents receive care that promotes their dignity and respect. Additionally, the resident's fingernails were observed to be dirty, with a yellow-orange film and debris under the tips, indicating a lack of attention to personal hygiene needs. This incident highlights a failure in maintaining the resident's dignity and respect, as well as a lapse in providing necessary personal care.
Plan Of Correction
1. Facility nursing staff provided nail care to Resident 3. 2. DON/designee to perform an audit of cognitively intact residents to determine if they feel as if they are treated with respect and dignity and have sufficient nail care performed to promote dignity. 3. ADON/educator/designee to provide education to staff on resident rights and dignity, on not leaving residents exposed in view of others, and to include nail care. 4. Department Heads/designee to perform observation/interview audits for 10 residents 5X per week X 2 weeks then 3X per week X 2 weeks, then weekly X 2 weeks to ensure they feel treated with dignity and respect, that no residents were left exposed in view of others, and that nail care has been performed. 5. Audit findings to be reported and reviewed at facility QAPI monthly X 3 to evaluate process improvement.
Failure to Ensure Safe Discharge Plan for Resident
Penalty
Summary
The facility failed to develop and implement a safe discharge plan for a resident, identified as Resident CR1, who was admitted with chronic kidney disease and traumatic brain injury. The resident was moderately cognitively impaired, as indicated by a BIMS score of 8. A progress note highlighted the need for 30 hours a week of caregiver support, and physical therapy discharge recommendations included significant supervision and assistance due to impaired cognition and safety. However, the clinical record lacked documentation of the total amount of supervision and assistance available upon discharge. The interdisciplinary team discharge summary indicated that Resident CR1 was to be discharged home with occupational and physical therapy home health services. However, there was no documented evidence ensuring safe medication administration upon discharge, nor was there evidence of self-medication training or education provided to the resident. The Director of Nursing and Director of Social Services confirmed the absence of a documented plan for safe medication administration, despite the resident's moderate cognitive impairment and the discharge plan not being against medical advice. Upon discharge, Resident CR1 was sent home with 24 medications, including insulin, without a plan for safe administration. The resident's representative confirmed that CR1 lived alone and was hospitalized two days after discharge due to the need for continued care. The facility's failure to ensure a safe discharge plan, including medication administration, led to the resident's hospitalization shortly after discharge.
Plan Of Correction
1. Facility staff unable to retroactively correct as resident has been discharged. 2. DON/designee to perform an audit of current short-term residents to determine that a discharge plan has been initiated and includes measures to promote safe discharge. 3. DON/designee to provide education to IDT members on the process for initiation and coordination for safe resident discharges. Facility to incorporate an evaluation of resident specific discharge needs during the initial assessment period. 4. Facility to audit discharge plans for 3 residents per week X 4 weeks then 2 residents per week X 2 weeks to ensure safe discharge plans have been initiated and include measures to promote safe discharge. 5. Audit findings to be reported and reviewed at facility QAPI monthly X 3 to evaluate process improvement.
Failure to Ensure Proper IV Medication Administration by LPNs
Penalty
Summary
The facility failed to ensure that nursing services met professional standards of quality by not implementing proper nursing practices for the administration of intravenous medication via a central venous catheter for one resident. According to the Pennsylvania Code Title 49, Professional and Vocational Standards, LPNs are required to have the necessary education and supervision to perform IV therapy functions safely. However, the facility did not have a policy available regarding LPNs providing care and administering medications through a central catheter line. The clinical record review revealed that a resident was admitted with bacterial meningitis and had a PICC line for intravenous medication administration. Physician's orders required the administration of Penicillin G Potassium in Dextrose intravenously every four hours. Between specific dates, three LPNs signed the Medication Administration Record as administering the IV antibiotic through the PICC line. However, there was no evidence that these LPNs received the necessary education or supervision for administering IV antibiotics through a PICC line. The Director of Nursing confirmed that LPNs did not receive education regarding this procedure.
Failure to Document Antibiotic Administration
Penalty
Summary
The facility failed to implement proper pharmacy procedures for medication administration and documentation for a resident diagnosed with bacterial meningitis, a serious infection. The resident was admitted with a PICC line and had physician's orders for Penicillin G Potassium in Dextrose to be administered intravenously every four hours for 27 days. However, the Medication Administration Record for October 2024 showed that the antibiotic was not documented as administered on several occasions, specifically on October 8, 10, 19, and 21. During an interview, the Director of Nursing confirmed that it could not be determined if the doses were administered on those dates.
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Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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