Inglis House
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- 2600 Belmont Avenue, Philadelphia, Pennsylvania 19131
- CMS Provider Number
- 395134
- Inspections on file
- 40
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 7 (1 serious)
Citation history
Health deficiencies cited at Inglis House during CMS and state inspections, most recent first.
A resident with COPD and obstructive sleep apnea was ordered to have a follow-up sleep study at a sleep disorder center. Facility documentation showed that after the resident reported ear pain, the sleep study was put on hold pending pulmonology input. The facility contacted the sleep center and learned the center could not provide needed ADL and transfer assistance, but there was no evidence that the facility arranged nursing support or other outside resources to assist the resident during the study, and the appointment was cancelled without being rescheduled.
A resident with chronic neuropathic pain did not receive a scheduled dose of Lyrica due to a gap between discontinuation of the previous order and initiation of a new, higher dose. The resident reported severe pain during this period, and the DON confirmed the medication was not administered on time.
A resident with severe cognitive impairment and a history of elopement risk was able to access a non-residential area after a door was left unsecured and fell down a flight of stairs while in a power wheelchair, resulting in multiple serious injuries. The resident was missing for several hours before being found, highlighting a failure in supervision and environmental safety measures.
A resident with severe cognitive impairment and multiple diagnoses, identified as an elopement risk, was able to access an unsecured stairwell after staff failed to provide adequate supervision and safety measures. The resident fell down a flight of stairs while in a power wheelchair, sustaining multiple serious injuries, due to failures by the NHA and DON to ensure proper monitoring and environmental controls.
A resident with paraplegia, seizure disorder, and legal blindness, who was care planned for two-person assistance with bed mobility and dressing, was provided only one-person assistance during morning care. While being turned in bed by a single aide, the resident fell when a bed rail disengaged, resulting in a severe laceration to the forehead and scalp that required extensive stitches. Documentation and staff interviews confirmed ongoing failure to follow the care plan and communicate required assistance levels.
A resident who was dependent for bed mobility, turning, repositioning, and dressing did not receive the required two-person assistance as outlined in their care plan and MDS assessment. Instead, a single nurse aide provided morning care alone due to staffing shortages, despite being aware of the two-person requirement. Facility policy and leadership confirmed the need for two-person assistance, but only one staff member was available during the observed care.
A resident with quadriplegia sustained a second-degree burn when a nurse aide accidentally spilled hot tea on their knee. The aide, carrying a personal hot beverage, placed it on the resident's overbed table while assisting with a task. The table was knocked by a door, causing the spill. The facility's policy prohibited beverages in resident areas, which was not followed, leading to the incident.
The facility failed to adhere to professional standards for food safety and sanitation. Observations revealed that food items in the walk-in refrigerator were opened, undated, and unlabeled, and some were stored for extended periods. Additionally, the dishwashing machines were not properly tested for sanitizer concentration, leading to improper sanitation of dishware. These deficiencies were confirmed by the Foodservice Director and other staff members.
The facility failed to properly dispose of garbage in the Foodservice Department, as observed during a tour with the FSD. Debris and dirty plastics were scattered around the dumpster, and there was a severe urine-like odor, an opened trash bin filled with waste, and five large opened cardboard boxes. These observations were confirmed by the FSD.
The facility failed to ensure proper use of PPE for residents on enhanced barrier precautions. Staff did not wear gowns during wound care and medication administration for residents with specific precaution orders, despite clear signage indicating the need for gowns and gloves. This non-compliance involved multiple staff members and residents, violating the facility's infection control protocols.
The facility failed to maintain confidentiality and privacy for residents during medication administration and room entry. An LPN left medication packets with personal information unattended, and two residents reported that staff frequently entered their rooms without knocking or introducing themselves, despite being cognitively intact. The facility's leadership confirmed that staff are expected to knock and identify themselves before entering rooms.
A resident with Multiple Sclerosis and a pressure ulcer did not have their care plan updated to include a current pressure wound on the right ischium, despite having a physician's order for treatment. The care plan still included a healed abrasion on the left arm. The DON confirmed the oversight.
An LPN at the facility administered Amlodipine to a resident despite the resident's blood pressure being below the threshold specified in the physician's order. The LPN acknowledged that the medication should have been held, indicating a failure to adhere to professional standards of nursing care.
A resident receiving respiratory services did not receive appropriate tracheostomy care. The resident had a tracheostomy tube size 6.0mm, but the spare tube was incorrectly sized at 7.0mm, against physician orders. The tracheostomy collar was also stained and soiled. Staff interviews confirmed these findings.
The facility failed to provide trauma-informed care for residents with PTSD, as their care plans did not address specific conditions, past experiences, or potential triggers. Interviews confirmed the lack of practice in identifying PTSD triggers, affecting the care provided to these residents.
The facility did not conduct annual performance reviews for five nurse aides, as required by personnel policies. The Nursing Home Administrator confirmed that no reviews had been completed for the current or previous year.
The facility failed to ensure complete reconciliation of controlled drugs due to missing signatures on the Narcotic Count Sheet for a medication cart. Over a specified period, seven out of 44 required nurse signatures were absent, as confirmed by a licensed nurse. The facility's protocol mandates that both oncoming and outgoing nurses verify and sign the narcotic count at each shift change, which was not followed.
The facility failed to properly store and label medications, with several instances of open medications lacking dates and an unattended, unlocked medication cart. Insulin pens, eye drops, and other medications were found without open or expiration dates, and a discontinued medication was still present in the cart. The DON confirmed the expectation for proper labeling and securing of medication carts.
A resident with paraplegia and a sacral pressure ulcer received a wound dressing change from an LPN during the night shift, despite already having the treatment completed earlier that day after a shower. The LPN did not follow the physician's order for every-other-day wound care, as confirmed by documentation and the DON.
A resident reported missing personal items to the social services department, but the facility failed to document and investigate the grievance as per its policy. Despite the resident's medical conditions, including schizophrenia and legal blindness, the grievance regarding missing items was not addressed, highlighting a lapse in the facility's grievance handling process.
A resident with heart failure did not have a person-centered care plan developed, as required by facility policy. The resident was not being weighed daily, hindering the monitoring of fluid retention and necessary medication adjustments. The ADON confirmed the absence of a care plan for heart failure, leading to the deficiency.
A resident with heart failure was not weighed daily as ordered by the physician, despite the importance of monitoring fluid retention for their condition. The resident's clinical records from March to October showed no evidence of daily weight measurements, and the MAR lacked documentation. The resident's nurse was unaware of the daily weight order, and the ADON confirmed the absence of documentation.
A resident with heart failure was not weighed daily as required by physician orders, with weights only recorded monthly over an eight-month period. Despite this, medical professionals documented stable weights without verifying daily records, leading to a failure in monitoring the resident's condition as per facility policy.
A resident with multiple medical conditions was left on a bedpan for several hours due to a nurse aide's oversight. The resident, who requires extensive assistance, was placed on the bedpan at night and not removed until the next morning. The facility's investigation confirmed the incident, but it was not classified as neglect by the administrator.
A resident's package was misappropriated by security staff at the facility. Despite the facility's policy against misappropriation, security employees mishandled and removed the package, as confirmed by security footage and interviews with the Nursing Home Administrator and DON. The resident, who had multiple medical conditions, reported the missing package, leading to an investigation.
The facility failed to implement comprehensive care plans for two residents requiring catheter care and enhanced barrier precautions. Despite having medical histories indicating the need for such precautions, the care plans did not include Enhanced Barrier Precautions as recommended by the CDC. This oversight was noted during observations and was in violation of the facility's resident care policies.
A resident with multiple diagnoses, including paraplegia and major depressive disorder, received an excessive dose of Fentanyl due to an unintentional order and application of a 50 mcg/hr patch instead of the correct 12 mcg/hr dosage. This error was noted by an LPN and confirmed by the DON.
Foods were not prepared and served by methods to conserve nutritive value, flavor, and appearance. Residents reported that hot foods were not being served hot, and a temperature test tray evaluation confirmed that hot food items were served below required temperatures, while cold food items were served warm. The equipment used to transport and serve foods was inadequate, contributing to the issue.
A resident with neuromuscular bladder dysfunction and insomnia did not receive prescribed medications due to insurance issues and lack of communication. The MAR inaccurately indicated that the medications were administered, despite the resident's refusal and lack of delivery.
Failure to Coordinate Outside Services for Resident Sleep Study
Penalty
Summary
The facility failed to employ or obtain outside professional resources to provide required services for a resident with obstructive sleep apnea. The resident’s comprehensive MDS showed they were cognitively intact and had a diagnosis of obstructive sleep apnea, and the care plan documented altered respiratory status/difficulty breathing related to COPD. An After Visit Summary from a Sleep Disorder Center indicated the resident was to have a follow-up sleep study. A progress note documented that the DON and nursing supervisor met with the resident, who reported right ear pain, and the resident was informed that the sleep study would be put on hold pending an update from pulmonology. The same progress note showed that the facility contacted the sleep center and informed them the resident required assistance with ADLs, but the sleep center stated they could not provide transfer or care assistance. The resident later reported in interview that the sleep study appointment was cancelled and that the facility did not further coordinate to reschedule the appointment. Review of the clinical record revealed no documentation that the facility coordinated nursing services to assist the resident during the sleep study and no evidence that the sleep study was rescheduled with the center, resulting in a failure to ensure use of outside resources when the facility could not provide the needed service.
Failure to Provide Timely Pain Management Due to Medication Order Gap
Penalty
Summary
A deficiency occurred when a resident with multiple pain-related diagnoses, including polyneuropathy, trigeminal neuralgia, paraplegia, and chronic pain, did not receive appropriate pain management as ordered. The resident's care plan included a routine pain medication regimen, specifically Lyrica, to manage neuropathic pain. On a specified date, the physician discontinued the resident's existing Lyrica 75 mg order in the late afternoon and issued a new order for Lyrica 100 mg to begin the following morning. This resulted in the resident not receiving her scheduled evening dose of Lyrica. During the evening, the resident reported severe pain and inquired about her medication. The evening nurse confirmed that the new order was not available for administration at that time and reported the issue to the supervisor. The resident continued to experience pain until the new Lyrica order was entered and administered later that night. The DON confirmed that the medication was not administered on time, resulting in a lapse in pain management consistent with professional standards of practice.
Failure to Supervise Elopement-Risk Resident Results in Serious Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, multiple sclerosis, bipolar disorder, and dementia, who was assessed as an elopement risk, was inadequately supervised. The resident was known to require extensive assistance for transfers and had a care plan in place that included interventions such as a Wander Alert device, an air tag, and staff education to prevent entry into restricted areas. Despite these measures, the resident was able to independently operate a power wheelchair and access a non-residential area of the facility. On the day of the incident, the resident was last seen in the dining room and later in a hallway, where staff instructed the resident to return to their unit. Subsequently, the resident could not be located, and staff initiated a search throughout the facility. The resident was missing for approximately four hours before being found at the bottom of a stairwell, still strapped into the wheelchair, after having fallen down a flight of stairs. The door to the stairwell had been left open accidentally, and there was no alarm or security device on the door, as it was not considered part of the resident area. The resident sustained multiple serious injuries, including rib fractures, a clavicle fracture, a subdural hematoma, a pneumothorax, a finger dislocation, and a scalp laceration requiring stitches. The incident was confirmed through staff interviews, clinical documentation, and hospital records. The failure to provide adequate supervision and to secure non-residential areas directly led to the resident's prolonged absence and subsequent injuries.
Removal Plan
- Assess the safety of residents utilizing power wheelchairs.
- Facility assessment for resident safety with use of power wheelchairs was completed.
- Facility identified five residents that are at potential at risk based on the completed audit.
- Resident R1 was assessed upon his return from hospitalization by rehabilitation services.
- Resident R1 was set up for manual wheelchair for safety.
- Ensure all doors are locked to non-resident areas.
- Set up of keypad lock to Morris Building to limit resident access to non-residential area.
- Education of staff that was responsible for non-compliant with security door process.
- Updated security process to monitor and audit identified doors to non-residential areas to ensure resident safety.
- Revise/ review resident safety policies to include power wheelchairs, locked doors, stairwells, and elopements.
- Facility review of resident safety policy initiated.
- Ensure development of care plan interventions to prevent residents from entering non-resident areas.
- Care plan for identified residents at risk were updated based on facility audit.
- Resident R1's care plan was updated upon return from hospitalization.
- Ensure doors are functioning properly and staff are in-serviced on areas in the building where residents are restricted related to resident safety.
- Ongoing security department monitoring and audit of identified doors to ensure that the doors are secured and functioning properly.
- Provide staff training on ensuring residents don't enter areas of the building where residents are restricted from being related to resident safety.
- Inglis House staff training on ensuring residents don't enter areas of the building where residents are restricted from related to resident safety started and is ongoing.
- Facility has completed approximately 50 percent of the training and is expected to complete 100 percent compliance.
Failure to Supervise Elopement Risk Resident Results in Serious Injury
Penalty
Summary
The facility failed to provide adequate supervision and management for a resident identified as being at risk for elopement, resulting in a serious incident. The Nursing Home Administrator (NHA) and Director of Nursing (DON) did not ensure that appropriate safety measures were in place or that staff were adequately monitoring the resident. The resident, who had a history of severe cognitive impairment, multiple sclerosis, bipolar disorder, and dementia, was known to be at risk for elopement and had interventions in place such as a Wander Alert and an air tag. Despite these interventions, the resident was able to move independently in a power wheelchair and access a restricted area of the facility that was not properly secured or monitored. On the day of the incident, the resident was last seen in the dining room and later observed wandering in a different area of the facility. Staff became aware that the resident was missing after an unsuccessful search of the unit and other accessible areas. Security measures, such as the Roam alert, did not activate, and staff were unable to locate the resident for several hours. Eventually, the resident was found at the bottom of a stairwell, having fallen down a flight of stairs while still strapped into the wheelchair. The door to the stairwell had been left open and was not equipped with a wanderguard detector, allowing the resident to access the area without triggering an alarm. As a result of the fall, the resident sustained multiple serious injuries, including rib fractures, a fractured clavicle, a subdural hematoma, a pneumothorax, a finger dislocation, and a scalp laceration requiring stitches. The incident was classified as Immediate Jeopardy Past Noncompliance due to the failure of the NHA and DON to fulfill their responsibilities in ensuring resident safety and compliance with federal and state regulations. The lack of effective supervision, inadequate environmental controls, and failure to follow established care plan interventions directly contributed to the resident's injuries.
Plan Of Correction
NHA and DON reviewed their job descriptions and duties of the administrator and Director of Nursing with the president and CEO of Inglis. There are no like instances. Education to DON and Administrator was completed by the CEO of Inglis. Job descriptions will be reviewed annually.
Failure to Provide Required Two-Person Assistance Results in Resident Injury
Penalty
Summary
The facility failed to provide appropriate staff supervision and assistance during morning care for a resident with significant physical and neurological impairments, resulting in actual harm. The resident, who was dependent for self-care tasks such as toileting, dressing, bed mobility, and personal hygiene, required two-person assistance for bed mobility and dressing as documented in the care plan and MDS assessment. Despite these documented needs, nurse aides provided only one-person assistance during care, both before and after the incident, as confirmed by staff interviews and documentation review. During the incident, a nurse aide was providing morning care to the resident alone and instructed the resident to hold onto the bed rail while being turned for hygiene care. The bed rail disengaged, causing the resident to fall from the bed to the floor, resulting in a severe laceration to the forehead and scalp that required 35-40 stitches. The resident was transferred to the emergency room for evaluation and treatment. The facility's investigation confirmed that the care plan required two-person assistance, but this was not followed at the time of the incident. Further review revealed inconsistencies and lack of clarity in documentation regarding the required level of assistance for the resident. Assignment sheets did not indicate which residents required two-person assistance, and rehabilitation screenings contained conflicting information that was not reflected in the care plan. Staff interviews confirmed that aides relied on assignment sheets, which failed to provide accurate information, and that one-person assistance was routinely provided despite the resident's documented needs. These failures in communication, documentation, and adherence to care plans directly led to the resident's injury.
Insufficient Staffing for Dependent Resident Care
Penalty
Summary
The facility failed to provide a sufficient number of nursing staff to meet the care needs of a resident who required two-person assistance for bed mobility, turning, repositioning, and dressing. According to the resident's care plan and MDS assessment, the resident was dependent on staff for all self-care tasks and required two staff members for safe transfers and personal care. However, observations revealed that a single nurse aide provided morning care, including turning, cleaning, and changing the resident, without the required second staff member. The aide acknowledged being aware of the two-person assistance requirement but stated that staffing shortages led to providing care alone. Further review of facility policy confirmed that two-person assistance was necessary for certain care activities to ensure resident safety. Interviews with facility leadership corroborated that the resident's care plan specified two-person assistance, yet staff continued to provide only one-person assistance as observed. The deficiency was identified through direct observation, staff interviews, and review of clinical records and facility policies.
Resident Burned by Staff's Hot Beverage
Penalty
Summary
The facility failed to maintain a safe environment for its residents, resulting in actual harm to a resident identified as R127. The incident occurred when a nurse aide, Employee E5, was on her way to the breakroom with a personal hot tea in hand. As she passed by Resident R127's room, the resident called for assistance. The aide entered the room and placed her hot tea on the resident's overbed table while attending to the resident's request to empty a urinal. Upon returning from the bathroom, the aide accidentally knocked the overbed table with the bathroom door, causing the hot tea to spill onto the resident's left knee. Resident R127, who was admitted with a diagnosis of quadriplegia and had no cognitive impairment, sustained a second-degree burn on the left knee due to the spill. The resident was sitting in a wheelchair with the overbed table in front of them when the incident occurred. The resident's clinical records indicated that the burn resulted in peeling skin and required medical treatment, including the application of a triple antibiotic ointment. The resident expressed that the incident was accidental and did not wish to change the assigned nurse aide. The facility's policy prohibited food or beverages in direct service delivery areas, which was not adhered to in this case. The nurse aide's action of bringing a personal hot beverage into the resident's room and placing it on the overbed table directly led to the accident. The facility's investigation confirmed the sequence of events, and the resident's statements corroborated the aide's account of the incident. The deficiency was identified as past non-compliance due to the failure to ensure a hazard-free environment, resulting in harm to the resident.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During an initial tour of the Foodservice Department, it was observed that several food items in the walk-in refrigerator were opened, undated, and unlabeled, including packages of cheddar cheese, mozzarella cheese, parmesan cheese, and blue cheese. Additionally, containers of diced pears, coleslaw, and potato salad were found with dates indicating they had been stored for an extended period. Marinated jerk chicken and chicken drumsticks and thighs were also found uncovered, undated, and unlabeled in the meat box. These findings were confirmed by the Foodservice Director during the tour. Further observations revealed issues with the dishwashing machines used in the facility. The dish machine on the third-floor nursing unit required chemical sanitation with a minimum recommended level of 50-100 ppm available chlorine. However, testing of the dish machine showed that the sanitizing solution was not present during the cycle, as indicated by the test strip not changing color. Documentation failed to show that the temperature was tested before use to ensure proper sanitation levels. Interviews with the Food Service Director, Food Service Supervisor, and facility administrator confirmed that the dish machine was not tested prior to use after both breakfast and lunch meals, resulting in dishware not being properly sanitized.
Improper Disposal of Garbage in Foodservice Department
Penalty
Summary
The facility failed to properly dispose of garbage in the Foodservice Department, as observed during an initial tour conducted with the Foodservice Director, Employee E4. The trash area was found to have debris and dirty plastics, such as gloves, cups, and utensils, scattered on the ground around the dumpster. Additionally, there was a severe urine-like odor present, an opened gray trash bin filled with waste, and five large opened cardboard boxes. These observations were confirmed during an interview with Employee E4, who accompanied the tour.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement proper use of personal protective equipment (PPE) for residents on enhanced barrier precautions during wound care and medication administration. Specifically, for four residents, staff did not adhere to the required use of gowns and gloves as indicated by the enhanced barrier precaution signs posted outside the residents' rooms. For Resident R18, despite a sign indicating the need for gown and gloves during wound care due to an ESBL infection in the urine, two licensed nurses did not wear gowns while providing wound care. Similarly, during medication administration for Resident R78, a licensed nurse did not wear a gown while applying facial cream, contrary to the enhanced barrier precaution requirements. Further observations revealed that for Residents R93 and R112, staff also neglected to wear gowns during wound care, despite clear signage indicating the necessity of gown and gloves for high-contact tasks. The staff involved included a certified nurse practitioner and licensed nurses, who failed to comply with the enhanced barrier precautions. These actions were in violation of the facility's infection prevention and control program, as well as specific physician orders for enhanced barrier precautions.
Confidentiality and Privacy Breaches in Resident Care
Penalty
Summary
The facility failed to maintain the confidentiality of residents' personal health information during medication administration. On March 19, 2025, it was observed that a medication cart on the first floor was left unattended with medication packets on top, displaying residents' names, room numbers, medication names, and dosages. Employee E6, a Licensed Practical Nurse, confirmed that the medication packets should not have been left exposed and unattended, as this compromised the confidentiality of the residents' personal information. Additionally, the facility did not ensure residents' privacy was maintained before entering their rooms. During interviews with two residents, it was reported that staff frequently entered rooms without knocking or introducing themselves. Resident R9 and Resident R62, both cognitively intact with BIMS scores of 14, confirmed that staff entered their rooms without knocking or identifying themselves, which was a regular occurrence. The Nursing Home Administrator and the Director of Nursing confirmed that the facility's expectation is for staff to knock and identify themselves before entering a resident's room.
Failure to Update Care Plan for Pressure Wound
Penalty
Summary
The facility failed to ensure the timely revision of the comprehensive care plan for a resident with a pressure wound. Resident R93, who was admitted with diagnoses including Multiple Sclerosis, Muscle Weakness, and a Pressure Ulcer of the Sacral Region, had a physician's order for Santyl ointment to be applied to a pressure wound on the right ischium. However, the resident's care plan only addressed an abrasion on the left lower arm and scattered bruises, which had already healed, and did not include the current pressure wound. This oversight was confirmed by the Director of Nursing, who acknowledged that the pressure wound should have been added to the care plan, and the resolved abrasion should have been removed.
Failure to Adhere to Medication Administration Protocols
Penalty
Summary
The facility failed to meet professional standards related to medication administration for a resident, identified as R167. According to the Pennsylvania Code Title 49, Chapter 21.145, an LPN is required to exercise sound nursing judgment and administer medication in accordance with physician orders. For Resident R167, there was a physician order for Amlodipine, a medication for high blood pressure, to be administered daily in the morning, with instructions to hold the medication if the systolic blood pressure was less than 110/70 or the heart rate was below 60. On March 19, 2025, at 9:20 a.m., an LPN, identified as Employee E6, administered Amlodipine to Resident R167 after checking the resident's vital signs. The blood pressure was recorded as 108/63, which was below the threshold specified in the physician's order. Despite this, the medication was administered. The LPN later acknowledged that the medication should have been held due to the low blood pressure reading, indicating a failure to adhere to the physician's order and professional standards of nursing care.
Inappropriate Tracheostomy Care for Resident
Penalty
Summary
The facility failed to provide appropriate tracheostomy care for a resident, identified as Resident R43, who was receiving respiratory services. The resident was admitted with a diagnosis requiring attention to a tracheostomy. A physician's order dated May 25, 2023, specified the use of a cuffed tracheostomy tube every shift, with instructions to clean around the tracheostomy and evaluate and document the skin condition. However, observations on March 19, 2025, revealed that the resident had a tracheostomy tube size 6.0mm, but the spare tracheostomy tube at the bedside was incorrectly sized at 7.0mm, contrary to the physician's order. Additionally, the tracheostomy collar was found to be stained and appeared soiled, with no date indicated on it. Interviews with the respiratory therapist and the Director of Nursing confirmed these findings and acknowledged the discrepancy in the spare tracheostomy tube size.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide culturally competent, trauma-informed care for residents diagnosed with PTSD, as required by professional standards of practice. This deficiency was identified for four residents, each with a diagnosis of PTSD, whose care plans did not address their specific condition, past experiences, or potential triggers that could lead to re-traumatization. The care plans for these residents lacked individualized strategies to mitigate triggers, which is essential for effective PTSD management. Interviews with the Social Service Director confirmed that the facility did not have a practice of inquiring about PTSD or potential triggers from residents or their families, nor were these factors documented in the care plans. This oversight affected the care provided to residents with PTSD, as their care plans were not tailored to their specific needs and experiences, potentially compromising their mental health and well-being.
Failure to Conduct Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to conduct annual performance reviews for five nurse aides, identified as Employees E13, E14, E15, E16, and E17, as required by the facility's personnel policies and procedures. This deficiency was identified during a review of facility documentation and staff interviews. On March 19, 2025, the Nursing Home Administrator and Director of Nursing were unable to provide the requested performance reviews for these employees. An interview on March 20, 2025, with the Nursing Home Administrator confirmed that no performance reviews had been completed for any staff for the current or previous year.
Incomplete Narcotic Reconciliation Documentation
Penalty
Summary
The facility failed to ensure the complete reconciliation of controlled drugs, as evidenced by missing signatures on the Narcotic Count Sheet for one of the medication carts reviewed. Specifically, between March 12, 2025, and March 18, 2025, seven out of the required 44 nurse signatures were absent on the narcotic reconciliation documentation for the medication cart on the 3 North unit. This deficiency was confirmed during an interview with a licensed nurse, employee E7, who acknowledged the absence of signatures. The facility's protocol requires that both the oncoming and outgoing nurses verify the narcotic count and sign the Narcotic Count Sheet at each shift change, which was not adhered to in this instance.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, as observed during a survey. On the first floor north cart, an insulin pen and eye drops were found without open or expiration dates. Similarly, on the first floor south cart, a Humalog pen and Lantus insulin bottles lacked open dates. These observations were confirmed by the respective licensed nurses, who acknowledged that insulin should be discarded 28 days after opening and should be dated when opened. Additionally, a medication cart on the third floor north was found unlocked and unattended, with several medications open and lacking open dates. These included Sucralfate Suspension, Valproate Sodium Oral Solution, GlycoLax Powder, Amantadine HCl Oral Solution, and Potassium Chloride Solution. One medication, GuaiFENesin Liquid, had been discontinued but was still present in the cart. The Director of Nursing confirmed that all multi-use medications should be labeled with the date they were opened and that carts should be locked when out of view.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
A deficiency was identified when a licensed nurse failed to follow physician orders regarding wound care for a resident with paraplegia, polyneuropathy, and a sacral pressure ulcer. The physician's order specified that the resident's sacral wound should be cleansed with soap and water, patted dry, and a foam dressing applied every other day during the evening shift. However, the resident received a wound dressing change at 2:30 a.m. by a licensed nurse, despite having already received the treatment the previous morning after a shower, when the dressing became wet and was changed by another nurse at the resident's request. Review of the clinical record and nursing notes confirmed that the wound treatment had already been completed on the morning prior to the night shift intervention. The nurse who performed the additional dressing change acknowledged in a written statement that the physician's order for every-other-day treatment was not followed. The Director of Nursing also confirmed that the nurse did not adhere to the prescribed treatment schedule, as documented in the Medication Administration Record.
Failure to Investigate Resident Grievance
Penalty
Summary
The facility failed to ensure that a grievance filed by a resident, identified as Resident R2, was properly documented and investigated. According to the facility's grievance policy, grievances can be submitted orally or in writing, and the employee receiving the grievance must notify the Director or designee immediately. The Director or designee is then required to contact the individual who filed the grievance within 24 hours to review the issues and document the discussion, including the nature of the complaint, investigation process, and resolution. However, in this case, the grievance regarding missing personal items, specifically black bras and a sapphire item, was not filed or investigated as per the policy. Resident R2, who has a medical history including arthritis, schizophrenia, diabetes, legal blindness, and cerebral palsy, reported the missing items to the social services department but received no follow-up. Interviews revealed that a facility life leader delivered the sapphire item to the resident and placed it in the resident's drawer. When the resident reported the item missing, the life leader attempted to open the drawer but did not pursue further action to address the grievance. This lack of action resulted in the facility's failure to adhere to its grievance policy, leaving the resident's complaint unresolved.
Failure to Develop Person-Centered Care Plan for Heart Failure
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident diagnosed with heart failure. The facility's policy, revised in September 2018, requires that care plans be developed through a comprehensive review of the resident's history, medical problems, and assessments by each discipline, with input from the resident or their representative. The care plan should address each identified problem with specific, realistic, and measurable goals, including a timeframe for completion. However, the review of Resident R1's records revealed that the care plan did not include any goals or interventions for managing the resident's heart failure. The deficiency was identified during a review of the resident's clinical records and staff interviews. The resident, who has multiple diagnoses including heart failure, was not being weighed daily, which is crucial for monitoring fluid retention—a key concern for heart failure management. The absence of daily weight monitoring made it difficult to assess the resident's condition and determine the need for medication adjustments, such as administering Lasix. The Assistant Director of Nursing confirmed that there was no person-centered care plan in place for the resident's heart failure, leading to the deficiency noted in the report.
Failure to Obtain Daily Weights for Resident with Heart Failure
Penalty
Summary
The facility failed to ensure that daily weights were obtained as ordered by the physician for a resident diagnosed with heart failure. The resident, who also had diagnoses of obesity, paraplegia, multiple sclerosis, depression, and hypertension, was supposed to be weighed daily to monitor fluid retention, which is critical for managing heart failure. Despite the physician's order dating back to March 2024, the resident's clinical records from March to October 2024 showed no evidence of daily weight measurements being taken by the nursing staff. This lack of documentation was confirmed by the Assistant Director of Nursing during an interview. The resident reported that he was supposed to be weighed daily since March 2024, but a nurse aide mentioned that the computer system only allowed for weight input once a day. The resident's daily assigned nurse was unaware of the physician's order for daily weights and stated that the resident was weighed monthly instead. The Medication Administration Record (MAR) also lacked documentation of daily weights, leaving the section for weight entries blank. This oversight made it difficult to monitor the resident's condition and adjust medication as needed, potentially impacting the resident's health management.
Failure in Daily Weight Monitoring for Heart Failure Resident
Penalty
Summary
The facility failed to ensure proper physician monitoring for a resident diagnosed with heart failure. The facility's policy required physicians to oversee services, write orders, conduct visits, and review the resident's care program, including medications and treatments. However, the facility did not adhere to these guidelines, as evidenced by the lack of daily weight monitoring for a resident with heart failure, which is crucial for managing fluid retention and adjusting medication like Lasix. The resident, who had multiple diagnoses including heart failure, was supposed to be weighed daily as per a physician's order from March 2024. Despite this, the resident's clinical records showed that weights were only recorded monthly, not daily, from March to October 2024. This oversight was not identified by the medical professionals involved, including the facility's staff physician, medical director, and nurse practitioner, who all documented that the resident's weights were stable without verifying the actual daily weight records. Interviews with the resident and the facility's medical director confirmed the failure to conduct daily weight monitoring. The medical director acknowledged that the weights were not reviewed or monitored, and the discrepancy was not noticed during medical visits or record reviews. This lack of monitoring persisted for eight months, indicating a significant lapse in the facility's adherence to its own policies and physician orders.
Resident Left on Bedpan for Extended Period
Penalty
Summary
The facility failed to ensure that residents were free from neglect, as evidenced by the incident involving a resident who was left on a bedpan for an extended period. The resident, who has multiple diagnoses including spastic quadriplegic cerebral palsy and neurogenic bladder, was placed on a bedpan by a nurse aide at 9:30 p.m. and was not removed until approximately 4:00 a.m. the following morning. This incident was reported by the resident's sister and confirmed through staff statements and facility investigation. The resident's clinical records indicate that they require extensive assistance with bed mobility and have limitations in range of motion in both upper and lower extremities. Despite these needs, the nurse aide, Employee E5, admitted to forgetting to remove the bedpan after completing her shift duties. The oversight was discovered by another nurse aide, Employee E6, during her rounds on the subsequent shift. The facility's investigation confirmed the timeline of events and the failure to provide necessary care. The Nursing Home Administrator, Employee E1, acknowledged the incident but did not classify it as neglect, citing the lack of willful intent. However, the facility's policy clearly defines neglect as the failure to provide necessary goods and services to avoid physical harm or distress. The incident highlights a lapse in care and communication among staff, resulting in the resident being left in an uncomfortable and potentially harmful situation for several hours.
Misappropriation of Resident's Package by Security Staff
Penalty
Summary
The facility failed to protect a resident from the misappropriation of their belongings, specifically a package that was confirmed delivered but not received by the resident. The facility's policy on abuse, neglect, and exploitation, which includes the prohibition of misappropriation of property, was not adhered to. The investigation revealed that the package was mishandled by security staff, Employees E4 and E5, who were seen on security footage with the package behind the security desk. Employee E4 was later observed leaving the facility with the package. The resident involved, identified as Resident R128, had been admitted to the facility with diagnoses including concussion, edema of the cervical spinal cord, major depressive disorder, and chronic pain due to trauma. The incident was reported on January 29, 2024, after the resident did not receive a package from Walmart that was confirmed delivered. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed the inappropriate handling and removal of the package by the security staff.
Deficiency in Care Plan Implementation for Catheter Care
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan that included measurable objectives, interventions, and time frames for catheter care and enhanced barrier precautions for two residents. Observations and reviews of clinical records revealed that the care plans for these residents did not incorporate Enhanced Barrier Precautions (EBP) as recommended by the CDC. Specifically, Resident R84, who had a medical history of urinary tract infections and issues related to an indwelling urethral catheter, did not have an updated care plan to include EBP despite recent infections. Similarly, Resident R77, with a history of neuromuscular dysfunction of the bladder and an indwelling urinary catheter, lacked a care plan addressing catheter care interventions. The facility's policy on 'Person-Centered Care Plan Process' was not adhered to, as evidenced by the absence of updated care plans for the residents in question. The deficiency was identified during observations on the first floor unit, where signs and supplies for enhanced barrier precautions were noted, but the care plans did not reflect these necessary precautions. This oversight was in violation of the facility's resident care policies and nursing services regulations, as outlined in the 28 Pa. Code 211.10(d) and 28 Pa. Code 211.12(d)(5).
Excessive Fentanyl Dosage Administered to Resident
Penalty
Summary
The facility failed to ensure that a resident was free from an excessive dose of pain medication. Resident R165, who was admitted with diagnoses including paraplegia, acquired deformity of chest and rib, psychoactive substance abuse in remission, generalized anxiety disorder, and major depressive disorder, was affected by this deficiency. A Fentanyl patch of 50 mcg per hour was unintentionally ordered and applied on May 13, 2024, instead of the correct dosage of 12 mcg per hour. This error was identified in a nursing note by a Licensed Nurse Practitioner on May 14, 2024, and confirmed by the Director of Nursing on May 22, 2024. The incorrect dosage was applied due to an error in the medication order history, which initially prescribed the higher dosage on May 10, 2024, before being discontinued and replaced with the correct dosage on May 13, 2024.
Deficiency in Food Preparation and Serving Temperatures
Penalty
Summary
Foods were not prepared and served by methods to conserve nutritive value, flavor, and appearance. The policy titled Food and Beverage Serving Temperature Requirements indicated that hot foods should be served at 140 degrees Fahrenheit and cold foods at 40 degrees Fahrenheit. However, interviews with three residents revealed that hot foods were not being served hot, and food items tasted cold and unflavored at the point of service. A temperature test tray evaluation during the noon meal service showed that hot food items like fried breaded fish and hush puppies were served at temperatures significantly below the required levels, and cold food items like cole slaw were served warm. The Director of Dietary Services confirmed these findings during the meal service. The review of hot food holding temperatures recorded by dietary staff showed that hot food items were being held between 165 and 180 degrees Fahrenheit, which contributed to the decreased nutritive value and unacceptable appearance of the foods at the point of service. Additionally, the equipment used to transport and serve foods for residents eating in their rooms was inadequate, as a full thermal heating system was not available. Residents received foods on a white plate with plastic wrap covering the plated foods, further contributing to the issue. These deficiencies were in violation of several Pennsylvania codes related to resident care policies, management, and nursing services.
Failure to Follow Physician's Orders and Clarify Medication Administration
Penalty
Summary
The facility did not ensure that physician's orders were followed or clarified regarding the administration of two medications for a resident diagnosed with neuromuscular bladder dysfunction and insomnia. The resident was supposed to receive Lithostat Tablet 250 mg three times a day, but the medication was never delivered due to insurance coverage issues. Despite this, the Medication Administration Record (MAR) indicated that the medication was administered from March 1, 2024, through March 15, 2024. The resident confirmed that she had never received any doses of Lithostat and was unaware of the physician's order for this medication until recently. Additionally, the resident had a physician's order for Temazepam Capsule 7.5 mg for insomnia, which was later changed to 15 mg due to insurance coverage. The resident refused to take the higher dose and indicated that the change was not discussed with her. Despite her refusal, the MAR showed that the 15 mg dose was administered on multiple occasions. Interviews with the Assistant Director of Nursing (ADON) and the Nurse Practitioner (CRNP) confirmed that the dosage change was not documented in the resident's medical record and that the higher dosage was marked as given in the MAR without the resident's consent.
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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