Hickory House Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Honey Brook, Pennsylvania.
- Location
- 3120 Horseshoe Pike, Honey Brook, Pennsylvania 19344
- CMS Provider Number
- 395436
- Inspections on file
- 20
- Latest survey
- April 14, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Hickory House Nursing Home during CMS and state inspections, most recent first.
A resident, cognitively intact and on hospice care, had an order for morphine sulfate concentrate 20 mg/mL to be given as 5 mg PO q2h PRN for pain/SOB, with non-pharmacological interventions attempted first. Facility policy required adherence to the 10 Rights of Medication Administration and preparedness for opioid-induced respiratory depression. Despite this, documentation on the controlled medication record showed the resident was given 1 mL of morphine concentrate instead of the prescribed 0.25 mL. Nursing notes and an employee statement confirmed that an excess dose was administered, after which the resident developed increased lethargy and decreased BP and required two IM doses of Narcan, with subsequent improvement and return to baseline.
A resident filed a grievance alleging that a CNA was verbally disrespectful, threw a shirt at the resident, refused to assist with socks, and left the room without returning. The DON confirmed that this abuse allegation was not reported to the State agency as required by facility policy and state regulations.
A resident reported that a CNA spoke disrespectfully, threw a shirt at the resident, refused to help with socks, and left the room without returning. The DON confirmed that this abuse allegation was not fully investigated, as required by facility policy.
Surveyors found that three residents did not receive care according to physician orders, including administration of Midodrine and Metoprolol outside of specified blood pressure parameters and failure to adhere to a prescribed fluid restriction for a resident with CHF. These deficiencies were confirmed through record review and staff interviews.
A resident with a physician's order for oxygen therapy via nasal cannula did not have their equipment changed as directed, with observations showing the cannula was not replaced weekly and was visibly soiled, contrary to facility policy and medical orders.
The facility failed to thoroughly investigate incidents involving three residents. A resident with dementia was found with a bleeding wrist, but the incident report lacked key details. Another resident with severe cognitive impairment reported feeling unsafe and alleged abuse, but no staff statements were taken. A third resident had a pen found in their rectum, but the investigation did not include interviews or contact with the hospital. The facility's investigations were confirmed to be incomplete.
The facility failed to follow physician's orders and notify the physician of missed medications for three residents. One resident missed doses of Vancomycin due to unavailability, another received Coreg despite a low heart rate, and a third was given Midodrine outside of ordered parameters. The DON confirmed these deficiencies.
A resident with severe cognitive impairment and a history of dementia and CVA experienced two falls in one day due to inadequate supervision and assistance. The resident, requiring two-person assistance for transfers, fell while attempting to enter a family van without proper assessment and later during a one-person transfer from a wheelchair to a bed, contrary to their care plan.
A resident with COPD and other respiratory conditions was receiving supplemental oxygen without a physician's order, contrary to the facility's policy. The resident had been on continuous oxygen since admission, but the order was only documented after several days, following confirmation by the DON.
A resident was given antibiotics for a probable UTI without a proper nursing assessment or lab confirmation. The decision was made after a phone call with a doctor, and the resident received antibiotics for five days without microbiological evidence. The DON and Nursing Home Administrator confirmed the lack of assessment and lab study.
Significant Morphine Dosing Error Requiring Narcan Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from a significant medication error involving morphine administration. Facility policy on Administration of Medications required staff to follow the 10 Rights of Medication Administration, including the right drug, right resident, and right dose, and the policy on Opioid-Induced Respiratory Depression required preparedness to address opioid-related emergencies. The resident involved was cognitively intact, dependent on staff for ADLs, and admitted for long-term care, later admitted to hospice. A physician’s order on the resident’s MAR directed that morphine sulfate concentrate 20 mg/mL be given as 5 mg by mouth every 2 hours PRN for pain or shortness of breath, with documentation of three non-pharmacological interventions prior to use for pain. Despite this order, the Controlled Medication Utilization Record showed that the resident received 1 mL of morphine concentrate instead of the prescribed 0.25 mL, resulting in a dose above the ordered amount. A nursing progress note documented that the resident received an excess dose of morphine concentrate, with initial vital signs, neurological status, and mentation within normal limits, and an employee statement confirmed that the nurse administered more than the prescribed dosage. A subsequent nursing note recorded that the resident then exhibited increased lethargy and decreased blood pressure, and Narcan was administered intramuscularly twice for possible side effects from the increased morphine dose, after which blood pressure and mentation improved. Later documentation indicated the resident was monitored with vital signs within normal limits and remained responsive, and a physician note confirmed that the resident had received a morphine dose above the prescribed amount, became lethargic with decreased blood pressure, was treated with Narcan, and returned to baseline.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving one resident. According to facility policy, any alleged violations involving neglect, abuse, or misappropriation of resident property must be reported immediately to the administrator and as required by state law. A grievance was filed by a resident stating that a CNA spoke to him disrespectfully, threw a shirt at him, told him to put it on, refused to help him put on socks, and then left the room without returning. The Director of Nursing confirmed that this abuse allegation was not reported to the State agency as required by policy and regulation.
Failure to Investigate Alleged Abuse
Penalty
Summary
The facility failed to investigate an allegation of abuse involving one resident. According to facility policy, any reported or suspected incident of abuse, neglect, or exploitation requires an investigation by the administrator or designee, with protective measures implemented as needed. Documentation review showed that a resident filed a grievance stating that a CNA spoke to him disrespectfully, threw a shirt at him, told him to put it on, refused to assist with putting on socks, and then left the room without returning. An interview with the Director of Nursing confirmed that this abuse allegation was not fully investigated, contrary to facility policy and regulatory requirements.
Failure to Follow Physician Orders for Medication and Fluid Restriction
Penalty
Summary
The facility failed to follow physician orders for three residents, resulting in deficiencies related to medication administration and fluid restriction. For one resident with hypotension, Midodrine was administered multiple times despite blood pressure readings exceeding the physician-ordered threshold for withholding the medication. Documentation showed that the medication was given on several occasions when the systolic blood pressure was above 125 mm/Hg, contrary to the order. Another resident with acute congestive heart failure and malnutrition had a physician order for a strict fluid restriction, but records indicated that the resident consistently received fluids in excess of the prescribed daily limit over several days. Additionally, a third resident with hypertensive chronic kidney disease received Metoprolol Succinate ER outside of the specified blood pressure and heart rate parameters on four occasions. These findings were confirmed through review of clinical records, medication administration records, and staff interviews.
Failure to Follow Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to follow a physician's order for oxygen therapy for one resident. According to the clinical record, the resident had a current order to receive oxygen via nasal cannula, with instructions for the cannula to be changed every night shift on Wednesdays. Facility policy also required oxygen supplies, including cannulas, to be changed weekly and when visibly soiled, and to be labeled with the resident's name and the date of setup or change. Observations on two consecutive days revealed that the resident's nasal cannula was dated from several weeks prior and was visibly soiled, with red-tinged nasal prongs and brownish-red dots on the wrapping. The resident confirmed regular use of the oxygen equipment while in the facility.
Failure to Investigate Incidents Thoroughly
Penalty
Summary
The facility failed to thoroughly investigate incidents involving three residents, as required by their policy on reducing the threat of abuse and neglect. For Resident 2, who has a history of dementia, anxiety disorder, and major depressive disorder, an incident occurred where the resident was found with a bleeding cut on the wrist. The incident report lacked documentation identifying the nurse who treated the wound and did not include any witness statements. The Nursing Home Administrator confirmed that the investigation was incomplete. Resident 95, who has severe cognitive impairment, reported feeling unsafe and alleged physical abuse by two men, described as EMT staff. The facility's documentation did not include statements from staff who had contact with the resident, and the Director of Nursing confirmed the lack of a comprehensive investigation into the allegation of physical abuse. For Resident 155, admitted after a hip fracture repair, an incident was reported where a pen was found in the resident's rectum. The facility's investigation did not include interviews with staff or residents, nor did it contact the hospital or transport company involved in the resident's admission. The Nursing Home Administrator and Director of Nursing confirmed the investigation was not thorough.
Failure to Follow Physician's Orders and Notify of Missed Medications
Penalty
Summary
The facility failed to follow physician's orders and notify the physician of missed medications for three residents. Resident 9 had a physician's order for Vancomycin to treat C-diff, but the medication was not administered until the morning of the last day of the order, missing three doses due to unavailability. The physician was not notified of the missed doses until several days later. Resident 51 received Coreg, a beta blocker, despite having a heart rate below the ordered parameter on multiple occasions over several months. The clinical records indicated that the medication was administered with a heart rate of less than 60, contrary to the physician's order. Resident 95 was administered Midodrine, a medication for low blood pressure, outside of the ordered parameters, as it was given 13 times with a systolic blood pressure above 130. The Director of Nursing confirmed that the medication was administered outside of the ordered parameters. These deficiencies indicate a failure to adhere to physician's orders and to communicate effectively with physicians regarding medication administration issues.
Failure to Provide Adequate Supervision and Assistance Leads to Resident Falls
Penalty
Summary
The facility failed to provide appropriate assessment and supervision to prevent falls for a resident with severe cognitive impairment and a history of dementia and cerebral vascular accident. The resident required extensive assistance with two persons for transfers using a hemi walker, as documented in their care plan. On January 1, 2024, the resident was found on the floor outside the facility after attempting to transfer into a family van without the necessary assistance. The rehabilitation department was not notified to assess the resident's safety with car transfers, which contributed to the incident. Later that same day, the resident experienced another fall when an aide attempted a one-person pivot transfer from a wheelchair to a bed, despite the care plan indicating the need for a two-person assist. The aide lowered the resident to the floor after the resident slipped during the transfer. Interviews with the Director of Nursing confirmed that the resident was not provided with the required two-person assistance, leading to two falls in one day.
Lack of Physician Order for Oxygen Use
Penalty
Summary
The facility failed to ensure a physician order for oxygen use was in place for a resident, identified as Resident 205, who was receiving supplemental oxygen. The facility's policy on oxygen administration, revised in February 2024, requires a written order specifying the liter flow needed by the resident. Resident 205, diagnosed with Chronic Obstructive Pulmonary Disease (COPD), bronchiectasis with an acute lower respiratory infection, and pleural effusion, was observed receiving supplemental oxygen at two liters per minute (LPM) via nasal cannula. Despite the resident's need for continuous supplemental oxygen since admission, there was no active physician's order documented in the clinical records. Interviews with Resident 205 revealed that they had been using supplemental oxygen as needed at home and required continuous oxygen since being admitted to the facility. The Director of Nursing confirmed the absence of a physician's order for the resident's supplemental oxygen from the time of admission. It was only on May 31, 2024, that a physician's order was documented, specifying oxygen administration at two to four LPM, with instructions to titrate to maintain saturation above 90% and notify the physician if needs could not be met at four liters.
Unnecessary Antibiotic Administration Due to Lack of Assessment
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. Specifically, Resident 79 was administered an antibiotic without a proper nursing assessment or laboratory confirmation of a urinary tract infection (UTI). The resident had reported symptoms of dysuria and was noted to have blood on his penis and in his brief. Despite these symptoms, there was no documented nursing assessment to confirm the signs and symptoms reported by the CNA, nor was there any laboratory testing conducted to confirm a UTI before the administration of antibiotics. The decision to prescribe antibiotics was made after a phone call with the doctor's office, where it was noted that it was a Friday afternoon and the resident was symptomatic. The resident was subsequently given Amoxicillin-Pot Clavulanate for five days based on a diagnosis of probable UTI, without any microbiological evidence to support this diagnosis. The Director of Nursing and the Nursing Home Administrator confirmed the lack of a nursing assessment and laboratory study to confirm the infection and its sensitivity prior to the administration of the antibiotics.
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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