Hanover Hall For Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Hanover, Pennsylvania.
- Location
- 267 Frederick Street, Hanover, Pennsylvania 17331
- CMS Provider Number
- 395016
- Inspections on file
- 30
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Hanover Hall For Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with visual impairment and chronic pain, who required one-person assist for toileting, sustained an unwitnessed fall while attempting to go to the bathroom alone. A NA observed wrist deformity, back abrasion, and a head bump with bleeding, and reported these findings to an RN. Despite facility policies requiring licensed nurse evaluation, neuro checks, vital signs, pain assessment, and physician/family notification after such falls, there was no documented assessment, no new neuro checks initiated, no notifications made, and no PRN acetaminophen given for reported pain. Later that night, the resident complained of excruciating wrist pain, was found to have visible deformity and bruising, and was sent to the hospital, where imaging confirmed a comminuted distal radius fracture, evidencing delayed assessment and pain management.
The facility failed to follow its own weight monitoring and nutritional intervention policies for multiple residents. One resident with dysphagia had weight changes greater than 5 lb on two occasions without required reweights being obtained. Another resident, at nutritional risk due to a healing femur fracture, experienced a sustained downward weight trend of over 20%, with inconsistent weekly weights despite orders and with physician-ordered fortified foods not added to the meal ticket or provided for an extended period, even though the RD documented significant weight loss and WEIGHT WARNING notes. A third resident with dysphagia and dementia did not have weekly weights ordered or obtained for four weeks after admission as required, with only two monthly weights documented. Staff interviews, including with the RD, DON, and NHA, confirmed that required reweights, weekly weights, and implementation of fortified foods were not carried out as expected.
The facility did not complete required annual performance evaluations for three nurse aides. Facility job descriptions required supervisors to perform yearly evaluations, and a review of personnel records showed that two aides had last been evaluated more than a year earlier, while a third aide who had been employed for over a year had no annual evaluation on file. During interview, the NHA acknowledged that current annual evaluations for these aides could not be located and should have been present in their employee files.
The facility did not consistently complete required monthly medication regimen reviews (MRRs) or ensure timely physician responses to pharmacist recommendations for three residents with conditions including GERD, dementia, Down syndrome, and repeated falls. For two residents, no MRRs were documented for a particular month, and later MRRs contained unaddressed recommendations regarding proper administration of PPIs and the need for routine labs. For another resident, pharmacist recommendations to specify the dose of topical diclofenac gel and to administer pantoprazole on an empty stomach were not documented as implemented, with some recommendations repeated in subsequent MRRs. The DON reported an expectation that MRRs be completed monthly and that prescribers respond promptly to identified irregularities.
Surveyors found that the facility did not follow its own policies or professional standards for food storage, labeling, and sanitation in the main kitchen and all nourishment pantries. In the kitchen, opened frozen pizza and large juice containers were not securely closed or date marked. Across multiple pantries, numerous thawed nutritional shakes/juices were not labeled with thaw or use-by dates, and various resident food items such as yogurt, ice cream, and prepared foods lacked resident identifiers. Dry goods including thickener, cereals, and peanut butter were not labeled and dated, and several refrigerators contained dried spills of liquids, applesauce, and pudding. In dry storage, multiple canned vegetables and beans were not date marked, despite the administrator’s stated expectation that food be stored to meet regulatory standards.
The facility did not follow its advance directive policy for a cognitively intact resident with hypertension and chronic kidney disease. The policy requires social services staff to inquire about existing advance directives and provide written information on the right to accept or refuse treatment and to formulate an advance directive, along with an explanation of facility policies and applicable state law. Review of the resident’s record showed no documentation that these rights were reviewed or that the resident was offered the opportunity to create an advance directive, and the SW confirmed there was no such documentation.
A resident with Down syndrome and dementia was prescribed risperidone twice daily, and the care plan included an intervention to monitor, record, and report potential antipsychotic side effects such as dystonia, tremors, confusion, restlessness, anxiety, tardive dyskinesia, and sedation. Despite a facility policy requiring monitoring and documentation of psychotropic medication response, review of the clinical record showed no documented side effect monitoring for this antipsychotic, and the DON confirmed that such monitoring was not documented.
Surveyors found that the facility did not develop or implement person-centered care plans for two residents who used bilateral bed enabler bars. One resident with hypertension and hemiparesis used the bars for bed positioning, but no care plan addressed this device in relation to his condition or bed mobility. Another resident with GERD, hyperlipidemia, and dementia had a completed bed rail evaluation and consent form, yet the care plan did not include interventions or goals related to the enabler bars. The NHA acknowledged that a care plan should have been in place for the use of bed rails.
A resident with GERD, muscle weakness, and HTN was found with a cup containing 11 medications left on the bedside table. An LPN reported that she had left the medications there while the resident was eating breakfast and had already documented them as administered earlier, stating the resident should have taken them by that time. The DON later confirmed the expectation that medications should not be left at the bedside and should not be signed as given until after the resident actually takes them.
Surveyors found that the facility did not ensure meals were palatable and served at appropriate temperatures. Resident council minutes and resident interviews documented ongoing complaints about cold food, dry meat, and concerns with meal temperature, texture, taste, and portion size. A test tray showed that while portions were adequate, chicken tenders, mixed vegetables, and potato salad were not palatable, with recorded temperatures below required standards for hot items and marginal for cold items. The in-house potato salad had hard potatoes and a thin, bland dressing, and the Food Service Director acknowledged the recipe did not contain a sufficient amount of mustard.
A resident admitted with hospice status and diagnoses including cerebral infarction and atrial fibrillation did not have a hospice baseline care plan developed within 48 hours of admission, had no documented physician order for hospice services over multiple months, and received hospice services without a fully executed hospice agreement between the facility and the hospice agency, contrary to facility policy.
Surveyors found that required nurse staffing information was not accurately posted at the start of each shift. On review, the posted staffing sheets were outdated, covered by other dates, and did not reflect the correct resident census, and on another day no current-day staffing sheet was posted at all. In interviews, the NHA acknowledged that daily staffing should be posted per federal regulation.
Two residents dependent on staff for bathing and personal hygiene did not consistently receive scheduled showers, with records showing missed or substituted care and several undocumented dates. Staff cited resident refusals, behavioral issues, and lack of documentation as contributing factors.
A resident with a history of urinary tract infection did not have a urinalysis and urine culture collected within the timeframe specified by physician orders. The delay was due to the resident's request for day shift collection and a nurse's documentation error, resulting in the order appearing completed in the electronic record before the sample was actually obtained.
The facility failed to meet the required LPN staffing ratios on multiple occasions in March 2025, with insufficient LPNs present for the number of residents during both day and night shifts. This deficiency was confirmed by the Nursing Home Administrator, highlighting a systemic issue in maintaining the mandated staffing levels.
The facility failed to create comprehensive care plans for two residents, one with quadriplegia and contractures, and another with end-stage renal disease and diabetes. The care plans lacked essential interventions and medical information, despite existing physician orders and therapy summaries.
The facility failed to provide necessary assistance with activities of daily living and personal hygiene for several residents. A resident with quadriplegia and another with dementia were not assisted with unwanted facial hair removal, and there was no documentation of efforts to address this with their families. Additionally, two residents requiring staff assistance for showers received fewer showers than scheduled, with no explanation provided by the DON.
The facility failed to administer prescribed treatments and notify the physician for two residents. A resident with lymphedema did not receive the ordered pump treatment and leg care on multiple occasions. Another resident with diabetes had an elevated blood sugar level, but the physician was not notified as required. The DON confirmed these lapses in care.
The facility failed to provide dialysis services consistent with professional standards for two residents. One resident with end-stage kidney disease had incomplete dialysis communication forms and missing daily weight documentation. Another resident with end-stage renal disease also had incomplete dialysis forms and missing weight records. Interviews with the NHA and DON confirmed these documentation lapses.
The facility failed to provide adequate nursing staff, resulting in two residents not receiving scheduled showers. Despite the facility's assessment outlining necessary staffing levels, actual staffing was below requirements. Resident 15, with muscle weakness and COPD, and Resident 93, with peripheral vascular disease, reported receiving fewer showers than scheduled. Staff interviews confirmed the shortage, with only two nurse aides covering the unit.
The facility's Director of Nursing (DON) was improperly serving as both the Infection Control Preventionist (ICP) and nursing supervisor, leading to a deficiency in infection control practices. Observations revealed that four residents requiring PPE and signage for enhanced barrier precautions did not have them, and staff entered a resident's room with contact precautions without PPE. The DON confirmed the dual roles, and the Nursing Home Administrator was unaware of the staffing requirements.
The facility failed to implement proper infection control practices, as staff did not use PPE for a resident on contact precautions and lacked enhanced barrier precautions for residents with wounds or indwelling devices. Observations showed missing signage and PPE, which were later addressed. Interviews confirmed the deficiencies, with the Nursing Home Administrator acknowledging the program's inadequacy.
The facility failed to ensure accurate MDS assessments for three residents, leading to deficiencies in documenting their medical status. A resident with lymphedema and peripheral vascular disease was not recorded as receiving prescribed opioid medication. Another resident with vascular dementia had a dose reduction of Seroquel not reflected in the MDS. Additionally, a resident with end-stage renal disease was not documented as receiving dialysis services. These inaccuracies were confirmed by the NHA and DON.
A facility failed to develop a baseline care plan for a resident with end-stage renal disease requiring dialysis within 48 hours of admission. Despite orders for dialysis services three times per week, the care plan did not address this need until over a month later. The Nursing Home Administrator confirmed the expectation that dialysis services should have been included in the baseline care plan.
A resident with an unstageable pressure ulcer on the left buttock did not have the required dressing in place, as observed during wound care. The facility's policy and physician orders required a hydrocolloid dressing to be applied three times a week and as needed. A nurse confirmed the dressing should have been in place, and the DON acknowledged the deficiency.
A resident with quadriplegia and muscle weakness did not consistently receive the application of splinting devices as ordered, particularly during the night shift. Despite being educated on the splint schedule, nurse aides failed to apply the splints regularly, raising concerns about potential further loss of mobility for the resident.
The facility failed to conduct timely Quarterly assessments for two residents using bilateral enabler bars for bed mobility assistance, as required by their policy. One resident with quadriplegia and another with muscle weakness had outdated assessments, indicating a lapse in ensuring resident safety and compliance with the facility's policy.
A resident with obstructive sleep apnea and diabetes mellitus was observed using supplemental oxygen without a current physician's order, contrary to the facility's policy. The resident's care plan indicated a need for oxygen therapy, but the order was not renewed after a hospital stay. The Nursing Home Administrator acknowledged the oversight, which violated nursing service regulations.
The facility did not act on a pharmacist's medication irregularity reports for two residents. One resident with dementia and anxiety disorder had a recommendation to reassess PRN lorazepam, and another with vascular dementia and anxiety disorder had a recommendation for Seroquel dose reduction. In both cases, the physician did not respond to the pharmacist's recommendations, and the DON could not provide reasons for the lack of response.
The facility failed to store medications according to manufacturer guidelines, as observed in the D-2 medication cart. Unopened Tresiba insulin pens were not dated, a Lantus Solostar pen was past its discard date, and Novolog and Fiasp pens lacked proper dating. The facility's policy requires refrigerated storage for such medications, which was not adhered to, as confirmed by the DON.
The facility failed to maintain clear exit access corridors in two smoke compartments. Observations revealed soiled-linen containers, trash containers, and an isolation cart obstructing corridors on the 1st and 2nd floors. The Director of Maintenance confirmed these obstructions.
The facility did not maintain continuous illumination of the means of egress in one of five stair towers. Light fixtures failed to illuminate the exit by Component 1, as observed and confirmed by the Director of Maintenance.
The facility did not maintain hazardous area doors properly, as observed in two smoke compartments. The basement Laundry Room door had excessive gaps, and a 1st floor hazardous area door near the elevator and Nurses' Station failed to latch. These deficiencies were confirmed by the Director of Maintenance.
The facility failed to ensure that the corridor door to a resident's room on the second floor positively latched, as observed during a survey. This deficiency was noted in one of the seven smoke compartments, indicating non-compliance with the requirement for corridor doors to resist smoke passage and have positive latching hardware.
The facility failed to secure portable oxygen cylinders as required by NFPA 99 standards. Five unsecured 'E' size portable oxygen cylinders were observed outside the Oxygen Storage Room on the first floor. The Director of Maintenance confirmed the unsecured state of the cylinders, affecting one of the seven smoke compartments.
The facility was found deficient in maintaining its essential electric system and monitoring outlet multipliers. A corridor door failed to latch properly, and a receptacle multiplier was used in the basement laundry, violating NFPA 101 standards. The Director of Maintenance confirmed these issues.
Hanover Hall for Nursing and Rehabilitation was found non-compliant with staffing requirements, failing to provide adequate nursing services for a resident. The resident, scheduled for showers twice a week, did not receive them due to staffing shortages. Documentation showed missed care, and interviews confirmed the facility's inability to meet the resident's care plan due to insufficient staff.
A facility failed to offer the 2024-2025 Spikevax COVID-19 vaccine to a resident with COPD and CKD, despite the vaccine being available. The resident's last COVID-19 vaccination was in early 2024, and there was no documentation of communication about the new vaccine. The resident contracted COVID-19 and passed away later that year. The DON stated the vaccine was not offered due to lack of interest and cost concerns.
The facility did not meet the required LPN staffing ratios on certain shifts. During the evening shift, there were 109 residents with only 4.31 LPNs, below the required 4.36 LPNs. On the overnight shift, 108 residents were attended by 2.06 LPNs, not meeting the required 2.70 LPNs. This was confirmed by the DON.
The facility did not meet the required RN staffing ratio of 1 RN per 250 residents during overnight shifts on two days. With 109 residents, the RN ratios were 0.88 and 0.81, falling short of the mandated levels. This was confirmed by staffing documents and the DON.
The facility failed to meet the required minimum nurse aide (NA) staffing ratios across multiple shifts, with consistent understaffing noted from January 6 to January 12, 2025. The deficiency was identified through staffing documents and staff interviews, revealing a systemic issue in maintaining adequate staffing levels according to state regulations.
The facility did not meet the required minimum of 3.20 hours of direct nursing care per resident per 24-hour period for five out of seven days reviewed. The recorded hours were below the mandated level, ranging from 2.74 to 3.18 hours. This was confirmed through staffing documents and communication with the Nursing Home Administrator.
The facility failed to meet the required nurse aide staffing ratios over a six-day period, with significant shortfalls in FTEs across day, evening, and night shifts. The Nursing Home Administrator confirmed these deficiencies were due to illness-related challenges.
The facility did not meet the required 3.2 hours of direct resident care per day for five out of six days reviewed, providing only between 2.18 and 3.08 hours. The NHA confirmed the shortfall, citing staffing challenges due to illnesses.
A facility failed to assist a resident with diabetes and COPD out of bed as requested, due to inadequate staffing. The resident, who requires a two-person assist and a walker for transfers, was unable to get out of bed before breakfast, leading to a refusal of breakfast in bed. A family member had to assist the resident. The DON confirmed that staffing ratios were not met on the day in question.
The facility failed to provide sufficient nursing staff, impacting a resident who requires a two-person assist for transfers. Due to only one NA being available, the resident was offered breakfast in bed, and a family member had to assist with getting the resident out of bed for lunch. The NHA confirmed the low staffing levels, violating Pennsylvania Code regulations.
The facility failed to ensure accurate resident assessments for three residents. One resident's hospice status was not indicated in three quarterly MDS assessments, another resident was incorrectly coded as being discharged to a hospital instead of home, and a third resident's hospice status was not indicated in a significant change MDS assessment. These errors were confirmed by the NHA and corrections were made.
A facility failed to develop a comprehensive care plan for a resident with PTSD and Type 2 Diabetes Mellitus. The care plan did not include the causes or triggers of the PTSD or interventions such as attending VFW events and experiencing night terrors, despite these being known to the staff.
The facility failed to ensure that a resident received proper vision treatment due to issues with insurance acceptance, resulting in a delay in necessary services from November 2023 through March 2024. The resident, with a history of multiple health issues, experienced significant vision problems and missed multiple appointments with specialists.
The facility failed to act on monthly pharmacy medication regimen review recommendations in a timely manner for two residents, as confirmed by the DON. This included updates to PRN Acetaminophen orders and discontinuation of Triamcinolone, which were not reflected in the physician orders.
Failure to Assess and Manage Pain After Unwitnessed Fall With Fracture
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assessment, monitoring, and pain management following an unwitnessed fall with injury. Facility policies required that any fall, including unwitnessed falls and those with possible head injury, receive a licensed nurse evaluation, documented neurological checks, vital signs, pain assessment, and appropriate notifications to the physician and responsible party. The resident involved had diagnoses including osteoarthritis, legal blindness, and a comminuted distal right radius fracture, was cognitively intact with a BIMS score of 14, and required one-person assist for ambulation to the toilet. The care plan identified the resident as high risk for falls due to vision impairment and chronic pain with muscle weakness, with interventions such as prompt response to call lights and therapy evaluations. On the evening in question, the resident experienced an unwitnessed fall at approximately 9:45 PM and was found on the floor next to the bed. A nurse aide reported that the resident stated she had tried to get to the bathroom herself and complained of right wrist pain, with a visible bump on the wrist and a scrape on the upper back. The aide further documented that the resident was unable to use the right wrist to hold the bathroom rail, later complained of head pain, and had a bump with a cut on the right side of the head that was bleeding, as well as another bump on the wrist. The aide reported these findings to the RN on duty. Despite these complaints and visible injuries, there was no documented assessment by the licensed nurse on that shift of the resident’s wrist, head, back, pain level, or vital signs, and no neurological evaluation flow record or progress note was completed for the fall on the 3–11 shift. Statements indicated that the RN on duty did not initiate a new neurological assessment, did not reassess the resident after being informed of pain and injuries, and did not notify the RN Supervisor, physician, or responsible persons about the fall and change in condition. The RN reported being overwhelmed with workload and stated that the resident was already on neuro checks from a previous fall, and therefore new neuro checks were not started. The Medication Administration Record showed that ordered PRN acetaminophen for pain scores of 4–10 was not administered on the day of the fall. Later, during the night, the resident complained of severe wrist pain, described as excruciating, and a subsequent evaluation identified visible deformity and bruising of the wrist. The physician was then notified and ordered transfer to the hospital, where imaging confirmed a comminuted distal right radius fracture. The facility’s failure to timely reassess after the fall, to perform and document required neurological and pain assessments, to manage pain, and to notify appropriate clinical and responsible parties resulted in fracture-related pain and delayed corrective treatment for the resident.
Failure to Monitor Weights and Implement Ordered Nutritional Interventions
Penalty
Summary
The deficiency involves the facility’s failure to monitor and respond to residents’ weight changes in accordance with its own policies and clinical standards of practice. The facility’s Weight Assessment and Intervention policy required weights on admission and then weekly for four weeks, with any weight change of 5 lb or more to be rechecked and, if verified, reported to the physician and dietitian. For one resident with dysphagia who was hospitalized and then readmitted, the weight increased from 130.5 lb to 143 lb between early November and the December readmission, and then decreased to 128 lb by early January, representing changes greater than 5 lb on both occasions. The clinical record showed that no reweights were obtained after these significant changes, and both the RD and the NHA acknowledged that a reweight should have been obtained but was not. Another resident, admitted with diagnoses including hypertension and a history of falls, was identified on admission as being at risk for weight loss due to the healing process from a femur fracture. This resident’s weight declined from 121.9 lb at admission to 96.6 lb over less than three months, with documented significant weight losses noted by the RD, including an 11 lb (9.1%) loss and subsequent 10% and 9.3% losses over 30-day periods. The RD recommended fortified foods, liquid protein, and weekly weights for four weeks, and obtained a physician’s order for a regular diet with fortified foods. However, weekly weights ordered in November and December were not consistently obtained, and the fortified foods ordered by the physician were not added to the resident’s meal ticket or provided until mid-January, despite multiple WEIGHT WARNING notes and acknowledgment by the RD and NHA that the fortified foods should have been implemented earlier. The resident’s nutritional assessments were based on the assumption that fortified foods were being consumed, although they were not. A third resident, admitted with dysphagia and dementia, also did not receive weight monitoring as required by facility policy. The December physician orders for this resident did not include weekly weights for four weeks following admission, and the weight history showed only two weights, one in early December and one in early January, with no weekly weights documented in between. The RD stated that the admission weight was obtained but nursing failed to enter the physician order for weekly weights, resulting in the absence of weekly weights for four weeks after admission. The NHA confirmed that weekly weights for four weeks after admission were not obtained for this resident, contrary to facility policy.
Failure to Complete Timely Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aide performance evaluations were completed at least once every 12 months for three of five nurse aides reviewed. Facility job description documentation for nurse aides stated that annual evaluations are to be completed by their supervisor. A facility-generated list identified nurse aides who had worked at the facility for more than one year, and three employees from this list were selected for review. Employee 7’s last annual performance evaluation was dated October 11, 2022, and Employee 8’s last annual performance evaluation was dated July 18, 2023, showing that neither had an evaluation within the past 12 months. Facility documentation showed Employee 9 had a hire date of August 19, 2024, but there was no annual evaluation for 2025 available for review. During an interview, the Nursing Home Administrator confirmed she was unable to locate annual evaluations within the past 12 months for Employees 7, 8, and 9 and stated she would have expected them to be available in their employee files. This deficiency was cited under 28 Pa. Code 201.14(a) Responsibility of licensee and 28 Pa. Code 201.18(b)(1) Management.
Failure to Complete Monthly Medication Regimen Reviews and Address Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that each resident’s drug regimen was reviewed at least monthly by a licensed pharmacist and that identified irregularities were addressed in a timely manner by the attending physician or prescriber. Facility policy on Medication Regimen Review required a comprehensive monthly medication regimen review (MRR) by the consultant pharmacist, with recommendations acted upon and documented by staff and/or the prescriber. For two residents with diagnoses including GERD, hyperlipidemia, dementia, repeated falls, and other conditions, the clinical records did not show that required monthly MRRs were completed for a specified month. In addition, multiple MRRs contained recommendations that lacked any documented response or evidence of implementation. For one resident with GERD and dementia, there was no MRR documented for April, and later MRRs in June and August included recommendations to administer omeprazole on an empty stomach before meals and to obtain routine lab values, with no documented response or implementation; the same omeprazole administration recommendation reappeared in a December MRR. For another resident with repeated falls and dementia, there was no MRR documented for April, and a September MRR recommendation to specify the gram amount for diclofenac gel application had no documented response or implementation and was repeated in December. For a third resident with Down syndrome and dementia receiving pantoprazole, an October MRR recommendation to administer the medication on an empty stomach 30–60 minutes before a meal was not addressed until several months later. In interviews, the DON stated an expectation that monthly MRRs be completed and available, and that physicians review and respond to MRR recommendations in a timely manner.
Improper Food Storage, Labeling, and Sanitation in Kitchen and Nourishment Pantries
Penalty
Summary
The deficiency involves the facility’s failure to store and serve food and beverages in accordance with its own policies and professional food safety standards in the main kitchen and all four nourishment pantries. Facility policies required that unserved leftovers, bulk items, and all foods be covered, labeled, and dated, and that dietary supplements removed from the freezer be labeled with a use-by date. Policies also required that food brought in from outside sources be labeled with the resident’s name, room number, and date. Surveyors observed in the walk-in freezer an open plastic bag containing one and a half frozen pizzas that was not securely closed or date marked. In the walk-in refrigerator, multiple opened 46-ounce containers of juice (apple and cranberry) were not marked with an open or use-by date, contrary to staff statements that they should be. In the C1/D1 nourishment pantry, surveyors observed multiple thawed health shakes/juices (orange, vanilla, and chocolate) that were not date marked with a thawed or use-by date, with staff relying on tray dates to infer when they were pulled from the freezer. Additional thawed shakes/juices in the refrigerator drawer were also undated, and several food items identified as resident-owned (Greek yogurt, ice cream, flavored creamer, and a bag with blueberries and yogurt) lacked resident identifiers. In the A1/B1 pantry, multiple resident food items (ice cream, mochi, coleslaw) lacked resident identifiers, and several dry goods (thickener, hot chocolate mix, cereals, peanut butter) were not labeled and dated; thawed nutritional shakes/juices were also undated, and dried spills were present inside the refrigerator. Similar issues were found in the B2 pantry, where a half chicken salad sandwich and numerous thawed shakes/juices were undated and dried liquid was on the bottom shelf, and in the C2/D2 pantry, where numerous frozen resident food items lacked identifiers and dates, thawed shakes/juices and applesauce cups were undated, and dried spills of liquids, applesauce, and pudding were present. In dry storage, multiple cans of vegetables and beans were not date marked. The Nursing Home Administrator stated the expectation that food would be stored to meet regulatory standards.
Failure to Offer and Document Opportunity to Formulate Advance Directive
Penalty
Summary
The facility failed to ensure a resident was informed of and given the opportunity to formulate an advance directive as required by its own policy and regulatory standards. The facility’s written policy on advance directives, revised in September 2022, states that prior to or upon admission, the Social Services Director or designee must inquire about any existing written advance directives, provide written information on the right to accept or refuse medical or surgical treatment, and inform the resident or representative of the right to formulate an advance directive. The policy also requires that this information be provided in an easily understood manner and include a description of the facility’s policies and applicable state law. For one resident reviewed, identified as Resident 39, the clinical record did not contain any documentation that staff had reviewed the resident’s right to formulate an advance directive or offered the opportunity to do so. Resident 39 had physician orders reflecting diagnoses including hypertension and chronic kidney disease, and a recent BIMS assessment showed a score of 15/15, indicating intact cognition. During an interview, the Social Worker (Employee 3) confirmed there was no documentation that the resident had been offered the opportunity to formulate an advance directive. This lack of documentation and action constituted the identified deficiency.
Failure to Monitor and Document Antipsychotic Side Effects
Penalty
Summary
The facility failed to monitor and document side effects for a resident receiving an antipsychotic medication. Facility policy on psychotropic medication use, revised February 2025, required that residents receiving psychotropic medications be monitored and that their response to treatment be documented. The resident had diagnoses including Down syndrome and dementia, and a physician’s order for risperidone 0.25 mg by mouth twice daily beginning December 2, 2025. The resident’s care plan, initiated in early November 2025, identified psychotropic medication use and included an intervention to monitor, record, and report to the physician any side effects of antipsychotic medications, listing multiple potential adverse effects such as dystonia, tremors, confusion, restlessness, anxiety, tardive dyskinesia, sedation, increased falls, and others. Review of the resident’s medical record showed no documented side effect monitoring for the antipsychotic medication, and the DON confirmed in interview that there was no side effect monitoring documented for this resident.
Failure to Care Plan Use of Bed Enabler Bars for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans addressing the use of bed enabler bars for two residents, as required by facility policy. The facility’s policy on comprehensive person-centered care plans, revised March 2022, requires measurable objectives and timetables to meet residents’ physical, psychosocial, and functional needs. For one resident with diagnoses including hypertension and hemiparesis, surveyors observed bilateral enabler bars attached to the bed, and the resident reported using them to help position himself. Review of this resident’s interdisciplinary plan of care showed no care plan developed to address his use of enabler bars in relation to his diagnoses and bed mobility status, and the NHA confirmed that no such care plan existed. For another resident with diagnoses including GERD, hyperlipidemia, and dementia, surveyors observed bilateral enabler bars attached to the bed. The clinical record contained a bed rail evaluation and a consent form completed previously, but review of the care plan did not reveal any plan of care addressing the resident’s use of enabler bars based on his diagnoses and bed mobility status. In an interview, the NHA stated she would expect this resident to have a care plan developed for his use of bed rails. These findings demonstrate that, for both residents, the facility did not follow its own policy and regulatory requirements to develop and implement person-centered care plans that included the use of enabler bars.
Medications Left at Bedside and Signed as Administered Before Ingestion
Penalty
Summary
The facility failed to ensure medications were administered in accordance with professional standards and facility policy for one resident. Facility policy on administering medications stated that medications are to be administered in a safe and timely manner and as prescribed. Resident 94 had diagnoses including gastroesophageal reflux disease, muscle weakness, and hypertension. During an observation in the resident’s room on January 11, 2026, at 11:10 AM, a cup containing 11 medications was found on the bedside table. In an interview at 11:11 AM, an LPN (Employee 4) stated that when she went to pass the resident’s medications, the resident was eating breakfast, so she left the medications on the bedside table and had already signed them off as administered at 8:51 AM, stating the resident should have taken them by then. In a subsequent interview on January 14, 2026, at 11:21 AM, the Director of Nursing stated that she would expect the resident’s medications not to be left at the bedside and would expect medications not to be signed off as administered until after they are taken by the resident.
Failure to Provide Palatable Meals at Appropriate Temperatures
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at safe and appetizing temperatures. Resident Council meeting minutes from two separate meetings documented resident complaints about cold food and dry meat. During the initial pool process, three residents reported concerns regarding meal temperature, texture, taste, and portion size. Review of the facility’s Culinary and Nutrition Test form showed required point-of-service temperatures of greater than 135°F for hot entrées and starches and less than 41°F for cold entrées and desserts. A test tray evaluation conducted on January 12, 2026, showed that while portion sizes were adequate, the chicken tenders, mixed vegetables, and potato salad were not palatable for temperature, and the potato salad was also not palatable for texture or taste. The test tray was placed on a meal cart and delivered to a unit, with 14 minutes elapsing before evaluation. At the time of evaluation, the Food Service Director recorded the following temperatures: chicken tenders at 115°F, potato salad at 44°F, mixed vegetables at 123°F, chocolate pudding at 42°F, and milk at 44°F. The potato salad was described as having hard potatoes and a thin, bland, stark white dressing. The potato salad was made in-house, and review of the recipe showed it contained potatoes, vegetable oil, cider vinegar, lemon juice, yellow mustard, salt, black pepper, and mayonnaise; the Food Service Director noted that mustard should have been used and that there was not a significant amount of mustard in the recipe.
Failure to Establish Timely Hospice Care Plan and Authorized Hospice Agreement
Penalty
Summary
The deficiency involves the facility’s failure to timely develop a hospice baseline care plan, obtain a hospice physician order, and secure an authorized hospice agreement prior to initiation of hospice services for one resident. The facility’s hospice program policy, last reviewed July 25, 2025, required that an agreement with the hospice provider be signed by a facility representative and a hospice agency representative before hospice services were furnished. The resident in question had clinical diagnoses including cerebral infarction, atrial fibrillation, and hospice status, and the admission MDS dated December 3, 2025, showed a BIMS score of 11, indicating moderately impaired cognition. Section O of the MDS documented that the resident was on hospice status upon admission on November 26, 2025. Record review showed that the resident’s baseline care plan was not created until December 4, 2025, which was eight days after admission and not within 48 hours as required. Review of the physician orders for November 2025, December 2025, and January 2026 did not reveal any physician order for hospice services. When surveyors requested the hospice agreement on January 13, 2026, the facility could not provide it until January 14, 2026, and the agreement produced was not signed by the hospice agency. In an interview on January 14, 2026, the Nursing Home Administrator confirmed that the baseline care plan was not developed within 48 hours of admission, there was no hospice physician order in the medical record, and the hospice agreement had not been authorized by both the facility and the hospice agency before hospice services were initiated.
Failure to Accurately Post Daily Nurse Staffing and Census Information
Penalty
Summary
The facility failed to post accurate nurse staffing information on a daily basis at the beginning of each shift, including an accurate resident census, on two consecutive days. On January 11, 2026 at 9:26 AM, surveyors observed that the posted staffing information was dated January 9, 2025, and an employee identified as the Director of Rehabilitation removed two sheets for January 9 and 10, 2026 that had been placed over the staffing data sheet for January 11, 2026. Further review of the January 11, 2026 posting showed a listed census of 120 residents, while the Nursing Home Administrator (NHA) stated during an interview at 10:13 AM that the actual facility census was 114 residents. On January 12, 2026 at 1:28 PM, the posted staffing information was again reviewed and found to be dated January 11, 2026, with no staffing sheet available for January 12, 2026. In a subsequent interview on January 13, 2026, the NHA stated that she would expect daily staffing to be posted in accordance with federal regulation. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency centers on inaccurate and missing daily staffing and census postings as observed and confirmed through staff interviews.
Failure to Provide and Document Adequate Hygiene for Dependent Residents
Penalty
Summary
The facility failed to maintain adequate personal hygiene and grooming for residents who were dependent on staff for assistance with activities of daily living. For one resident with multiple diagnoses including anxiety, depression, Alzheimer's disease, vascular dementia, bipolar disorder, and hallucinations, clinical records showed she was dependent on staff for bathing and scheduled for showers twice weekly. However, documentation revealed she often received only bed baths or wash-ups at the sink instead of showers, and there were several dates with no documentation of bathing at all. Family concerns were raised regarding missed showers, and staff statements indicated the resident sometimes refused to get out of bed or refused showers, with some care provided by night shift or occupational therapy on occasion. Another resident, diagnosed with dementia with behavioral disturbances, vascular parkinsonism, and adjustment disorder, was also dependent on staff for bathing and required two-person assistance due to combativeness. This resident was scheduled for showers twice weekly, but records showed only one shower and a few wash-ups at the sink during the review period, with several dates lacking any documentation of bathing. Interviews with facility leadership revealed a belief that bathing had been completed but not documented, and that the resident's behavioral issues and sleep patterns sometimes led staff to forgo scheduled bathing.
Delay in Timely Collection of Urine Sample for Laboratory Testing
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a urinalysis and urine culture and sensitivity were completed in a timely manner for a resident with a history of urinary tract infection. Physician orders directed that a urinalysis and culture be obtained, but the urine sample was not collected until several days after the initial order. The delay was partly due to the resident requesting the collection be done during the day shift, and the nurse documenting the order as completed in the electronic record without extending it to the following day. As a result, the laboratory test was not performed within the timeframe specified by the physician order.
LPN Staffing Ratio Deficiency
Penalty
Summary
The facility failed to meet the required minimum staffing ratios for Licensed Practical Nurses (LPNs) on both the day and night shifts over several days in March 2025. Specifically, the facility did not maintain the mandated ratio of one LPN per 25 residents during the day shift on seven occasions and one LPN per 40 residents during the night shift on three occasions. The staffing document review revealed that on these days, the number of LPNs present was insufficient for the number of residents, with shortfalls ranging from a fraction to over one LPN less than required. The deficiency was confirmed through an email exchange with the Nursing Home Administrator, who acknowledged the failure to meet the staffing requirements. The report details specific instances where the LPN staffing levels fell short, such as on March 9, 2025, when there were only 2.94 LPNs for 112 residents, whereas 4.48 LPNs were required. This pattern of inadequate staffing was consistent across the identified dates, indicating a systemic issue in maintaining the necessary LPN-to-resident ratios as per the regulation effective July 1, 2023.
Plan Of Correction
1. Facility cannot retroactively correct staffing deficiencies. 2. All residents are at risk for staffing levels that fail to meet minimum ratio requirements. 3. Facility utilizes recruiting services to fulfill staffing needs. Facility is currently re-evaluating LPN rates for hiring and has recently increased agency LPN rates. Recent re-education was provided to licensed nursing staff regarding staffing requirements and ratios. Bonuses continue to be offered to assist with filling open positions. Administrative nurses will also assist as needed to meet minimum ratio requirements. 4. NHA/DON will monitor daily staffing needs to ensure adequate licensed staffing is met. Audits will be reviewed at QAPI for ongoing compliance and quality assurance.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for two residents, leading to deficiencies in their care. Resident 63, diagnosed with quadriplegia and muscle weakness, was observed with contractures in both hands and was using a splinting device. Despite having a physician's order since June 2023 to cleanse and check the placement of the splint each shift, and an occupational therapy discharge summary from December 2024 that communicated the splint wearing schedule and skin assessment needs to the nursing staff, the care plan did not include these interventions until February 25, 2025. This omission was acknowledged by the Nursing Home Administrator, who stated that the information should have been included earlier. Similarly, Resident 99, who has end-stage renal disease and type II diabetes mellitus, had a physician's order for insulin administration before meals and at bedtime since December 2024. However, the care plan lacked any information regarding the resident's diabetes diagnosis or insulin use. The Director of Nursing confirmed via email that there was no existing care plan addressing these needs, indicating a failure to incorporate critical medical information into the resident's care plan.
Failure to Provide Adequate ADL Assistance and Hygiene Care
Penalty
Summary
The facility failed to provide necessary services for residents unable to perform activities of daily living, specifically in maintaining good grooming and personal hygiene. Resident 3, diagnosed with hypertension and quadriplegia, was observed with unwanted facial hair and expressed a desire for assistance with shaving, yet there was no documentation of efforts to obtain an electric razor from her family. Similarly, Resident 17, who has muscle weakness and dementia, was observed with facial hair and expressed dissatisfaction with the lack of assistance, with no documented communication with her family regarding grooming needs. Additionally, the facility did not adhere to scheduled shower routines for Residents 15 and 93, both of whom require staff assistance. Resident 15, with muscle weakness and chronic obstructive pulmonary disease, reported receiving only four showers over several months despite being scheduled for twice-weekly showers. Resident 93, with peripheral vascular disease and an acquired absence of the left foot, also reported receiving fewer showers than scheduled, often receiving bed baths instead. The Director of Nursing could not provide explanations for these discrepancies, indicating a failure in providing adequate nursing services as required by regulations.
Failure to Administer Prescribed Treatments and Notify Physician
Penalty
Summary
The facility failed to provide care and services as ordered by the physician for two residents. Resident 6, who has lymphedema and peripheral vascular disease, did not receive the prescribed lymphedema pump treatment twice daily as ordered. The Treatment Administration Record (TAR) indicated multiple days in February 2025 when the treatment was not administered. Additionally, the prescribed cleansing and application of ointment to Resident 6's lower legs were not completed on several days. The Director of Nursing (DON) stated that staff were unable to perform these treatments because they were occupied with other duties. Resident 99, diagnosed with end-stage renal disease and type II diabetes mellitus, had a physician's order for insulin administration based on a sliding scale and required notification if blood sugar levels exceeded 351. On February 17, 2025, Resident 99's blood sugar was recorded at 365, but there was no evidence that the physician was notified. The DON confirmed the lack of documentation regarding the notification of the physician about the elevated blood sugar level.
Failure to Ensure Proper Dialysis Care and Documentation
Penalty
Summary
The facility failed to provide dialysis services consistent with professional standards of practice for two residents requiring such care. Resident 80, diagnosed with hypertension and chronic end-stage kidney disease, had physician orders for dialysis treatments three times a week and daily weight monitoring. However, the facility did not complete or maintain communication forms with the dialysis center on several occasions in February 2025, and daily weights were not documented as ordered on multiple dates. Interviews with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) confirmed these lapses in documentation and communication. Similarly, Resident 99, who had end-stage renal disease and was dependent on renal dialysis, had physician orders for dialysis three times a week and daily weight monitoring. The facility failed to maintain complete dialysis communication forms for several dates in February 2025, and daily weights were not recorded on multiple dates in January and February 2025. Interviews with the DON and NHA confirmed the absence of complete documentation and the inability to locate additional information regarding the missing weights. These deficiencies were in violation of 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
Insufficient Staffing Leads to Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by the experiences of two residents. The facility's assessment, approved in August 2024, outlined the necessary resources to care for residents competently, including staffing needs based on resident acuity and care requirements. However, the documented staffing levels for nurse aides on specific days in February 2025 were significantly below the required number, indicating a failure to meet the assessed staffing needs. Resident 15, diagnosed with muscle weakness and chronic obstructive pulmonary disease, reported that she was scheduled for showers twice a week but often only received bed baths, sometimes going weeks without having her hair washed. Her clinical records confirmed that she had only received four showers since her admission in August 2024. Similarly, Resident 93, with peripheral vascular disease and an acquired absence of the left foot, stated she was scheduled for showers twice a week but usually only received one. Her records showed multiple instances where she received bed baths instead of showers or had no documentation of receiving a shower at all. Interviews with the Nursing Home Administrator and Director of Nursing confirmed the existence of staffing issues, with no additional information provided on why the residents were not receiving their scheduled showers. Staff interviews further corroborated the shortage, indicating that typically only two nurse aides were available to cover the entire unit, which was insufficient to meet the residents' care needs, particularly for showers.
Deficiency in Infection Control and Staffing Roles
Penalty
Summary
The deficiency involves the Director of Nursing (DON) at the facility who was also serving as the Infection Control Preventionist (ICP) and occasionally as the nursing supervisor, which is not in compliance with the requirement for the DON to function on a full-time basis. The facility's staffing information revealed that the DON was fulfilling multiple roles due to the departure of the previous ICP in May 2024. During the health survey, it was observed that four residents requiring personal protective equipment (PPE) and signage for enhanced barrier precautions due to wounds, dialysis, colostomy, and catheter did not have the necessary PPE or signage present. Additionally, two staff members were seen entering a resident's room with contact precautions signage without wearing PPE while providing direct care. The DON confirmed the situation during an interview, and the Nursing Home Administrator (NHA) admitted to being unaware of the requirement that the DON could not also serve as the ICP, and acknowledged the lack of a backup ICP to share the responsibilities.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control policies and practices, as evidenced by staff not using personal protective equipment (PPE) for residents on contact precautions. Specifically, two employees entered the room of a resident with clostridium difficile without wearing gloves or gowns, despite a sign indicating contact precautions. Additionally, there was no current physician's order or care plan for contact precautions for this resident, which was confirmed by the Director of Nursing. Further deficiencies were noted in the implementation of enhanced barrier precautions for residents with wounds, indwelling medical devices, or dialysis access ports. The clinical records and care plans for three residents with such conditions did not include information regarding enhanced barrier precautions. Observations revealed a lack of signage and PPE availability in or around these residents' rooms, which was later rectified, but only after the initial observation. Interviews with staff, including an LPN and the Nursing Home Administrator, confirmed the deficiencies in the infection prevention and control program. The Nursing Home Administrator acknowledged that the enhanced barrier program was not adequately implemented, indicating a systemic issue in the facility's infection control practices.
Inaccurate Resident Assessments in MDS Documentation
Penalty
Summary
The facility failed to ensure accurate resident assessments for three residents, leading to deficiencies in the documentation of their medical status. Resident 6, diagnosed with lymphedema and peripheral vascular disease, was prescribed Oxycodone for severe pain. However, the quarterly Minimum Data Set (MDS) did not reflect the administration of this opioid medication, as confirmed by the Nursing Home Administrator (NHA). Similarly, Resident 41, who has vascular dementia and anxiety disorder, had a physician's order to reduce Seroquel from 100 mg to 75 mg. Despite this, the MDS was incorrectly coded to indicate that a general dose reduction had not been attempted, which was later acknowledged by the NHA and Director of Nursing (DON). Resident 99, suffering from end-stage renal disease and dependent on dialysis, had physician orders for dialysis services three times a week. Nonetheless, the MDS failed to document that the resident received dialysis services while at the facility. This oversight was also confirmed by the NHA. These inaccuracies in the MDS assessments highlight the facility's failure to maintain accurate and up-to-date records of the residents' medical treatments and conditions, as required by regulatory standards.
Failure to Implement Baseline Care Plan for Dialysis
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident within 48 hours of admission, as required. The resident, who had end-stage renal disease and was dependent on renal dialysis, was admitted to the facility and required dialysis services three times per week. Despite this critical need, the resident's care plan did not include a baseline care plan addressing dialysis services within 48 hours of admission on two separate occasions. The care plan for dialysis was not initiated until over a month after the second admission. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the resident's need for dialysis services should have been included in the baseline care plan.
Failure to Maintain Dressing on Pressure Ulcer
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for Resident 8, who had an unstageable pressure ulcer on the left buttock and chronic kidney disease, stage 3. According to the facility's wound care policy, a dressing should have been applied and secured as ordered. Resident 8's physician orders specified cleansing the wound with normal sterile saline and applying a hydrocolloid dressing three times a week and as needed. However, during an observation of wound care, it was noted that no dressing was in place on Resident 8's left buttock. A Registered Nurse confirmed that a dressing should have been in place and that staff should notify the nurse if the dressing comes off during incontinence care, prompting a PRN dressing change. The Director of Nursing also confirmed that Resident 8 should have had a dressing in place.
Inconsistent Application of Splints for Resident with Limited Mobility
Penalty
Summary
The facility failed to ensure that a resident with limited mobility received appropriate services and assistance to maintain or improve mobility. The resident, diagnosed with quadriplegia and muscle weakness, had physician orders for the application of splinting devices to prevent further functional loss due to contractures. However, observations and interviews revealed that the splints were not consistently applied, particularly during the night shift. The resident expressed concerns about the inconsistency in applying the splints, which he feared could lead to further loss of mobility, especially in his left hand, which he used for feeding himself. Interviews with staff confirmed the resident's concerns, with a nurse aide acknowledging that the splints were often not applied when she started her shift. The occupational therapy discharge summary indicated that nursing staff had been educated on the resident's splint schedule and the need for skin assessments. Despite this, the Nursing Home Administrator confirmed that the nurse aides, who were educated on the application of the splints, were not consistently fulfilling this responsibility, leading to the deficiency.
Failure to Conduct Timely Assessments for Enabler Bar Use
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards and that residents received adequate supervision and assessment regarding the use of enabler bars. Specifically, the facility did not conduct recent Quarterly assessments for two residents who were using bilateral enabler bars for bed mobility assistance. Resident 3, who has diagnoses including hypertension and quadriplegia, had a Quarterly assessment dated October 17, 2024, while Resident 39, diagnosed with hypertension and muscle weakness, had their last assessment dated August 19, 2024. The facility's policy on the use of bed rails, revised in September 2022, requires staff to assess and document the resident's risk for injury and to periodically check the resident's safety concerning bed rail use. However, an interview with the Nursing Home Administrator revealed that the required recent Quarterly assessments for the continued use of enabler bars for Residents 3 and 39 were not conducted, indicating a lapse in following the facility's policy and ensuring resident safety.
Failure to Provide Physician-Ordered Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory services for a resident, identified as Resident 90, who was observed using supplemental oxygen without a current physician's order. The facility's policy on oxygen administration, last revised in October 2010, requires verification of a physician's order before administering oxygen. However, a review of Resident 90's clinical records on February 24, 2025, revealed no current physician order for the supplemental oxygen being administered at 2 liters per minute. The resident's care plan, revised on February 20, 2025, indicated a focus on oxygen therapy related to a respiratory condition, but the necessary physician's order was missing. Resident 90, who has diagnoses including obstructive sleep apnea and diabetes mellitus, reported using supplemental oxygen at night and while sleeping in bed. An interview with the Nursing Home Administrator on February 26, 2025, confirmed that the resident required supplemental oxygen, but the order had lapsed when the resident was hospitalized and was not reordered upon their return to the facility. This oversight resulted in the facility's failure to comply with its own policy and regulatory requirements for nursing services, as outlined in 28 Pa. Code 211.12(d)(3) and 28 Pa. Code 211.12(d)(5).
Failure to Act on Pharmacist's Medication Irregularity Reports
Penalty
Summary
The facility failed to act upon the licensed pharmacist's report of medication irregularities for two residents. For Resident 8, who has diagnoses of dementia and anxiety disorder, the pharmacist recommended evaluating the discontinuation or reassessment of PRN lorazepam. However, the physician did not respond to or sign the pharmacist's medication regimen review document dated October 5, 2024. During an interview, the Director of Nursing (DON) could not provide additional information on why the physician did not respond, although it was the facility's expectation for timely responses to pharmacy recommendations. Similarly, for Resident 41, who has vascular dementia with agitation and anxiety disorder, the pharmacist recommended a dose reduction or trial discontinuation of Seroquel. The physician also did not respond to or sign the pharmacist's medication regimen review document dated January 11, 2025. The DON again could not provide further information on the lack of response from the physician. The facility's policy requires physicians to respond appropriately to pharmacy recommendations, but this was not adhered to in these cases.
Improper Medication Storage in Facility
Penalty
Summary
The facility failed to store medications in accordance with manufacturer guidelines, as observed during a review of the D-2 medication cart. Specifically, the cart contained two unopened Tresiba insulin pens that were not dated, a Lantus Solostar pen with an open date of November 25, 2024, a Novolog insulin pen with no open date, and two unopened Fiasp insulin pens with no date removed from refrigeration. According to the facility's policy, medications requiring refrigeration should be stored at temperatures between 36 to 46 degrees Fahrenheit, and outdated or improperly stored medications should be immediately removed and disposed of. The product packaging for Tresiba, Lantus, Novolog, and Fiasp specifies that these medications should be refrigerated and discarded after a certain period if removed from refrigeration. Tresiba should be discarded 8 weeks after removal, Lantus after 28 days once opened, and both Novolog and Fiasp after 28 days even if unopened. The Director of Nursing confirmed the expectation that product instructions would be followed, indicating a failure to adhere to these guidelines. This deficiency was identified under the regulations 28 Pa. Code 201.18(b)(1) Management and 28 Pa. Code 211.9(a)(1) Pharmacy services.
Obstructed Exit Access Corridors
Penalty
Summary
The facility failed to maintain clear and unobstructed exit access corridors in two of seven smoke compartments. During an observation conducted on February 12, 2025, between 12:30 PM and 1:30 PM, various items were found stored in the egress corridors. Specifically, soiled-linen containers were located between Resident Rooms 226 and 228 on the 2nd floor at 12:30 PM, trash containers were found between Resident Rooms 222 and 224 on the 2nd floor at 1:05 PM, and an isolation cart without signage was positioned outside Resident Room 121 on the 1st floor at 1:30 PM. An interview with the Director of Maintenance confirmed the facility's failure to keep the corridors clear and unobstructed.
Plan Of Correction
1. Facility cannot retroactively correct this concern. Sign was obtained for the isolation cart when it was observed to be missing. 2. Education will be provided to staff on storage of trash containers, and isolation carts needing signage. 3. Maintenance director/designee will complete audits of corridors to ensure trash containers are not stored in corridors, and all isolation carts have signs. Audits will be 3x/week x 4 weeks, then 5x monthly x 2 months to ensure compliance. Audits will be reviewed at QAPI to ensure compliance.
Failure to Maintain Continuous Egress Illumination
Penalty
Summary
The facility failed to maintain continuous illumination of the means of egress for one of five stair towers. During an observation on February 12, 2025, at 2:30 PM, it was noted that the light fixtures did not illuminate the exit by Component 1. This was confirmed in an interview with the Director of Maintenance at the same time.
Plan Of Correction
1. Stairwell exit light was repaired. 2. Facility audited stairwell lighting to ensure proper illumination. 3. Maintenance director/ designee will conduct monthly audits of stairwell lighting to ensure proper illumination. Audits will be reviewed at QAPI to ensure compliance.
Deficient Hazardous Area Door Maintenance
Penalty
Summary
The facility failed to maintain the integrity of hazardous area doors in two of seven smoke compartments. During an observation, it was noted that the basement Laundry Room's rated door had gaps exceeding the allowed 3/16 inch margin. This was confirmed in an interview with the Director of Maintenance. Additionally, another observation revealed that a hazardous area door on the 1st floor, located by the elevator and Nurses' Station, did not positively latch when closed. This issue was also confirmed by the Director of Maintenance.
Plan Of Correction
1. NGP9990 fire and smoke seal will be added to door. Second door was adjusted to ensure it positively latched. 2. Facility has conducted an audit to ensure other hazardous area doors compliance with regulation. 3. Maintenance director/designee will conduct monthly inspections of doors to ensure they positively latch, and gaps are within appropriate parameters. Audits will be reviewed at QAPI to ensure compliance.
Failure to Maintain Positive Latching on Corridor Door
Penalty
Summary
The facility failed to maintain corridor doors to positively latch in one of the seven smoke compartments. During an observation on February 12, 2025, at 1:15 PM, it was noted that the corridor door to Resident Room 207 on the second floor did not positively latch when closed. This deficiency was identified through both observation and interview, indicating a failure to comply with the requirement for corridor doors to resist the passage of smoke and to have positive latching hardware.
Plan Of Correction
Facility has repaired the door so it does positively latch. Facility has conducted an audit to ensure corridor doors were within compliance of regulation. Maintenance director/designee will conduct monthly inspections to ensure they positively latch. Audits will be reviewed at QAPI to ensure compliance.
Unsecured Portable Oxygen Cylinders
Penalty
Summary
The facility failed to secure portable oxygen cylinders, which is a requirement under NFPA 99 standards for handling gas equipment. During an observation on February 12, 2025, at 2:00 PM, five unsecured 'E' size portable oxygen cylinders were found outside the Oxygen Storage Room, within a first-floor room by SC-5. This deficiency was confirmed through an interview with the Director of Maintenance, who acknowledged the unsecured state of the oxygen cylinders. This issue affected one of the seven smoke compartments within the component.
Plan Of Correction
1. Cylinders were placed back into proper storage area after observation. 2. Facility will provide re-education to staff regarding appropriate storage of oxygen cylinders. 3. Maintenance director/designee will complete audits of storage areas monthly to ensure they are properly stored. Audits will be reviewed at QAPI to ensure compliance.
Deficiencies in Electrical System Maintenance and Outlet Monitoring
Penalty
Summary
The facility was found to have deficiencies related to the maintenance and testing of its electrical systems, specifically concerning the essential electric system (EES) and the use of outlet multipliers. During an interview with the Director of Maintenance, it was confirmed that a corridor door did not positively latch, which is a requirement under the National Fire Protection Association (NFPA) 101 standards. Additionally, the facility failed to meet the NFPA 101 requirements for monitoring the use of outlet multipliers, as evidenced by the observation of a receptacle multiplier being used in the basement laundry area by the dryers. The report highlights that the generator and associated equipment must be capable of supplying service within 10 seconds, and if this criterion is not met during monthly tests, an annual confirmation process is required. The facility is also required to maintain written records of maintenance and testing, ensure EES electrical panels and circuits are marked and separate from normal power circuits, and minimize the possibility of damage to the emergency power source. However, the facility's failure to monitor the use of outlet multipliers in one of the smoke compartments indicates a lapse in adhering to these standards, as confirmed by the Director of Maintenance.
Plan Of Correction
1. Multiplier was removed and existing receptacle is now being utilized. 2. Facility has completed an audit to ensure no other multipliers are being used. 3. Maintenance director/designee will conduct monthly inspections to ensure no multipliers are being utilized. Audits will be reviewed at QAPI to ensure compliance.
Insufficient Nursing Staff Leads to Care Deficiency
Penalty
Summary
Hanover Hall for Nursing and Rehabilitation was found to be non-compliant with the requirement for sufficient nursing staff as per 42 CFR Part 483.35(a)(1)(2). The facility failed to provide adequate nursing services to ensure the safety and well-being of its residents, specifically for one resident. The deficiency was identified through document reviews, policy reviews, and interviews with residents and staff. The facility's policy on comprehensive person-centered care plans, which mandates the development and implementation of care plans to meet residents' needs, was not adhered to. Additionally, the facility's policy on resident rights, which includes treating residents with dignity and responding to grievances, was not fully implemented. The deficiency was highlighted by the case of a resident who was scheduled to receive showers twice a week during the day shift. However, a grievance was filed by the resident's daughter, indicating that the resident was not receiving the scheduled showers. Documentation revealed that the resident only received bed baths on two occasions in January 2025, with no record of showers or bed baths on two other scheduled dates. An interview with the DON and a nurse aide confirmed that the facility was short-staffed on those dates, preventing the provision of care as per the resident's person-centered plan.
Plan Of Correction
1. R4 did receive a shower on 1/24, 1/31, 2/4, and 2/7, and a bed bath on 1/27. There were no adverse effects from not receiving a shower on 1/17 and 1/21; he did receive AM and PM personal hygiene care on these days. 2. The facility will audit the last two weeks of shower schedules to ensure residents are receiving showers/bed baths as scheduled. 3. Re-education will be provided to nursing staff regarding documentation with bathing, as well as offering showers the next shift or day as necessary. Re-education will be provided on staffing ratios and minimum PPD. 4. DON/designee will conduct audits of 10 residents/week x4 weeks, and then 10 monthly x2 months to ensure residents are receiving showers/or bed baths as scheduled. Staffing levels will be monitored daily to ensure minimum requirements are being met. Results will be reviewed at QAPI to ensure compliance and ongoing quality care.
Failure to Offer COVID-19 Vaccine to Resident
Penalty
Summary
The facility failed to implement policies and procedures to ensure that each resident is offered the COVID-19 vaccine when available. Specifically, the facility did not offer the 2024-2025 Spikevax COVID-19 vaccine to Resident 2 or their representative, despite the vaccine being available from the facility's pharmaceutical provider. The facility's policy required that educational information and consents be completed for each dose administered, and documentation of vaccination acceptance or refusal be maintained. However, there was no documentation in Resident 2's clinical record indicating communication about the availability of the new vaccine or any offer made to the resident or their representative. Resident 2 had a medical history that included chronic obstructive pulmonary disease (COPD) and chronic kidney disease (CKD). The resident's immunization documentation showed that the last COVID-19 vaccination was administered in February 2024. Unfortunately, Resident 2 contracted COVID-19 in December 2024 and passed away in January 2025. An interview with the Director of Nursing revealed that the facility did not offer the vaccine to Resident 2 due to a lack of interest from residents or staff, which led to the decision not to order the vaccine from the pharmacy to avoid cost and waste.
Plan Of Correction
1. Facility cannot retroactively correct this concern for R2. 2. The facility will complete an audit of residents who have not received this season's Covid-19 vaccine and offer accordingly. 3. Re-education will be completed with licensed nursing staff to ensure residents are offered this at admission and then annually. 4. DON/designee will audit new admits x 2 months for offering of Covid-19 vaccine to ensure those who consented will receive the vaccine. Audits will be reviewed at QAPI for compliance and quality assurance.
LPN Staffing Ratio Deficiency
Penalty
Summary
The facility failed to meet the required minimum Licensed Practical Nurse (LPN) staffing ratios on specific shifts, as evidenced by a review of staffing documents and staff interviews. On January 25 and 26, 2025, during the evening shift, the facility had 109 residents but only 4.31 LPNs, falling short of the required 4.36 LPNs. Additionally, on January 26, 2025, during the overnight shift, there were 108 residents with only 2.06 LPNs, not meeting the required 2.70 LPNs. This deficiency was confirmed through an interview with the Director of Nursing on February 3, 2025.
Plan Of Correction
1. Facility cannot retroactively correct staffing deficiencies. 2. All residents are at risk for staffing levels that fail to meet minimum ratio requirements. 3. Facility continues to use recruiting services to fulfill staffing needs. Facility is currently re-evaluating LPN rates for hiring. Re-education will be provided to licensed nursing staff regarding staffing requirements and ratios. Facility continues to offer bonuses, use of agency, and mandate as needed to meet requirements. 4. NHA/DON will monitor daily staffing needs to ensure adequate licensed staffing is met. Audits will be reviewed at QAPI for ongoing compliance and quality assurance.
Failure to Meet RN Staffing Requirements
Penalty
Summary
The facility failed to meet the required minimum staffing ratio of one Registered Nurse (RN) per 250 residents during all shifts on two specific days. On January 24 and 25, 2025, during the overnight shifts, the facility had 109 residents but did not have the required RN staffing levels, with ratios of 0.88 and 0.81 RNs, respectively. This deficiency was confirmed through a review of staffing documents and an interview with the Director of Nursing, who acknowledged the shortfall in meeting the mandated RN staffing ratio on those dates.
Plan Of Correction
1. Facility cannot retroactively correct staffing deficiencies. 2. All residents are at risk for staffing levels that fail to meet minimum ratio requirements. 3. Facility continues to use recruiting services to fulfill staffing needs. Re-education will be provided to licensed nursing staff regarding staffing requirements and ratios, as well as education to ensure they do not leave the building before their relief has arrived. Facility continues to offer bonuses, use of agency, and mandate as needed to meet requirements. 4. NHA/DON will monitor daily staffing needs to ensure adequate licensed staffing is met. Audits will be reviewed at QAPI for ongoing compliance and quality assurance.
Facility Fails to Meet Minimum Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required minimum nurse aide (NA) staffing ratios across multiple shifts from January 6 to January 12, 2025. Specifically, the facility did not provide the mandated number of NAs per resident during the day, evening, and night shifts on several days. For instance, on January 6, 2025, the day shift had 102 residents but only 9.10 NAs, falling short of the required 10.20 NAs. Similar deficiencies were noted on other days and shifts, with the facility consistently understaffed compared to the state-mandated ratios. The deficiency was identified through a review of staffing documents and staff interviews, which confirmed the facility's failure to comply with the staffing requirements. The Nursing Home Administrator acknowledged the expectation for the facility to be appropriately staffed according to state regulations during an email correspondence on January 14, 2025. This consistent understaffing across various shifts indicates a systemic issue in maintaining adequate staffing levels to meet regulatory requirements.
Plan Of Correction
1. Facility cannot retroactively correct this concern. 2. Current residents are at risk of being affected by staffing levels. Will review resident council meeting minutes for staffing related concerns. 3. Will continue to offer bonuses when PPD is below minimum and attempt to mandate staff when call outs and absences occur. Agency rates for aides were recently increased to assist with staffing challenges. 4. NHA/designee will monitor staffing ratios and PPD daily to ensure appropriate levels are being met. Audits will be reviewed at QAPI to ensure compliance and quality care.
Deficiency in Nursing Care Hours
Penalty
Summary
The facility failed to meet the required minimum of 3.20 hours of direct nursing care per resident per 24-hour period for five out of seven days reviewed. Specifically, on January 6, 7, 9, 11, and 12, 2025, the facility provided less than the mandated hours, with recorded hours being 2.74, 2.83, 2.85, 3.18, and 2.94 respectively. This deficiency was identified through a review of staffing documents and confirmed during an electronic mail correspondence with the Nursing Home Administrator, who acknowledged the expectation for the facility to be staffed according to State Regulations.
Plan Of Correction
1. Facility cannot retroactively correct this concern. 2. Current residents are at risk of being affected by staffing levels. Will review resident council meeting minutes for staffing related concerns. 3. Will continue to offer bonuses when PPD is below minimum and attempt to mandate staff when call outs and absences occur. Agency rates for aides were recently increased to assist with staffing challenges. 4. NHA/designee will monitor staffing ratios and PPD daily to ensure appropriate levels are being met. Audits will be reviewed at QAPI to ensure compliance and quality care.
Staffing Deficiencies in Nurse Aide Ratios
Penalty
Summary
The facility failed to meet the required minimum nurse aide staffing ratios across multiple shifts over a six-day period in December 2024. Specifically, the day shift was understaffed on all six days reviewed, with the number of nurse aides consistently falling short of the required full-time equivalent (FTE) needed to meet the minimum staff-to-resident ratio. For instance, on December 5, 2024, with a resident census of 115, the facility provided only 5.37 FTEs against the required 11.50. Similar shortfalls were observed on subsequent days, with the facility providing significantly fewer nurse aides than required. The evening and night shifts also experienced staffing deficiencies. On four of the six evenings reviewed, the facility did not meet the required nurse aide FTEs, with notable shortfalls such as providing only 7.10 FTEs against a required 10.36 on December 5, 2024. Additionally, the night shift was understaffed on two of the six nights, with the facility providing only 3.37 FTEs against a required 7.60 on December 5, 2024. The Nursing Home Administrator confirmed these deficiencies, attributing them to challenges related to illness among staff.
Plan Of Correction
1. Facility cannot retroactively correct this concern. 2. All residents are at risk of being affected by staffing levels. An audit of the grievance log on the days cited below staffing ratios will be audited for any grievances related to staffing. 3. Facility continues to partner with company in recruiting for the CNA classes. Will continue to offer bonuses when ratios are below minimum and attempt to mandate when call outs and absences occur. CNA agency rates were recently increased to assist with CNA coverage. Facility is limiting daily admissions as well. 4. NHA/designee will monitor staffing ratios and PPD daily to ensure appropriate levels are being met. Audits will be reviewed at QAPI to ensure compliance and quality care.
Failure to Meet Minimum Direct Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident per day for five out of six days reviewed. Specifically, on December 5, 6, 7, 9, and 10, 2024, the facility provided only 2.18, 2.62, 3.08, 2.92, and 2.95 hours respectively. This deficiency was identified through a review of the facility's staffing documentation and confirmed by the Nursing Home Administrator (NHA) during an email exchange. The NHA acknowledged the shortfall in meeting the required care hours and attributed the deficiency to staffing challenges due to illnesses.
Plan Of Correction
1. Facility cannot retroactively correct this concern. 2. All residents are at risk of being affected by staffing levels. An audit of the grievance log on the days cited below staffing PPD will be audited for any grievances related to staffing. 3. Re-education was previously completed with nursing staff on staffing and minimum requirements. Will continue to offer bonuses when PPD is below minimum and attempt to mandate staff when call outs and absences occur. Agency rates for aides were recently increased to assist with staffing challenges. Facility is limiting daily admissions at this time. 4. NHA/designee will monitor staffing ratios and PPD daily to ensure appropriate levels are being met. Audits will be reviewed at QAPI to ensure compliance and quality care.
Failure to Assist Resident Out of Bed Due to Inadequate Staffing
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not assisting Resident 2 out of bed when requested. Resident 2, who has diagnoses of diabetes mellitus and COPD, requires a two-person assist and a walker for transfers. The care plan for Resident 2 emphasized the importance of maintaining a consistent routine to prevent confusion due to fluctuating mental status. On the morning of July 13, 2024, Resident 2 was unable to get out of bed before breakfast, despite ringing the call bell for assistance. As a result, Resident 2 refused breakfast in bed, and a family member had to come in to assist with getting the resident out of bed. The Director of Nursing (DON) confirmed that on July 13, 2024, there was only one Nurse Aide (NA) working the unit during the dayshift, which did not meet the required staffing ratios. The DON, who was covering as the dayshift supervisor on that day, was made aware of the situation and acknowledged the staffing shortfall. This deficiency highlights the facility's failure to provide adequate staffing to meet the needs of its residents, as required by regulations.
Insufficient Nursing Staff Leads to Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, specifically affecting one of the four residents reviewed. On July 30, 2024, a review of Resident 2's clinical record revealed that there was only one Nurse Aide (NA) available on the unit. As a result, when Resident 2, who requires a two-person assist with a walker for transfers, rang the call bell to get out of bed for breakfast, the resident was offered breakfast in bed due to the lack of a second NA to assist. Consequently, the spouse of Resident 2 had to call a family member to the facility to help dress and assist the resident out of bed for the lunch meal. During an interview on August 1, 2024, the Nursing Home Administrator confirmed the low staffing levels, which contributed to the deficiency in providing adequate care for Resident 2. This situation was found to be in violation of several Pennsylvania Code regulations related to nursing services, the responsibility of the licensee, and management.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' status for three residents. Resident 53, who had diagnoses including vascular dementia and heart failure, was admitted to hospice services on February 27, 2023. However, the facility did not indicate that Resident 53 was receiving hospice services in three quarterly MDS assessments dated May 31, 2023; August 30, 2023; and November 23, 2023. This discrepancy was confirmed during an interview with the NHA, who acknowledged the incorrect coding and stated that corrections had been made. Resident 107 was admitted to the facility following a total knee replacement and was discharged home on December 26, 2023. Despite this, the Discharge Return Not Anticipated MDS inaccurately coded the resident as being discharged to a short-term general hospital. This error was confirmed by the Nurse Assessment Coordinator and the NHA. Additionally, Resident 358, who had diagnoses including neuroleptic-induced parkinsonism and dysphagia, was admitted to hospice services on November 13, 2023. The facility failed to indicate hospice services in the significant change MDS assessment. The NHA confirmed this error and stated that corrections had been made.
Failure to Develop Comprehensive Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident diagnosed with PTSD and Type 2 Diabetes Mellitus. The care plan did not include the causes or triggers of the resident's PTSD, despite the resident being a Vietnam War veteran with a history of night terrors and flashbacks. The resident's care plan also lacked interventions such as his participation in activities at the VFW and his experiences with night terrors and flashbacks, which were known to the staff but not documented in the care plan. During the survey, it was revealed through staff interviews and clinical record reviews that the resident had been receiving geri-psychiatric services and had interventions in place, such as attending VFW events and talk therapy. However, these interventions were not reflected in the resident's care plan until after the surveyor's inquiry. The Nursing Home Administrator acknowledged that the care plan should have been comprehensive, including the source of the PTSD, triggers, and interventions.
Failure to Ensure Proper Vision Treatment for Resident
Penalty
Summary
The facility failed to ensure that Resident 90 received proper treatment to maintain vision. Resident 90, who has a history of adult failure to thrive, hemiplegia following a stroke, diabetes mellitus, chronic kidney disease, and depressed mood, had not seen an eye doctor for necessary treatments for at least two months. The resident's clinical record indicated a need for routine ophthalmic consults and treatments, but due to issues with insurance acceptance, the resident missed multiple appointments. Despite the facility's attempts to schedule appointments, the resident was not seen by the retinal specialist or other ophthalmologists because they did not accept his new insurance. This resulted in a delay in required vision services and treatments from November 2023 through March 2024. The resident experienced blurred vision and was almost blind in one eye, which led to a hospital visit where it was emphasized that follow-up with an ophthalmologist was imperative. The facility's Social Services Director attempted to schedule an in-house optometry service, but it was canceled, and subsequent appointments with out-of-facility doctors also failed due to insurance issues. The facility's failure to verify insurance acceptance and manage the resident's routine eye appointments effectively led to a significant delay in the resident receiving necessary vision treatments.
Failure to Act on Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that monthly pharmacy medication regimen review recommendations were acted upon in a timely manner for two residents. For Resident 37, the clinical record revealed diagnoses including pain in the left knee, hypertension, and osteoarthritis. The pharmacy made recommendations in July and August 2023 to update the PRN Acetaminophen orders, but these recommendations were not reflected in the physician orders. The Director of Nursing (DON) confirmed that the recommendations should have been reviewed and acted upon promptly by the nursing staff. For Resident 49, who had diagnoses including PTSD and diabetes mellitus, the pharmacy made similar recommendations in July 2023 to update the PRN Acetaminophen orders, which were not reflected in the physician orders. Additionally, a recommendation from November 2023 to discontinue Triamcinolone was not acted upon until January 2024, and the order remained active until March 2024. Another recommendation in December 2023 to specify the level of pain for PRN Tramadol administration was also not reflected in the physician orders. The DON acknowledged that these recommendations should have been addressed in a timely manner. The deficiencies were identified through a review of facility policies, clinical records, and staff interviews. The facility's policy on medication monitoring and management was not dated but indicated that pharmacy recommendations should be implemented appropriately. The failure to act on these recommendations in a timely manner was confirmed by the DON during interviews, highlighting a lapse in the facility's adherence to its own policies and procedures.
Latest citations in Pennsylvania
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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