John J Kane Regional Center-mc
Inspection history, citations, penalties and survey trends for this long-term care facility in Mckeesport, Pennsylvania.
- Location
- 100 Ninth Street, Mckeesport, Pennsylvania 15132
- CMS Provider Number
- 395640
- Inspections on file
- 31
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 3 (1 serious)
Citation history
Health deficiencies cited at John J Kane Regional Center-mc during CMS and state inspections, most recent first.
A resident with dementia, encephalopathy, mobility limitations, and a history of APS involvement was assessed multiple times as not being at risk for elopement, and the care plan did not include elopement goals or interventions. Despite a physician order stating the resident could not leave without supervision, the resident was approved for an overnight LOA with her daughter, after previously stating she wanted to go home and would not return. The resident left by private car and did not return at the scheduled time; staff made repeated but unsuccessful phone calls to the daughter and other contacts and took no other immediate actions, and facility leadership later confirmed they did not know the resident’s location or safety after departure, resulting in an immediate jeopardy finding for failure to provide adequate supervision to prevent elopement.
Facility leadership, including the NHA and DON, failed to effectively manage operations and nursing services to ensure adequate resident supervision, resulting in an elopement when a resident did not return from a leave of absence. Review of job descriptions, facility documents, clinical records, and staff interviews showed that the NHA and DON did not carry out their defined responsibilities to operate in accordance with federal and state regulations, and the current NHA and DON acknowledged that administration failed to provide adequate supervision, creating an immediate jeopardy situation.
A resident with cognitive communication deficits and CHF experienced a documented change in condition involving altered mental status. Facility policy required physician notification and documentation of findings and notifications in the nurses' notes. Although an RN stated the physician was notified via text message from a personal phone, there was no documentation in the nurse progress notes of the physician notification, follow-up assessments, or treatment plans. The DON confirmed the absence of this documentation, resulting in incomplete and inaccurate clinical records.
A resident with COPD and Alzheimer's disease, requiring moderate assistance for transfers, sustained a deep laceration to the right lower leg during a stand-to-pivot transfer with a CNA. The injury occurred when the resident's leg caught on the wheelchair's leg rest hinge bracket, resulting in profuse bleeding and the need for staples, sutures, and repeated hospital visits. The facility failed to provide adequate supervision and assistance during the transfer, leading to actual harm.
A newly admitted resident with high blood pressure and alcohol abuse disorder eloped from the facility due to inadequate supervision. The resident left the unit independently and was mistaken for a visitor by security, who allowed him to exit. Staff failed to conduct proper safety checks, with a nurse aide relying on previous reports and pre-charting care activities without verification. The RN also did not complete safety checks or inform the doctor of the admission, contributing to the resident's unsupervised departure.
The facility failed to accurately complete MDS assessments for two residents and BIMS/PHQ-9 assessments for six residents. Discrepancies included incorrect documentation of hospice services and incomplete cognitive and mood assessments, as confirmed by staff interviews.
A facility failed to provide a resident with the Notice of Medicare Non-Coverage (NOMNC) form, which is crucial for informing beneficiaries about their rights regarding service termination. Despite the resident having intact cognition, neither the resident nor their emergency contact received or signed the NOMNC form. This was confirmed by the Director of Nursing, highlighting a failure to ensure residents' rights to make informed decisions.
A facility failed to complete a Significant Change MDS assessment for a resident who was admitted to hospice care, despite the requirement to conduct a comprehensive assessment within 14 days of a significant change in condition. The oversight was confirmed by facility staff, highlighting a lapse in regulatory compliance.
The facility did not provide transfer notices to the LTC Ombudsman for eight months, as required by federal regulations. The facility's policy mandates sending a monthly list of facility-initiated transfers or discharges to the Ombudsman, but this was not done from December 2023 to August 2024. The DON confirmed the oversight during an interview.
A resident with morbid obesity and osteoarthritis, requiring substantial assistance for bed mobility, was injured due to neglect when a CNA failed to follow the care plan requiring three staff members for assistance. The CNA attempted to assist the resident alone, resulting in the resident falling and sustaining a leg fracture and a skin tear requiring sutures. The facility's investigation confirmed the neglect, as the CNA did not adhere to the prescribed care plan or verify the bed mobility order.
A resident with morbid obesity and osteoarthritis, requiring substantial assistance for bed mobility, suffered a leg fracture and skin tear after a CNA failed to follow the care plan requiring three staff members for assistance. The CNA allowed the resident to roll onto a bedpan without additional help, resulting in a fall and subsequent injuries.
A resident with dementia and post-surgical care needs was prescribed gabapentin 100 mg twice daily for anxiety, but due to a pharmacy error, received 800 mg twice daily for several days. The error was confirmed by the DON after the family refused the medication.
A resident with cognitive impairment and multiple diagnoses was found with a sheet and gown tied in a manner that restricted movement. The responsible Nurse Aide had a prior warning for abuse and neglect and was subsequently terminated. The incident was reported to the physician, and the facility initiated staff education on physical restraints.
Failure to Supervise Resident on Leave of Absence Leading to Elopement
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and monitoring to prevent an elopement for one resident, resulting in an immediate jeopardy situation. The resident was admitted as an APS case due to being unable to care for herself at home and had multiple diagnoses including encephalopathy, dementia, dysphagia, muscle weakness, unsteadiness on feet, history of falling, and adult failure to thrive. Hospital documentation at admission described the resident being found at home in poor hygienic conditions, covered in urine, feces, and vomit, with EMS and ED staff expressing concern about the condition of the home and the need for APS involvement. Despite these concerns and the resident’s functional and cognitive vulnerabilities, the facility’s elopement evaluations completed on several dates in 2025 concluded that the resident was not at risk for elopement, and no further elopement assessments were documented after September 2025. The resident’s care plan, initiated in May 2025, did not include goals or interventions related to elopement, even though the discharge planning section identified that the resident was unable to care for herself, had limited assistance in the community, and might require protective care services. A physician’s order authorized the resident to move about the unit and facility without supervision but prohibited leaving the facility without supervision. Later, a physician’s order approved an overnight leave of absence (LOA) with medications. Progress notes documented that the resident expressed a desire to go home and stated that if she went home with her daughter, she would not return. A care conference note described that the resident wanted to discharge in the future, still required assistance and cueing with ADLs in therapy, had difficulty maneuvering her wheelchair, and could not clearly describe where she was going for the planned LOA or how she would get there, repeatedly stating that her daughter would pick her up even though the daughter did not drive. The resident left the facility on an approved overnight LOA with her daughter and a friend by private car, with the expectation that she would return by a specified time the following day. When the resident did not return at the scheduled time, staff documented multiple attempts to contact the daughter and other listed contacts by phone during the late evening and early morning hours, but no other actions were taken at that time. Progress notes show repeated unsuccessful calls to the daughter’s phone number, including the number the resident had written on the LOA form, which was not in service. Additional attempts to reach the daughter, pastor, and a church friend were also unsuccessful. The DON and ADON later confirmed that the facility did not take actions beyond phone calls when the resident failed to return as scheduled and that they were unaware of the resident’s location or safety from the time she left on LOA. The Chief Nursing Officer acknowledged that the facility failed to provide adequate supervision to prevent elopement, resulting in an immediate jeopardy situation for this resident.
Failure of Administration and Nursing Leadership to Prevent Resident Elopement
Penalty
Summary
The deficiency involves the failure of the Nursing Home Administrator (NHA) and the Director of Nursing (DON) to effectively manage the facility and ensure adequate supervision of residents, resulting in an elopement incident for one of forty residents (R1). The facility-provided job description for the NHA states that the NHA is responsible for directing the day-to-day functions of the facility, managing all aspects of operations, and ensuring resident safety and comfort in accordance with federal, state, and local regulations. The DON job description states that the DON is responsible for planning, organizing, developing, and directing the overall operation of the nursing department in accordance with Professional Nursing Law and applicable regulations. Despite these defined responsibilities, the facility did not take appropriate action when a resident failed to return from a leave of absence. Based on review of job descriptions, facility documents, clinical records, and staff interviews, surveyors determined that the previously employed NHA and DON did not fulfill their essential job duties to ensure that federal and state guidelines and regulations were followed. Specifically, the facility failed to provide adequate supervision to prevent an elopement, which created an immediate jeopardy situation for one resident. During an interview, the current NHA and current DON confirmed that facility administration had failed to effectively manage the facility to provide adequate supervision to prevent the elopement. The cited regulatory references include 28 Pa. Code 201.14(a) (Responsibility of licensee), 28 Pa. Code 201.18(b)(1)(3)(e)(1) (Management), and 28 Pa. Code 211.12(d)(1)(2)(3)(5) (Nursing services).
Failure to Document Physician Notification and Follow-Up After Change in Condition
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately documented for a resident who experienced a change in condition. Facility policy titled "Notification of Changes in Resident Condition and Treatment Changes" required nursing staff to notify the physician of changes, accidents, and injuries, obtain treatment and diagnostic orders, and document findings and notifications in the nurses' notes. The resident was admitted with diagnoses including cognitive communication deficits and congestive heart failure, and a subsequent MDS confirmed these diagnoses remained current. A change in condition report documented that the resident was observed with altered mental status on a specified date. Despite the documented change in condition, the resident’s nurse progress notes did not contain any documentation of physician notification, follow-up assessments, or treatment plans related to this event. An RN reported that the physician had been notified of the change in condition via text message from the RN’s personal phone but acknowledged that this communication was not documented in the medical record. The DON confirmed that the medical record lacked documentation of the physician notification and related follow-up, resulting in incomplete and inaccurate clinical records for this resident in violation of 28 Pa. Code 211.5(f)(g)(h).
Failure to Provide Adequate Supervision During Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to prevent an injury to a resident with chronic obstructive pulmonary disease and Alzheimer's disease, who required partial to moderate assistance for transfers and had a physician order for one-person assist with a rolling walker. During a stand-to-pivot transfer from bed to wheelchair, the resident became weak, buckled at the knees, and was assisted by a nurse aide into the wheelchair. After the transfer, it was discovered that the resident had sustained a deep laceration to the right lower leg, which was bleeding profusely. The laceration was caused by the resident's leg coming into contact with the wheelchair's leg rest hinge bracket during the transfer. Immediate first aid was provided, and the resident was sent to the emergency department, where the wound required multiple staples, sutures, and application of hemostatic dressings due to continued bleeding. The injury resulted in repeated hospital visits within a short period due to ongoing bleeding from the wound site. Documentation and staff interviews confirmed that the transfer was performed with a single staff member as per the care plan at the time, but the incident revealed that this level of assistance was insufficient to prevent injury for this resident. The facility's failure to provide adequate supervision and appropriate transfer assistance directly led to the resident sustaining actual harm in the form of a significant laceration requiring medical intervention.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a newly admitted resident, identified as Resident R1. The resident, who had diagnoses of high blood pressure and alcohol abuse disorder, was admitted to the facility in the evening. Despite being a new admission, the resident was able to leave the facility without being noticed by the staff. The resident was last seen on CCTV leaving the unit independently and fully dressed, and was mistaken for a visitor by the security guard, who allowed him to exit the building. The deficiency was further compounded by the failure of the staff to conduct proper safety and accountability checks. A nurse aide, Employee E1, admitted to not physically checking on the resident and instead relied on the report given by the previous shift. The nurse aide also pre-charted care activities without verifying the resident's presence. Similarly, RN Employee E2 did not complete the required safety checks and failed to inform the doctor of the new admission. These lapses in protocol allowed the resident to leave the facility unnoticed. The security personnel, Employee E3, also contributed to the deficiency by not recognizing the resident as a newly admitted individual and assuming he was a visitor. This assumption led to the security guard unlocking the door for the resident, facilitating his elopement. The facility's policies on elopement prevention and safety checks were not adequately followed, resulting in the resident's unsupervised departure from the facility.
Inaccurate MDS and BIMS/PHQ-9 Assessments
Penalty
Summary
The facility failed to ensure that comprehensive Minimum Data Set (MDS) assessments were completed accurately for two residents and that Brief Interview for Mental Status (BIMS) and/or Patient Health Questionnaire-9 (PHQ-9) assessments were completed accurately for six residents. Specifically, Resident R41's MDS inaccurately indicated that they did not receive hospice services, despite being on the facility's list of residents receiving such services. Additionally, discrepancies were found in the cognitive and mood assessments for several residents, where the BIMS and Resident Mood Interviews were not completed despite indications that they should have been. The report highlights specific instances where the facility did not adhere to the guidelines outlined in the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual. For example, Resident R13 was noted to be sometimes understood, yet the BIMS and Resident Mood Interview were not completed. Similar issues were identified for Residents R35, R41, R53, R169, R174, and R190, where the assessments were either incomplete or inaccurately documented. These deficiencies were confirmed through interviews with the Registered Nurse Assessment Coordinator and the Social Services Director.
Failure to Provide Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to ensure that residents were properly informed about their Medicare coverage and potential liabilities for services not covered. Specifically, the facility did not provide Resident R203 with the Notice of Medicare Non-Coverage (NOMNC) form, which is essential for informing beneficiaries of their right to request a review of service termination. Despite Resident R203 having intact cognition, as indicated by a BIMS score of 15, neither the resident nor their designated emergency contact received or signed the NOMNC form. The deficiency was confirmed during an interview with the Director of Nursing Registered Nurse Assessment Coordinator (RNAC), who acknowledged that the NOMNC was not explained to Resident R203 or their representative in a comprehensible manner. This oversight was identified as a failure to uphold resident rights to make informed decisions about their health, safety, and welfare, as required by the relevant Pennsylvania codes.
Failure to Complete Significant Change MDS Assessment
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment for a resident, identified as R40, who experienced a significant change in condition. According to the Resident Assessment Instrument 3.0 User's Manual, a comprehensive assessment must be conducted within 14 days after determining a significant change in a resident's physical or mental condition. Resident R40, who was admitted to the facility, had diagnoses of Alzheimer's disease and neuropathy. A physician order dated 10/7/24 indicated that the resident was admitted to hospice care, which is a significant change in condition requiring an updated MDS assessment. Upon review of Resident R40's MDS assessments, it was found that a significant change MDS was not completed to include the hospice services. This oversight was confirmed during interviews with the Registered Nurse Assessment Coordinator and the Nursing Home Administrator. The failure to complete the required MDS assessment for Resident R40 was acknowledged by the facility staff, indicating a lapse in adhering to the regulatory requirements for resident assessments.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide transfer notices to the representatives of the Office of the Long-Term Care Ombudsman Division for eight out of ten months, specifically from December 2023 through August 2024. According to the facility's policy dated January 6, 2024, a monthly list of residents who were facility-initiated transfers or discharges should be sent to the Ombudsman. However, this procedure was not followed. The federal regulation Title 42 Code of Federal Regulations S483.15(c)(3) requires that before a facility transfers or discharges a resident, the facility must notify the resident and their representative(s) in writing and send a copy of the notice to the Ombudsman. The Director of Nursing confirmed during an interview on November 7, 2024, that the facility had not provided these notices since December 31, 2023.
Neglect Leads to Resident Injury Due to Non-Compliance with Care Plan
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in actual harm, including a leg fracture and a skin tear requiring sutures. The resident, who had diagnoses of morbid obesity and osteoarthritis, required substantial assistance for bed mobility. A physician's order specified that three staff members were needed to assist with the resident's bed mobility. However, during an incident, a CNA attempted to assist the resident alone, contrary to the care plan and physician's orders. The incident occurred when the CNA was providing care and attempted to place the resident on a bedpan. The resident, weighing 338 pounds, attempted to assist by grabbing the headboard, which led to her falling off the bed. The CNA was unable to prevent the fall, resulting in the resident sustaining a laceration to the left knee and a comminuted fracture of the distal femur. Emergency services were called, and the resident was transferred to a hospital for further evaluation and treatment. The facility's investigation revealed that the CNA did not follow the prescribed care plan or verify the bed mobility order before providing care. This failure to adhere to the care plan and physician's orders was identified as neglect, leading to the resident's injuries. The Director of Nursing confirmed the facility's failure to protect the resident from neglect, which resulted in significant harm.
Failure to Provide Adequate Supervision Leads to Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent falls, resulting in actual harm to a resident who suffered a leg fracture and a skin tear requiring sutures. The incident involved a resident with a history of morbid obesity and osteoarthritis, who required substantial assistance for bed mobility. A physician's order specified that the resident needed assistance from three staff members for bed mobility, which was also reflected in the resident's care plan. On the day of the incident, a CNA attempted to assist the resident onto a bedpan without the required assistance from two additional staff members. The CNA allowed the resident to grab the headboard to assist with rolling, which led to the resident losing balance and falling off the bed. The fall resulted in a laceration to the left knee and a comminuted fracture of the distal femur, necessitating emergency medical attention and transfer to a higher-level hospital for further evaluation. The facility's investigation revealed that the CNA did not follow the prescribed plan of care or physician orders, which required three staff members for bed mobility. The CNA's failure to verify the bed mobility order before providing care was identified as neglect, and the incident was confirmed by the Director of Nursing. The facility documented the incident as a substantiated case of neglect due to the CNA's actions.
Medication Error Due to Pharmacy Mismanagement
Penalty
Summary
The facility failed to implement pharmaceutical services accurately, resulting in a medication error for one resident. The facility's policy required the contracted pharmacy to dispense prescriptions accurately based on authorized prescriber orders. However, a review of the resident's medication administration record revealed that the resident was prescribed gabapentin 100 mg twice daily, but was instead administered 800 mg twice daily from August 9 to August 14. This error was confirmed by the Director of Nursing during an interview. The resident involved had a history of dementia and was receiving aftercare following surgery. A psychiatric evaluation had led to a new order for gabapentin to manage anxiety, but the incorrect dosage was provided due to a pharmacy error. The error was identified when the family refused the medication on two occasions, prompting a review and confirmation of the mistake by the facility's Director of Nursing.
Failure to Ensure Resident was Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints. Resident R1, who was admitted on 10/6/23 and had diagnoses including unspecified dementia, muscle wasting, diabetes, and adult failure to thrive, was found on 3/13/24 with a sheet tied behind their lower back and the corners of their gown tied behind their thighs. The resident had a BIMS score of 5, indicating cognitive impairment. Nurse Aide Employee E1 was identified as the individual who tied the sheet and gown, and had a previous verbal warning for abuse and neglect on 4/4/23. Employee E1 was suspended on 3/13/24 and terminated on 3/20/24. The incident was reported to the physician on 3/16/24. The facility's policy on physical restraints, last reviewed on 2/07/23, defines a restraint as anything that restricts freedom of movement and limits one's sense of control and independence. The incident was discovered by the oncoming 7 a.m. shift Nurse Aide Employee E2, who reported the restraint. The facility initiated education on physical restraints on 3/18/24, which included defining restraints, identifying physical risks and psychosocial impacts, determining if position change alarms are restraints, and identifying key elements of non-compliance. Seven direct care staff confirmed receiving this education during interviews on 3/26/24.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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