Julia Ribaudo Extended Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lake Ariel, Pennsylvania.
- Location
- 1404 Golf Park Drive, Lake Ariel, Pennsylvania 18436
- CMS Provider Number
- 395493
- Inspections on file
- 28
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 29
Citation history
Health deficiencies cited at Julia Ribaudo Extended Care Center during CMS and state inspections, most recent first.
The facility failed to follow its infection control and animal visitation policies when an LPN brought a sick backyard chicken into the building without prior approval, veterinary clearance, or documentation, kept it at the nurses’ station, removed it from its carrier, and allowed residents to handle it, contrary to the facility’s pet protocol and CDC guidance on poultry. The facility also failed to adhere to its indwelling urinary catheter care procedure for two residents with cognitive impairment and urinary conditions, as both residents’ urinary drainage bags were observed resting directly on the floor instead of being maintained below bladder level and off the floor as required by policy and their care plans.
The facility failed to prevent ongoing intrusions into residents' rooms by other residents with cognitive impairments, resulting in repeated complaints about privacy violations, rummaging of personal belongings, and consumption of food. Despite these concerns being raised in council meetings and interviews, the issue persisted without documented resolution, impacting residents' dignity and quality of life.
The facility did not maintain an adequate supply of clean linens for resident care in two care units, as evidenced by resident concerns, staff reports of frequent shortages, and observations of insufficient linens on carts and in storage. The issue was compounded by delays in linen delivery and problems with linens not being returned from laundering.
The facility did not consistently provide evening snacks to residents, resulting in meal intervals exceeding 14 hours in several nursing unit areas. Multiple residents reported that snacks were not regularly offered, and the NHA could not provide documentation to show that evening snacks were consistently available, despite facility policy requiring them.
The facility did not maintain an effective pest control program, resulting in ongoing issues with small black flies, gnats, and ants in resident rooms and common areas. Multiple residents reported persistent pest sightings, and surveyors observed flying insects in hallways, resident rooms, and near food service areas. Pest control services were performed but lacked detailed documentation and follow-up, and the facility could not provide evidence of consistent efforts to resolve the issue.
A resident with chronic kidney disease, anxiety disorder, and moderate cognitive impairment was manually transferred to bed by two staff without the use of the ordered standing lift, causing significant distress and resulting in the resident biting a nurse aide. The care plan at the time did not address the resident's anxiety regarding transfers or provide alternative interventions, leading to a failure in implementing a comprehensive, person-centered care plan.
Surveyors identified that two residents were exposed to accident hazards due to unsecured medications left accessible in a resident's room and a cognitively impaired resident gaining unauthorized access to a restricted area behind the front desk. The facility did not follow its own policies for medication security or implement effective supervision to prevent these incidents.
Surveyors found that two residents receiving oxygen therapy did not have their equipment maintained or labeled according to physician orders and facility policy. Observations revealed humidification bottles and tubing were not dated, bottles were stored on the floor, and in one case, the bottle could not be secured due to broken straps. Staff interviews confirmed these deficiencies, and the administrator acknowledged the improper storage and lack of dating.
A resident with severe cognitive impairment and multiple pain management orders received PRN opioid medication without documented attempts at non-pharmacological interventions or assessment of pain level, contrary to facility policy. Staff administered morphine on several occasions without determining if a non-opioid medication was appropriate, and physician orders lacked clear guidance on pain intensity for medication selection.
A resident's personal belongings were not properly documented upon admission and discharge, as required. The inventory list lacked signatures from the resident or responsible party, and there was no record confirming the return of the resident's possessions at discharge. The DON confirmed that no further documentation was available to verify the release of these items.
Surveyors found that the facility did not maintain documented job descriptions in the personnel files of a nurse aide, an activities aide, and a dietary aide, as required by policy. This was confirmed by the administrator during the review.
A newly hired LPN began providing resident care without documentation from a healthcare practitioner confirming they were free from communicable diseases, as required by regulation. The administrator confirmed the absence of this documentation in the employee's file.
A review of staffing records and interviews confirmed that the facility did not meet required nurse aide-to-resident ratios on multiple day, evening, and night shifts, with no additional higher-level staff available to compensate for the shortfall.
The facility did not provide the required number of LPNs on several day and night shifts, resulting in staffing levels below the mandated ratios for the census on those dates. Staffing records and an interview with the DON confirmed that no additional higher-level staff were available to compensate for the LPN shortfall.
The facility did not consistently provide the required 3.2 hours of direct nursing care per resident per day, as evidenced by staffing records and confirmation from the DON. On multiple days, the nursing hours fell below the regulatory minimum.
A registered nurse failed to implement a physician's order to hold an anticoagulant (Eliquis) for a resident with atrial fibrillation in preparation for a scheduled procedure. The medication was not held as ordered, resulting in the cancellation and rescheduling of the procedure. The nurse acknowledged not saving the order during entry, which led to the deficiency.
The facility failed to conduct a comprehensive assessment to determine necessary resources for resident care, inaccurately reflecting the needs of residents with Alzheimer's, dementia, and behavioral health issues. The assessment did not evaluate staff capabilities to ensure adequate care, leading to a deficiency.
The facility failed to maintain a comprehensive infection prevention and control program. Infection control data lacked an operational system to monitor and investigate infections, with incomplete logs from November 2023 to October 2024. Clinical records showed residents treated for various infections, and interviews confirmed the absence of complete logs and a comprehensive program.
A resident frequently incontinent of bowels was not assessed for a bowel management program, despite being cognitively intact and aware of toileting needs. The facility's policy requires a continence evaluation and toileting plan, but the resident experienced 96 episodes of bowel incontinence without proper assessment or intervention.
The facility failed to maintain accurate records and ensure proper administration of controlled drugs for a resident, with discrepancies found between the Controlled Medication Utilization Record and the MAR. Additionally, another resident's medication was improperly stored in a dialysis communication binder instead of a secure area. The DON confirmed these failures in adhering to the facility's policies.
A resident with a history of dementia and aggressive behavior physically and verbally abused two other residents in an LTC facility. Despite known aggressive tendencies, the facility failed to implement adequate supervisory measures, resulting in incidents where one resident was grabbed by the chin and another was bear-hugged, leading to bruising. The facility's policy on abuse prevention was not effectively enforced.
A resident with Alzheimer's, malnutrition, and dysphagia was not provided with prescribed adaptive dining equipment, such as a maroon spoon and Provale cup, during meal observations. Despite physician orders, the resident received standard utensils, which was confirmed by the Director of Rehab, indicating a failure to adhere to prescribed care.
A resident was transferred to a hospital due to urgent medical needs, but the facility failed to provide a written notice with the medical reason for the transfer. This deficiency was confirmed during an interview with the Nursing Home Administrator.
A resident with dementia and psychosis was found to have been given Benadryl without a physician's order, leading to increased sedation and reduced behavioral symptoms. The facility's investigation revealed that a staff member administered the medication for convenience, but the individual responsible was not identified.
Failure to Enforce Pet Visitation Rules and Maintain Proper Catheter Bag Positioning
Penalty
Summary
The facility failed to establish, maintain, and implement an effective infection prevention and control program related to animal visitation and indwelling urinary catheter care. The facility’s Infection Control Policies and Practices required an organized, effective program to prevent, identify, control, and reduce the risk of infections, and the Animal Visitation Pet Policy limited visiting animals to certain species, required prior arrangements with the activity department, and mandated up-to-date vaccinations and veterinary checkups with documentation on file. The pet policy also prohibited animals from nurses’ stations and other areas requiring sanitary precautions, and required pets to be leashed or caged. Despite these policies, an LPN brought a sick chicken from her home into the facility without prior administrative approval, without veterinary evaluation, and without any documentation of vaccinations or preventive care. The LPN reported that she brought the sick chicken into the building at the start of her shift, kept it at the nurses’ station, and removed it from its carrier at the nurses’ station to clean the cage and to feed and hydrate the animal. She carried the chicken in her arms within the facility and allowed residents to pet it. The DON confirmed that the chicken was present for several hours, that he was aware the animal was sick, and that the LPN removed the chicken from its cage and allowed resident contact. These actions were not in compliance with the facility’s animal visitation policy and infection control protocols. CDC guidance cited in the report indicated that backyard poultry can carry multiple infectious agents and recommended that poultry and related equipment be kept outside and not permitted inside areas where people live or receive care. The facility also failed to follow its own policy for indwelling urinary catheter care for two residents with catheters. The Indwelling Urinary Catheter Care Procedure required that urinary drainage bags be positioned below the level of the bladder for gravity drainage but not placed directly on the floor, as improper handling or contamination of the drainage system increases the risk of urinary tract infection. Resident 1, who had dementia, severe cognitive impairment, urinary retention, and a suprapubic catheter, had a care plan that included maintaining a closed catheter system and providing full assistance with catheter care. During observation, this resident was in bed with the urinary collection bag resting directly on the floor, which was confirmed by the LPN present. Resident 2, who had obstructive and reflux uropathy, morbid obesity, moderate cognitive impairment, and an indwelling urinary catheter, also had a care plan specifying catheter care per routine and positioning the collection bag and tubing below the bladder with a privacy cover. During observation, this resident was seated in a wheelchair at the nurses’ station with the urinary collection bag resting directly on the floor, again confirmed by the LPN. The DON later confirmed that urinary collection bags should be maintained off the floor. These observations demonstrated that the facility did not adhere to its catheter care policy and did not maintain proper infection control practices for residents with indwelling urinary catheters.
Failure to Prevent Resident Room Intrusions and Protect Resident Rights
Penalty
Summary
Julia Ribaudo Extended Care Facility was found noncompliant with federal and state regulations regarding resident rights and the promotion of a dignified environment. Surveyors identified that the facility failed to ensure residents' personal spaces were protected from intrusions by other residents. Multiple residents reported ongoing issues with other residents, particularly those with severe cognitive impairments, wandering into their rooms uninvited, rummaging through personal belongings, and consuming their food. These incidents were documented through clinical record reviews, resident council meeting minutes, and direct resident interviews. Specific examples included one resident with severe cognitive impairment repeatedly entering the rooms of other residents, sitting on their beds, and taking their snacks. Residents affected by these intrusions expressed frustration, anger, and the need to hide their belongings or call for staff assistance to remove the wandering resident. The issue was persistent, as evidenced by repeated mentions in resident council meeting minutes over several months, with no clear documentation of resolution or effective intervention by the facility. Interviews with the Nursing Home Administrator and Director of Nursing confirmed that resident wandering and room intrusions had been a recurring concern raised by residents. Despite some reports of improvement, the problem remained unresolved for several residents, as indicated by their continued complaints during group interviews and council meetings. The facility's failure to address these concerns and protect residents' rights to privacy and dignity led to the cited deficiency.
Plan Of Correction
Preparation, submission, and implementation of the Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our Plan of Correction is prepared and executed as a means to continuously improve the quality of care and to comply with state and federal regulatory requirements. The facility is unable to retroactively correct Resident 3 and Resident 29's personal space being impeded on by wandering residents 16 and 19. All residents who voiced concerns during the resident council meeting were offered interventions that will deter wandering residents from entering their rooms. To identify like residents that could be affected by wandering residents, the DON/designee will interview all current alert and oriented residents with BIMS of 12 and greater. To prevent reoccurrence, the NHA/designee will educate the IDT team completing concierge rounds to follow up with the identified alert and oriented residents to monitor any further concerns or resolution. To prevent reoccurrence, nursing staff re-educated on the redirection of wandering residents to prevent the wandering of residents into peers' rooms. To monitor and maintain compliance, the DON/designee will interview 6 random alert and oriented residents with BIMS of 12 and greater to monitor resolution of wandering residents weekly x4 and then monthly x2. Results will be reviewed at QAPI. The team completing concierge rounds will follow up with the identified alert and oriented residents to monitor any further concerns or resolution. To prevent reoccurrence, nursing staff re-educated on the redirection of wandering residents to prevent the wandering of residents into peers' rooms. To monitor and maintain compliance, the DON/designee will interview 6 random alert and oriented residents with BIMS of 12 and greater to monitor resolution of wandering residents weekly x4 and then monthly x2. Results will be reviewed at QAPI.
Failure to Maintain Adequate Supply of Clean Linens
Penalty
Summary
The facility failed to maintain an adequate supply of clean linens to meet the needs of residents in two of four resident care units, specifically in the E Hallway and A Hallway. Resident council meeting minutes documented concerns from residents about linen availability, and the Nursing Home Administrator acknowledged that nurse aides were discarding washcloths and that additional linen had been ordered. Observations over several days revealed that linen carts in these hallways frequently contained only a minimal number of washcloths and bath towels, with some instances where no washcloths were available for resident care. Staff interviews confirmed ongoing difficulties in obtaining clean linens, with reports that clean linens were not delivered to the floors until after 9:00 AM, despite care being provided earlier, resulting in shortages. Further observations showed that the facility laundry room had no additional linens available for staff use at the time, and the linen closet outside the E Hallway had a limited supply. The Nursing Home Administrator also reported issues with linens being sent out for laundering and not returned, and was unable to confirm that the facility maintained an adequate number of linens to meet residents' daily needs.
Plan Of Correction
The facility is unable to retroactively correct the available linen supply on E Hallway and A Hallway linen cart. This has the potential to affect all residents. The NHA/designee completed an audit of all linen carts and rooms to ensure there was available linen. To prevent reoccurrence, the NHA/designee will educate housekeeping/laundry aides and CNAs on facility linen laundering processes and the location of clean linen should the linen cart need to be restocked. To monitor and maintain compliance, the NHA/designee will ensure an adequate supply of linens is available in linen carts and supply closets weekly x 4 and monthly x 2. Results will be reviewed at QAPI.
Failure to Consistently Provide Required Evening Snacks
Penalty
Summary
The facility failed to consistently provide evening snacks to residents, as required by federal regulations and its own policy. Scheduled mealtimes in multiple nursing unit areas resulted in more than 14 hours elapsing between the evening meal and breakfast the following day. Specifically, the intervals ranged from 14 hours and 15 minutes to 14 hours and 30 minutes, exceeding the 14-hour maximum unless a nourishing snack is provided at bedtime or a resident group agrees to a longer interval. During a resident council interview, four out of eight residents reported that snacks were not consistently offered in the evenings. One resident stated that snacks were only occasionally offered, while three others indicated they were not offered snacks at all. These resident accounts were corroborated by the lack of documentation showing that snacks were consistently provided during the evening hours. The Nursing Home Administrator confirmed that it is the facility's policy to offer nourishing snacks in the evening but was unable to provide evidence that this was being done consistently. The deficiency was identified through a combination of policy review, scheduled mealtime analysis, and resident and staff interviews.
Plan Of Correction
Resident#28, #32, #69, and 90 are currently being offered HS snacks. To identify like residents that have the potential to be affected, an audit was completed of current residents to ensure that snacks are being offered. To prevent this from recurring, the DON/designee will educate the nursing staff on offering HS snacks to the residents. To monitor and maintain ongoing compliance, the DON/designee will audit 5 residents weekly for 4 weeks, then monthly for 2 months, to ensure that snacks are being offered by the nursing staff. Results will be reported to QAPI for recommendations and follow-up.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as required, resulting in ongoing issues with small black flies, gnats, and ants in resident rooms and common areas across two nursing units and a resident dining/lounge area. Multiple residents reported persistent sightings of these pests, and direct observations by surveyors confirmed the presence of flying insects in hallways, resident rooms, and near food service areas such as the pantry and around the garbage can and ice machine. Resident council meeting minutes and interviews further documented that these pest issues had been ongoing for several months, despite the facility being informed by residents. A review of the facility's pest control policy and contract revealed that while routine pest control services were in place, the contract specifically excluded certain pests such as gnats and other free-flying insects. Pest control invoices showed treatments were performed, but lacked detailed descriptions of services, follow-up actions, or outcomes. The facility was unable to provide documentation of consistent follow-up or contractor recommendations to resolve the persistent pest issues. The Nursing Home Administrator acknowledged the ongoing pest problems despite treatments.
Plan Of Correction
The facility cannot go back and retro-correct the pest control concern. Pest control strips were added to the community to decrease pest concerns. NHA has pest control services on a weekly/as needed schedule to tour the facility to ensure that pest control techniques are effective. This has the ability to affect all residents. To prevent this from recurring, NHA/designee will educate staff on the Pest Control Policy. NHA has pest control services on a weekly/as needed schedule to tour the facility to ensure that pest control techniques are effective. To monitor and maintain ongoing compliance, NHA/designee will complete weekly rounds with the pest control technician weekly x 4, then monthly x 2, to ensure that pest control techniques are effective. NHA/designee will interview 5 alert and oriented residents to verify that the techniques are effective. Results will be reported to QAPI for recommendations and follow-up.
Failure to Develop and Implement Comprehensive Care Plan for Safe Transfers
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed the individualized needs and interventions for safe transfers for one resident. The resident, who was admitted with chronic kidney disease and an anxiety disorder, had a physician's order requiring the assistance of two staff members for transfers using a standing lift. Despite this order, there was an incident where two staff members manually transferred the resident to bed without the use of the standing lift, which was not in accordance with the care plan or physician's order. The resident, who was moderately cognitively impaired, experienced significant distress during the manual transfer and bit a nurse aide as a result. The incident was documented in a progress note, and the resident later explained that she was upset and frightened by the way she was transferred, as it deviated from the usual method involving the standing lift. Staff interviews confirmed that the manual transfer occurred and that the resident became anxious during the process. At the time of the incident, the resident's care plan did not identify her anxiety regarding transfers nor did it include the option for a manual two-person assist. The care plan was only updated after surveyor inquiries to reflect the resident's anxiety and to specify the appropriate transfer methods. Prior to this update, staff were expected to follow the physician's orders and the individualized plan of care, but the plan did not adequately address the resident's specific needs related to transfers.
Plan Of Correction
Resident 22's Transfer Care Plan was updated with individualized needs on. To identify like residents, a facility audit was completed by the DON/designee to identify any residents using a stand lift that have associated anxiety or behaviors. Care plans were updated to reflect individualized preferences for alternative safe transfers, other than facility policy to utilize Hoyer lift. To prevent reoccurrence, the DON/designee will educate licensed nursing on updating resident care plans with individualized preferences as they occur. To monitor and maintain compliance, the DON/designee will audit residents with new orders for stand lift/Hoyer lift, with associated anxiety or behaviors requiring individualized needs related to transfers, and update care plans as needed weekly x 4 and monthly x 2. Results will be reviewed at QAPI.
Failure to Secure Medications and Prevent Unauthorized Access
Penalty
Summary
The facility failed to implement adequate safety measures to prevent accidents for two residents. For one resident with chronic obstructive pulmonary disease (COPD), surveyors observed a bottle of Pepto Bismol and two prescription inhalers stored in an unlocked bedside table drawer and on the bed. The resident stated that her nephew brought her the Pepto Bismol and that a nurse had given her the inhalers, which she kept accessible in case she became short of breath. The resident's clinical record indicated she did not wish to self-administer medications, and the facility's policy required that self-administration be assessed, documented, and that medications be stored in a locked compartment if permitted. However, the medications were not secured, and the resident's drawer did not lock, making them accessible to others. For another resident with Parkinson's disease and moderate cognitive impairment, the care plan noted issues with noncompliance, including attempts to access restricted areas. Despite interventions such as a gate and education, the resident was observed behind the front desk, where he activated the door mechanism to allow entry to the survey team. The resident acknowledged he was not permitted in that area and asked the surveyors not to report his actions. The Nursing Home Administrator confirmed that adequate safety measures were not in place to prevent the resident from accessing the restricted area. These findings demonstrate that the facility did not maintain a resident environment free of accident hazards and did not provide adequate supervision or assistance devices to prevent accidents, as required by facility policy and federal regulations. The deficiencies were identified through observations, record reviews, and interviews with residents and staff.
Plan Of Correction
Resident 62's POC was reviewed, CRNP was notified of Pepto Bismol at bedside. New orders received for Pepto Bismol and self-administration assessment completed. Trellegy inhaler removed from resident room and explained that there was no current order without incident. Resident 62 has an order in place from 10/10/2024 that she may keep her Combivent inhaler at bedside and self-administer. Resident instructed to keep medications in locked bedside table. Initial audit performed to ensure that no other residents had medications at bedside and if so, medications were removed and if indicated, self-assessment were completed. Resident 63 was immediately educated on facility policy for visitor entry. Facility staff immediately educated on visitor entry policy and keeping the entry behind the desk restricted if staff not present. Maintenance director applied plastic casing with lock over unlocking mechanism. To identify like residents that could be affected, the resident's DON/designee will interview residents with a BIMS of 12 or higher to ask if they would like to self-administer and if they request, a self-administration assessment will be completed. All residents assessed and determined to self-administer will be educated on keeping medications locked at bedside. To identify like residents that could be affected, all residents that are alert and oriented with a BIMS of 12 and above that are independently mobile were educated on the visitor entry policy. To prevent reoccurrence, DON/designee will educate licensed nurses on the self-administration policy. To prevent reoccurrence, DON/designee will educate all facility staff; all staff were educated on visitor entry policy and keeping the entry behind the desk restricted if staff not present. To identify like residents that could be affected, the resident's DON/designee will interview residents with a BIMS of 12 or higher to ask if they would like to self-administer and if they request, a self-administration assessment will be completed. All residents assessed and determined to self-administer will be educated on keeping medications locked at bedside. To identify like residents that could be affected, all residents that are alert and oriented with a BIMS of 12 and above that are independently mobile were educated on the visitor entry policy. To prevent reoccurrence, DON/designee will educate licensed nurses on the self-administration policy. To prevent reoccurrence, DON/designee will educate all facility staff; all staff were educated on visitor entry policy and keeping the entry behind the desk restricted if staff not present. To monitor and maintain compliance, DON/designee will audit all new residents with a BIMS of 12 or higher for self-administration preferences and self-administration assessments weekly for 4 weeks and monthly for 2 months. To monitor and maintain compliance, DON/designee will audit that medications are not left out and available for other residents to get. To monitor and maintain compliance, DON/designee will audit front desk to ensure resident access behind the desk is restricted if an employee is not present behind the desk and that access to the entry mechanism is not accessible if staff is not present behind the desk weekly for 4 weeks and monthly for 2 months. Results will be reviewed at QAPI.
Failure to Maintain and Label Oxygen Therapy Equipment per Policy
Penalty
Summary
Surveyors identified that the facility failed to ensure oxygen therapy was administered and maintained according to physician orders and facility policy for two residents. The facility's policy required licensed clinicians to administer oxygen as ordered, change humidifier bottles when empty, and date equipment. For one resident with chronic obstructive pulmonary disease (COPD), observations revealed the oxygen humidification bottle was stored directly on the floor, was empty, and neither the bottle nor the tubing was dated. These issues persisted over two consecutive days, and a registered nurse confirmed the deficiencies during an interview. For another resident, also with COPD, staff were ordered to administer oxygen with humidification as needed, clean the concentrator, and change tubing weekly. Observations showed the nasal cannula and tubing were left across the bed with the cannula on the floor, and the humidification bottle was also on the floor with broken attachment straps, preventing it from being secured to the concentrator. The bottle was not dated, and these conditions were confirmed by a staff member during an interview. The Nursing Home Administrator acknowledged that humidification bottles should not be stored on the ground and should be dated when changed. The findings were based on clinical record reviews, facility policy, direct observations, and staff interviews, and demonstrated a failure to follow established protocols for oxygen therapy equipment maintenance and infection control.
Plan Of Correction
Resident #3 concentrator fixed, and humidifier bottle and tubing replaced. Resident #62 concentrator fixed, oxygen bag replaced and dated per policy, humidifier bottle and oxygen tubing replaced. To identify like residents that have the potential to be affected, DON/designee audited residents receiving oxygen therapy to ensure concentrator working properly, humidification bottle not on floor, and documentation present in the electronic clinical record. To prevent this from recurring, licensed staff will be educated on the oxygen administration policy by the DON/designee. To monitor and maintain ongoing compliance, DON/designee will audit 5 residents weekly x4 then monthly x2 to ensure concentrator working properly, humidification bottle changed, tubing changed, and documented in the electronic record. Result to QAPI for recommendation and follow-up.
Failure to Attempt Non-Pharmacological Pain Interventions Before Administering Opioids
Penalty
Summary
The facility failed to follow its own pain management policy by not attempting non-pharmacological interventions before administering a narcotic pain medication on an as-needed basis to a resident. The policy required that non-pharmacological interventions be tried prior to giving PRN pain medication, and if these interventions failed, medication would be administered according to the resident's pain intensity rating. However, documentation showed that staff did not attempt these interventions or assess the resident's pain level before administering opioid medication. The resident involved had a history of major depressive disorder and unspecified dementia with agitation, and was severely cognitively impaired, as indicated by the absence of a BIMS score on the MDS assessment. The resident had multiple physician orders for pain management, including acetaminophen for mild pain and morphine sulfate for pain or shortness of breath, but the orders for morphine did not specify a pain level or scale, making it unclear when to use each medication as per facility policy. Review of the electronic Medication Administration Record revealed that the resident received PRN morphine sulfate on multiple occasions without any documented attempts at non-pharmacological interventions and without assessment of pain level to determine if a non-opioid medication would have been appropriate. This was confirmed during an interview with the Nursing Home Administrator, who reviewed the findings related to the failure of licensed nursing staff to follow the required pain management procedures.
Plan Of Correction
Resident #19 Morphine order clarified to indicate levels of pain. Cannot go back and retro-correct non-pharmacology interventions for resident #19. To identify like residents that have the potential to be affected, DON/designee audited all residents with PRN pain medication to ensure that residents' pain levels are clarified in the physician order and non-pharmacological interventions are being offered prior to administration of the medication. To prevent this from recurring, licensed staff will be educated on pain management by the DON/designee. To monitor and maintain ongoing compliance, DON/designee to audit 5 residents x4 weeks then monthly x 2 months to ensure that pain levels are completed and non-pharmacological interventions offered prior to administration of the medication. Results to QAPI for recommendations and follow-up.
Failure to Document and Return Resident's Personal Belongings at Discharge
Penalty
Summary
The facility failed to maintain a complete and accurate record of a resident's personal possessions upon both admission and discharge. Specifically, for one resident, the inventory list documenting personal belongings at admission and discharge did not include a signature from either the resident or a responsible party. Additionally, there was no documentation in the resident's discharge information indicating that the belongings were returned to the resident upon discharge. An electronic observation detail report showed that the resident arrived with four belongings, but the facility was unable to provide further documentation confirming the release of these items at discharge. During an interview, the Director of Nursing confirmed that no additional records could be produced to verify the return of the resident's possessions.
Plan Of Correction
Resident #94 received all of his personal belongings upon discharge. To identify like residents that have the potential to be affected, the DON/designee completed a 2-week audit of new admissions to ensure that personal inventory sheets were completed upon admission and discharge of the residents. To prevent this from recurring, the DON/designee educated the nursing staff on the completion of the personal inventory sheet upon admission and discharge of the resident. To monitor and maintain ongoing compliance, the DON/designee will audit personal inventory sheets of new admissions and discharges weekly for 4 weeks, then monthly for 2 months, to ensure they are being completed and signed per the policy. Results will be reported to QAPI for recommendations and follow-up.
Missing Job Descriptions in Employee Personnel Files
Penalty
Summary
The facility failed to ensure that the personnel records for three employees, specifically a nurse aide, an activities aide, and a dietary aide, contained documented evidence of their job descriptions. Review of the personnel files for these employees, all hired in 2025, revealed that none included a written job description outlining the duties, responsibilities, and qualifications for their respective roles. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the facility could not produce the required documentation for these employees.
Plan Of Correction
Employee #5, #7, and #8 have signed job descriptions. To identify like individuals that have the potential to be affected, NHA/designee will audit new hires in the last 14 days to ensure job descriptions are signed by the employee. To prevent this from recurring, Human Resources will be educated by NHA/designee on personnel policies and procedures. To monitor and maintain ongoing compliance, NHA/designee will audit new personnel files weekly for the first four weeks, then monthly for two months, to ensure personnel files contain the signed job description. Results will be reported to QAPI for recommendations and follow-up.
Lack of Communicable Disease Clearance for New LPN Hire
Penalty
Summary
The facility failed to ensure that an employee was assessed by a healthcare practitioner and determined to be free from communicable diseases or conditions prior to providing resident care. Specifically, a review of the personnel file for a Licensed Practical Nurse revealed that there was no documentation showing a healthcare practitioner had made this determination at or before the employee's hire date. During an interview, the Nursing Home Administrator confirmed that the required written determination was not present in the employee's file as mandated by regulation.
Plan Of Correction
Employee #6 received her physical. To identify like residents that have the potential to be affected. NHA/designee to audit new hire files for the last 14 days to ensure personnel files contain employee physical. To prevent this from recurring, Human Resources educated by NHA/designee on personnel policies and procedures. To monitor and maintain ongoing compliance, NHA/designee to audit new personnel files weekly x4 then monthly x 2 to ensure personnel files contain employee physical. Results to QAPI for recommendations and follow-up.
Failure to Meet Minimum Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required minimum nurse aide staffing ratios across multiple shifts, as evidenced by a review of weekly staffing records. On numerous occasions, the number of nurse aides scheduled for the day, evening, and night shifts did not meet the mandated ratios based on the facility's census. For example, on several dates, the day shift had fewer nurse aides than the required 1:10 ratio, the evening shift fell short of the 1:11 ratio, and the night shift did not meet the 1:15 ratio. These deficiencies were documented for a total of 45 out of 63 reviewed shifts. Specific staffing shortfalls were detailed, including instances where the number of nurse aides was below the required threshold for the number of residents present. The report lists exact numbers for each shift and census, showing consistent under-staffing. Additionally, it was noted that on these dates, there were no additional higher-level staff available to compensate for the lack of nurse aides. An interview with the Director of Nursing confirmed that the facility did not meet the required nurse aide to resident ratios on the identified dates. The report does not mention any specific residents affected or provide details about their medical history or condition at the time of the deficiency.
Plan Of Correction
The facility cannot correct the CNA staffing hours on the cited dates; however, efforts are continuously being made to maintain the staffing hours within regulatory guidelines. Moving forward, the facility will make good faith efforts by continuing to recruit staff through participation in job fairs, offering sign-on and referral bonuses, and utilizing internal/external resources in the event of staffing requirement deficits. RDCS will re-educate the NHA, Nursing Administration, RN Supervisors, and Scheduler and HR/Payroll staff on PA staffing ratio requirements. To monitor and maintain ongoing compliance, the NHA/designee will audit the CNA staffing ratios weekly for four weeks, and then monthly for two months. The audit outcomes will be presented to the QAPI Committee for further review and recommendations. The facility cannot correct the LPN staffing hours on the cited dates; however, efforts are continuously being made to maintain the staffing hours within regulatory guidelines. Moving forward, the facility will make good faith efforts by continuing to recruit staff through participation in job fairs, offering sign-on and referral bonuses, and utilizing internal/external resources in the event of staffing requirement deficits. RDCS will re-educate the NHA, Nursing Administration, RN Supervisors, and Scheduler and HR/Payroll staff on PA staffing ratio requirements. To monitor and maintain ongoing compliance, the NHA/designee will audit the LPN staffing ratios weekly for four weeks, and then monthly for two months. The audit outcomes will be presented to the QAPI Committee for further review and recommendations.
Failure to Meet Minimum LPN Staffing Ratios on Multiple Shifts
Penalty
Summary
The facility failed to meet the required minimum staffing ratios for Licensed Practical Nurses (LPNs) on both day and night shifts for 15 out of 63 reviewed shifts. Specifically, on multiple dates, the number of LPNs scheduled for the day shift did not meet the mandated ratio of 1 LPN per 25 residents, with actual staffing falling short of the required number based on the facility's census. Similarly, on several night shifts, the facility did not provide the required 1 LPN per 40 residents, again resulting in fewer LPNs than necessary according to the census. Staffing records confirmed these deficiencies, and it was noted that no additional higher-level staff were present to compensate for the shortfall in LPN coverage on the affected shifts. An interview with the Director of Nursing corroborated that the facility did not meet the required LPN-to-resident ratios on the specified dates. The report does not mention any specific residents affected or detail any medical conditions or outcomes related to the staffing deficiencies.
Plan Of Correction
The facility cannot correct the LPN staffing hours on the cited dates; however, efforts are continuously being made to maintain the staffing hours within regulatory guidelines. Moving forward, the facility will make good faith efforts by continuing to recruit staff through participation in job fairs, offering sign-on and referral bonuses, and utilizing internal/external resources in the event of staffing requirement deficits. RDCS will re-educate the NHA, Nursing Administration, RN Supervisors, Scheduler, and HR/Payroll staff on PA staffing ratio requirements. To monitor and maintain ongoing compliance, the NHA/designee will audit the LPN staffing ratios weekly for four weeks, and then monthly for two months. The audit outcomes will be presented to the QAPI Committee for further review and recommendations.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to consistently provide the minimum required 3.2 hours of direct general nursing care per resident per 24-hour period, as mandated by regulation effective July 1, 2024. A review of staffing records revealed that on 17 out of 21 days reviewed, the facility's nursing hours fell below this minimum threshold. Specific dates were identified where the direct care nursing hours per resident ranged from 2.71 to 3.16, all below the required standard except for one day. An interview with the Director of Nursing confirmed that the facility did not consistently meet the required nursing care hours for each resident on a daily basis. The deficiency was identified through a combination of staffing level reviews and staff interviews, with no additional information provided regarding the medical history or condition of individual residents at the time of the deficiency.
Plan Of Correction
The facility cannot correct the inability to meet the minimum nurse staffing of 3.2 hours of general nursing care to each resident on the cited dates; however, efforts are continuously being made to maintain staffing hours within regulatory guidelines. Moving forward, the facility will make good faith efforts by continuing to recruit staff by participating in job fairs, offering sign-on and referral bonuses, and utilizing internal/external resources in the event of staffing requirement deficits. RDCS will re-educate the NHA, Nursing Administration, RN Supervisors, and Scheduler and HR/Payroll staff on PA staffing PPD requirements. To monitor and maintain ongoing compliance, the NHA/designee will audit daily nursing hours weekly for 4 weeks, and then monthly for 2 months. The audit outcomes will be presented to the QAPI Committee for further review and recommendations.
Failure to Implement Physician's Order for Anticoagulant Hold
Penalty
Summary
A deficiency occurred when a registered nurse failed to implement a physician's order to hold a resident's Eliquis (an anticoagulant) in preparation for a scheduled procedure. The resident, who had diagnoses including depression and atrial fibrillation, was admitted with a physician's order for Eliquis 5 mg every 12 hours. On March 7, 2025, a nursing progress note documented that the Eliquis was to be held starting March 21, 2025, in anticipation of a procedure scheduled for March 24, 2025, and that a new physician's order would be required to resume the medication post-procedure. However, on March 24, 2025, it was documented that the Eliquis had not been held as ordered, resulting in the cancellation and rescheduling of the procedure. The Director of Nursing confirmed that the registered nurse responsible for entering the hold order admitted to mistakenly not saving the order during the entry process. This failure to implement the physician's order as written led directly to the postponement of the resident's scheduled procedure.
Inadequate Facility-Wide Assessment for Resident Care Needs
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for resident care, as required by the Centers for Medicare and Medicaid Services. The assessment did not accurately identify the specific needs and services required by the resident population, including those with Alzheimer's, dementia, and behavioral health needs. The facility's assessment, last reviewed on July 26, 2024, did not reflect the current resident population's characteristics, such as the 30 residents with Alzheimer's or dementia and the 47 residents receiving psychiatric or psychological services. The facility's assessment inaccurately indicated that there were no residents with behavioral health needs requiring special treatments, despite evidence to the contrary. Additionally, the assessment failed to evaluate the overall number of facility staff and their capabilities to ensure a sufficient and competent workforce to meet each resident's needs. During an interview, the Nursing Home Administrator confirmed that the Facility Assessment lacked the required information, leading to a deficiency in meeting the regulatory requirements for resident care.
Inadequate Infection Control Program
Penalty
Summary
The facility failed to maintain and implement a comprehensive infection prevention and control program. A review of the facility's policy indicated the need for an organized, effective program to prevent, identify, control, and reduce infection risks, conduct surveillance of communicable diseases, and monitor employee health. However, the facility's infection control data did not reflect an operational system to monitor and investigate infection causes and spread. There was no evidence of a system to analyze clusters, changes in prevalent organisms, or increases in infection rates in a timely manner. The facility's infection control logs from November 2023 through October 2024 were incomplete, with no accurate tracking of infections for several months. Clinical records showed that a resident was treated for a fungal skin infection in April 2024, another for a urinary tract infection in July 2024, and another for a c-diff infection in August 2024. Interviews with the Director of Nursing and the Infection Preventionist confirmed the absence of complete infection control logs and the failure to maintain a comprehensive program. The facility did not demonstrate a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, and visitors according to accepted standards and guidelines.
Failure to Implement Bowel Management Program for Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services to restore normal bowel function for a resident, identified as Resident 75, who was frequently incontinent of bowels. The facility's Continence Management Program policy requires a plan to manage incontinence based on the resident's needs and capabilities, including a continence evaluation and a toileting plan. However, the clinical record review revealed that Resident 75, who was admitted with diagnoses including cellulitis and morbid obesity, was not properly assessed for a bowel management program despite being frequently incontinent. The resident was cognitively intact, with no communication or mental status issues, and was aware of his toileting needs but unable to walk to the bathroom. The admission Minimum Data Set assessment indicated frequent bowel incontinence, and the care plan noted occasional incontinence with interventions such as offering toileting after meals. Despite this, the resident experienced bowel incontinence on 96 occasions from admission through October 9, 2024. The Director of Nursing confirmed that the facility did not assess the resident for a bowel management program or implement interventions to minimize incontinence episodes, failing to provide the necessary treatment and services to restore normal bowel function.
Medication Administration and Storage Deficiencies
Penalty
Summary
The facility failed to maintain accurate records of controlled drugs and ensure proper drug administration for one resident, identified as Resident 75. The facility's policy requires maintaining separate individual controlled substance records for Schedule II medications and regularly reconciling inventory records with the medication administration record (MAR). However, a review of Resident 75's records revealed discrepancies between the Controlled Medication Utilization Record and the MAR, with 19 instances where the administration of OXYcodone-acetaminophen was not documented in the MAR. The Director of Nursing (DON) was unable to explain these discrepancies, confirming the facility's failure to implement effective procedures for reconciling controlled substance medications. Additionally, the facility did not store medications safely for another resident, identified as Resident 39. The facility's policy mandates that medications be stored securely in locked cabinets or medication rooms. However, during an observation, two medication packs of midodrine were found in Resident 39's dialysis communication binder at the nursing station, which is not an approved storage area. A registered nurse confirmed that the medication should not have been stored in the binder and should have been secured in an appropriate storage area. The Director of Nursing confirmed the facility's responsibility to ensure proper storage and security of medications, acknowledging that Resident 39's midodrine should not have been left in the dialysis communication binder. These deficiencies indicate a failure to adhere to the facility's policies and procedures regarding medication administration and storage, as outlined in the facility's pharmacy services manual.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect two residents from abuse by another resident, resulting in physical and verbal altercations. Resident 76, who has a history of dementia and unspecified psychosis, was involved in incidents where he physically and verbally abused Residents 35 and 64. On August 14, 2024, Resident 76 grabbed Resident 64's chin, shook her face, and used offensive language. On September 17, 2024, Resident 76 wrapped his arms around Resident 35 from behind, leading to faint bruising on her neck. Resident 76 has a documented history of aggressive behavior, including previous incidents of physical and verbal aggression towards staff and other residents. Despite this, the facility did not implement adequate supervisory measures to monitor Resident 76's behavior and prevent further incidents. Progress notes and incident reports indicate ongoing aggressive behavior by Resident 76, including attempts to enter other residents' rooms, verbal outbursts, and physical aggression towards staff. The facility's policy on abuse prevention was not effectively enforced, as evidenced by the repeated incidents involving Resident 76. The Director of Nursing confirmed the facility's responsibility to prevent resident-to-resident abuse and acknowledged the failure to adequately supervise Resident 76. The facility's lack of sufficient measures to monitor and manage Resident 76's behavior resulted in the physical abuse of Residents 35 and 64.
Failure to Provide Prescribed Adaptive Dining Equipment
Penalty
Summary
The facility failed to provide adaptive dining equipment as required and prescribed for a resident diagnosed with early onset Alzheimer's disease, protein-calorie malnutrition, and oropharyngeal dysphagia. The resident was admitted with specific needs for a maroon spoon and a Provale cup to manage food and liquid intake safely, as documented in a Speech Therapy discharge summary and a current physician order. These adaptive tools were intended to help the resident control the rate and amount of food and liquids to prevent aspiration and choking. During observations on two separate lunch meals, the resident was not provided with the prescribed maroon spoon or Provale cup. Instead, the resident was served with a white plastic spoon, a regular carton of milk, and a regular plastic juice cup on one occasion, and a stainless-steel spoon and a regular plastic juice cup with a straw on another occasion. The Director of Rehab confirmed that the adaptive equipment was not utilized during these meal observations, indicating a failure by the facility to adhere to the physician's orders and provide necessary adaptive eating/drinking equipment.
Failure to Provide Written Transfer Notice
Penalty
Summary
The facility failed to provide written notices of a facility-initiated hospital transfer for one resident, identified as Resident 53. According to regulatory requirements, a facility must notify the resident and their representative(s) of any transfer or discharge, including the reasons for the move, in writing and in a language and manner they understand. On August 5, 2024, Resident 53 was transferred to a hospital due to urgent medical needs that could not be met at the facility. However, the Immediate Discharge/Transfer Notice provided by the facility did not include a medical reason for the transfer. This deficiency was confirmed during an interview with the Nursing Home Administrator on October 11, 2024.
Unauthorized Administration of Benadryl to Control Resident Behavior
Penalty
Summary
The facility failed to ensure that a resident was free from chemical restraints not required for medical treatment. Resident B1, who was admitted with diagnoses including unspecified dementia, unspecified psychosis, and insomnia, was prescribed Risperdal to manage behaviors. Despite the medication, the resident continued to exhibit wandering behaviors and required constant redirection. During the period from June to July, the resident displayed symptoms such as drooling, being hunched over, and increased confusion, which were not consistent with the effects of Risperdal. Upon further investigation, it was discovered that the resident's urine tested positive for diphenhydramine (Benadryl), a medication for which he had no prescription. The presence of diphenhydramine coincided with periods when the resident appeared more sedated and did not exhibit his usual behavioral symptoms. Interviews with staff confirmed that the resident did not have visitors who could have provided the drug, suggesting that it was administered by facility staff without a physician's order. The facility's follow-up to the lab results concluded that a staff member had given the resident Benadryl to control his behaviors for convenience, but the individual responsible was not identified. This unauthorized administration of medication constitutes a failure to protect the resident from chemical restraints not required for medical treatment, as there was no documented evidence of a physician's order for Benadryl.
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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