King Of Prussia Skilled Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in King Of Prussia, Pennsylvania.
- Location
- 600 West Valley Forge Road, King Of Prussia, Pennsylvania 19406
- CMS Provider Number
- 395834
- Inspections on file
- 33
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at King Of Prussia Skilled Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with dementia, anemia, impaired mobility, and a high Braden risk score developed an in-house acquired right heel pressure injury that progressed to an unstageable ulcer with eschar, slough, malodor, and increasing size. Although a wound specialist repeatedly evaluated the wound, performed debridements, and issued updated orders to change from betadine and foam dressing to specific regimens using Vashe, medical-grade honey, and later 0.125% Dakin’s solution with dampened gauze and silicone foam adhesive dressings, staff continued to provide only the original betadine and foam treatment. Review of the TAR showed the specialist’s later orders were never implemented, and the DON confirmed the wound care recommendations were not followed, during which time the wound deteriorated and caused actual harm.
A resident with a documented rash and a dermatology diagnosis of arthropod assault had physician orders for Permethrin 5% cream that were not carried out on multiple ordered treatment dates. MAR review showed the medication was not administered as prescribed, and nursing notes indicated it was either not given without explanation or was awaiting pharmacy delivery. The DON reported that the cream was not applied because the pharmacy did not deliver it and acknowledged there was no follow-up with the pharmacy and no documentation that the physician was notified of the missed treatments.
A resident with a history of stroke, major depressive disorder, generalized anxiety disorder, and adult failure to thrive was mistakenly given nine medications prescribed for another resident when a nurse relied solely on verbal confirmation of identity instead of using two identifiers and triple-checking medications per facility policy. The resident became drowsy with low O2 saturation, later deteriorated to lethargy with hypotension, and was transferred to the ER, where they were diagnosed with accidental drug overdose, intubated, and admitted to the ICU.
Surveyors found an unidentified pill on the floor outside a resident’s room that was not labeled, packaged, or stored in a secure medication container, in violation of the facility’s medication storage policy requiring drugs to remain in pharmacy-dispensed containers within controlled environments. An LPN interviewed could not identify the pill or determine which resident it was prescribed for, and the DON confirmed that medications must be secured at all times and that an unidentified pill outside a resident room posed a risk for unintended ingestion.
The facility did not notify the ombudsman for a resident with a pulmonary embolism and failed to document the return of personal belongings for two residents after discharge or death, as confirmed by the DON and review of clinical records.
Two residents did not receive care according to physician orders: one received antihypertensive medication outside of prescribed blood pressure parameters, and another, who was NPO with a PEG-tube, was documented as receiving oral medications and pain medication for pain levels below the ordered threshold. Staff and leadership confirmed these discrepancies.
Two residents experienced significant weight loss that was not properly monitored or addressed. One resident with GERD lost over 6% of body weight in two weeks without a reweight or dietitian notification, while another with edema and dementia lost over 14% in two months without identification or intervention. The dietitian confirmed lack of notification and follow-up.
A resident with a physician's order for continuous oxygen via nasal cannula was not provided oxygen during ambulation, as documented in the clinical record. Staff failed to ensure oxygen therapy was maintained during mobility activities, resulting in noncompliance with the prescribed treatment.
A resident was discharged with 30 unused Morphine Sulfate Oral Tablets, and the facility failed to document the disposition of these controlled medications as required by policy and regulations. The DON confirmed that no medication disposition sheet was completed for the unused medication.
The facility did not maintain essential kitchen equipment, as evidenced by ongoing water leaks from the dishwasher and sink faucet. Staff and maintenance were aware of these issues for an extended period before repairs were requested, resulting in persistent water accumulation on the kitchen floor.
A resident with multiple medical conditions was transferred to the hospital after consuming liquid soap, but the incident was not reported to the DON or Department of Health as required. The resident was found with a soap bottle up to their mouth and later with vomit and an empty soap bottle in their room. The failure to report this incident violated federal and state regulations.
The facility did not meet the required nurse aide staffing ratios from December 30, 2024, to January 8, 2025. Specifically, the day shift was understaffed for ten days, the evening shift for four days, and the night shift for one day. These deficiencies were confirmed with the Nursing Home Administrator.
The facility did not meet the required LPN staffing levels during specific shifts over a ten-day period. On one evening shift, the facility lacked the mandated minimum of one LPN per 30 residents, and on two night shifts, it did not meet the requirement of one LPN per 40 residents.
The facility did not meet the required 3.2 PPD of direct resident care on four days within a ten-day period. The PPD was below the required level on December 31, January 2, January 4, and January 6, as confirmed by the Nursing Home Administrator.
The facility did not implement or maintain an effective training program for new and existing staff. Interviews with the Staff Educator, DON, and NHA confirmed the absence of a developed training program, as no facility policy was available to guide staff training.
The facility failed to provide effective communication training for four staff members, including an NA, LPN, RN, and Dietary Aid, hired between June and July 2024. The deficiency was confirmed by the NHA and violates Pennsylvania Code sections related to licensee responsibility, management, and staff development.
The facility failed to provide Resident Rights training for four new hires, including an NA, LPN, RN, and Dietary Aid, as revealed by a review of personnel records and confirmed by interviews with the Staff Educator and NHA.
The facility did not provide required training on abuse prohibition policies to a new hire, Dietary Aid Employee E6, as confirmed by interviews with the Staff Educator and NHA. This lack of training documentation violates Pennsylvania Code requirements for staff development and resident rights.
The facility failed to provide mandatory Infection Control training for four out of five new hires, including a Nurse Aide, an LPN, an RN, and a Dietary Aid. The Staff Educator could not provide evidence of the training, and the Nursing Home Administrator confirmed the deficiency.
The facility failed to provide consistent in-service training and competency evaluations for a nursing assistant employed for over a year. A review of the personnel file for this employee revealed a lack of documentation for required training, including dementia care and abuse prevention. Interviews with the Nursing Home Administrator and DON confirmed the absence of necessary training records.
The facility failed to provide behavioral health training for four staff members, including a Nurse Aide, an LPN, an RN, and a Dietary Aid, as required by a facility assessment. Training records showed no evidence of such training between specified dates, and interviews confirmed the deficiency.
A resident with moderate cognitive impairment reported being hit by a nursing assistant, but the facility's investigation was insufficient, as it only involved interviewing two staff members. The facility's policy requires a thorough investigation, including interviews with all potential witnesses, which was not conducted.
The facility failed to notify the State LTC Ombudsman of hospital transfers for four residents, including those with vomiting, a fall, a clogged feeding tube, and bleeding. The deficiency was confirmed through record reviews and an interview with the Director of Social Services.
A facility failed to accurately complete an MDS assessment for a resident with a tracheostomy. Despite a physician's order for daily tracheostomy care, the MDS did not reflect this care. The inaccuracy was confirmed by the LPN MDS Coordinator responsible for the assessment.
A facility failed to develop a baseline care plan within 48 hours of admission for a resident with complex medical conditions, including a stage 2 pressure ulcer. Despite receiving treatment for the ulcer, the care plan did not document the condition, and physician orders upon readmission lacked directives for ulcer care. Interviews confirmed the presence of the ulcer, but the care plan was not updated to include necessary interventions.
A resident received Midodrine, a medication for hypotension, against physician orders when their systolic blood pressure was above 140. This occurred four times in early August and 13 times in July, as confirmed by the MAR and the DON.
The facility failed to provide physician-ordered wound care for two residents with pressure ulcers. One resident's Stage 4 ulcer was not treated on multiple occasions due to a transcription error, while another resident's unstageable ulcer lacked documented treatment for an extended period. These deficiencies highlight lapses in following prescribed wound care protocols.
A facility failed to implement interventions to prevent a potential elopement for a resident. Despite the resident expressing a desire to escape and attempting to do so, no assessments were conducted to evaluate the risk, and no care plan was developed. The DON confirmed the lack of further assessments or interventions.
A resident with a Foley catheter did not receive appropriate care and services as required by facility policy. The resident returned from the hospital with a catheter, but there was no physician order, assessment, or documented care provided since readmission. Additionally, there was no follow-up with urology as indicated by a physician entry. The DON confirmed the lack of documentation and care, leading to a deficiency in catheter management.
The facility failed to monitor and address significant weight changes for two residents. One resident experienced a significant weight gain without a reweigh or physician notification, while another had an incorrect initial weight recorded, leading to a delayed response to a significant weight loss. These deficiencies violated several Pennsylvania codes related to clinical records, nursing services, and resident care policies.
A resident with a history of traumatic brain injury and other conditions did not receive the prescribed enteral nutrition as ordered by the physician. The resident's Medication Administration Record for two months showed no documentation of receiving the ordered 1600 ml per day. This was confirmed by the Nursing Home Administrator and DON.
The facility failed to properly manage psychotropic medications for two residents. One resident's medication dosage was not adjusted as recommended by a psychiatrist, while another resident was not monitored for behaviors or side effects after being prescribed Risperidone. Additionally, required AIMS testing was not conducted for the second resident. These deficiencies were confirmed by the DON.
The facility failed to date insulin pens on two medication carts and did not properly reconcile medications for a resident who passed away. Insulin pens were found opened and undated, and the medication disposition form for the resident's unused medications was incomplete and unsigned.
A facility failed to obtain laboratory studies as ordered for a resident, as determined through clinical record review and staff interview. The resident had physician orders for a CBC and CMP on three occasions, along with a tacrolimus level on two occasions. However, these tests were not completed as ordered. An interview with the DON confirmed the failure to perform the necessary laboratory tests, constituting a deficiency in nursing services.
A resident underwent several laboratory tests, including a Magnesium level, BMP, CBC, and UA C+S, without physician orders on multiple occasions. The DON confirmed these tests were conducted without the necessary orders, violating nursing services regulations.
The facility failed to implement infection control measures for two residents. A resident with an indwelling catheter was not placed on Enhanced Barrier Precautions, and another resident's tracheostomy care was conducted without proper hand hygiene and glove changes. These deficiencies were confirmed by the DON.
A resident with severe cognitive impairment was found lying naked in bed with the door and privacy curtain open, exposing the resident to anyone passing by. Housekeeping staff were present, and a nurse aide stated the resident was getting ready to be washed up before closing the door. The deficiency was confirmed by the DON and NHA.
The facility failed to provide hot water for all residents for two consecutive days. Maintenance staff confirmed the issue and indicated it would take a few hours to resolve. A water pipe burst on the second day caused no water in the shower rooms and low flowing water in the bathrooms. The deficiency was confirmed during an interview with the DON and the Nursing Home Administrator.
The facility failed to ensure that three out of six medication carts were locked and secured. One cart contained various creams, ointments, bandages, gauze, and powders, while another contained expired house medications. The DON was unaware of the unlocked carts and confirmed the expired medications should not have been in the unlocked cart.
Failure to Implement Wound Specialist Orders for Unstageable Heel Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to follow wound specialist treatment orders and provide consistent, appropriate care for an unstageable pressure ulcer on a resident’s right heel, resulting in wound deterioration and actual harm. The resident had dementia, anemia, and unspecified abnormalities of gait and mobility, and a Braden Scale score of 12 indicating high risk for pressure injury. The resident’s care plan included weekly wound assessments with measurements and descriptions, provision of ordered wound treatments, and monitoring for signs of skin breakdown. A progress note documented an in-house acquired right heel pressure ulcer on January 22, 2026, but did not include measurements or a description of the wound. An order dated January 25, 2026, directed skin prep to the right heel and offloading every shift, which was later discontinued. A wound consult on January 30, 2026, described the right heel as a deep tissue injury with intact skin, dark purple discoloration, and no drainage, and recommended discontinuing current wound care orders and following new recommendations. The wound at that time measured 2.8 x 4.4 x 0 cm. On March 21, 2026, a physician order was entered to paint the right heel with betadine and cover with a foam dressing daily and as needed. Subsequent wound consults documented progression of the wound to an unstageable pressure injury with 100% lifting eschar and malodor on April 10, 2026, at which time targeted debridement was performed and new treatment recommendations were given: cleanse with Vashe solution, apply medical-grade honey gel as the primary dressing, and cover with a silicone foam adhesive dressing daily and as needed. On April 15, 2026, the wound was noted to have worsened, with 100% slough, malodor, and positive autofluorescent imaging for bacterial burden; sharp debridement was performed and new orders were given to cleanse with 0.125% Dakin’s solution, apply Dakin’s-dampened gauze, and cover with silicone foam adhesive dressing daily and as needed. Further wound consults on April 22 and April 29, 2026, continued to categorize the right heel wound as unstageable, with measurements showing increasing size, moderate exudate, malodor, well-defined margins, dry/scaly periwound, and necrotic material, with updated recommendations to continue cleansing with 0.125% Dakin’s solution, using Dakin’s-dampened gauze and silicone foam adhesive dressing daily and as needed. Review of the March and April Treatment Administration Records showed that the wound specialist’s treatment recommendations and corresponding orders from April 10 and April 29, 2026, were not implemented; instead, staff continued to provide the earlier betadine and foam dressing treatment initiated on March 21, 2026, while the wound deteriorated. In an interview, the Director of Nursing confirmed that the wound care recommendations from the wound specialist were not followed and that the resident’s wound care was never changed as recommended on April 10 and April 29, 2026. The facility therefore failed to ensure that the resident’s wound care changes were followed, resulting in harm from deterioration of the unstageable right heel pressure ulcer.
Failure to Administer Ordered Permethrin Treatment and Notify Physician
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s orders for Permethrin 5% cream treatment for a resident with a dermatological rash and a dermatology diagnosis of arthropod assault. Nursing progress notes documented that the resident had a rash on the right front axilla, and a physician’s order dated February 4, 2026, directed application of Permethrin 5% cream from neck to feet for one day, to be left on for eight hours, then showered off, and repeated in seven days. The February 2026 MAR showed that Permethrin was not administered on February 4 and February 12, 2026. Nursing notes on February 5, 2026, recorded that Permethrin was not administered without providing a reason, and on February 12, 2026, documented that the medication was awaiting delivery. There was no documentation that the physician was notified of these missed treatments. A dermatology consult dated March 4, 2025, documented a diagnosis of arthropod assault and an order to start Permethrin 5% cream, applied from neck down to feet for eight hours and then rinsed off. The MAR showed that Permethrin was not administered on March 5, 2026, and nursing notes on that date indicated the medication was waiting for delivery from the pharmacy. During an interview, the DON stated that Permethrin cream was not applied on the identified dates because the pharmacy did not deliver the medication and confirmed there was no follow-up by the facility to the pharmacy to obtain the medication. There was also no documentation that the physician was notified of the missed Permethrin treatments, resulting in a failure to ensure the ordered treatment was provided as prescribed.
Significant Medication Error Leading to Hospitalization and ICU Admission
Penalty
Summary
The deficiency involves the facility’s failure to prevent a significant medication error when one resident was administered medications prescribed for another resident. Facility policy on Medication Administration, dated January 2025, required staff to review and confirm medication orders on the MAR and compare the medication label with the MAR, and to follow the Rights of Medication Administration, including using two resident identifiers and performing triple checks for the right drug and right dose. Despite these requirements, a licensed nurse entered a resident’s room, asked if the individual was the intended resident, accepted the affirmative response without further verification, and proceeded to administer the scheduled 8:00 p.m. medications. The resident who received the medications in error had been admitted with diagnoses including unspecified sequelae of cerebral infarction, major depressive disorder, generalized anxiety disorder, and adult failure to thrive. On the evening of the incident, this resident was given nine medications that were ordered for another resident: hydralazine 50 mg, buprenorphine 8 mg sublingual, quetiapine 25 mg, prazosin 1 mg, clonidine 0.3 mg, lorazepam 0.5 mg, melatonin 5 mg, mirtazapine 45 mg, and atorvastatin 40 mg. The error was discovered only after another resident informed the nurse that the individual who received the medications was not the intended resident. Following the administration of the wrong medications, the resident was assessed and found to be awake but drowsy, with a blood pressure of 110/61 and an oxygen saturation of 72%, which improved to 94% after 2L supplemental oxygen was applied. Later that evening, the resident’s condition changed, with the resident becoming lethargic, only arousable to sternal rub, and snoring, and the blood pressure recorded as 51/73. The resident was sent to the emergency room, where hospital records documented admission with a diagnosis of accidental drug overdose, the need for intubation in the emergency department, and subsequent transfer to the intensive care unit. The facility’s leadership confirmed that this was a medication error that resulted in hospitalization.
Unsecured, Unidentified Medication Found Outside Resident Room
Penalty
Summary
Surveyors identified a deficiency in medication storage and control when, during an onsite investigation on January 29, 2026, at approximately 10:15 a.m., they observed an unidentified pill on the floor outside the entrance of Resident R6’s room. The pill was not labeled, packaged, or stored in a secure medication container, contrary to the facility’s January 2025 medication storage policy, which requires medications to remain in pharmacy-dispensed containers that meet state and federal labeling requirements and to be stored in controlled environments such as medication carts, rooms, or cabinets. In an interview at 12:20 p.m., licensed employee E13 stated that staff were unable to identify the pill or determine which resident, if any, it had been prescribed to. In a subsequent interview at approximately 12:33 p.m., the Director of Nursing confirmed that medications are required to be secured at all times and acknowledged that an unidentified pill found outside a resident room posed a risk for unintended ingestion. The facility was found to have failed to ensure medications were properly controlled and secured in accordance with its policy and regulatory requirements.
Failure to Notify Ombudsman and Document Return of Personal Property
Penalty
Summary
The facility failed to follow required procedures for ombudsman notification and documentation of personal property return for residents upon discharge or death. Specifically, for one resident with a diagnosis of pulmonary embolism, there was no evidence that the ombudsman was notified as required. This was confirmed through interview with the Director of Nursing, who acknowledged that no notification had been sent. Additionally, for two other residents, the facility did not document the return of personal belongings after discharge or death. Both residents had lists of personal items recorded upon admission, but their closed clinical records lacked documentation showing that these items were returned to the appropriate parties. The Director of Nursing confirmed the absence of such documentation when presented with these findings.
Failure to Follow Physician Orders for Medication Administration and Pain Management
Penalty
Summary
The facility failed to follow physician orders and established policies for two residents. For one resident with essential hypertension, the clinical record showed that Metoprolol Tartrate was ordered to be held if systolic blood pressure (SBP) was less than 130. However, the medication was administered eight times outside of these parameters over a three-month period, contrary to the physician's order. This was confirmed through review of the medication administration record (MAR) and conveyed to facility leadership. For another resident with diagnoses including malignant neoplasm of the tongue, tracheostomy, and dysphagia, physician orders specified an NPO (nothing by mouth) diet and that all medications be administered via PEG-tube. Despite this, the MAR documented that multiple medications, including Morphine, Risperdal, Amoxicillin, and Docusate, were administered by mouth. Additionally, Morphine, ordered for moderate to severe pain, was given when the resident's documented pain level was 0 to 2. Interviews with staff and the resident confirmed that all medications should have been given via PEG-tube and that the resident was NPO. Documentation errors were also acknowledged by the Director of Nursing.
Failure to Monitor and Address Significant Weight Changes
Penalty
Summary
The facility failed to adequately monitor and address significant weight changes for two residents. For one resident with a diagnosis of gastroesophageal reflux disease, physician orders required weekly weights, but after a 6.2% weight loss was recorded over a two-week period, there was no evidence of a reweight being performed or that the facility dietitian was notified of the weight loss. The clinical record did not show any follow-up or intervention in response to this significant change. Another resident, diagnosed with localized edema and dementia, experienced a 14.25% weight loss over a two-month period. The clinical records and nutrition assessment did not indicate that this significant weight loss was identified or that any interventions were implemented to address it. Interviews with the dietitian confirmed that no reweight was obtained for the first resident and that the dietitian was not notified of the weight loss for either resident.
Failure to Follow Physician's Order for Continuous Oxygen Therapy
Penalty
Summary
The facility failed to follow a physician's order for continuous oxygen therapy for a resident who required oxygen via nasal cannula. Clinical record review showed that the resident had a current order for continuous oxygen, but documentation indicated that oxygen was not in use during ambulation. The facility's policy required oxygen to be provided according to equipment-specific procedures, and staff were aware that the resident was to receive oxygen continuously. An interview with the Director of Physical Therapy confirmed that the deficiency occurred when the resident was ambulated without oxygen, contrary to the physician's order.
Failure to Document Disposition of Controlled Medication After Resident Discharge
Penalty
Summary
The facility failed to document the disposition of medication for a discharged resident, specifically regarding 30 Morphine Sulfate Oral Tablets that were not administered. Facility policy requires that all medications not taken by the resident upon discharge must be disposed of according to federal, state, and local regulations, with proper documentation of the process. In this case, the resident was admitted to a hospital for observation due to chronic mid-line low back pain, and there was no further documentation regarding the resident's discharge or the handling of the remaining medication. A review of the closed records did not reveal any documentation indicating what happened to the unused Morphine Sulfate tablets. The DON confirmed during an interview that there was no medication disposition sheet for this resident. This lack of documentation is a violation of both facility policy and regulatory requirements for pharmaceutical services and recordkeeping.
Failure to Maintain Kitchen Equipment in Safe Operating Condition
Penalty
Summary
The facility failed to maintain essential kitchen equipment, specifically the dishwasher and sink faucet, in safe and operating condition. Observations on two separate occasions revealed puddles of water on the floor near the dishwasher and a leak in the sink faucet. Staff interviews confirmed that the maintenance department had been made aware of the dishwasher drain issue three months prior and the leaking faucet a month prior, but repairs had not been completed at the time of the observations. Review of facility work orders showed that a repair request for the faucet was only submitted after the most recent observation. The Nursing Home Administrator confirmed these findings.
Failure to Report Resident's Hospital Transfer Due to Soap Ingestion
Penalty
Summary
The facility failed to report an incident involving a resident who was transferred to the hospital after consuming a liquid soap product. The resident, who has medical diagnoses including dementia, heart failure, hypertension, stage 3 kidney disease, anxiety, and major depressive disorder, was found by a Certified Nursing Employee with a soap bottle up to their mouth. The resident was later discovered in their room with large amounts of vomit on the floor and an empty soap bottle in hand. Despite the severity of the situation, the incident was not reported to the Director of Nursing or the Department of Health as required. The incident was initially observed by Certified Nursing Employee E3, who reported it to Licensed Nursing Employee E4. However, the Director of Nursing confirmed that the incident was not communicated to them at the time it occurred. The failure to report the incident in a timely manner is a violation of the requirements under 42 CFR Part 483, Subpart B, and the 28 PA Code, which mandate immediate reporting of such incidents to the appropriate authorities.
Plan Of Correction
1. Resident 2 has suffered no adverse effects and a thorough investigation was complete. 2. Director of Nursing to be re-educated by designee and educate other staff members involved in any investigations the importance of thoroughly investigating allegations. 3. Director of Nursing or designee will conduct weekly audits x 12 weeks to ensure all DOH Event Reports are thoroughly investigated. 4. Nursing Home Administrator or designee will review outcome audits at QAPI Committee X 3 months. 5. March 15th, 2025
Staffing Deficiency in Nurse Aide Ratios
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides during the period from December 30, 2024, through January 8, 2025. Specifically, the facility did not maintain the minimum staffing ratio of one nurse aide per 10 residents on the day shift for ten days, one nurse aide per 11 residents on the evening shift for four days, and one nurse aide per 15 residents on the night shift for one day. These deficiencies were identified through a review of facility staffing data and were confirmed with the Nursing Home Administrator during a telephone interview on January 16, 2025.
Plan Of Correction
1. All residents received care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly for 4 weeks, then monthly for two months. Results will be taken to the QAPI for review and revision as needed. Date of compliance for this case: Monday, March 17th, 2025.
LPN Staffing Deficiency
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) during specific shifts over a ten-day period. Specifically, on one evening shift, the facility did not have the mandated minimum of one LPN per 30 residents. Additionally, on two separate night shifts, the facility did not meet the requirement of one LPN per 40 residents. These deficiencies were identified through a review of the facility's staffing data for the period from December 30, 2024, through January 8, 2025.
Plan Of Correction
1. All residents received care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly for 4 weeks, then monthly for two months. Results will be taken to the QAPI for review and revision as needed. Date of compliance for this case: Monday, March 17th, 2025.
Failure to Meet Required Nursing Care Hours
Penalty
Summary
The facility failed to meet the required Per Patient Day (PPD) of 3.2 hours of direct resident care for each resident on four specific days within a ten-day period from December 30, 2024, through January 8, 2025. The staffing data review revealed that on December 31, 2024, the PPD was 2.80, on January 2, 2025, it was 3.11, on January 4, 2025, it was 3.12, and on January 6, 2025, it was 2.98. This deficiency was confirmed through a telephone interview with the Nursing Home Administrator on January 16, 2025.
Plan Of Correction
1. All residents received care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly for 4 weeks, then monthly for two months. Results will be taken to the QAPI for review and revision as needed. Date of compliance for this case: Monday, March 17th, 2025.
Failure to Implement Staff Training Program
Penalty
Summary
The facility failed to implement and maintain an effective training program for new hires and existing staff members. This deficiency was identified through a review of facility policy, documentation, personnel records, and staff interviews. During an interview with the Staff Educator, it was revealed that there was no facility policy available regarding an effective training program for all staff. Further confirmation of this deficiency was obtained during an interview with the Director of Nursing and the Nursing Home Administrator, who acknowledged the absence of a developed training program for both new and existing staff members.
Failure to Provide Effective Communication Training
Penalty
Summary
The facility failed to provide training on effective communication for four out of five staff members, as revealed by a review of facility documents and staff interviews. The staff members identified without documented training included a Nurse Aide (NA), a Licensed Practical Nurse (LPN), a Registered Nurse (RN), and a Dietary Aid. These employees, hired between June and July 2024, did not receive effective communication training during the specified period from August 16, 2023, to August 15, 2024. During an interview on August 15, 2024, the Nursing Home Administrator confirmed the lack of training for these staff members. This deficiency is in violation of the Pennsylvania Code sections 201.14 (a), 201.18 (b)(1), and 201.20 (a)(c), which pertain to the responsibility of the licensee, management, and staff development.
Deficiency in Resident Rights Training for New Hires
Penalty
Summary
The facility failed to provide training on Resident Rights for four out of five staff members, which was identified through a review of new hire personnel records and interviews. Specifically, Nurse Aide Employee E3, Licensed Practical Nurse Employee E4, Registered Nurse Employee E5, and Dietary Aid Employee E6, all hired in 2024, did not have documented training on Resident Rights between August 16, 2023, and August 15, 2024. An interview with the Staff Educator, Employee E7, confirmed the absence of evidence for such training. The Nursing Home Administrator also confirmed the deficiency during an interview.
Failure to Train New Hire on Abuse Prohibition Policy
Penalty
Summary
The facility failed to provide necessary training on its abuse prohibition policy and specific procedures to a new hire, identified as Dietary Aid Employee E6. The personnel record of Employee E6, who was hired on July 29, 2024, lacked evidence of training on abuse, neglect, and exploitation for the period between August 16, 2023, and August 15, 2024. This deficiency was confirmed through interviews with the Staff Educator, Employee E7, and the Nursing Home Administrator, who both acknowledged the absence of training documentation for Employee E6. The failure to provide this essential training is a violation of the facility's obligations under the specified Pennsylvania Code sections related to staff development, management, and resident rights.
Failure to Provide Infection Control Training for New Hires
Penalty
Summary
The facility failed to provide mandatory Infection Control training as part of its infection prevention and control program for four out of five new hires. The personnel records and training documents reviewed revealed that a Nurse Aide, an LPN, an RN, and a Dietary Aid, all hired in 2024, did not receive documented Infection Control training within the specified period from August 16, 2023, to August 15, 2024. During an interview, the Staff Educator was unable to provide evidence of the required training for these employees. The Nursing Home Administrator confirmed the facility's failure to provide the necessary training, which is a requirement under the cited Pennsylvania Code regulations.
Deficiency in Nurse Aide Training and Competency Documentation
Penalty
Summary
The facility failed to ensure consistent in-service training and competencies for a nursing assistant, identified as Employee E13, who had been employed for over twelve consecutive months. A review of Employee E13's personnel file revealed a lack of documentation for ongoing training or an annual performance evaluation. Specifically, there was no evidence of at least twelve hours of in-service training per year, including essential topics such as dementia care, abuse prevention, addressing areas of weakness identified in performance reviews, facility assessments, special needs of residents, and care for cognitively impaired residents. An interview with the Nursing Home Administrator and the Director of Nursing confirmed the absence of required training documentation for Employee E13. This deficiency was identified during a review of personnel files, where Employee E13 was the only nursing assistant employed for over a year without the necessary training records.
Failure to Provide Behavioral Health Training
Penalty
Summary
The facility failed to provide required behavioral health training for four out of five staff members, as determined by a facility assessment. The staff members without documented training included a Nurse Aide, an LPN, an RN, and a Dietary Aid, all hired in 2024. The training records reviewed did not show any evidence of behavioral health training for these employees between August 16, 2023, and August 15, 2024. During interviews, the Staff Educator was unable to provide evidence of the training, and the Nursing Home Administrator confirmed the lack of training for these staff members. This deficiency is in violation of specific Pennsylvania Code regulations regarding the responsibility of the licensee, management, and staff development.
Failure to Investigate Alleged Physical Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of physical abuse involving a resident with a history of cerebrovascular disease and anxiety disorder. The resident, who was noted to have moderate cognitive impairment and was resistive and non-compliant with care, reported that a nursing assistant became angry and hit them in the face. The resident was unclear about the time of the incident and could not remember the staff member's name. Despite the resident's report, the facility's investigation was limited to interviewing only two staff members who initially received the report, without interviewing other staff who worked during the relevant time frame. The facility's policy on abuse prohibition requires a comprehensive investigation of any alleged abuse, including documentation of interviews with witnesses. However, the investigation into this incident did not meet these requirements, as it lacked interviews with additional staff who might have had relevant information. The nursing home administrator confirmed that only two staff members were interviewed, indicating a failure to conduct a thorough investigation as mandated by the facility's policy.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman regarding the transfer of four residents to the hospital. Resident 17 was transferred due to vomiting and weakness, Resident 96 due to a fall with a laceration, Resident 332 for multiple issues including a clogged feeding tube and lethargy, and Resident 333 for bleeding and changes in mental status. In each case, there was no documented evidence that the facility provided the required written notice to the Ombudsman. The deficiency was confirmed through a review of clinical records and an interview with the Director of Social Services. The lack of notification was identified for transfers occurring on various dates in 2024, affecting the residents' rights as outlined in the state code. The facility's failure to provide timely notification to the Ombudsman was a violation of the residents' rights and the facility's responsibilities under the applicable regulations.
Inaccurate MDS Assessment for Tracheostomy Care
Penalty
Summary
The facility failed to complete an accurate Minimum Data Set (MDS) assessment for a resident, specifically in Section O0110, which pertains to special treatments, procedures, and programs. The resident, who was at risk for respiratory impairment due to a tracheostomy, had a physician's order for daily tracheostomy care. However, the annual MDS assessment did not reflect this care, as column (2) of Section O0110E was not marked to indicate that the resident received tracheostomy care. This inaccuracy was confirmed during an interview with the LPN MDS Coordinator responsible for completing the MDS assessment.
Failure to Develop Timely Baseline Care Plan for Resident
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident, identified as Resident 333, which included the necessary information to properly care for the resident. Resident 333 was admitted with multiple medical diagnoses, including seizures, nontraumatic intracerebral hemorrhage, acute respiratory failure, gastrostomy, hepatic encephalopathy, cirrhosis of the liver with ascites, and rhabdomyolysis. Despite these complex medical conditions, the care plan did not adequately address the resident's needs, particularly concerning a stage 2 pressure ulcer. The physician orders dated July 9, 2024, included instructions for wound care, but the care plan dated July 10, 2024, only documented plans for wound management without specific details on the pressure ulcer. Upon readmission on July 26, 2024, after hospitalization for a change in mental status, the physician orders failed to include directives for pressure ulcer care, and the care plan did not document the presence of a pressure ulcer. Despite this omission, the Treatment Administration Report for July and August 2024 indicated that the resident was receiving treatment for a sacral pressure ulcer. Interviews with the wound nurse and the Director of Nursing confirmed the presence of a sacral pressure wound, yet the care plan lacked focus, goals, and interventions related to this condition. This oversight highlights a deficiency in the facility's ability to promptly and accurately update care plans to reflect the resident's current medical needs.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to administer medications as ordered for a resident, leading to a deficiency. The resident had a physician's order for Midodrine, a medication used to increase blood pressure, to be administered at a dosage of 5 milligrams three times a day for hypotension, with instructions to hold the medication if the systolic blood pressure exceeded 140. However, a review of the Medication Administration Record (MAR) for August 1-13, 2024, showed that the resident received Midodrine four times when the systolic blood pressure was above 140. Additionally, the MAR for July 2024 revealed that the resident received the medication 13 times under the same conditions. An interview with the Director of Nursing confirmed that the medication was not administered according to the physician's orders.
Failure to Administer Physician-Ordered Wound Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care as ordered by the physician for two residents. Resident 54 had a Stage 4 pressure ulcer on the sacrum, with physician orders to cleanse the wound with normal saline, apply Puracol and calcium alginate, and cover with foam dressing daily. However, the Treatment Administration Record (TAR) indicated that the wound was not treated on several specified dates in August 2024. An interview with the Director of Nursing revealed that the wound nurse had incorrectly transcribed the order, leading to the treatment being administered every other day instead of daily. Resident 127 had an unstageable pressure ulcer on the sacrum, with orders to cleanse the wound with wound spray, apply calcium alginate, and cover with foam dressing daily. The TAR showed that the wound was not treated from late June to early July 2024. The facility could not provide documentation to confirm that the wound care was administered during this period. These failures to adhere to physician orders for wound care resulted in deficiencies in the care provided to both residents.
Failure to Prevent Potential Elopement
Penalty
Summary
The facility failed to provide necessary interventions to prevent a potential elopement for a resident. According to the facility's policy on wandering, behaviors should be documented and reviewed to determine triggers and the effectiveness of interventions, which should then be addressed in the care plan. However, a review of the resident's progress notes revealed that the resident had expressed a desire to escape and had attempted to do so by entering a staircase. Despite this, there were no assessments conducted to evaluate the resident's risk for elopement, nor was a care plan developed to implement interventions to prevent such an event. The Director of Nursing confirmed that no further assessments or interventions were developed following the resident's statements.
Deficiency in Foley Catheter Care for a Resident
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with a Foley catheter. The resident, identified as Resident 20, was observed with a Foley catheter on August 12, 2024. Upon review of the resident's clinical records, it was found that there was no physician order for the Foley catheter, no assessment to determine the necessity of the catheter, and no documented evidence of care provided to the catheter since the resident's readmission. The resident had returned from the hospital with the catheter, as noted in the Nursing Clinical Admission Notes dated June 19, 2024, and a physician entry on June 25, 2024, indicated the need for a follow-up with urology. However, there was no order for a urology consult or any report of the resident being seen by urology. The Director of Nursing confirmed during an interview on August 15, 2024, that there was no order, assessment, urology consult, or documented evidence of care for the Foley catheter. This lack of documentation and follow-up care is a violation of the facility's policy and procedure titled 'Catheter: Urinary-Justification for Use,' which requires an assessment for the removal of the catheter and obtaining a physician order if the catheterization is necessary. The facility's failure to adhere to these protocols resulted in a deficiency in providing appropriate catheter care for Resident 20.
Failure to Monitor and Address Significant Weight Changes
Penalty
Summary
The facility failed to appropriately monitor and address significant weight changes for two residents, leading to deficiencies in care. Resident 85, diagnosed with Progressive Supranuclear Ophthalmoplegia and on a gastrostomy tube, experienced a significant weight gain of 34.6 pounds (31.86%) in one month. Despite the dietitian's note indicating the need for a reweigh to confirm the weight gain, the clinical records did not show that a reweigh was conducted or that the physician was notified of this significant change. Similarly, Resident 127, admitted with multiple fractures and a sacral pressure ulcer, had an initial weight recorded incorrectly at 166 pounds. This error was not identified until a month later when a reweigh showed a significant weight loss to 116.6 pounds, indicating a 29.79% decrease. The facility's records did not show that the physician was notified or that the resident's nutritional status was thoroughly assessed following this significant weight loss. The facility's failure to monitor and address these significant weight changes resulted in deficiencies under several Pennsylvania codes related to clinical records, nursing services, and resident care policies.
Failure to Administer Ordered Enteral Nutrition
Penalty
Summary
The facility failed to provide enteral nutrition as ordered by the physician for a resident. The resident, who was admitted from the hospital with a history of traumatic brain injury, gastrostomy, epilepsy, and encephalopathy, had a physician's order for Osmolite 1.5 at 100 ml/hr for 16 hours, totaling 1600 ml per day. However, a review of the Medication Administration Record for July and August 2024 revealed that there were no days documented where the resident received the prescribed total volume of 1600 ml per day. This deficiency was confirmed during an interview with the Nursing Home Administrator and Director of Nursing, who acknowledged the lack of documented evidence that the resident received the ordered tube feeding.
Failure to Monitor and Adjust Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents did not receive unnecessary psychotropic medications, as evidenced by the cases of two residents. For one resident, a psychiatrist recommended an increase in Depakote dosage from 250 milligrams twice a day to three times a day. However, the resident continued to receive the medication at the original dosage, indicating a failure to implement the psychiatrist's recommendation. This was confirmed by the Director of Nursing during an interview. Another resident was prescribed Risperidone for psychosis, hallucinations, and delusions, following the discontinuation of Abilify. The facility did not document any monitoring of the resident's behaviors or side effects related to the psychotropic medication. Additionally, there was no evidence of the Abnormal Involuntary Movement Scale (AIMS) test being completed, which is required for residents on antipsychotic medications. This lack of monitoring and testing was also confirmed by the Director of Nursing.
Failure to Date Insulin Pens and Reconcile Medications
Penalty
Summary
The facility failed to properly date and label insulin pens on two medication carts, as observed during a survey. On the skilled nursing unit, four insulin pens on medication cart 1 and one insulin pen on medication cart 2 were found to be opened and in use without being dated. Licensed Nursing Employees E10 and E5 confirmed that these pens should have been dated with the date they were first used, as per the facility's policy and procedure for insulin pens. Additionally, the facility did not correctly reconcile medications upon the discharge of a resident who passed away. The medical record of the resident showed active orders for Morphine Sulfate Solution and Lorazepam, but the medication disposition form did not specify the quantities of these medications that were destroyed. Furthermore, the staff responsible for the disposal of these medications failed to sign the medication disposition form. The Director of Nursing confirmed that the medication disposition form was not completed correctly.
Failure to Complete Ordered Laboratory Tests
Penalty
Summary
The facility failed to obtain laboratory studies as ordered for a resident, identified as Resident 20, which was determined through clinical record review and staff interview. The resident had physician orders for a CBC and CMP on three separate occasions: June 24, July 5, and August 1, 2024. Additionally, orders for a tacrolimus level were included on June 24 and July 5, 2024. However, the review of the resident's laboratory results revealed that these tests were not completed as ordered on any of these dates. An interview with the Director of Nursing on August 15, 2024, confirmed that the laboratory studies for Resident 20 were not completed as ordered. This failure to perform the necessary laboratory tests as per the physician's orders constitutes a deficiency in the facility's provision of nursing services, as outlined in 28 Pa. Code 211.12(c)(d) (1)(3)(5).
Unauthorized Laboratory Tests Conducted
Penalty
Summary
The facility conducted laboratory tests on a resident without obtaining a physician's order, which constitutes a deficiency. Specifically, the resident underwent several laboratory studies, including a Magnesium level, Basic Metabolic Panel (BMP), Comprehensive Blood Count (CBC), and a Urinalysis with Culture and Sensitivity (UA C+S), on multiple occasions without any corresponding physician orders. These tests were performed on June 11, June 21, June 24, and August 12, 2024. The Director of Nursing confirmed that these laboratory studies were completed without the necessary physician orders, which is a violation of the required nursing services regulations.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to implement proper infection control management for two residents, leading to deficiencies in care. For Resident 4, who had an active order for an indwelling catheter, the facility did not place the resident on Enhanced Barrier Precautions as required. Observations confirmed the absence of Enhanced Barrier Precaution signs in or outside the resident's room, and the clinical record lacked an order for these precautions. This oversight was confirmed by the Director of Nursing during an interview. For Resident 85, the facility did not adhere to infection control protocols during tracheostomy care. An observation of a licensed employee performing tracheostomy care revealed multiple breaches in infection control practices. The employee failed to perform hand hygiene, used unsterile gloves, and did not change gloves or wash hands between different stages of the procedure. These actions were discussed with the Director of Nursing, confirming the failure to ensure proper infection control during the resident's care.
Failure to Ensure Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure treatment with dignity and respect for a resident with severe cognitive impairment. The resident, who had multiple medical diagnoses including Dementia, Diabetes II, Peripheral Vascular Disease, and Chronic Kidney Disease, was observed lying naked in bed with the door and privacy curtain open, exposing the resident to anyone passing by. A female housekeeper was mopping the room at the time, and a male housekeeper was about to enter when the surveyor intervened. A nurse aide, who was informed of the situation, stated that the resident was getting ready to be washed up and then closed the door. The deficiency was confirmed during an interview with the Director of Nursing and the Nursing Home Administrator.
Failure to Provide Hot Water for Residents
Penalty
Summary
The facility failed to provide hot water for all residents for two consecutive days. On April 16, 2024, a tour revealed that the shower rooms and bathrooms were not receiving sufficient hot water, with temperatures approximately 98 degrees. Maintenance staff confirmed the issue and indicated that it would take a few hours to resolve. On April 17, 2024, a tour revealed no water in the shower rooms and low flowing water in the bathrooms due to a recent water pipe burst. Maintenance staff provided documentation from the repair company indicating an estimated arrival time of 3:30 pm on April 17, 2024. The deficiency was confirmed during an interview with the Director of Nursing and the Nursing Home Administrator on April 17, 2024.
Failure to Secure Medication Carts
Penalty
Summary
The facility failed to ensure that three out of six medication carts were locked and secured. Observations revealed that one cart behind the nurses' station contained various creams, ointments, bandages, gauze, and powders, while another cart adjacent to the nurses' station contained expired house medications. A third cart labeled as an emergency cart contained medical supplies but no medications. The Director of Nursing (DON) was unaware of the unlocked carts and confirmed that the expired medications should not have been in the unlocked cart. The deficiency was confirmed during an interview with the DON and the Nursing Home Administrator (NHA).
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.
Trusted data from CMS and state health departments
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.
Trusted by long-term care providers and associations.
