Maple Ridge Rehabilitation & Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Kingston, Pennsylvania.
- Location
- 615 Wyoming Avenue, Kingston, Pennsylvania 18704
- CMS Provider Number
- 395345
- Inspections on file
- 25
- Latest survey
- April 24, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Maple Ridge Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
Inaccurate MDS Coding for IV Hydration Infusions The facility incorrectly coded MDS Section K0520 and K0710 for three residents by recording IV hydration infusions as parenteral or IV feeding. The MARs showed one-time IV infusions of normal saline with added micronutrients, vitamins, supplements, and amino acids given for hydration and wellness, but the records did not support that the infusions provided nutritional support such as calories, protein, fat, or carbohydrates. Residents involved had diagnoses including TBI, bipolar disorder, intellectual disability, type 2 DM, vascular dementia, cerebral infarction, and protein calorie malnutrition.
Failure to Monitor Weight Loss and Use Less Invasive Nutrition and Hydration Measures Before IV Therapy: The facility did not consistently track weight loss or low fluid intake, and did not document that food-first and oral hydration interventions were fully tried and found ineffective before IV therapy was used for three residents. One resident with TBI and severe cognitive impairment had significant weight loss and persistent low intake despite fortified foods and supplements; another resident with dementia had an 8.4% one-month weight loss and later received IV micronutrient infusion despite normal labs; a third resident with protein-calorie malnutrition had rapid weight loss and continued low fluid intake before IV hydration was given.
A facility failed to maintain acceptable sound levels from the resident call bell system on one floor after the system malfunctioned and was left at the loudest volume. Three cognitively intact residents reported that the loud speaker disrupted rest and comfort, including nighttime sleep loss and daytime amplification with hearing aids. One resident with rheumatoid arthritis and DM, another with orthopedic aftercare following surgical amputation and DM, and a third with poly-osteoarthritis and lack of coordination all described the noise as extremely loud and disruptive.
Inconsistent Restorative Nursing Services: A resident with osteoarthritis and abnormal posture received PT and was discharged with recommendations for continued use of a walker, ADL assistance, and a restorative nursing program to maintain mobility. The care plan included ROM exercises and ambulation, but the task record and documentation showed multiple missed or undocumented restorative interventions, and the resident reported staff were often too busy to help.
Unsafe medication storage and access were identified when a resident’s nasal spray and opened OTC antacid were left on the bedside table and accessible for use without documentation that the resident had been assessed or approved to self-administer. The resident, who had peripheral vascular disease and muscle weakness, said staff left the meds at the bedside for PRN use, and there was no physician order for the OTC medication.
Controlled substance count records were not properly completed for two medication carts when the off-going nurse failed to sign the narcotic count verification at shift change. Facility policy required the oncoming nurse and off-going nurse to count controlled meds together and both sign the record, but an LPN confirmed the records were unsigned and the DON and NHA acknowledged the policy was not consistently followed.
Failure to promptly notify the physician of abnormal lab results occurred for a resident with DM, dysphagia, and hypokalemia who was receiving potassium chloride and spironolactone. A CMP showed elevated K+, BUN, creatinine, and reduced eGFR, but nursing documentation did not show physician notification. The resident later developed increased confusion and a critically high K+ level, and the physician was then notified and ordered transfer to the ER.
Two residents reported prolonged call bell response times, with one experiencing incontinence due to delayed assistance. Despite repeated complaints voiced in Resident Council meetings and written grievances, the facility did not provide documented resolutions or timely responses, and leadership acknowledged the lack of follow-through on grievances.
A resident with vascular dementia and polyosteoarthritis, who was found to be cognitively intact, was not invited to participate in the development or review of her person-centered care plan. There was no documentation of care plan conferences or invitations for the resident to attend, and this was confirmed by both the resident and facility leadership.
A resident with a new diagnosis of PTSD did not have an individualized, person-centered care plan addressing their PTSD symptoms, triggers, or interventions to minimize re-traumatization. The facility was unable to demonstrate provision of culturally competent, trauma-informed care in line with professional standards.
A resident with severe cognitive impairment and a Stage 2 pressure ulcer did not consistently receive planned interventions such as barrier cream application and regular turning/repositioning. Documentation failed to show that wound care recommendations were followed or that wound progression was adequately monitored. As a result, the resident's pressure ulcer worsened to an unstageable wound, with no evidence of updated interventions after the decline.
Maple Ridge Rehabilitation and Healthcare Center failed to conduct comprehensive nutritional assessments and monitor weight changes for two residents, leading to significant health declines. One resident experienced severe weight loss and was hospitalized in a malnourished state, while another resident's weight loss was not identified or addressed in a timely manner. The facility lacked a qualified nutrition professional during a critical period, and care-planned interventions were not consistently implemented.
A resident with chronic pain and osteoarthritis slipped on a wet floor caused by a leaking window, resulting in a right ankle sprain. Despite the resident's prior report of the issue, the facility failed to address the hazard in a timely manner, leading to the incident. The maintenance department had marked the repair as completed, but the issue persisted until after the resident's injury.
The facility did not address concerns raised by residents about vegetarian food options and failed to involve them in discussions about resident fund activities. Residents reported that their dietary preferences were ignored, and there was no documentation of actions taken to resolve these issues. Additionally, residents were not involved in decision-making regarding the resident fund, and the facility lacked evidence of resident input.
The facility failed to implement person-centered care plans for four residents, leading to deficiencies in addressing specific medical needs and fall risks. A resident's care plan did not include monitoring for a pacemaker, while others were found with beds not in the lowest position or call bells out of reach, contrary to their care plans. These issues were confirmed by facility staff.
The facility failed to involve three residents in the development and revision of their care plans, despite their cognitive ability to participate. Residents with conditions such as schizophrenia, cerebral infarction, chronic kidney disease, and atherosclerotic heart disease reported not being invited to care plan meetings. The DON and NHA confirmed the lack of documented evidence of resident participation in care planning over the past six months.
The facility failed to timely identify and address significant weight loss in two residents. One resident, with conditions like GERD and COPD, experienced a 6.39% weight loss without staff intervention or communication. Another resident, with subarachnoid hemorrhage and dysphagia, lost 13.1% of body weight, and a prescribed Healthshake was not provided. The DON confirmed the facility's failure to act on these issues.
A resident with specific dietary preferences, including being a vegetarian who eats fish, was not provided with a nutritionally adequate menu. Despite expressing dissatisfaction and requesting vegetarian options, the facility failed to plan a suitable menu, resulting in significant weight loss. The resident's preferences were not adequately reflected in her care plan, and there was no follow-up on her concerns.
A resident with severe cognitive impairment was physically abused by another resident with a history of aggressive behavior. Despite interventions, the aggressive resident punched and threw juice at the vulnerable resident. The facility's administration confirmed the failure to prevent this abuse, violating their policy against resident abuse.
A facility failed to ensure an accurate MDS assessment for a resident, as the recorded weight in Section K0200 did not match the most recent weight prior to the assessment. The discrepancy was confirmed by the facility's RD.
The facility failed to properly dispose of garbage and refuse, as observed when two large trash dumpsters were left uncovered. The Nursing Home Administrator confirmed that the dumpster lids should be closed, indicating a lapse in waste management protocols.
The facility failed to maintain a clean and homelike environment on multiple floors, with issues such as black substances on vents, sticky floors, and stained equipment. Observations included dirt, debris, and scuff marks on floors and walls, as well as damaged floor tiles. The Nursing Home Administrator confirmed the expectation for cleanliness and sanitation.
The facility failed to implement policies to protect residents from being disenrolled from Medicare health plans without informed consent. Seven residents were disenrolled without proper documentation of their understanding or consent, despite discussions about potential benefits. The facility lacked procedures for assisting residents with Medicare plan changes, leading to non-compliance with CMS guidelines.
Inaccurate MDS Coding for IV Hydration Infusions
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the clinical status of 3 residents by incorrectly coding Section K0520 (Nutritional Approaches) and Section K0710 (Intake by Artificial Route) to show parenteral or IV feeding when the documented IV therapy was for hydration and wellness purposes. The report states that the Resident Assessment Instrument (RAI) User’s Manual specifies IV fluids given for hydration or as a vehicle for medications are not to be coded as parenteral feeding, and the clinical records did not contain documentation showing that the IV therapy provided nutritional support such as calories, protein, fat, or carbohydrates. Resident 59 had diagnoses including traumatic brain injury, bipolar disorder, and intellectual disability. The MAR showed one-time IV hydration infusions in October and November 2025 consisting of normal saline with added micronutrients such as B-complex vitamins, vitamin B12, zinc, magnesium, and calcium. The quarterly MDSs for this resident coded Sections K0520 and K0710 to reflect IV feeding, but the record did not support that the infusions met criteria for nutritional support under the RAI guidance. Resident 45 had diagnoses including type 2 diabetes, muscle atrophy, and vascular dementia. The MAR showed a physician-ordered one-time IV hydration infusion through an outside contracted infusion service that included normal saline with added micronutrients, supplements, and amino acids for hydration and general wellness purposes. The quarterly MDS coded Section K0520 as parenteral or IV feeding and Section K0710 as intake by artificial route, but the record did not support that the infusion was used to provide nutrition. Resident 66 had diagnoses including cerebral infarction, protein calorie malnutrition, and cognitive communication deficits. The MAR showed one-time IV hydration infusions in November and December 2025 consisting of normal saline with added micronutrients, and the quarterly MDSs again coded Sections K0520 and K0710 as IV feeding despite no documentation that the infusions met criteria for parenteral nutrition. The findings were reviewed with the Nursing Home Administrator during interview.
Failure to Monitor Weight Loss and Use Less Invasive Nutrition and Hydration Measures Before IV Therapy
Penalty
Summary
The facility failed to consistently monitor residents’ nutritional and hydration status and did not timely identify declines, implement individualized less invasive interventions, or ensure clinical justification before starting invasive IV interventions for three residents. The cited deficiency involved Residents 59, 45, and 66, each of whom had documented weight loss and/or low fluid intake, but the clinical records did not consistently show that oral nutrition and hydration measures were fully implemented, monitored for effectiveness, and exhausted before IV therapy was used. Resident 59 had diagnoses including TBI, bipolar disorder, and unspecified intellectual disabilities, and had severe cognitive impairment with a BIMS score of 4. The resident required supervision and assistance with eating. The record showed significant weight loss over one, three, and six months, with the dietitian documenting loss greater than 5 percent in one month and greater than 10 percent in six months. Although the resident was receiving fortified foods, Health Shakes, and ice cream, the dietitian recommended increasing Health Shakes to all meals and weekly weights, but the record did not show the supplements were ordered three times daily until after the recommendation. The record also documented persistent low fluid intake, with the CRNP noting decreased appetite, recent falls, and decreased sense of thirst and determining IV hydration was appropriate. However, the chart did not contain consistent documentation that oral hydration interventions were implemented or effective, and laboratory data were not present to clinically support the need for IV hydration before the one-time IV infusion and later repeated IV micronutrient infusions. Resident 45 had diagnoses including type 2 diabetes, muscle wasting, and vascular dementia, and had severe cognitive impairment with a BIMS score of 3. The resident required set-up or clean-up assistance with meals and had a significant one-month weight loss of 8.4 percent. The dietitian noted the resident accepted Health Shake but refused the liquid protein supplement, which was documented at zero percent intake, and recommended discontinuing the supplement and monitoring weekly weights. The CRNP later documented persistent low fluid intake, recent weight loss, decreased appetite, recent falls, and decreased perception of thirst, and determined IV hydration was appropriate. The resident then received a one-time IV micronutrient infusion, but the laboratory results obtained that day were within normal limits except for elevated glucose, and the record did not show weekly weights were completed as recommended or that less invasive nutritional and hydration interventions were attempted and evaluated before IV therapy was used. Resident 66 had diagnoses including cerebral infarction, protein calorie malnutrition, and cognitive communication deficits, and had intact cognition with a BIMS score of 15. The resident required set-up or clean-up assistance with meals. The record showed a rapid 6-pound weight loss in one week, followed by continued significant weight loss over one month. The dietitian identified the resident as underweight for advanced age and recommended fortified foods with all meals and weekly weights, but the record did not show these interventions were implemented timely after the initial weight loss. A later CRNP note documented increased cognitive decline and continued low fluid intake, with fluids encouraged and preferred beverages offered, yet the resident still received IV hydration. The record did not demonstrate that less invasive nutritional and hydration interventions were implemented, monitored, and found ineffective before IV therapy was initiated.
Excessive Call Bell Noise Disrupted Resident Comfort
Penalty
Summary
The facility failed to provide a comfortable and homelike environment by not maintaining acceptable sound levels from the resident call bell system on the Fourth Floor. A review of the facility policy stated that the resident call system must remain functional at all times and, if audible communication is used, the volume must be maintained at an audible level that can be easily heard. An employee reported that the call bell system malfunctioned and, after repair, remained set at the loudest volume, with staff notifying maintenance of the excessive loudness. An observation later confirmed the Fourth Floor call bell system continued to operate at the loudest setting. Three residents reported that the loud call bell system disrupted their rest and comfort. One cognitively intact resident with rheumatoid arthritis and diabetes mellitus stated the noise during the night was extremely loud and prevented sleep. Another cognitively intact resident with diagnoses including orthopedic aftercare following surgical amputation and diabetes mellitus, whose room was directly across from the nurse's station, reported repeated sleep disruption because the speaker outside the room rang all night. A third cognitively intact resident with poly-osteoarthritis and lack of coordination reported that the call bell noise was amplified when wearing hearing aids and was terribly loud during the day.
Inconsistent Restorative Nursing Services
Penalty
Summary
The facility failed to consistently provide restorative nursing services as planned to maintain mobility for one resident. Resident 79 was admitted with diagnoses including osteoarthritis and abnormal posture, and the March 2026 MDS showed the resident was cognitively intact with a BIMS score of 15. Physical therapy was provided from March 12, 2026, through April 7, 2026, and the discharge summary stated the resident could ambulate 10 to 25 feet with one staff person using a front-wheeled walker. The discharge recommendations included continued use of an assistive device, assistance with ADLs, and implementation of a restorative nursing program. The discharge summary also communicated restorative interventions to the IDT, including ambulation of approximately 15 feet with a front-wheeled walker and assistance from one staff person to maintain functional mobility and prevent decline. The resident’s care plan included active ROM exercises to the right upper extremity for at least 15 minutes. However, review of the electronic task report and April 2026 Documentation Survey Report showed multiple shifts where restorative nursing interventions were not documented as completed, and the clinical record did not consistently support that ambulation and ROM exercises were provided as planned. During interview, the resident stated she was upset about the lack of consistent restorative nursing services and reported that staff sometimes helped but were often busy and did not assist her.
Unsafe Medication Storage and Access
Penalty
Summary
The facility failed to ensure the environment remained free from potential accident hazards related to the unsafe storage and access of medications on Unit 4 and for one resident sampled. Facility policy required medications to be administered safely and, for self-administered medications, to be stored in a safe and secure place not accessible by other residents. However, a review of Resident 58’s clinical record showed no documented assessment that the resident had been evaluated and approved to self-administer medications. Resident 58 was admitted with diagnoses including peripheral vascular disease and muscle weakness. On observation, a bottle of Ipratropium Bromide nasal spray and an opened bottle of Tums were found on the resident’s bedside table and were accessible to the resident. The resident stated the medications were used as needed and that staff left them at the bedside for use. The record contained no physician order for the Tums observed at the bedside, and the Nursing Home Administrator acknowledged that nursing staff left medications accessible without evidence the resident had been assessed or approved to self-administer.
Controlled Substance Count Records Not Properly Signed
Penalty
Summary
The facility failed to implement procedures to ensure accurate controlled medication records for one of two medication carts observed. A review of the facility policy titled Controlled Substances showed that controlled medications are to be counted at the end of each shift, with the oncoming licensed nurse and off-going licensed nurse completing the count together, and both nurses signing the controlled substance record to verify receipt and accuracy of the count. A review of the Controlled Drug Key Exchange Audit for the fourth floor back hall nursing unit medication cart showed that on April 20, 2026, the evening shift off-going nurse did not sign the controlled substance record to verify the narcotic count was completed and correct. The same issue was identified for the fourth floor front hall nursing unit medication cart on the same date. During interviews, an LPN confirmed that the controlled substance records for both carts were not signed by the off-going nurses, and the DON and NHA reviewed and confirmed that the facility did not consistently follow its policy requiring completion and verification of controlled substance counts at shift change.
Failure to Notify Physician of Abnormal Potassium Result
Penalty
Summary
Timely physician notification of clinically significant abnormal laboratory results was not ensured for one resident. Resident 87 was admitted with diagnoses including diabetes, dysphagia, and hypokalemia, and had moderately impaired cognition with a BIMS score of 12. Physician orders included potassium chloride 20 mEq by mouth twice daily and spironolactone 25 mg daily. A CMP obtained revealed abnormal values including elevated BUN, creatinine, reduced eGFR, and a potassium level of 5.2 mmol/L, with the potassium elevation occurring while the resident was receiving potassium-increasing medications. The clinical record did not show that licensed nursing staff notified the physician of the abnormal laboratory results after they were obtained. A nursing progress note later documented that the resident's daughter reported the resident was tired, not herself, and more confused, and the RN supervisor was notified, but there was still no documented evidence that the physician had been informed of the earlier abnormal lab findings or the change in condition. The resident continued to receive potassium supplementation and spironolactone as ordered after the abnormal potassium result was identified. A CRNP later evaluated the resident and ordered repeat laboratory testing. When repeat labs were drawn, the potassium level was critically high at 7.4 mmol/L, and the resident had increased confusion and complaints of crushing pain at the base of the neck. The physician was then notified and ordered immediate transfer to the emergency room. Hospital records showed the resident was admitted with hyperkalemia.
Failure to Resolve Resident Grievances and Delayed Call Bell Response
Penalty
Summary
The facility failed to adequately address and resolve resident complaints and grievances, as evidenced by a review of facility policy, Resident Council meeting minutes, written grievances, and interviews with residents and staff. The facility's Grievance Policy requires that all grievances be considered and responded to in writing, with the Nursing Home Administrator (NHA) responsible for overseeing the process. Despite this, concerns about delayed call bell responses were repeatedly raised during Resident Council meetings and in written grievances. Specifically, one resident reported having to wait a long time for staff to respond to her call bell, and although the facility conducted call bell audits, the resident refused to sign the grievance as resolved, stating the issue persisted. The grievance was nonetheless marked as completed and resolved by the NHA. Interviews with two cognitively intact residents revealed ongoing issues with staff response times to call bells, with both reporting waits exceeding 30 minutes, particularly during the second and third shifts. One resident described experiencing a bowel incontinence episode due to delayed assistance. The NHA and Director of Nursing (DON) acknowledged that there was no documented evidence of completed resolutions for grievances raised during Resident Council meetings or for verbal complaints. These findings indicate that the facility did not follow its own grievance policy and failed to ensure prompt and effective resolution of resident complaints.
Resident Not Invited to Participate in Care Planning
Penalty
Summary
The facility failed to ensure that a resident was invited to participate in the development and implementation of her person-centered care plan. Clinical record review showed that the resident, who was admitted with vascular dementia and polyosteoarthritis, was cognitively intact as evidenced by a BIMS score of 15. Despite this, there was no documentation that the resident had been invited to participate in care planning or attend any care plan meetings. During an interview, the resident confirmed she had not been invited to participate in the care planning process or attend any care plan meetings. Further review of the clinical record revealed that no care plan conference had been conducted for the resident since November of the previous year, and there was no documentation of any invitation to participate in the care plan process. The DON and NHA confirmed the absence of such documentation.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan to provide trauma-informed care for a resident who had been newly diagnosed with Post-Traumatic Stress Disorder (PTSD). A review of the resident's clinical record showed that the care plan in effect did not identify the resident's PTSD symptoms, triggers, or include resident-specific interventions to minimize triggers or prevent re-traumatization. The deficiency was confirmed through staff interview, which revealed the facility could not demonstrate that culturally competent, trauma-informed care was provided in accordance with professional standards of practice or that the resident's experiences and preferences were considered to eliminate or mitigate triggers related to PTSD.
Failure to Implement Pressure Ulcer Interventions Resulting in Wound Deterioration
Penalty
Summary
The facility failed to consistently implement planned interventions and provide necessary treatment and services to prevent the worsening of a pressure ulcer for a resident with significant cognitive impairment and multiple care needs. The resident was admitted with a Stage 2 pressure ulcer and was identified as being at moderate risk for pressure injuries, requiring total staff assistance for activities of daily living, including turning and repositioning. The care plan included specific interventions such as application of a protective barrier cream after incontinence episodes, regular turning and repositioning, weekly skin inspections, wound evaluations, and use of pressure-reducing devices. Despite these planned interventions and recommendations from the wound care consultant, documentation revealed that the recommended barrier cream was not ordered or applied as directed, and there was no consistent evidence that staff turned and repositioned the resident according to the care plan. Additionally, wound measurements and thorough evaluations were not consistently documented, making it difficult to assess the wound's progression or the effectiveness of interventions. The resident's pressure ulcer worsened from a Stage 2 to an unstageable wound, with a significant increase in size and the presence of slough, indicating a decline in skin integrity. Interviews with facility leadership confirmed the lack of evidence for implementation of the wound care consultant's recommendations, absence of a consistent turning and repositioning schedule, and insufficient evaluation of the wound's status. There was also no documentation of updated or intensified interventions in response to the worsening wound, contrary to facility policy and best practice guidelines for pressure ulcer management.
Failure to Conduct Nutritional Assessments and Monitor Weight Loss
Penalty
Summary
Maple Ridge Rehabilitation and Healthcare Center was found to be non-compliant with federal and state regulations regarding nutrition and hydration status maintenance. The facility failed to conduct a comprehensive nutritional assessment and monitor resident weights consistently and accurately, which led to a failure in identifying changes in nutritional status and implementing appropriate interventions for two residents. Resident CR1, admitted with dysphagia and other conditions, experienced significant weight loss shortly after admission. Despite a policy requiring a nutritional assessment within 72 hours, no such assessment was completed, and no interventions were initiated to address the resident's poor intake or weight loss. The resident was later transferred to the hospital in a severely malnourished and dehydrated state. Resident A1, who had a history of Barrett's esophagus and cancer, also experienced significant weight loss over a 30-day period. Although the resident's care plan included periodic weight monitoring and nutritional interventions, the facility failed to identify the weight loss in a timely manner and did not implement additional nutritional strategies. Observations revealed that the resident was not consistently provided with finger foods, an intervention included in the care plan to support the resident's independence and nutritional intake. Interviews with facility staff, including the RD and DON, confirmed the deficiencies in nutritional assessments and interventions. The facility lacked a qualified nutrition professional during a critical period, and the care-planned accommodations for Resident A1 were not consistently implemented. These failures contributed to the residents' deteriorating nutritional status and were not addressed in a timely manner, leading to significant health declines.
Plan Of Correction
Please note that the filing of this Plan of Correction does not constitute any admission to the alleged violations set for in the statement of deficiencies. This Plan of Correction is being filed as evidence of the facility's continued compliance with all applicable laws. 1. Resident CR1 was discharged from facility on 3/25/25. Resident Al therapy screen for eval placed 4/16/25. Resident Al reassessed by RD on 4/16/25, and a revised nutrition plan will be implemented if necessary. 2. A facility-wide audit will be completed on residents with nutritional risks over the past 14 days to determine if Initial Nutritional Assessment was completed within 72 hours and interventions are in place for those at risk. Will review residents over last 2 weeks who trigger for significant weight loss to ensure that proper interventions have been implemented. 3. Education on and review of facility policy provided to RD on timely completion of Initial Nutrition Assessment. Education provided to Nursing staff/RD to ensure that interventions put in place for residents who trigger at risk for weight or have significant weight loss. 4. DON/Designee will audit 10 random resident charts weekly x 4 weeks, then q 2 weeks x 2 months for timely completion of Initial Nutrition Assessment, RD interventions are in place for those at risk, and nutrition care plans are updated. Results of audits will be reviewed at monthly QAPI meeting.
Failure to Address Leaking Window Leads to Resident Injury
Penalty
Summary
The facility failed to provide an environment free from accident hazards, resulting in an incident involving a resident who slipped on a wet floor caused by a leaking window. The resident, who was cognitively intact and able to ambulate independently with a walker, reported twisting her ankle during the incident. The resident had previously informed her social worker about the leaking window, and a maintenance repair ticket was created. However, the facility did not address the issue until after the resident's slip, leading to a minor injury. The investigation revealed that the maintenance department had marked the repair order as completed, despite the window still leaking. The facility's Regional Maintenance Director confirmed that a quote for repairs was obtained only after the incident, with plans to address the issue during upcoming renovations. The Nursing Home Administrator acknowledged the facility's failure to respond promptly to the resident's concerns, which resulted in the accident and subsequent injury.
Failure to Address Resident Concerns and Involve in Fund Activities
Penalty
Summary
The facility failed to consider and act upon the views and recommendations raised during resident group meetings, as evidenced by the lack of response to concerns expressed by residents regarding vegetarian food options. During a resident council meeting, residents raised concerns about the availability of vegetarian hotdogs and bacon, but these concerns were not documented in the facility's grievance log, nor was there any evidence of a response in subsequent meeting minutes. Resident 22 specifically noted that her dietary preferences were not addressed, and the Nursing Home Administrator could not provide documentation of any actions taken to resolve these issues. Additionally, the facility did not involve residents in discussions or decision-making regarding resident fund activities. The resident council meeting minutes included a Treasurer's Report section, but there was no documented evidence of discussions about monetary activities or resident input. Residents interviewed were unaware of the purpose of the Treasurer's Report and did not recall any discussions about the resident fund. The Activities Director maintained financial records but could not provide evidence of resident involvement in fund activities. The Nursing Home Administrator acknowledged the facility's responsibility to consider resident views but could not provide documentation of such considerations.
Failure to Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to implement person-centered care plans for four residents, leading to deficiencies in addressing their specific medical needs and fall risks. Resident 8's care plan did not include the presence of a pacemaker or how to monitor it, despite the resident's diagnosis of heart failure and having a pacemaker. This oversight was confirmed by the Director of Nursing during the survey. Resident 7, diagnosed with chronic kidney disease, had a care plan indicating a risk for falls due to generalized weakness and poor balance. However, during an observation, it was found that the resident's bed was not in the lowest position as required by the care plan. Similarly, Resident 66, who had a history of falls and was at high risk for falling, was found without the call bell within reach, contrary to the care plan's interventions. This was confirmed by a Nurse Aide during an observation. Resident 64, diagnosed with osteoarthritis and at high risk for falls, had a care plan that included a bed clip alarm and keeping the bed in the lowest position. However, during an observation, it was noted that the bed alarm was not connected, and the bed was not in the lowest position. These deficiencies were acknowledged by the facility's Director of Nursing and Nursing Home Administrator, who confirmed the responsibility to ensure the implementation of person-centered care plans to mitigate fall risks.
Failure to Include Residents in Care Plan Development
Penalty
Summary
The facility failed to ensure that comprehensive care plans were developed and revised with the participation of the residents and their representatives for three residents. Resident 15, who was admitted with schizophrenia and cerebral infarction, was found to be cognitively intact with a BIMS score of 15. However, she reported not being invited to participate in recent care plan meetings and expressed interest in discussing her discharge options and goals. Similarly, Resident 31, with chronic kidney disease and chronic respiratory failure, and a BIMS score of 14, also indicated not being invited to participate in care plan meetings. Resident 49, diagnosed with atherosclerotic heart disease and a BIMS score of 15, reported not being included in care plan meetings and expressed a desire to attend. The Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed that it is the facility's responsibility to ensure residents are given the opportunity to participate in the development and revision of their care plans. Despite the interdisciplinary team meeting quarterly to discuss and revise each resident's plan of care, there was no documented evidence that Residents 15, 31, and 49 were offered the opportunity to participate in their care plan meetings over the past six months. The DON and NHA acknowledged the necessity of including residents in the care planning process to the greatest extent possible.
Failure to Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to timely identify and assess a significant weight loss in Resident 22, who was admitted with conditions including GERD, COPD, and cerebral atherosclerosis. Despite being cognitively intact and aware of her weight loss, the resident reported that staff had not discussed her weight loss or dietary preferences with her. The facility's policy required monitoring and intervention for weight changes, but there was no documented evidence of a nutritional assessment or notification to the resident or physician about the weight loss. The resident's weight dropped below her ideal body weight range, yet no reassessment or care plan revision was conducted. Additionally, the facility did not implement a planned nutrition intervention for Resident 142, who experienced a significant weight loss of 13.1% over a short period. The resident, diagnosed with subarachnoid hemorrhage, diabetes, and dysphagia, was ordered a Healthshake with meals to address the weight loss. However, during a survey, it was observed that the Healthshake was not provided as ordered, and the resident's meal ticket did not reflect this intervention. The registered dietitian confirmed the oversight, indicating a failure to follow the physician's order. The Director of Nursing confirmed the facility's failure to timely identify and address the weight loss issues for both residents. The lack of timely intervention and communication with the residents and their physicians contributed to the deficiencies noted in the survey. The facility did not act upon the significant weight changes, nor did it develop and implement necessary nutritional support measures to maintain the residents' nutritional status.
Failure to Provide Adequate Vegetarian Menu for Resident
Penalty
Summary
The facility failed to ensure a pre-planned nutritionally adequate menu for a resident, identified as Resident 22, who was admitted with diagnoses including gastro-esophageal reflux disease (GERD), chronic obstructive pulmonary disease (COPD), and cerebral atherosclerosis. The resident was cognitively intact and had specific dietary preferences, being a vegetarian who also consumed fish and seafood. Despite these preferences being noted in the resident's nutritional risk assessment, they were not adequately reflected in the resident's profile or plan of care. The facility's diet manual included a vegetarian diet, but there was no planned menu for such a diet at the time of the survey. Resident 22 expressed dissatisfaction with the food choices available, specifically requesting vegetarian options like veggie hot dogs and veggie bacon during a Resident Council Meeting. However, there was no follow-up or resolution to these concerns in subsequent meetings. The resident also reported significant weight loss over a short period, which was confirmed by the Nursing Home Administrator. The facility did not engage with the resident regarding her weight loss or dietary preferences, leading to a failure in meeting her nutritional needs and preferences.
Failure to Prevent Resident Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, which is a violation of their policy prohibiting such acts. The incident involved Resident 39, who is severely cognitively impaired with a BIMS score of 2, indicating severe cognitive impairment. Resident 39 was subjected to physical abuse by Resident CR4, who is cognitively intact with a BIMS score of 14. Resident CR4 has a history of behaviors related to dementia, including agitation and aggression, which were documented in his care plan. On April 19, 2024, Resident CR4 was observed yelling at Resident 39 in the dining room. Despite staff attempts to redirect Resident CR4, he continued to be aggressive. Witnesses reported that Resident CR4 punched and kicked Resident 39 and attempted to throw coffee on him. A progress note confirmed that Resident CR4 punched Resident 39 in the face and threw a glass of orange juice at him, stating aggressive intentions. Resident CR4 was subsequently sent to a community hospital due to his combative behavior. The facility's Nursing Home Administrator and Director of Nursing confirmed the incident and acknowledged the failure to prevent the abuse. The facility's policy clearly states that residents should be free from abuse by anyone, including other residents. Despite interventions in place for Resident CR4's aggressive behaviors, the facility did not effectively prevent the physical abuse of Resident 39, highlighting a deficiency in ensuring resident safety.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure the Minimum Data Set Assessment (MDS) accurately reflected the status of a resident. Specifically, the admission MDS assessment for Resident 142 incorrectly recorded the resident's weight in Section K0200. The assessment indicated a weight of 116 pounds, whereas the resident's weight record showed a weight of 115.6 pounds on the date of admission and 108.6 pounds on the most recent date prior to the MDS assessment. This discrepancy was confirmed during an interview with the facility's registered dietitian, who acknowledged that the MDS should have been coded to reflect the most recent weight prior to the assessment date.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed on July 18, 2024. During observations at 8 AM and again at 12 PM, it was noted that the facility's two large trash dumpsters, which contained bags of garbage and trash, were not covered. The lids to both garbage dumpsters were observed to be open during each observation. In an interview conducted on the same day at approximately 2:30 PM, the Nursing Home Administrator confirmed that the dumpster lids should be closed, indicating a failure to adhere to proper waste management protocols.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for residents on the second, third, and fourth floors, as observed during a survey. On the second floor, a black substance was found on the air vent above the nurses' station, and the community television and dining area had a sticky floor with dried liquid stains and food crumbs in the refrigerator. The counter was littered with liquid stains, food, and paper debris, and the microwave contained dried food and liquid stains. The garbage can lacked a lid and was filled with trash. The second-floor hallway had dirt, debris, and black scuff marks, and resident rooms, except for one, had floors coated with a thick brown residue and black scuff marks. On the third floor, liquid stains, black scuff marks, and gouges were observed on the hallway walls, and damaged floor tiles were found under the bed legs in a resident room. A thick brown substance accumulated along the baseboard of the dining/activity room. On the fourth floor, a wheelchair and broda chair were stained with dried substances, and the floor baseboard had a thick black substance. Damaged floor tiles were also observed under the bed legs in a resident room, and the hallway floor had dirt, debris, and black scuff marks. The resident rooms on this floor had floors covered with a thick brown residue and black scuff marks. The Nursing Home Administrator confirmed that the environment and equipment were expected to be clean and sanitary.
Failure to Ensure Informed Consent for Medicare Disenrollment
Penalty
Summary
The facility failed to develop and implement policies and procedures to protect residents from being disenrolled from their Medicare health plans without their informed consent. This deficiency was identified through a review of clinical records, CMS guidance, facility documentation, and staff interviews. The facility disenrolled seven residents from their Medicare Advantage plans without ensuring that the residents or their representatives fully understood the implications of such changes. The residents affected included those with various medical conditions such as diabetes, bipolar disorder, cognitive communication deficits, and dementia. The review revealed that the facility's Business Office Manager (BOM) had discussions with residents about transitioning to traditional Medicare, citing potential benefits such as increased therapy time and reduced need for authorizations. However, there was no evidence that the residents were provided with written and verbal explanations of the risks associated with disenrollment, nor was there documentation of the residents' cognitive ability to understand these changes. In some cases, the residents were noted to be cognitively intact, while others had moderate cognitive impairments, raising concerns about their capacity to make informed decisions. Interviews with the Nursing Home Administrator and BOM confirmed that the facility lacked policies and procedures for assisting residents with Medicare plan changes. This oversight led to the facility initiating changes in Medicare health plans without proper documentation of the residents' requests or consent. The deficiency was cited as past non-compliance, indicating that the facility had not adhered to CMS guidelines and resident rights regarding Medicare health plan enrollment and disenrollment.
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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