Lakewood Rehabilitation & Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Nanticoke, Pennsylvania.
- Location
- 147 Old Newport Street, Nanticoke, Pennsylvania 18634
- CMS Provider Number
- 395298
- Inspections on file
- 45
- Latest survey
- April 24, 2026
- Citations (last 12 mo.)
- 19 (1 serious)
Citation history
Health deficiencies cited at Lakewood Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
A resident with cerebral infarction, hemiplegia, and moderate cognitive impairment received IV micronutrient and hydration therapy with NS and added vitamins/minerals. The record showed no documentation that the resident or representative was informed of the risks, benefits, purpose, or alternatives, and no documented consent before the therapy was administered, despite a POLST indicating no hydration.
The facility failed to fully implement abuse prohibition procedures when it did not ensure required criminal background screening documentation was obtained and maintained for an external RN before the RN provided resident care and accessed resident medical records. Facility policy required background checks, including a PA State Police criminal history check and, when applicable, an FBI check, and the external IV therapy agreement assigned background screening and exclusion checks to the outside company. Review of the employee file did not show a PA PATCH clearance for the RN.
A resident with dementia alleged that she had been hit in the right shoulder, and a witness statement documented that she identified an agency LPN as the person who hurt her arm. The facility investigated the allegation but did not identify that staff member as the alleged perpetrator in its reports or investigative documentation, and the investigation concluded no perpetrator was identified.
Inaccurate MDS Coding for IV Nutritional Support: The facility incorrectly coded K0520 and K0710 on two residents’ MDS assessments after each resident received a one-time IV micronutrient hydration infusion ordered by the provider and administered by an outside nursing service. The records showed the infusions contained vitamins and minerals mixed in NS, but did not document that they provided calories as a primary nutritional source or met the RAI Manual definition of parenteral feeding. Despite this, the MDS assessments reflected parenteral/IV feeding and artificial route intake.
Failure to Check Ordered Vital Sign Parameters Before Medication Administration: The facility did not ensure nurses followed physician-ordered parameters before giving or evaluating the need for medications for two residents. One resident ordered Midodrine for hypotension did not have BP obtained every 8 hours to determine need, and another resident ordered Metoprolol ER did not have HR assessed before administration, despite facility policy requiring verification of vital signs when necessary.
Failure to individualize and evaluate restorative nursing services for a cognitively intact resident with DM and obesity who wanted to regain strength and return home. Staff documented restorative care and multiple refusals, but the care plan lacked measurable resident-centered goals, specific interventions, frequency/duration, and progress evaluation. The resident said he was not included in planning, and records did not show reasons for refusals, time spent on services, or program changes based on his needs or declining mobility.
Failure to assess ongoing need for indwelling catheter. A resident with CKD and Parkinson's disease had a Foley catheter ordered for neurogenic bladder, and the care plan addressed catheter-related care. However, the record showed no documented assessment for catheter removal or evaluation of whether continued catheterization remained clinically necessary after admission, and the NHA and RNC could not provide evidence of such review.
Failure to Timely Address Significant Weight Loss: A resident with PTSD and major depressive disorder, who was cognitively intact, had a significant 1-month weight loss that was not promptly reweighed, and the record did not show timely notification of the attending MD or the resident. The RD recommended fortified foods with meals after the weight loss was confirmed, but the nutritional interventions were not implemented promptly, and later ongoing weight loss led to a recommendation for a daily health shake.
PICC line care was not consistently completed or documented for two residents with PICC lines for IV antibiotics. One resident with COPD and another resident with chronic osteomyelitis had orders for daily external PICC length measurements, but records showed missed documentation on multiple days. For one resident, ordered PICC dressing and cap changes every 7 days were also not documented. The Regional Administrator of Clinical Operations stated the facility did not consistently monitor and maintain the PICC lines in accordance with physician orders, facility policy, and professional standards of practice.
Insufficient nursing staffing caused delays in resident care. The facility did not meet minimum NA and LPN staffing levels on multiple shifts, and two residents with significant care needs experienced delays in assistance. One resident with diabetes, depression, weakness, and neuropathy waited for help off a bedpan while an LPN remained outside the room and a nurse aide arrived later. Another resident with rheumatoid arthritis and schizophrenia waited over 2 hours for two-staff assistance out of bed because staff were busy and an aide was on break.
Pharmacist Failed to Complete Monthly MRRs A resident with major depressive disorder and PTSD, who was cognitively intact with a BIMS of 15, did not receive monthly MRRs as required by facility policy. Review of the clinical record showed missing pharmacist MRRs for multiple months, and the Regional Nurse Consultant confirmed there was no evidence the reviews were completed as required.
Failure to offer pneumococcal vaccination per CDC guidance: A resident with dementia had received PPSV23, but the clinical record showed no additional pneumococcal immunization and no evidence that the resident or representative was offered PCV15, PCV20, or PCV21. Surveyors also found no documentation that education or information was provided to support an informed decision, and the NHA and RNC could not provide evidence that the vaccine offer or education occurred.
Lack of PICC Line Training and Competency Validation: The facility failed to maintain an effective staff development program to ensure LPNs had documented education and competency for PICC line care. Two residents had PICC lines for antibiotic therapy, and agency LPNs accessed the lines to provide NS flushes and IV antibiotics. Records showed no PICC-specific training or competency validation for the LPNs, and the RA confirmed no structured PICC line training program existed for agency licensed nurses.
A resident admitted with a right foot abscess and MRSA had a physician order for Vancomycin IV every 12 hours, but two scheduled doses were not administered because the medication was not available. Facility policy required staff to ensure medication availability and, if unavailable, to notify the physician and obtain revised or hold orders. Review of the MAR and clinical record showed the missed doses and no documentation of physician notification, and the NHA and DON confirmed both the missed administrations and the lack of documented notification.
A cognitively impaired resident with dementia and severe impairment on BIMS was repeatedly exposed to sexual contact from another resident with intact cognition, beginning with an observed kiss in a shared bathroom and escalating to an incident where staff found the impaired resident naked in the other resident’s bed while he was touching her vaginal area and she complained of vaginal pain. Despite prior knowledge of inappropriate behaviors, staff reports of the aggressor sitting outside the victim’s room and staring at her, and documentation of the aggressor entering her room, the facility did not relocate the victim, did not fully investigate or rule out sexual abuse per its own policies, did not send the victim for emergency evaluation, and allowed the two residents to continue to be alone together. Safety interventions such as q15-minute checks were delayed, incompletely documented, and later supplemented with conflicting entries, and leadership could not explain the altered records, leading surveyors to cite the facility for failing to protect the resident from sexual abuse and to follow abuse investigation and monitoring requirements.
The facility failed to accurately and completely report an alleged sexual abuse incident between two residents, one with severe cognitive impairment and one with intact cognition. Staff eyewitnesses observed one resident unclothed in another resident’s bed and documented that the cognitively intact resident was touching the other’s vaginal area, followed by the impaired resident’s complaint of vaginal pain. However, the information submitted to external agencies omitted these observations and instead stated that the residents were just talking and that there were no signs of distress, contrary to the facility’s own abuse reporting policies requiring immediate, thorough, and factual reporting of such events.
Facility leadership, including the NHA and DON, did not effectively coordinate, monitor, or implement systems to protect residents from abuse, despite job descriptions requiring them to ensure a safe environment, oversee daily operations, and maintain resident safety through nursing services. The facility failed to identify, mitigate, and manage foreseeable risks in interactions between residents, particularly those with cognitive impairment, and did not ensure appropriate supervision or consistent enforcement of abuse-prevention policies. As a result of these administrative failures, one resident with cognitive impairment was sexually abused by another resident, leading to an Immediate Jeopardy citation under F600 for failure to ensure freedom from abuse.
Staff used a personal cell phone to record a resident with severe cognitive impairment receiving incontinence care, without consent and in violation of facility policy. The recording was made through a window with the blinds left open, and neither the resident nor the staff providing care were aware of being recorded.
Two corridor doors, serving resident rooms in a smoke compartment, were found to be stuck in their frames and unable to fully latch, as confirmed by facility leadership during the survey.
The facility did not perform four out of twelve required fire drills on a random basis, with all first shift drills occurring within the same hour over a twelve-month period. This was confirmed by both the Administrator and Director of Maintenance.
The facility did not ensure that residents were invited to participate in the development and review of their person-centered care plans, as required by policy. For three residents, including those with cognitive capacity and complex medical needs, there was no documentation of care plan conferences with the required interdisciplinary team or evidence that the residents or their representatives were invited to participate. Interviews confirmed that these residents had not been included in care planning meetings.
Three residents did not receive prescribed medications as ordered due to the facility's failure to follow procedures for obtaining and administering medications in a timely manner. Missed doses occurred when medications were unavailable, new prescriptions were needed, or pharmacy communication was delayed, as documented in medication records and nursing notes. The DON confirmed that procedures were not adequately implemented, resulting in missed medication administration for the affected residents.
Several residents reported that fresh ice water was only provided during the overnight shift and not during the day or evening unless specifically requested. Residents expressed that water left overnight became warm and was not routinely refilled during the day, contrary to facility policy. The NHA confirmed that the protocol for providing fresh water each shift was not consistently followed.
A resident with moderate cognitive impairment and neurological conditions was not provided access to a scheduled telephone hearing with an Administrative Law Judge due to a staff member's abrupt resignation and lack of communication to other staff, resulting in the resident missing the hearing and the appeal being dismissed.
A resident with dementia was inaccurately documented in the MDS assessment as having a limb restraint used less than daily, despite no physician orders for restraints and confirmation from the Regional Nurse Consultant that no restraints were ever used.
A resident with severe cognitive impairment and a high risk for falls did not have required fall prevention measures, such as a bed bolster and fall mat, in place as specified in the care plan. This lapse was confirmed by an LPN and the Nursing Home Administrator, indicating staff did not consistently follow the resident's fall safety interventions.
A resident with cancer and atrial fibrillation received an excessive dose of apixaban after both an outdated 5 mg order and a new 2.5 mg order remained active on the MAR following hospital readmission. An agency LPN administered both doses, resulting in a medication error due to failure to discontinue the previous order and remove the medication from the cart. The DON confirmed that professional nursing standards were not followed.
A resident with Alzheimer's disease and severe cognitive impairment, who had completed physical therapy, did not receive the recommended restorative nursing program (RNP) for ambulation as planned. The RNP was not incorporated into the care plan or implemented, and there was no documentation that staff were aware of this lapse, resulting in a failure to maintain the resident's functional mobility.
A resident with respiratory failure and COPD was observed receiving supplemental oxygen at 3 L/min via nasal cannula, despite a physician's order for 4 L/min. An LPN confirmed the discrepancy, and the Corporate Regional Nurse acknowledged the facility's responsibility to follow physician orders for oxygen administration.
A resident with multiple sclerosis was not properly offered or provided pneumococcal and influenza vaccines, as required by facility policy. Consent forms in the clinical record were incomplete, and there was no documentation of vaccine administration, refusal, prior receipt, or contraindication. The facility did not follow up to clarify the resident's immunization status.
A resident with paraplegia was discharged home without receiving the required prescriptions for physician-ordered medications, despite the discharge plan indicating these would be provided. Documentation showed that discharge instructions and medications were sent, but follow-up revealed the resident did not have the necessary prescriptions or an adequate medication supply until the next provider appointment. Facility leadership confirmed the error in the discharge summary and acknowledged the prescriptions were not given.
A resident requiring substantial staff assistance for ADLs, including showering, did not consistently receive scheduled showers as planned. Despite being cognitively intact and having a set shower schedule, the resident missed multiple showers due to staff not getting her up on time and not returning to offer showers after therapy or family visits. Documentation did not reflect refusals or preferences for bed baths, and the facility was unable to explain the lack of consistent shower provision.
Lakewood Rehabilitation and Healthcare Center failed to investigate an incident where a resident with a history of sexual offenses was observed masturbating in view of another resident with severe cognitive impairment. Despite the facility's policy requiring thorough investigations, no documented evidence of such an investigation was found. Staff interviews confirmed the lack of follow-up, highlighting a significant oversight in protecting residents from abuse.
The facility did not meet the required nurse aide staffing ratios on three night shifts, with staffing levels below the mandated minimum of 1 nurse aide per 15 residents. On these shifts, the facility had fewer nurse aides than required for the resident census, and no additional higher-level staff were available to compensate for the deficiency. The Nursing Home Administrator confirmed the failure to provide the minimum staffing hours.
The facility did not meet the required 3.2 hours of direct nursing care per resident per day on two occasions, providing only 3.14 and 3.02 hours. This was confirmed by the Nursing Home Administrator.
Lakewood Rehabilitation and Healthcare Center failed to provide timely pharmaceutical services for two residents, resulting in delays in medication administration and improper accounting of controlled substances. A resident admitted with a prescription for oxycodone-acetaminophen experienced delays due to pharmacy delivery issues, and discrepancies were found in the accounting of narcotic medications. Another resident faced delays in receiving Effexor and other medications, with no documentation explaining the delays. The facility confirmed these deficiencies during interviews.
A resident with known wandering risks and severe cognitive impairment eloped from Lakewood Rehabilitation and Healthcare Center due to inadequate supervision. The RN supervisor, unfamiliar with the residents, mistakenly allowed the resident to exit the facility, leading to the resident being found 0.5 miles away with hypothermia and injuries. The facility's failure to monitor and prevent the resident's unsupervised departure placed the resident in immediate jeopardy.
The facility failed to prevent a resident's elopement, placing eight residents at risk in immediate jeopardy. The administration and DON did not provide necessary supervision or implement effective interventions, demonstrating a systemic failure in oversight and resource allocation.
A resident at Lakewood Rehabilitation and Healthcare Center experienced a significant change in condition, including acute kidney injury and metabolic abnormalities. Despite these indicators, the facility failed to conduct timely monitoring or escalate care, resulting in the resident's deterioration and eventual death. The facility was aware of the condition change but did not provide necessary interventions or hospital transfer.
A facility failed to provide a written notice for a facility-initiated hospital transfer for a resident, as required by regulations. The notice should have included the reason for the transfer in a language and manner easily understood by the resident and their representative.
A facility failed to provide a resident or their representative with the required written notice of the bed-hold policy upon the resident's transfer to the hospital. The resident, who was cognitively intact, did not receive documentation detailing the duration and reserve bed payment policy. The Business Office Manager and nursing staff were responsible for providing this information, but no documentation confirmed the process was completed. The Nursing Home Administrator acknowledged the oversight, which potentially compromised the resident's rights and ability to plan for continuity of care.
A facility failed to complete prescribed lab services for a resident with elevated potassium levels, resulting in delayed monitoring and management. Despite orders for medication and a repeat BMP, the test was not conducted, and staff did not follow up or notify the prescribing practitioner. This oversight posed significant health risks to the resident.
The facility did not meet the required nurse aide to resident ratios on multiple shifts, failing to provide adequate staffing on the evening and night shifts. For example, there were insufficient nurse aides on the evening shift for a census of 99 and on the night shift for a census of 100. The Nursing Home Administrator confirmed the shortfall, and no additional staff were available to compensate.
The facility did not meet the required LPN to resident ratios on six shifts. On specific dates, the day, evening, and night shifts were understaffed, with no additional higher-level staff available to compensate. The Nursing Home Administrator confirmed these staffing deficiencies.
The facility did not meet the required minimum of 3.2 hours of direct resident care per resident daily. On several occasions, the facility provided less than the mandated hours, with the lowest being 2.69 hours. The Nursing Home Administrator confirmed this deficiency.
The facility failed to provide adequate supervision and effective safety interventions for two residents with dementia, resulting in multiple falls and a major injury. One resident, despite being severely cognitively impaired and requiring substantial assistance, did not receive consistent 1:1 supervision, leading to a hip fracture. Another resident experienced multiple unwitnessed falls due to ineffective interventions, with the facility failing to adjust measures to prevent further incidents.
A resident with pressure injuries and post-surgical care needs experienced inadequate pain management due to the facility's failure to implement timely interventions. Despite having physician orders for pain medications, the resident did not receive necessary pharmacological or non-pharmacological treatments, leading to severe pain episodes. Interviews with staff and family highlighted issues with medication availability and lack of adherence to the facility's pain management policy.
The facility failed to maintain a comprehensive infection control program, with incomplete tracking of UTIs and no analysis of infection clusters. An LPN did not follow proper infection control procedures during medication administration, and ice storage was unsanitary. These deficiencies highlight a lack of consistent infection control implementation.
The facility failed to maintain an effective pest control program, with observations of rodent feces in resident rooms and structural deficiencies allowing pest entry. Interviews with two residents confirmed sightings of mice, and the NHA and DON could not provide evidence of addressing pest management recommendations.
The facility compromised the privacy of several residents during a physician visit by conducting examinations in a room with glass walls and open doors, visible to others. Additionally, a resident's therapy instructions were improperly posted on their room wall, visible from the bed. The NHA confirmed these actions compromised residents' dignity and privacy.
Failure to Obtain Informed Consent for IV Micronutrient and Hydration Therapy
Penalty
Summary
The facility failed to ensure Resident 103 was fully informed of and able to participate in treatment decisions related to intravenous micronutrient and hydration therapy. Resident 103 was admitted with diagnoses including cerebral infarction and hemiplegia, and the quarterly MDS dated November 3, 2025, indicated problems with short-term and long-term memory, moderate cognitive impairment, and a need for cues and supervision for daily decisions. The record also included a Pennsylvania POLST dated July 20, 2024, showing the resident elected that no hydration and no artificial nutrition by tube be provided. A physician order dated October 28, 2025, directed one-time hydration infusion of 500 ml of 0.9 percent normal saline at 250 ml per hour through an outside contracted nursing service, with added micronutrients including B-complex, thiamine, riboflavin, niacin, dexpanthenol, pyridoxine, methylcobalamin, magnesium chloride, calcium chloride, and zinc. The MAR showed the therapy was administered on October 28, 2025. The clinical record contained no documented evidence that Resident 103 or the resident's representative was provided information about the risks, benefits, purpose, or alternatives of the therapy, and no documented evidence of consent before administration. During interview, the NHA and RNC were unable to provide documentation that the resident or representative had been informed, given an opportunity to participate in the decision-making process, or consented prior to treatment.
Missing Criminal Background Clearance for External RN
Penalty
Summary
The facility failed to fully implement abuse prohibition procedures by not ensuring required criminal background screening documentation was obtained and maintained for Employee 9 before the employee provided resident care and accessed resident medical records. The facility policy stated it would not employ or otherwise engage individuals found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law, and that it would obtain required background checks, including a Pennsylvania State Police criminal history check within 30 days of hire and an FBI check when applicable. A review of the external intravenous therapy services agreement also showed the external company was responsible for conducting background checks and federal exclusion screenings for associates with direct resident contact or access to resident records. Clinical record review showed Employee 9, an external registered nurse, provided care to residents and accessed resident medical records on October 27 and October 28, 2025. During interview, the Nursing Home Administrator and Regional Nurse Consultant stated the external intravenous therapy company maintained Employee 9's personnel records. However, the personnel records provided by the facility did not show evidence of a Pennsylvania State Police criminal history clearance through the PATCH system for Employee 9. The deficiency was cited because the facility failed to ensure the required criminal background screening documentation was obtained and maintained for this employee before allowing resident care and record access.
Failure to Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to accurately and completely report, document, and investigate an allegation of abuse involving Resident 81, a resident admitted with dementia. The resident stated she had been hit in the right shoulder by a woman, and the facility investigated the allegation as physical abuse but concluded it could not be substantiated based on resident and staff witness statements, resident assessment findings, and the facility investigation. A witness statement documented that Resident 81 identified the assistant director of nursing's daughter, an agency LPN, as the person who hurt her arm, and also complained of pain to her right upper arm. During interviews, facility staff confirmed that Resident 81 identified the agency LPN as the individual who hurt her arm, but the facility's submitted reports and investigative documentation did not identify that staff member as the alleged perpetrator. The facility investigation concluded there was no alleged perpetrator identified, and the report states the facility failed to thoroughly investigate the allegation to determine whether the agency LPN was involved and failed to provide complete reporting information to the State Survey Agency and the AAA.
Inaccurate MDS Coding for IV Nutritional Support
Penalty
Summary
The facility failed to ensure MDS assessments accurately reflected the clinical status of two residents by incorrectly coding Sections K0520 and K0710 on their assessments. The deficiency involved Resident 112 and Resident 103, whose records were reviewed along with the RAI Manual, MDS assessments, and staff interview. The report states that the facility did not code the assessments in accordance with RAI Manual guidance for parenteral/IV feeding and artificial route intake. Resident 112 had diagnoses including moderate protein-calorie malnutrition and received a one-time IV micronutrient hydration therapy ordered by the CRNP and administered by an outside contracted nursing service. The infusion consisted of vitamins and minerals, including B-complex, thiamine, riboflavin, niacin, dexpanthenol, pyridoxine, methylcobalamin, magnesium chloride, calcium chloride, and zinc, mixed in 500 ml of normal saline. The MAR showed the infusion was administered and completed, but the record did not document that it provided calories as a primary nutritional source, replaced oral intake, or met the RAI Manual definition of parenteral nutrition. Despite this, the IPA MDS coded K0520 as yes and K0710A and K0710B to reflect parenteral/tube feeding intake and fluid intake. Resident 103 had diagnoses including cerebral infarction and hemiplegia and also received a one-time IV micronutrient hydration therapy ordered by the physician and administered by an outside contracted nursing service. The infusion contained vitamins and minerals mixed in 500 ml of normal saline, and the MAR documented that it was given. The quarterly MDS coded K0520A as parenteral/IV feeding performed and also coded K0710A and K0710B for artificial route intake and fluid intake, but the clinical record did not support that the infusion constituted parenteral feeding or artificial nutritional support under the RAI Manual. During interview, the NHA and RNC reviewed the information and the facility acknowledged the inaccuracies related to both residents' MDS assessments.
Failure to Check Ordered Vital Sign Parameters Before Medication Administration
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of quality by not ensuring licensed nurses accurately administered or evaluated the need for prescribed medications according to physician-ordered parameters for two residents. Facility policy required medications to be given in accordance with provider orders and only after verification of the right medication, dose, route, time, resident identity, and any contraindications, with vital signs verified when necessary. The report identified that the facility did not follow these requirements for Resident 4 and Resident 12. Resident 4 was cognitively intact with a BIMS score of 15 and had diagnoses including cerebral infarction. A physician ordered Midodrine HCl 5 mg by mouth every eight hours as needed for hypotension, with instructions to hold the medication if systolic blood pressure was greater than 100 mmHg. Review of the eMAR showed that during the period the medication was ordered, Midodrine was not administered and blood pressure was not obtained every eight hours to determine the need for the medication. Resident 12 was cognitively intact with a BIMS score of 13 and had diagnoses including primary generalized osteoarthritis and tachycardia. A physician ordered Metoprolol Succinate 12.5 mg ER daily, with instructions not to administer if systolic blood pressure was less than 90 mm/Hg or heart rate was less than 60 beats per minute. Review of the eMAR showed that the resident's heart rate was not assessed prior to administering Metoprolol Succinate to determine whether it was safe to give the medication.
Failure to Individualize and Evaluate Restorative Nursing Program
Penalty
Summary
The facility failed to implement and evaluate an individualized restorative nursing program for a cognitively intact resident with diabetes mellitus and obesity who wanted to get stronger enough to return home. The resident stated that restorative nursing services were being documented as provided, but he was not being offered the services in a way that supported consistent strengthening, was not included in decisions about when services would occur or what exercises would be done, and did not receive periodic updates or changes to the program. The resident also reported that the program was not effective to meet his needs to improve strength and independence. Clinical record review showed the resident was discharged from therapy to a restorative nursing program to maintain current functioning, and therapy staff reported that at discharge the resident ambulated 25 feet with a front-wheeled walker. Facility staff identified restorative nursing as including bed positioning and mobility activities such as rolling side to side and sitting at the edge of the bed, and an occupational therapist stated the resident’s ability to roll in bed had declined since the March 2026 assessment. However, the care plan did not contain an individualized restorative nursing plan with specific interventions, exercise frequency or duration, measurable goals, methods to evaluate progress, or interventions tied to the resident’s stated goal of improving strength for possible discharge home. Restorative documentation for March 2026 showed the resident refused services 17 times on day shift and 10 times on evening shift, but the records did not identify reasons for the refusals, resident concerns, or attempts to modify the program to improve participation. Documentation for completed services also did not include the amount of time services were provided, making it impossible to determine whether the program was effective in maintaining, improving, or declining the resident’s functioning. The nurse aide interviewed could not explain how the facility evaluated the program for needed modifications, and the Nursing Home Administrator could not provide evidence of ongoing documentation showing measurable results, resident-centered goals, evaluation of effectiveness, or changes based on the resident’s progress, refusals, declining functioning, or stated preferences.
Failure to Assess Ongoing Need for Indwelling Catheter
Penalty
Summary
The facility failed to ensure a resident who entered with an indwelling urinary catheter was assessed for catheter removal at the earliest possible time unless continued catheterization was clinically necessary. Resident 11 was admitted with diagnoses including chronic kidney disease and Parkinson's disease, and had a physician order for a Foley catheter with a 30 cc balloon to straight bag gravity drainage for neurogenic bladder. A care plan initiated on March 6, 2026 identified the resident's need for an indwelling catheter related to neurogenic bladder and included interventions for catheter-related complications, including reviewing catheter risks with the resident and resident representative and providing catheter care every shift and as needed. Clinical record review found no documented evidence that the facility assessed Resident 11 for catheter removal or evaluated whether continued catheterization remained clinically necessary after admission on December 10, 2025. During an interview on April 24, 2026, the nursing home administrator and regional nurse consultant were unable to provide documentation showing an ongoing need for catheterization or that the resident's clinical condition demonstrated continued necessity. After surveyor inquiry, the facility obtained a physician order scheduling the resident for an appointment with an external urology specialist.
Failure to Timely Address Significant Weight Loss
Penalty
Summary
The facility failed to timely identify changes in nutritional parameters, implement appropriate nutritional interventions, and notify the attending physician and the resident regarding significant weight loss for one resident. The resident was admitted with diagnoses including PTSD and major depressive disorder, and a Quarterly MDS dated February 2, 2026, documented that the resident was cognitively intact with a BIMS score of 15. The resident’s weight record showed a weight of 125.3 pounds on February 1, 2026, and 115.4 pounds on March 1, 2026, reflecting a loss of 9.9 pounds, or 7.9 percent body weight loss in one month. The facility policy required a re-weight when a significant weight change was identified, but the re-weight was not obtained until 22 days later. A nutrition note dated March 22, 2026, documented the significant weight loss and underweight status, noted the resident was receiving a vegetarian diet with regular textures and thin liquids, and recommended fortified foods with all meals to increase calorie and protein intake. The record also showed that physician orders for weekly weights were obtained on March 22, 2026, and orders for fortified foods and continuation of the vegetarian diet preference were entered on March 24, 2026, two days after the RD recommendation. Later, another RD note documented continued weight loss of 8.9 percent since February 1, 2026, and recommended a daily health shake with breakfast, which was ordered the same day. The clinical record did not show documented evidence that the attending physician and the resident were notified of the significant weight loss identified on March 1, 2026, and it also did not show that the recommended nutritional interventions, including fortified foods with meals, were implemented timely.
PICC Line Monitoring and Dressing Care Not Completed as Ordered
Penalty
Summary
The facility failed to ensure intravenous therapy was provided and monitored in accordance with physician orders and professional standards of practice for two residents with PICC lines. Facility policy for central venous catheter care stated that IV site care and dressing changes were required at established intervals or immediately if the dressing was damp, loosened, or visibly soiled, and that the external length of the catheter should be measured with each dressing change or if dislodgement was suspected. The policy also directed staff to check the State Nurse Practice Act regarding LPN scope of practice for central venous catheter dressing care. Resident 1, who was cognitively intact and had a PICC line for antibiotic administration, had a physician order requiring daily measurement of the external PICC length, but the eMAR showed no documentation of measurements on February 5, 11, 24, 25, and 26, 2026. Resident 30, who was cognitively intact and had a PICC line for antibiotic administration related to chronic multifocal osteomyelitis of the left ankle and foot, also had an order for daily external PICC length measurement, but the treatment record showed no documentation on March 14, 15, and 21, 2026. In addition, physician orders required PICC dressing and cap changes every seven days for Resident 30, and the treatment administration record showed no documentation that those changes were completed at the required intervals. The Regional Administrator of Clinical Operations stated the facility did not consistently monitor and maintain PICC lines in accordance with physician orders, facility policy, and professional standards of practice for Residents 1 and 30.
Insufficient nursing staffing caused delays in resident care
Penalty
Summary
The facility failed to provide sufficient nursing staff with the appropriate competencies to meet resident needs, including not meeting minimum nurse aide staffing requirements on five of 21 shifts reviewed and not meeting minimum LPN staffing requirements on nine of 21 shifts reviewed. The staffing shortages occurred on multiple dates in January, March, and April 2026, and the deficiency was cited under management, resident rights, and nursing services regulations. Resident 10 had diagnoses including diabetes and depression and was cognitively intact with a BIMS score of 14. His care plan required assistance with bed mobility from one staff member, transfers from two staff members, and toileting assistance as needed due to generalized weakness and neuropathy. During an observation on April 22, 2026, at 8:33 AM, Resident 10 stated he had been waiting about ten minutes for help after using the call bell for assistance off a bedpan. An LPN was observed standing outside the room near a medication cart while the resident waited, and a nurse aide did not enter the room until 8:46 AM and assist him off the bedpan at 8:47 AM. Resident 14 had diagnoses including rheumatoid arthritis and schizophrenia and was cognitively intact with a BIMS score of 15. Her care plan required assistance from two staff members for all transfers and ADLs related to rheumatoid arthritis and generalized weakness. During an observation on April 21, 2026, at 9:50 AM, Resident 14 was in bed and said she had been waiting since about 7:20 AM for staff to help her out of bed. At 10:01 AM, an LPN entered, administered medications, and acknowledged the active call light, stating the resident would need to wait until two nurse aides were available because the assigned aide was on break. Staff later confirmed that the resident had requested help around breakfast time but could not be assisted because staff were busy passing out meals and only later had two nurse aides available. The Nursing Home Administrator was unable to explain the delays in care.
Pharmacist Failed to Complete Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist completed monthly medication regimen reviews for one resident reviewed, Resident 42. The facility policy titled Medication Regimen Reviews stated the consultant pharmacist reviews each resident’s medication regimen at least monthly and conducts a thorough review of the medical record to identify medication-related problems, errors, and other irregularities. Review of Resident 42’s clinical record showed the resident was admitted with diagnoses including major depressive disorder and PTSD, and the Annual MDS dated January 28, 2026, indicated the resident was cognitively intact with a BIMS score of 15. Review of the resident’s clinical record and medication regimen reviews from June 2025 through March 2026 showed the pharmacist did not complete MRRs during June 2025, August 2025, September 2025, and October 2025. During an interview on April 24, 2026, the Regional Nurse Consultant confirmed there was no evidence the pharmacist conducted monthly medication regimen reviews as required for Resident 42.
Failure to Offer Pneumococcal Vaccination per CDC Guidance
Penalty
Summary
The facility failed to offer pneumococcal immunization in accordance with its policy and current CDC recommendations for one resident reviewed. The facility policy titled Pneumococcal Vaccine stated that pneumococcal vaccines are to be offered to residents and administered or re-administered in accordance with current CDC recommendations at the time of vaccination. CDC guidance reviewed by surveyors stated that individuals age 50 years or older who previously received PPSV23 should receive PCV15, PCV20, or PCV21 at least one year after the PPSV23 dose. Resident 81 was admitted with a diagnosis that included dementia and was documented as [AGE] years old. The resident received PPSV23 on September 1, 2024, but the clinical record contained no additional documentation of pneumococcal immunization. Surveyors found no evidence that the resident or the resident's legal representative was offered PCV15, PCV20, or PCV21, and no documented evidence that education or information was provided to support an informed decision regarding pneumococcal vaccination. During interview, the NHA and RNC were unable to provide evidence that the resident or representative had been offered pneumococcal vaccination or educated in accordance with current CDC recommendations.
Lack of PICC Line Training and Competency Validation
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for licensed nursing staff to ensure they had the knowledge and competencies needed to safely manage PICC lines for two residents. The report states that federal requirements call for staff training based on the facility assessment, and Pennsylvania nursing regulations require nurses performing IV therapy, including PICC line care, to complete appropriate education, supervised clinical instruction, and ongoing competency validation. The facility policy on administration of medication or flush through a central venous line also stated that the procedure is complex and requires necessary education, training, and experience. One resident was admitted with a PICC line for antibiotic administration, and physician orders required routine flushing of the line with 10 mL of normal saline. The eMAR showed two agency LPNs repeatedly accessed the PICC line to administer normal saline flushes on multiple occasions in February 2026. Another resident was admitted with a PICC line for antibiotic therapy related to chronic multifocal osteomyelitis, and physician orders required the line to be flushed with 10 mL of normal saline before and after medication administration and during the day and evening shift. The March 2026 eMAR showed an agency LPN accessed the PICC line to administer flushes and IV antibiotics, including Ampicillin Sodium and Ceftriaxone Sodium. Employee personnel records showed no documented education, training, or competency validation related to PICC line management for either agency LPN. The report also states there was no evidence that the facility or contracted agency provided a structured training program, competency validation, or ongoing education specific to PICC line care for licensed nursing staff. During interview, the Regional Administrator of Clinical Operations confirmed the facility could not provide documentation of PICC line-specific training or competency validation and had not developed or implemented a training program specific to PICC line management for agency licensed nurses.
Failure to Obtain and Administer Ordered IV Antibiotic and Notify Physician When Medication Unavailable
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely acquisition and administration of a prescribed IV antibiotic and to follow its own policy for unavailable medications. Facility policy on unavailable medications, last reviewed December 8, 2025, requires nursing staff, in conjunction with the contracted pharmacy, to make every effort to ensure ordered medications are available, and upon learning a medication is unavailable, to notify the physician, obtain a new order and discontinue the prior order, or obtain a hold order. For one resident, a physician’s order for Vancomycin IV 1000 mg/200 ml every 12 hours for MRSA was initiated on March 20, 2026. An admission progress note that day documented the resident’s admission with a right foot abscess and MRSA and indicated that the physician’s orders were reviewed with no clinically significant order issues identified. A review of the medication administration record for March 2026 showed that the resident did not receive the ordered Vancomycin IV doses scheduled for 9:00 PM on March 20 and 9:00 AM on March 21. The clinical record contained no documentation that staff notified the physician that the Vancomycin IV was not available for administration. During interviews, the NHA and DON confirmed that the resident did not receive the Vancomycin IV as ordered because the medication was not available at those scheduled times and that they were unable to provide documentation of physician notification regarding the unavailability of the antibiotic. This resulted in two missed administrations of the prescribed antibiotic medication for this resident.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse and Inadequate Investigation
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from sexual abuse by another resident and to follow its own abuse and sexual abuse investigation policies. Resident 1, who had dementia and a BIMS score of 7 indicating severe cognitive impairment and impaired judgment and decision-making capacity, shared a bathroom with Resident 2, who had intact cognition with a BIMS score of 14. On one evening, a nurse aide (Employee 1) observed Resident 1 in the shared bathroom unlocking and slightly opening the door to Resident 2’s room, which was described as a habitual signal that she was finished using the bathroom. Resident 2 opened his door, leaned toward Resident 1, and kissed her on the lips. Employee 1 immediately removed Resident 1 from the bathroom and notified the RN Supervisor. The facility’s investigation documented this event and noted that Resident 2 later stated, “She is my friend. Who cares if we kissed.” Following this initial incident, staff reported ongoing concerning behaviors by Resident 2 toward Resident 1. Employee 1 stated that she and another nurse aide frequently remained in Resident 1’s room to ensure her safety because Resident 2 continued to sit outside Resident 1’s room and stare at her in common areas. Facility documentation showed that the inside door to Resident 2’s side of the shared bathroom was locked and a bedside commode was provided to limit his access to the shared bathroom, and that the facility attempted to relocate Resident 2 but he declined. The Nursing Home Administrator acknowledged that Resident 1 was not relocated after the first incident due to concern that a move would increase her confusion, and Resident 1 was not offered a room change despite her cognitive impairment. Progress notes documented that Resident 2 exited Resident 1’s room after a visit with her and her family and that he later argued with staff, felt he was being watched, and could not be redirected. Social Services met with Resident 2 and documented that he reflected on past interactions with Resident 1 and was instructed not to enter her room or allow her into his room. A subsequent, more serious incident occurred when Employee 3 and Employee 4, both nurse aides, were conducting rounds after midnight and found Resident 1 missing from her bed, with her wheelchair empty and next to the bed. They found the shared bathroom door locked from the inside and, due to the known prior history between the residents, proceeded to Resident 2’s room. There, they observed Resident 1 lying naked in Resident 2’s bed while Resident 2 was touching her vaginal area, with her legs open. Employee 3 later clarified in interview that she observed Resident 2’s fingers inside Resident 1’s vagina and that she yelled for the supervisor, at which point Resident 1 went to the bathroom, dressed, and wiped herself. Both aides documented that Resident 1 complained of vaginal pain and was observed checking herself in the bathroom. The facility’s investigative documentation recorded that both residents stated they had been talking, that the facility determined there was no evidence of penetration, and that no further assessment was completed at that time. The Nursing Home Administrator stated Resident 1 was not sent to the emergency department for evaluation despite facility policy indicating the need for evaluation following suspected sexual abuse. Despite these events and the facility’s own policy defining sexual abuse as non-consensual sexual conduct and requiring investigation and protection when a resident may lack capacity to consent, the facility did not fully investigate or rule out sexual abuse and did not implement timely and effective interventions to prevent further contact between the two residents. Employee 3 reported that staff were aware of multiple prior incidents, including Resident 2 being found in the bathroom with Resident 1 on multiple occasions and an additional incident where Resident 2 was found caressing Resident 1’s breast. Employee 1 reported that even after the January 11 incident, the two residents were still found unattended together multiple times, and at the time of her interview, they were alone together in the chapel, which the surveyor confirmed. Resident 2 acknowledged spending time alone with Resident 1 and described her as infatuated, while recognizing her dementia diagnosis. Resident 1’s care plan did not include 15-minute safety checks until days after the sexual abuse incident, and the safety check documentation for both residents was incomplete or delayed, with later-added entries and signatures that conflicted with the original records. The Director of Nursing could not explain why incomplete safety check records were later supplemented. Staff reported observable changes in Resident 1’s behavior after the incident, including staying awake later than usual and appearing fearful when using the bathroom, frequently looking toward the doorway previously used by Resident 2. These failures led surveyors to determine that the facility did not ensure Resident 1 was free from sexual abuse by Resident 2 and did not follow its abuse policies, resulting in Immediate Jeopardy to residents’ health and safety.
Removal Plan
- Provide staff education on facility abuse policies, including allegations of sexual abuse.
- Provide education to nurse aides and licensed nurses on documenting resident behaviors.
- Monitor documentation of resident behaviors and update resident care plans as needed.
- Continue education prior to each licensed staff member’s next shift.
- Immediately place the perpetrator and victim on 1:1 supervision in the event of sexual abuse.
Failure to Accurately Report Alleged Sexual Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to accurately and completely report and document an alleged incident of sexual abuse to the State Survey Agency and the Area Agency on Aging, as required by its own abuse policies. The facility’s Abuse Protection policy required reporting occurrences of abuse, neglect, misappropriation, and suspicions of a crime to the State Survey Agency, Department of Aging, and local law enforcement, and specified that events involving serious bodily injury, including sexual abuse, must be reported within two hours of forming the suspicion. A related policy on Identifying Sexual Abuse and Capacity to Consent required immediate protective measures, immediate reporting to appropriate authorities, a thorough investigation including assessment of capacity to consent, and thorough documentation and reporting of the investigation results. These policies formed the basis for the expectations the facility did not meet. Resident 1, who had dementia and a BIMS score of 7 indicating severe cognitive impairment, and Resident 2, who had a cerebral infarction and a BIMS score of 14 indicating intact cognition, were involved in the incident. According to the facility’s abuse investigation report, a nurse aide (Employee 3) observed Resident 1 on Resident 2’s bed at approximately 1:15 AM, with Resident 2 seated in his wheelchair at the bedside and Resident 1 unclothed. The facility’s report stated that both residents indicated they were talking and concluded there was no evidence of penetration. However, written witness statements from Employee 3 and Employee 4 documented additional details that were not reflected in the facility’s report, including that Resident 1 had been last seen in her own chair around 12:50 AM, was later found unclothed in Resident 2’s bed, and that Resident 2 was observed touching Resident 1’s vaginal area while her legs were open. The witness statements further documented that after the incident Resident 1 complained of vaginal pain or discomfort and was observed checking herself in the bathroom. Despite these eyewitness accounts, the information submitted by the facility to the State Survey Agency and the Area Agency on Aging did not identify that staff directly observed Resident 2 touching Resident 1’s vaginal area and did not report Resident 1’s complaint of vaginal pain immediately following the incident. Instead, the facility reported that Resident 1 exhibited no signs or symptoms of distress, which was inconsistent with the written statements of Employees 3 and 4. During interviews, the Nursing Home Administrator acknowledged that the facility did not report all observed findings because both residents stated they were just talking, and it was confirmed that the facility did not follow its established abuse policy and procedures for reporting abuse or factually report all relevant information obtained during the investigation.
Administrative Failure to Prevent Sexual Abuse Between Residents
Penalty
Summary
Facility administration failed to effectively use its resources to promote resident safety and maintain residents’ highest practicable physical and mental well-being, resulting in a resident being subjected to sexual abuse by another resident. The Nursing Home Administrator’s job description required fostering a safe environment, providing emotional and psychological support, overseeing day-to-day operations to ensure quality care in accordance with state and federal standards, and implementing and enforcing company policies and procedures. The DON’s job description required assuring resident safety through nursing staff, evaluating the effects of care delivered, assigning special treatments when indicated, and reviewing and revising care plans and assessments as necessary. However, review of facility documentation and staff interviews showed that administrative oversight did not ensure effective coordination, monitoring, and implementation of systems designed to protect residents from abuse. The facility did not identify, mitigate, or manage known and foreseeable risks associated with resident interactions, particularly among residents with cognitive impairment, which limited their ability to understand, process, or make safe decisions. This failure in administrative oversight, including failure to ensure appropriate supervision, consistent implementation of resident safety and abuse prevention policies, and timely administrative intervention when safety risks were present, allowed one resident to sexually abuse another. The deficient practice was directly related to an Immediate Jeopardy citation under F600 (Freedom from Abuse, 42 CFR §483.12), with leadership’s lack of effective oversight, monitoring, and enforcement of policies contributing to the Immediate Jeopardy situation.
Unauthorized Video Recording of Resident During Incontinence Care
Penalty
Summary
Facility staff failed to protect and maintain personal privacy and dignity when a nurse aide used a personal cell phone to record video footage of a resident receiving incontinence care without consent. The recording was made through a window where the blinds had not been lowered, and neither the resident nor the staff member providing care were aware of the recording. Facility policies reviewed indicated that staff are prohibited from taking or releasing images or recordings of any resident without explicit written consent, and that resident privacy must be maintained during personal care. The resident involved had diagnoses including dementia and cerebral infarction, with severe cognitive impairment documented on a recent assessment. The resident required assistance with toileting and incontinence care due to impaired mobility and physical limitations. The incident occurred when two nurse aides positioned themselves across the facility courtyard and recorded the resident during care, in violation of facility policies and without any form of consent.
Corridor Doors Failed to Latch in Smoke Compartment
Penalty
Summary
Surveyors observed that two corridor doors, specifically those to Resident Room 217 and Resident Room 223, were not functioning as required. During an inspection, it was found that these doors were getting stuck in their frames, which prevented them from fully latching. This issue was directly observed between 10:56 am and 10:57 am on June 30, 2025. At the exit conference, both the Administrator and the Director of Maintenance confirmed that the doors failed to positively latch into their frames. The deficiency was limited to these two doors within one of six smoke compartments in the facility. No additional information about the residents in these rooms or their medical conditions was provided in the report.
Plan Of Correction
Maintenance has repaired the doors to rooms 217 and 223 to ensure that they latch appropriately. NHA to re-educate facility Maintenance Director on proper latching of corridor doors. A full house audit completed by maintenance to ensure that corridor doors were not getting stuck in their corresponding frames to prevent them from fully latching. Maintenance will conduct weekly audits x 4 weeks and monthly audits x 2 months to ensure doors latch appropriately. Audits to be submitted to QAPI for review and recommendations.
Failure to Conduct Fire Drills on a Random Basis
Penalty
Summary
The facility failed to conduct four out of twelve required fire drills on a random basis, as evidenced by documentation review and staff interviews. Specifically, observations showed that all first shift fire drills over the past twelve months were performed within the same hour each time (between 9:08 am and 10:03 am), rather than at varying times as required. During the exit conference, both the Administrator and Director of Maintenance confirmed that the fire drills were not performed randomly.
Plan Of Correction
A fire drill has been conducted for the first shift at 11:15 AM. Administrator to re-educate Maintenance Director on fire drills being held at random. Maintenance Director will continue to perform monthly fire drills on a random basis. NHA/designee will conduct audits weekly for 4 weeks and monthly for 2 months to ensure fire drills are being held randomly each month. Audits to be submitted to QAPI for review and recommendations.
Failure to Involve Residents in Person-Centered Care Planning
Penalty
Summary
The facility failed to ensure that residents were invited to participate in the development and implementation of their person-centered care plans, as required by both facility policy and regulatory standards. Specifically, for three residents reviewed, there was no documented evidence that care plan conferences were conducted with the required interdisciplinary team (IDT) members, nor that the residents or their representatives were invited to participate in the care planning process. The facility's policy mandates that the IDT, including nursing, social services, activities, and other relevant staff, involve the resident and/or their representative in care plan meetings, and document if participation is not practicable. For one resident with a history of respiratory failure and Parkinson's disease, who was cognitively intact, there was no documentation of a care plan meeting or invitation to participate following both admission and quarterly MDS assessments. Although a meeting was documented between the resident and the social worker, there was no evidence that other required IDT members were present, nor that the comprehensive care plan was reviewed by the full team. The resident confirmed not being invited to participate in any care plan meetings and expressed interest in doing so. Two additional residents, one with spinal cord compression and another with hereditary ataxia, were also found to be cognitively intact or only moderately impaired, yet neither had documentation of care plan conferences or invitations to participate in the care planning process. Both residents confirmed in interviews that they had not been invited to participate in care plan meetings since admission. The Nursing Home Administrator was unable to provide documentation to show that care plan conferences had been held or that the residents or their responsible parties had been invited to participate, as required.
Failure to Ensure Timely Acquisition and Administration of Prescribed Medications
Penalty
Summary
The facility failed to implement procedures to ensure the timely acquisition and administration of prescribed medications for three residents. For one resident with dementia, Xanax was not administered as ordered on multiple occasions due to the medication being unavailable; documentation showed delays in obtaining a new prescription and in communication with the pharmacy and physician. Another resident with atrial fibrillation and diabetes did not receive a prescribed dose of Macrobid because the medication was unavailable from the pharmacy, and the facility could not provide a reason for the unavailability. A third resident with unspecified dementia did not receive a scheduled dose of Oxycodone due to the need for a new prescription and unsuccessful attempts to obtain a release code from the pharmacy. Facility policy required nurses to check the Med Cubex inventory, contact the pharmacy for medication status, and notify the physician if a new order was needed. However, interviews with the DON and clinical nurse consultant confirmed that procedures were not adequately followed to ensure timely medication acquisition and administration. Documentation in the medication administration records and nursing notes consistently indicated medication unavailability and delays in obtaining necessary prescriptions or pharmacy codes, resulting in missed doses for the affected residents.
Failure to Consistently Provide Fresh Drinking Water to Residents
Penalty
Summary
The facility failed to ensure that fresh drinking water was consistently accessible to residents in accordance with their needs and preferences. According to facility policy, residents are to receive a fresh supply of drinking water, with new cups provided daily and refills occurring each shift and as needed. However, interviews with five alert and oriented residents revealed that fresh ice water was only reliably provided during the overnight shift, and not during the day or evening shifts unless specifically requested by the resident. Residents reported that water provided overnight would become room temperature by the time they awoke, and that staff did not routinely refill water during the day unless asked. The Nursing Home Administrator confirmed that the facility's protocol was not being followed, as fresh ice water was not consistently made available to residents during all shifts. This deficiency was identified for five residents, all of whom expressed a preference for cold, fresh water and reported discomfort or dissatisfaction with the current water service practices. The findings were based on resident and staff interviews, as well as a review of facility policy.
Failure to Ensure Resident Access to External Services
Penalty
Summary
The facility failed to ensure a resident's right to communication with and access to persons and services outside the facility. The resident, who was moderately cognitively impaired with a diagnosis of hereditary ataxia and muscle weakness, had a scheduled telephone hearing with an Administrative Law Judge regarding a fair hearing appeal. Documentation showed that the resident's attendance at the hearing was confirmed by a staff member, who signed and returned the required acknowledgement card. However, the staff member responsible for this process resigned abruptly prior to the hearing and did not inform other facility staff about the scheduled event. As a result, the resident was not made available for the hearing, and no valid reason for the absence was provided. Consequently, the resident's appeal was dismissed due to non-attendance. The Nursing Home Administrator confirmed that the facility did not ensure the resident had access to the scheduled external service.
Inaccurate MDS Assessment Regarding Physical Restraint Use
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident. A review of the resident's clinical record showed an admission with a diagnosis of dementia. The quarterly MDS assessment indicated that a limb restraint was used less than daily, as documented in Section P0100. However, a review of the physician's orders did not reveal any orders for a physical restraint for this resident. Furthermore, the Regional Nurse Consultant confirmed in an interview that the resident had never had any type of physical restraint while residing in the facility.
Failure to Consistently Apply Fall Prevention Interventions
Penalty
Summary
Facility staff failed to consistently implement fall prevention interventions as outlined in the comprehensive care plan for one resident. The resident, who was admitted with diagnoses including liver cancer and major depressive disorder, was identified as being at high risk for falls following a documented fall and a subsequent fall risk evaluation. The care plan specified the use of a bolster on the right side of the bed and a beveled fall mat on the left side of the bed as preventative measures. During an observation, it was noted that neither the bolster nor the fall mat were in place as required by the care plan. This absence was confirmed by an LPN and acknowledged by the Nursing Home Administrator, who confirmed that staff had not consistently followed the care plan interventions for fall safety for this resident. The deficiency was cited under 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.
Medication Transcription and Administration Error Resulting in Overdose
Penalty
Summary
A deficiency occurred when nursing staff failed to ensure that medication orders were accurately transcribed and administered according to professional standards. A resident with a history of rectal and lung cancer and atrial fibrillation was admitted and later readmitted to the facility. Upon the resident's discharge to the hospital, an order for apixaban 5 mg twice daily was not discontinued, and the medication remained accessible in the medication cart. When the resident was readmitted, new orders for apixaban 2.5 mg twice daily were transcribed, but the previous 5 mg order was still active on the medication administration record (MAR). On the day of readmission, an agency LPN administered both the 5 mg and 2.5 mg doses of apixaban, resulting in a total dose of 7.5 mg, which exceeded the prescribed amount and constituted a medication error. The facility's medication error report confirmed that the previous order had not been discontinued and that the medication was still available in the cart. Additionally, the report noted that no employee witness statements were obtained at the time of the incident. The Director of Nursing acknowledged that professional nursing standards were not followed, leading to the medication error.
Failure to Implement Restorative Nursing Program for Resident Mobility
Penalty
Summary
The facility failed to consistently provide restorative nursing services as planned for a resident with Alzheimer's disease and generalized muscle weakness. The resident, who was severely cognitively impaired and required substantial to maximal assistance for ambulation, had completed a course of physical therapy. At discharge, physical therapy recommended a Restorative Nursing Program (RNP) to maintain the resident's current level of mobility, specifically ambulation of 150 feet with a front-wheeled walker and the assistance of one person. These recommendations were intended to prevent decline and maintain functional abilities. Despite these recommendations, there was no documented evidence that the RNP for ambulation was incorporated into the resident's care plan or implemented. Reviews of the electronic task report and documentation for the relevant months showed no record of the restorative ambulation program being carried out. Additionally, there was no indication that licensed staff were aware that the program was not being implemented as planned. The Assistant Director of Nursing confirmed that the facility did not consistently implement the restorative nursing program as recommended by physical therapy.
Failure to Administer Oxygen Therapy per Physician's Order
Penalty
Summary
The facility failed to ensure that oxygen therapy was administered according to the physician's orders for one resident. The facility's Oxygen Administration Policy requires verification of a physician's order and documentation of the oxygen flow rate, route, and rationale. A review of the clinical record showed that the resident was admitted with respiratory failure and had a physician's order for oxygen at 4 liters per minute via nasal cannula for COPD. However, observations on two separate days revealed that the resident was receiving oxygen at 3 liters per minute instead of the prescribed 4 liters per minute. An LPN confirmed during observation that the oxygen flow was set at 3 liters per minute, not the ordered 4 liters. The Corporate Regional Nurse also confirmed that it is the facility's responsibility to ensure oxygen therapy is administered as prescribed.
Failure to Document and Offer Required Vaccinations
Penalty
Summary
The facility failed to ensure that pneumococcal and influenza immunizations were properly offered and/or provided to a resident, as required by facility policy and state regulations. Specifically, for one resident with a diagnosis including multiple sclerosis, the clinical record contained informed consent forms for both pneumococcal and influenza vaccines that did not indicate whether the resident accepted or declined the vaccines. There was no documentation to show that the facility identified these incomplete forms or made further attempts to determine the resident's immunization preferences. Additionally, there was no evidence in the clinical record that the vaccines were administered, declined, previously received, or medically contraindicated for this resident. The regional nurse consultant confirmed that the facility did not offer or provide the required vaccinations in accordance with established policies. This deficiency was identified through a review of facility policies, clinical records, and staff interviews.
Failure to Provide Prescriptions at Discharge
Penalty
Summary
A resident with paraplegia was discharged from the facility to home, with the discharge plan indicating that written prescriptions for physician-ordered medications would be provided to the resident or their representative. The Discharge Summary and Plan Policy required that a discharge summary and post-discharge plan be developed, including a complete list of medications and arrangements for follow-up care. Documentation in the clinical record stated that discharge instructions were reviewed and medications were sent with the resident at the time of discharge. However, a follow-up discharge call revealed that the resident did not receive the necessary prescriptions for their medications. Further, an email from the home health agency confirmed that the resident was not discharged with an adequate supply of medication to last until the scheduled follow-up appointment. There was no documented evidence that the facility addressed the issue after being made aware that the resident had not received prescriptions at discharge. Facility leadership confirmed that the Discharge Summary incorrectly indicated prescriptions were provided and acknowledged that this did not occur.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
A resident with spinal cord compression, muscle weakness, and a need for assistance with personal care was admitted to the facility and required substantial to maximal staff assistance for showering and bathing, as documented in the Minimum Data Set Assessment. The resident was cognitively intact and had scheduled shower days on Tuesdays and Saturdays, as indicated in the electronic Kardex. Despite this, the resident reported that staff were not consistent in providing showers on the scheduled days, citing instances where she missed showers due to being gotten up late by staff or because staff did not return to offer a shower after her therapy or family visit. The resident also stated that staff marked her as refusing showers when she had not refused, but rather was unable to receive them due to scheduling conflicts caused by staff actions. A review of the resident's shower logs for April and May revealed that she did not receive any showers during April and missed several scheduled showers in May, with bed baths documented instead. There was no documentation indicating that the resident refused showers or requested bed baths in lieu of showers. Additionally, there was no explanation documented for the omission of scheduled showers. The Nursing Home Administrator confirmed the resident's shower schedule and acknowledged that showers should have been provided as planned but could not explain the inconsistency in care.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
Lakewood Rehabilitation and Healthcare Center was found to be non-compliant with federal and state regulations due to its failure to conduct a thorough investigation into allegations of potential resident-to-resident abuse. The incident involved Resident CR1, who was observed masturbating in the doorway of his room, which was directly across from Resident 2's room. Despite being redirected by staff, Resident CR1 continued the behavior for a few minutes, visible to staff and other residents. The facility's policy mandates a comprehensive investigation into such incidents, but there was no documented evidence that this was done. Resident 2, who was potentially affected by the incident, was admitted to the facility with severe cognitive impairment, as indicated by a BIMS score of 00. This score reflects significant cognitive challenges, making it difficult for Resident 2 to describe or react to the incident. Resident CR1, on the other hand, was cognitively intact with a BIMS score of 13 and had a history of inappropriate sexual behavior, including a past conviction for a sexual offense. Despite these factors, the facility did not conduct a thorough investigation into the incident involving Resident CR1's behavior. Interviews with facility staff revealed that the social services director was unaware of any other residents involved in the incident, and the LPN who witnessed the event was not asked for further information. The Nursing Home Administrator confirmed the lack of a documented investigation, acknowledging the facility's responsibility to protect residents from abuse. The failure to investigate the incident thoroughly was a significant oversight, given the nature of the behavior and the potential impact on Resident 2.
Plan Of Correction
1. Resident CR1 has discharged from the facility. 2. Current residents have been interviewed. No residents report any knowledge of Resident CR1 behavior, sexual gratification, on the identified date. No residents or staff report an allegation of abuse related to resident R #1 behavior, on the identified date. 3. Facility staff will be re-educated by the NHA and or designee to the facility policy for abuse reporting and investigation to rule out potential resident abuse. 4. The Inter Disciplinary Team will audit resident progress notes, daily as part of the facility Clinical meeting process, to identify any instances of resident behavior requiring initiation of abuse reporting and investigation. If an allegation of abuse is identified, NHA and DON will follow abuse investigation policy. All abuse investigations will be submitted to and reviewed by the facility QAPI Committee.
Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide staffing ratios on three out of 21 shifts reviewed. Specifically, on March 27, 29, and 30, 2025, the night shift staffing levels were below the mandated minimum of 1 nurse aide per 15 residents. On March 27, there were 5.63 nurse aides instead of the required 6.47 for a census of 97 residents. On March 29, there were 5.00 nurse aides instead of the required 6.20 for a census of 93 residents. On March 30, there were 3.63 nurse aides instead of the required 6.13 for a census of 92 residents. No additional higher-level staff were available to compensate for this deficiency. An interview with the Nursing Home Administrator on April 2, 2025, confirmed the facility's failure to consistently provide the minimum nurse aide staffing hours required for each resident during the specified shifts.
Plan Of Correction
1. The facility cannot retroactively correct nurse aide staffing ratio. 2. NHA/designee will conduct an initial audit of the past two weeks' schedule to determine if nurse aide ratio is in compliance. 3. NHA/designee will re-educate the scheduler on the proper nurse aide staffing ratios. The facility will hold labor meetings Monday-Friday to verify ratios are made. 4. NHA/designee will conduct random audits of nurse aide staffing weekly for four weeks, then monthly for two months thereafter to verify proper nurse aide ratios. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day. This deficiency was identified during a review of the facility's weekly staffing records, which showed that on two specific days, March 28 and March 30, 2025, the facility provided only 3.14 and 3.02 hours of direct care nursing per resident, respectively. This shortfall in nursing hours was confirmed during an interview with the Nursing Home Administrator on April 2, 2025, indicating a failure to consistently meet the mandated staffing levels for resident care.
Plan Of Correction
1. The facility cannot retroactively correct staffing PPD. 2. NHA/designee will conduct an initial audit of the past two weeks scheduled to determine if PPD are in compliance. 3. NHA/designee will re-educate the scheduler on the proper PPD. The facility will hold labor meetings Monday-Friday to verify PPD is made. 4. NHA/designee will conduct random audits of facility PPD weekly for four weeks, then monthly for two months thereafter to verify proper PPD hours. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Pharmacy Service Deficiencies at Lakewood Rehabilitation
Penalty
Summary
Lakewood Rehabilitation and Healthcare Center was found to be non-compliant with federal and state regulations regarding pharmacy services. The facility failed to provide timely pharmaceutical services to meet the needs of two residents. Resident 1, who was admitted with a prescription for oxycodone-acetaminophen for severe pain, experienced delays in receiving the medication upon admission. The facility cited pharmacy delivery issues as the reason for the delay, and there was no documented evidence explaining why the medication was not administered despite the availability of an emergency supply. Additionally, there were discrepancies in the accounting of narcotic medications for Resident 1, with tablets signed out by nursing staff but not documented as administered. Resident 2, admitted with prescriptions for Effexor and other medications, also faced delays in receiving prescribed medications. Effexor was not ordered until several days after admission, and there was no documentation explaining the delay. Furthermore, Resident 2's nighttime medications were not administered as scheduled on the day of admission, with no explanation provided for the omission. Both residents reported experiencing delays in receiving their medications, which the facility confirmed during interviews. The facility's failure to ensure timely acquisition and administration of medications, as well as proper accounting of controlled substances, resulted in non-compliance with pharmacy service regulations. The Nursing Home Administrator and Corporate Nurse Consultant acknowledged the deficiencies, confirming the facility's responsibility to meet residents' pharmaceutical needs.
Plan Of Correction
1. Resident R 1 discharged from the facility to home on 2/08/25. Resident R 2 discharged from the facility to home on 2/08/25. 2. Current residents admitted to the facility in the past 7 days have been reviewed to ensure that hospital discharge medications are transcribed as ordered and available for administration. Current residents with physician orders for narcotic medications have been reviewed to ensure narcotic count sheets are in place and accurate for medication administration. 3. Licensed nurses will be reeducated by the DON and or designee to correct transcription of admission medications and scheduling to ensure medication availability. Licensed nurses will be reeducated by the DON and or designee to the facility process for narcotic administration including the documentation for accounting of narcotic medications. 4. Audits will be completed twice weekly by the Clinical administrative team, x 2 weeks, then monthly x 2 months, to ensure new resident medications are available for administration, per physician orders. Audits will be completed twice weekly by the Clinical administrative team, x 2 weeks, then monthly x 2 months, to ensure narcotic medications administered are being accurately documented per the facility process for narcotic medication administration records. Trends will be reviewed by the QAPI committee for further follow-up as needed.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
Lakewood Rehabilitation and Healthcare Center failed to ensure adequate supervision and safety measures for a resident identified as a wandering risk, leading to the resident's elopement. The resident, who had been admitted with Parkinson's disease and schizoaffective disorder, was known to exhibit exit-seeking behaviors and had a severe cognitive impairment with a BIMS score of 6. Despite these known risks, the facility did not effectively monitor or prevent the resident from leaving the premises unsupervised. On the night of the incident, the resident was last seen by staff at 9 P.M. and was reported missing at 1:45 A.M. The RN supervisor on duty, who was unfamiliar with the residents and the facility's wandering identification process, mistakenly allowed the resident to exit the building, believing the resident was a visitor. This lack of awareness and failure to confirm the resident's identity contributed to the resident's unsupervised departure. The resident was found 0.5 miles away at a car wash, exhibiting signs of hypothermia and injuries consistent with a fall. The facility's failure to promptly identify the resident's absence and implement effective supervisory measures placed the resident in immediate jeopardy, resulting in potential harm and necessitating emergency medical intervention.
Plan Of Correction
1. Resident # 1 no longer resides in the facility. 2. Current residents have been evaluated for exit seeking/elopement risk. Those residents identified as at risk for exit seeking and or elopement have had safety measures/interventions updated in their plan of care. 3. Facility staff have been re-educated by the NHA and or Designee to the facility processes for Elopement management and Prevention and the Visitation- Visitor Badge Process. Random audits will be completed by the NHA and or designee, weekly x 2 then monthly x 2, on residents at risk for exit seeking and or elopement. Random audits will be completed by the NHA and or designee, weekly x 2 weeks then monthly x 2, to ensure staff knowledge is maintained on the facility processes for Elopement management and Prevention and the Visitor Badge Process. Trends will be reviewed by the QAPI Committee for further follow-up as needed.
Removal Plan
- The resident was discharged from the facility from the hospital emergency room and admitted to a facility with a locked dementia unit.
- All residents were assessed for elopement/wandering.
- Staff education was completed regarding elopement/wandering/resident safety.
- The facility visitation policy reviewed and revised.
- Audits were completed to ensure that no other residents in the facility are affected.
- Implemented a process of the RN supervisor will verify that all residents are accounted for at the beginning of each shift by physically performing walking rounds in the facility each shift.
- RN Supervisor will validate that nurse aides understand assignments/assigned residents. Education to Nursing staff regarding staff assignments was completed.
- Facility completed staff education regarding elopement/wandering and visitation. Education regarding staffing, staff assignments and staffing responsibility was initiated for the 7 A.M. to 3 P.M. and 3 P.M. to 11 P.M. shifts. The 11pm-7am shift will be educated when they arrive before their scheduled shift. All nonscheduled staff will be educated prior to their next scheduled shift, and no staff will be permitted to work until they have received the education.
- Facility QAPI committee convened to review the initial interventions and start this plan. The QAPI committee to meet to complete the plan.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility's administration failed to effectively use its resources to ensure resident safety and maintain the highest practicable physical and mental functioning of its residents. This was evidenced by the elopement of one resident, which placed eight residents identified as at risk for elopement in immediate jeopardy. The administration did not provide necessary supervision and effective safety measures to monitor the resident's whereabouts, leading to the elopement incident. The review of the administrator's job description highlighted a lack of effective oversight and failure to address identified elopement risks for at-risk residents. The Director of Nursing Services (DON) also failed to provide adequate monitoring or implement effective interventions to prevent the resident's elopement. There was insufficient coordination of staff to ensure the safety of other residents at risk for elopement. The facility's inability to implement and enforce policies to monitor the resident and address elopement risks resulted in immediate jeopardy to the health and safety of the residents. This demonstrated a systemic failure in the administration's oversight and resource allocation to ensure a safe environment for residents.
Plan Of Correction
1. Resident #1 no longer resides in the facility. 2. Current residents have been evaluated for exit seeking/elopement risk. Those residents identified as at risk for exit seeking and or elopement have had safety measures/interventions updated in their plan of care, per IDT review of the resident's individual behaviors, patterns, and routines. Residents who have been identified as at risk for exit seeking and or elopement have been entered into the facility resident exit seeking/elopement identification binder; present at the front desk, nurses stations, and dietary department; with current photo and profile, updated. 3. The NHA and DON have been reeducated by the Regional Director of Clinical Services, RN, to the facility processes for resident safety monitoring; elopement management; includes the exit seeking/elopement identification binder and Prevention and Visitation-Visitor Badge Process. Facility staff have been reeducated by the NHA and or designee to the facility processes for Elopement management; includes the exit seeking/elopement identification binder and Prevention and Visitation-Visitor Badge Process. New staff hired will be educated to the facility processes for resident safety monitoring; elopement management and Prevention and Visitation-Visitor Badge process by the NHA and or Designee prior to working in the facility as well as directed in-service for staff. 4. The NHA and or DON has audited the facilities compliance with resident safety monitoring; elopement management and Visitation Process-Visitor Identification Badge system with no further incidence of resident incident; occurring. The NHA and or DON will review new hired staff education, prior to working in the facility, to ensure resident safety monitoring; elopement management and Prevention and Visitation-Visitor Badge process has been completed. The NHA and or DON will monitor that the Exit Seeking/elopement binder has been updated, daily, for any residents identified as exit seeking/elopement risk. Trends will be reviewed by the QAPI Committee for further follow-up as needed.
Failure to Escalate Care for Resident with Acute Condition
Penalty
Summary
Lakewood Rehabilitation and Healthcare Center failed to provide timely and appropriate care to a resident who experienced a significant change in condition. The resident, admitted with diagnoses including muscle weakness and hypertension, showed signs of acute kidney injury and metabolic abnormalities, as evidenced by laboratory results and vital signs. Despite these indicators, the facility did not conduct timely monitoring or escalate care appropriately. The resident's condition deteriorated, with symptoms such as lethargy, diaphoresis, and poor oral intake, yet there was no documented escalation of care or transfer to a hospital. On January 5, 2025, the resident's vital signs indicated a concerning change, including low blood pressure and elevated heart rate, but no interventions were documented at that time. The following day, intravenous fluids were initiated, but the resident's condition continued to decline. By January 7, 2025, the resident was found unresponsive and later pronounced deceased after CPR was attempted. Interviews confirmed the facility was aware of the resident's condition change but failed to provide necessary interventions or hospital transfer, resulting in a missed opportunity to address the resident's acute medical needs.
Plan Of Correction
1. Resident R1 no longer resides in the facility. 2. Current residents identified as having a change in condition in the past 7 days have had their records reviewed to ensure timely interventions have been initiated as applicable. 3. The DON/Designee will reeducate licensed nurses to the facility Change in Resident Condition or Status policy. 4. The DON/Designee will audit random audit progress notes weekly x 4 weeks, then monthly x 2 months to ensure resident changes in condition have applicable interventions or transfer to higher level of care. Audits will be presented to the QA Committee for review and follow-up as needed.
Failure to Provide Written Notice for Hospital Transfer
Penalty
Summary
Lakewood Rehabilitation and Healthcare Center was found to be non-compliant with the requirements of 42 CFR Part 483 Subpart B, specifically regarding notice requirements before transfer or discharge. The facility failed to provide a written notice for a facility-initiated transfer to the hospital for one resident. This notice should have included the reason for the transfer in a language and manner easily understood by the resident and their representative. The deficiency was identified during a survey conducted on December 30, 2024, which reviewed clinical records and included staff interviews. The specific incident involved a resident who was transferred to the hospital on December 29, 2024, due to a change in mental status. The clinical record indicated that the transfer was initiated by the facility, but there was no evidence of a written notice being provided to the resident or their representative. This lack of documentation and communication was a key factor in the facility's failure to meet the regulatory requirements for notice before transfer or discharge.
Plan Of Correction
1. The facility has provided Resident 2/resident representative with the facility transfer notice via certified mail. 2. The facility has reviewed resident's transfers and discharges for the past 14 days to ensure the notice of transfer has been provided. 3. DON/designee will re-educate licensed nursing staff to the facility process of notifying residents/resident representatives on facility transfers. 4. DON/designee will audit random resident transfers and discharges to ensure a written notice and the reason for transfer has been provided. Audits to be completed weekly for four weeks and monthly for two months. Audits to be submitted to QAPI for review and recommendations.
Failure to Provide Bed-Hold Policy Notice
Penalty
Summary
The facility failed to provide the required written notice of the bed-hold policy to a resident or their representative upon the resident's transfer to the hospital. This deficiency was identified during an interview with the Nursing Home Administrator (NHA) and a review of clinical records, the facility's bed-hold policy, and interviews with staff and family. The resident, who was cognitively intact with a BIMS score of 15 and had a diagnosed intellectual disability, was transferred to the hospital. Despite the facility's standard practice of sending a copy of the bed-hold policy with the resident during transfers, there was no documented evidence that this was done in this instance. The Business Office Manager (BOM) stated that she provides written bed-hold notifications during business hours, and nursing staff is responsible for this task when she is unavailable. However, no documentation confirmed that this process was completed for the resident in question. The NHA confirmed the failure to provide the required written notice, which deprived the resident and their representative of critical information regarding the bed-hold policy, including the duration and reserve bed payment policy. This oversight potentially compromised the resident's rights and ability to plan for continuity of care.
Plan Of Correction
1. The facility has provided Resident 2/resident representative with the facility bed hold policy via certified mail. 2. The facility has reviewed resident's transfers and discharges for the past 14 days to ensure the bed hold policy has been provided. 3. DON/designee will re-educate licensed nursing staff to the facility process of notifying residents/resident representatives on facility bed hold policy. 4. DON/designee will audit random resident transfers and discharges to ensure the bed hold policy was provided. Audits to be completed weekly for four weeks and monthly for two months. Audits to be submitted to QAPI for review and recommendations.
Failure to Complete Prescribed Lab Services
Penalty
Summary
The facility failed to ensure the timely completion of prescribed laboratory services for a resident, which resulted in a delay in monitoring and managing the resident's elevated potassium levels. The resident, who was admitted with diagnoses including diabetes, heart failure, and morbid obesity, had consistently elevated potassium levels documented over several days. Despite new orders being written for medication to treat hyperkalemia and a repeat Basic Metabolic Panel (BMP) to be conducted, the facility did not collect the BMP as prescribed. During an interview, the corporate nurse confirmed that the BMP lab test was not drawn and could not explain why the nursing staff did not follow up or notify the prescribing practitioner about the missed test. There was no documented evidence of attempts to reobtain the BMP or notify the practitioner of the failure to complete the ordered diagnostic testing. This inaction posed significant risks to the resident's health, as timely monitoring and addressing of elevated potassium levels are crucial.
Plan Of Correction
1. Physician was immediately notified on 12/30/24 of the ordered lab not being drawn as ordered on 11/22/24. NOR for CMP to be drawn on 12/31/24. Same completed. 2. Current residents with ordered labs have been reviewed to ensure labs have been obtained per physician order and completed. 3. DON/designee will re-educate licensed nursing staff were immediately to facility process for requisitioning of physician ordered labs. 4. DON/designee will perform random audits to ensure lab protocols are being followed and reviewed in a timely matter. Audits to be conducted weekly for four weeks and monthly for two months. Audits to be completed and submitted to QAPI for review and recommendations.
Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios on eight out of 21 shifts reviewed. Specifically, on December 23, 24, 25, 26, and 27, 2024, the facility did not provide the minimum number of nurse aides needed for the evening and night shifts based on the census. For instance, on December 23, 2024, there were only 8.33 nurse aides on the evening shift when 9 were required for a census of 99. Similarly, on December 24, 2024, the night shift had only 5.03 nurse aides instead of the required 6.67 for a census of 100. The deficiency was confirmed during an interview with the Nursing Home Administrator on December 30, 2024, who acknowledged the shortfall in meeting the required staffing ratios. No additional higher-level staff were available to compensate for this deficiency on the mentioned dates.
Plan Of Correction
1. The facility cannot retroactively correct nurse aide staffing ratio. 2. DON/designee will conduct an initial audit of the past two weeks' schedule to determine if nurse aide ratio is in compliance. 3. DON/designee will re-educate the scheduler on the proper nurse aide staffing ratios. The facility will hold labor meetings Monday-Friday to verify ratios are made. 4. DON/designee will conduct random audits of nurse aide staffing weekly for four weeks, then monthly for two months thereafter to verify proper nurse aide ratios. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Failure to Meet LPN Staffing Ratios
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios on six out of 21 shifts reviewed. Specifically, on December 22, 2024, the day shift had 3.22 LPNs instead of the required 4 for a census of 100 residents, the evening shift had 2.72 LPNs instead of 3.33, and the night shift had 2.03 LPNs instead of 2.5. On December 25, 2024, the day shift had 3.66 LPNs instead of 4 for a census of 100. On December 27, 2024, the night shift had 2.19 LPNs instead of 2.45 for a census of 98. On December 28, 2024, the evening shift had 2.97 LPNs instead of 3.20 for a census of 96. No additional higher-level staff were available to compensate for this deficiency. The Nursing Home Administrator confirmed the facility's failure to meet the required LPN to resident ratios on these dates.
Plan Of Correction
1. The facility cannot retroactively correct LPN staffing ratio. 2. DON/designee will conduct an initial audit of the past two weeks' schedule to determine if nurse aide ratio is in compliance. 3. DON/designee will re-educate the scheduler on the proper LPN staffing ratios. The facility will hold labor meetings Monday-Friday to verify ratios are made. 4. DON/designee will conduct random audits of LPN staffing weekly for four weeks, then monthly for two months thereafter to verify proper LPN ratios. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to consistently meet the state regulation requiring a minimum of 3.2 hours of direct resident care per resident in each 24-hour period. On December 22, 2024, the facility provided 3.07 hours, on December 24, 2024, 3.13 hours, and on December 25, 2024, only 2.69 hours of direct care per resident. These staffing levels were below the mandated minimum requirement. An interview with the Nursing Home Administrator on December 30, 2024, confirmed the facility's failure to provide the required minimum general nursing care hours to each resident daily.
Plan Of Correction
1. The facility cannot retroactively correct staffing PPD. 2. DON/designee will conduct an initial audit of the past two weeks scheduled to determine if PPD are in compliance. 3. DON/designee will re-educate the scheduler on the proper PPD. The facility will hold labor meetings Monday-Friday to verify PPD is made. 4. DON/designee will conduct random audits of facility PPD weekly for four weeks, then monthly for two months thereafter to verify proper PPD hours. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Inadequate Supervision and Safety Interventions Lead to Falls and Injury
Penalty
Summary
The facility failed to implement timely and effective safety interventions and necessary staff supervision for a resident with known unsafe behaviors, resulting in multiple falls and a major injury. Resident 91, who was admitted with dementia and mobility issues, was identified as being at high risk for falls. Despite being severely cognitively impaired and requiring substantial assistance, the facility did not consistently provide the ordered 1:1 supervision. This lack of supervision led to several incidents where the resident attempted to self-transfer and fell, ultimately resulting in a hip fracture. The facility's documentation revealed that Resident 91 exhibited exit-seeking behaviors and was difficult to redirect, necessitating close supervision. However, the facility failed to maintain the required level of supervision, as evidenced by multiple falls, including a significant fall that resulted in a hip fracture. The facility did not provide documented evidence that the physician-ordered 1:1 supervision was consistently implemented, contributing to the resident's repeated falls and eventual major injury. Similarly, Resident 33, also severely cognitively impaired and at risk for falls, experienced multiple unwitnessed falls. The facility's interventions, such as bed and chair alarms, were ineffective in preventing these falls. The facility did not adjust its interventions to address the root causes of the falls or increase staff supervision, leading to repeated incidents. The Director of Nursing confirmed the inadequacy of the facility's interventions and supervision in preventing falls for Resident 33.
Failure in Pain Management for Resident
Penalty
Summary
The facility failed to implement appropriate pain management interventions for a resident, identified as Resident 260, who was admitted with significant medical conditions including aftercare following digestive tract surgery and pressure injuries. The facility's policy on pain management emphasizes a multidisciplinary approach, including regular assessment and treatment of pain. However, the facility did not adhere to this policy, as evidenced by multiple instances where Resident 260's pain was not adequately assessed or managed. Resident 260 experienced various levels of pain, ranging from mild to severe, due to pressure ulcers and other conditions. Despite having physician orders for pain medications such as Ultram and Norco, there were several documented instances where the resident did not receive any pharmacological or non-pharmacological interventions to manage her pain. For example, on August 22, 2024, the resident was noted to be very agitated and yelling, yet there was no documentation linking this behavior to pain or any subsequent intervention. Similarly, on August 26 and 27, 2024, the resident's pain was not managed effectively, with reports of severe pain and family complaints about the lack of pain relief. Interviews with staff and family members further highlighted the facility's failure to provide timely pain management. The resident's husband expressed frustration over the lack of pain relief, and staff interviews revealed issues with obtaining prescribed medications from the pharmacy. The Corporate Nurse Consultant and Corporate Administrator were unable to provide explanations or documentation for the lack of interventions during critical periods when the resident was in severe pain. This deficiency in pain management was a clear violation of the facility's own policies and professional standards of care.
Inadequate Infection Control and Monitoring
Penalty
Summary
The facility failed to maintain a comprehensive infection prevention and control program, as evidenced by inadequate tracking and analysis of infections, particularly urinary tract infections (UTIs) occurring on the same hallways from January to May 2024. The infection control data was incomplete for June and July 2024, and there was no evidence of a functional system to analyze clusters or increases in infection rates. Although staff education on infection control practices was provided in January and February, there was no investigation into the causes of the UTIs or implementation of interventions to prevent their recurrence. Additionally, during a medication pass observation, an agency LPN failed to follow proper infection control procedures. The LPN did not change gloves or sanitize hands between tasks and residents, potentially spreading infection. The LPN also did not clean a blood glucose monitor between uses. Furthermore, the facility did not maintain ice storage in a sanitary manner, as an ice scoop was found resting directly on the ice in a portable ice chest, with the handle in contact with the ice. These deficiencies indicate a lack of consistent implementation of infection control procedures.
Ineffective Pest Control Program in LTC Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by observations and interviews conducted during the survey. The pest management report from August 16, 2024, highlighted several recommendations that were not addressed, including replacing damaged exterior grates, repairing door gaps, and filling gaps between pipes and walls. Observations on August 27, 2024, revealed brown/black feces-like pellets in multiple resident rooms, indicating rodent activity. Interviews with two residents confirmed sightings of mice in their rooms, further supporting the presence of a pest issue. During a facility tour, several structural deficiencies were noted, such as an ajar main entry door, loose exterior vent screens, holes in window screens, and gaps around air conditioning units and garage doors, all of which provide entry points for pests. The Nursing Home Administrator and Director of Nursing were unable to provide evidence that the facility had addressed the pest management company's recommendations, confirming the inadequacy of the current pest control program.
Privacy Breach During Physician Visit
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents during a physician visit, affecting seven residents. During an observation, it was noted that a contracted eye doctor was examining a resident in a room with glass walls and open doors, allowing other residents, staff, and visitors to view the examination. The residents waiting for their eye examinations were seated in wheelchairs in the lounge and hallway, with no screen or partition to ensure privacy. The Nursing Home Administrator confirmed that the residents' dignity was compromised as their examinations were visible to others. Additionally, the facility did not ensure personal privacy for one resident by posting therapy instructions on the wall of the resident's room, visible from the bed. The interim Director of Nursing confirmed that these instructions should not have been displayed in such a manner. The Nursing Home Administrator acknowledged that the facility staff is responsible for addressing residents' needs in a way that promotes their quality of life and protects their privacy, and confirmed that physician examinations should be conducted in private.
Latest citations in Pennsylvania
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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