Maybrook Hills Rehabilitation And Healthcare Cente
Inspection history, citations, penalties and survey trends for this long-term care facility in Altoona, Pennsylvania.
- Location
- 301 Valley View Boulevard, Altoona, Pennsylvania 16602
- CMS Provider Number
- 395514
- Inspections on file
- 37
- Latest survey
- August 12, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Maybrook Hills Rehabilitation And Healthcare Cente during CMS and state inspections, most recent first.
Comprehensive MDS assessments and Care Area Assessment processes were not completed within the required time frames for multiple residents, with assessments being finalized several days late. The RNAC confirmed that these delays occurred, as identified through review of clinical records and staff interviews.
Quarterly MDS assessments were not completed within the required time frames for multiple residents. Review of clinical records and staff interviews confirmed that several MDS assessments were either delayed or missing, in violation of regulatory requirements for timely resident assessment documentation.
The facility did not transmit MDS assessments to the CMS QIES ASAP System within the required 14-day period for three residents. Quarterly MDS assessments for these residents were submitted late, with delays ranging from several weeks to over six months, as confirmed by the RNAC.
Surveyors found that several residents' MDS assessments were inaccurately coded, failing to reflect the administration of medications such as antidepressants, insulin, anticonvulsants, diuretics, opioids, and antibiotics, despite physician orders and documentation in the MARs. The errors were confirmed by the RN Assessment Coordinator after review of clinical records and staff interviews.
Three residents did not receive medications according to physician orders, including failure to administer constipation treatments as prescribed, not assessing vital signs before giving antihypertensive medication, and administering blood pressure medication despite parameters to hold. The DON confirmed these lapses in medication administration.
A resident with a history of UTIs and sepsis, who was receiving daily amoxicillin and Methenamine Hippurate for UTI prevention, did not have a comprehensive care plan addressing their specific needs related to ongoing antibiotic use. The absence of this care plan was confirmed by the DON.
An opened multidose vial of Aplisol solution used for TB skin testing was found undated in a medication storage refrigerator on one unit. Facility policy and manufacturer instructions require opened vials to be dated and discarded after 30 days. An LPN and the DON both confirmed the vial was not dated as required.
A resident with unstageable pressure ulcers did not have Enhanced Barrier Precautions (EBP) implemented as required by infection control guidelines. There was no signage or PPE available in the resident's room, and EBP was not ordered or care planned until several days after the wounds were identified. Staff confirmed that EBP was missed for this resident, resulting in a deficiency for not following infection prevention protocols.
A resident with multiple fractures and cognitive intactness received PRN pain medications outside of physician-ordered parameters. Oxycodone was administered for mild pain and Tylenol for moderate pain, contrary to the specified pain level guidelines. The DON confirmed the medications were not given as ordered.
A resident with an indwelling catheter was not provided care in accordance with Enhanced Barrier Precautions, as an LPN failed to use gloves or a gown during medication administration, including handling spilled pills and applying medicated patches. The LPN was unaware of the resident's EBP status and did not follow facility policy prohibiting direct contact with medications, as confirmed by the DON.
The facility failed to follow proper infection control practices for handling soiled linen for two residents. A nurse aide was observed carrying soiled laundry with bare hands, and two other aides threw soiled items on the floor during care. The facility's policy requires gloves and proper disposal of soiled items, which was confirmed by the Nursing Home Administrator.
The facility failed to complete comprehensive admission and annual MDS assessments within the required time frame for four residents. The assessments were completed 15, 18, 21, and 19 days after admission, exceeding the 14-day requirement. This delay was confirmed through staff interviews.
The facility failed to complete quarterly MDS assessments within the required timeframe for four residents. The assessments were completed beyond the 14-day requirement after the ARD, as confirmed by the Nursing Home Administrator.
The facility failed to accurately complete MDS assessments for several residents, omitting critical information such as the administration of antibiotics, use of medical devices, and provision of hospice care. These inaccuracies were confirmed by the Nursing Home Administrator.
The facility failed to administer medications as ordered for two residents. One resident did not receive Lasix and Potassium despite weight increases and was given Midodrine when blood pressure was too high. Another resident missed doses of Insulin Aspart, Renvela, and Insulin Glargine due to being at dialysis, with no administration upon return. These issues were confirmed by the Assistant DON.
The facility failed to administer enteral feedings according to physician's orders for two residents. One resident did not receive Jevity 1.5 when her meal intake was below 50%, and received it when her intake was above 50%. Another resident did not receive a 240 ml bolus of Isosource 1.5 when her intake was below 50%, and received it when her intake was above 50%. Additionally, staff did not check residuals before administering tube feedings, as required by policy.
The facility failed to follow infection control practices, including not cleaning a blood pressure cuff between residents and not using Enhanced Barrier Precautions (EBP) for residents with indwelling devices. Observations revealed staff handling soiled linen without gloves and providing care without appropriate PPE, as confirmed by staff interviews.
The facility failed to allow residents to dine in the main dining room due to a broken air conditioner, affecting their right to make choices about significant aspects of their lives. Despite residents' expressed desires, the dining room remained closed without alternative measures, as confirmed by staff and residents.
The facility failed to provide timely and accurate notices regarding the end of Medicare coverage for two residents. One resident did not receive a timely SNF Beneficiary Protection Notification Review form or ABN, and the ABN lacked details on coverage and costs. Another resident received an incomplete ABN notice. The Nursing Home Administrator confirmed these deficiencies.
The facility failed to provide written notices to residents and their representatives regarding hospital transfers for six residents, including those with conditions like sepsis, cancer, and acute kidney injury. This deficiency was confirmed through record reviews and staff interviews, revealing a lack of compliance with notification requirements.
The facility failed to complete timely significant change MDS assessments for two residents admitted to hospice care. One resident with an end-stage illness and another with COPD did not have their assessments completed within the required time frame, as confirmed by the Nursing Home Administrator.
A facility failed to develop a care plan for a resident with cognitive impairment who required a CPAP machine for sleep apnea. Despite physician's orders and documented use of the CPAP, no care plan was in place to address this need, as confirmed by the Assistant DON.
The facility failed to update care plans for two residents, leading to discrepancies in documented care needs. One resident's care plan inaccurately reflected anticoagulant therapy, while another's tube feeding regimen was not updated to match physician's orders. These issues were confirmed through staff interviews and record reviews.
A resident with a history of falls and cognitive impairment experienced two falls without new interventions being implemented to prevent future incidents. Despite the resident's need for extensive assistance and the presence of a bed alarm during one fall, the facility did not document any new preventive measures, as confirmed by staff interviews.
A facility failed to provide trauma-informed care for a resident with PTSD, as evidenced by the absence of documented triggers and preventive measures in the care plan. The resident, who was moderately cognitively impaired and diagnosed with depression and PTSD, did not have a trauma-informed care assessment completed, as confirmed by the Assistant Director of Nursing.
The facility failed to conduct annual performance evaluations for three nurse aides as required. Personnel files showed that evaluations were not completed according to hire dates, and the Nursing Home Administrator confirmed the absence of these evaluations, indicating non-compliance with staff performance review protocols.
The facility failed to secure and label medications properly. A controlled medication was found unsecured and unlabeled in a medication cart, and another resident's medication was administered incorrectly due to outdated labeling. The facility's policies on medication security and labeling were not followed.
The facility failed to maintain sanitary conditions in the kitchen as dietary workers did not comply with the policy requiring beard and hair nets. Several workers were observed without proper beard and hair coverings during food preparation, which was confirmed by the Dietary Manager and Nursing Home Administrator.
A facility failed to document daily weights for a resident undergoing hemodialysis, as required by their care plan and physician's order. Despite obtaining the weights, staff did not have a designated area in the clinical record to chart them, leading to incomplete documentation.
A facility failed to obtain necessary hospice documentation for a resident with dementia receiving hospice care. Despite a care plan indicating hospice services, there was no evidence of obtaining the current hospice recertification of terminal illness or plan of care for the specified certification period, as confirmed by the Nursing Home Administrator.
The facility's QAPI committee failed to address repeated deficiencies in comprehensive assessments, care plans, medication management, food service, and medical records, despite having plans of correction involving audits and committee reviews.
A resident with heart failure did not receive prescribed Torsemide due to a transcription error by a nurse, leading to fluid overload and severe swelling. The error occurred when the nurse failed to update the medical record with the physician's order.
A resident with heart failure did not receive prescribed Torsemide due to a nurse's failure to transcribe a physician's order into the medical record. This oversight led to the resident missing doses from late May to early June, confirmed by the DON.
A facility failed to administer oxygen therapy as ordered by a physician for a resident. The resident, who was cognitively intact and required oxygen for hypoxia, was observed receiving oxygen at a flow rate of five lpm instead of the prescribed two lpm. This discrepancy was confirmed by an LPN during an interview.
A cognitively impaired resident reported verbal abuse by a family member, but the facility failed to report the allegation to the Department of Health. Despite the resident's distress and fear, the Director of Nursing did not report the incident, citing lack of direct witness accounts and the resident's cognitive impairment.
The facility did not develop comprehensive care plans for two residents. One resident with a skin tear on the left shin did not have an updated care plan reflecting wound clinic recommendations. Another resident with End Stage Renal Disease requiring dialysis lacked a care plan for managing the dialysis catheter and process. The DON confirmed the absence of these care plans.
A facility failed to obtain necessary physician's orders for a resident with ESRD requiring dialysis. The resident received dialysis treatments without documented orders, and there were no orders for the care and monitoring of the dialysis catheter or emergency equipment at the bedside. This was confirmed by the DON.
The facility failed to accurately complete MDS assessments for two residents, resulting in incorrect documentation of hypoglycemic medication administration and omission of oxygen therapy, non-invasive mechanical ventilation, and dialysis. Physician's orders and treatment records confirmed these treatments, but the MDS assessments did not reflect them, as confirmed by the RNAC.
The facility failed to adhere to wound care recommendations for a resident, continuing an outdated treatment alongside a new one. Additionally, staff did not notify a physician about another resident's elevated blood sugar levels as required. These deficiencies were confirmed by the DON.
The facility failed to maintain complete and accurate clinical records for two residents. One resident experienced an unwitnessed fall, and although assessed, the documentation was not included in the clinical record. Another resident frequently rang the call bell, but this behavior was not documented, leading to the use of a non-working call bell. The DON confirmed these documentation lapses.
Failure to Complete MDS Assessments Within Required Time Frames
Penalty
Summary
The facility failed to complete comprehensive Minimum Data Set (MDS) assessments and Care Area Assessment (CAA) processes within the required time frames for 11 out of 65 residents reviewed. According to the Resident Assessment Instrument (RAI) User's Manual, admission MDS assessments and CAA completion dates must be no later than 13 days after admission, and comprehensive MDS assessments must be completed at least every 92 days. Review of clinical records, the CMS MDS validation report, and staff interviews confirmed that multiple MDS assessments were completed several days past the required deadlines for the identified residents. Specific examples include assessments being completed between 1 and 15 days late for various residents. The Registered Nurse Assessment Coordinator (RNAC) confirmed during an interview that these comprehensive MDS assessments were not completed within the mandated time frames. This deficiency was identified through review of clinical documentation and staff interviews, as well as validation against regulatory requirements.
Failure to Complete Quarterly MDS Assessments Within Required Time Frames
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed within the required time frames for 15 out of 65 residents reviewed. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, a quarterly MDS assessment must have an assessment reference date (ARD) no more than 92 days after the ARD of the most recent assessment, and the assessment must be completed within 14 calendar days after the ARD. Review of clinical records revealed that for multiple residents, either the quarterly or comprehensive MDS assessments were not completed within these mandated time frames. Specific examples included assessments with ARDs that were not followed by timely completion, as well as instances where no prior assessment was completed within the required 92-day period. Interviews with the Registered Nurse Assessment Coordinator (RNAC) confirmed that the MDS assessments for the identified residents were not completed as required. The deficiency was identified through review of the RAI Manual, clinical records, and staff interviews, and it was determined that the facility did not comply with the regulatory requirements for timely completion of resident assessments as outlined in 28 Pa. Code 211.5(f) regarding clinical records.
Failure to Timely Transmit MDS Assessments
Penalty
Summary
The facility failed to transmit Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) System within the required 14-day timeframe for three residents. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, comprehensive MDS assessments must be transmitted electronically within 14 days of the Care Plan Completion Date, and all other MDS assessments must be submitted within 14 days of the MDS Completion Date. Review of the MDS validation report from iQIES revealed that three residents had quarterly MDS assessments that were submitted late. Specifically, one resident's quarterly MDS assessment was completed but not submitted until over six months later, another resident's assessment was submitted more than three weeks after completion, and a third resident's assessment was submitted nearly a month late. An interview with the Registered Nurse Assessment Coordinator (RNAC) confirmed that these MDS assessments were not completed and transmitted within the required timeframes.
Inaccurate MDS Assessments for Medication Administration
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for six residents, as required by the Resident Assessment Instrument (RAI) User's Manual. Specifically, the assessments did not accurately reflect the medications administered to the residents during the seven-day assessment periods. For example, residents who received antidepressants, insulin, anticonvulsants, diuretics, opioids, and antibiotics according to physician orders and Medication Administration Records (MARs) were not properly coded in the corresponding MDS sections. These discrepancies were identified through a review of clinical records, MARs, and staff interviews. The affected residents had documented orders and received medications such as Venlafaxine, Escitalopram, Keppra, Insulin Glargine, Mirtazapine, Lasix, Gabapentin, Tramadol, and Bacitracin-Polymixin B ointment. However, their MDS assessments failed to indicate the administration of these medications in the relevant sections. The Registered Nurse Assessment Coordinator confirmed that the assessments for these residents were coded incorrectly, resulting in inaccurate documentation of their care needs and treatments.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to follow physician's orders for medication administration for three residents. One resident, who was cognitively impaired and required extensive assistance, had physician's orders for Senna and Bisacodyl to be administered as needed for constipation if no bowel movement occurred within a specified number of days. Review of records showed that the resident went up to seven days without a bowel movement, and staff did not administer the prescribed medications until the sixth day, contrary to the physician's orders. The Director of Nursing confirmed that the medications were not given as ordered. Another resident, also cognitively impaired and diagnosed with hypertension, had an order for Propranolol with instructions to hold the medication if the heart rate was below 60 or systolic blood pressure was below 100. Staff failed to assess and document the resident's heart rate and blood pressure prior to administration. A third resident, who was cognitively intact and had renal insufficiency requiring dialysis, had an order for Midodrine to be held if systolic blood pressure exceeded 130. Despite this, the medication was administered multiple times when the resident's systolic blood pressure was above the threshold. The Director of Nursing confirmed that the medication should have been held on those occasions.
Failure to Develop Individualized Care Plan for Antibiotic Use
Penalty
Summary
The facility failed to develop a comprehensive and individualized care plan for a resident who was cognitively intact but required substantial assistance with daily care tasks. Clinical records showed that the resident had physician's orders for daily amoxicillin and Methenamine Hippurate for the prevention of urinary tract infections (UTIs), due to a history of UTIs with sepsis. Despite these ongoing medication orders, there was no documented evidence that a care plan was created to address the resident's specific care and treatment needs related to the use of these antibiotic medications. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that a care plan should have been developed for the resident's antibiotic use.
Undated Opened Aplisol Vial Found in Medication Refrigerator
Penalty
Summary
Surveyors found that the facility failed to date an opened multidose vial of Aplisol solution, used for tuberculosis skin testing, in one of two medication storage area refrigerators on Unit D2. The facility's medication storage policy requires all medications to be stored according to the manufacturer's recommendations, which for Aplisol specify that vials in use for more than 30 days should be discarded. During an observation, an opened and undated vial of Aplisol was found in the refrigerator. An LPN confirmed at the time of observation that the vial was not dated when opened and acknowledged it should have been. The DON also confirmed that the vial should have been dated upon opening.
Failure to Implement Enhanced Barrier Precautions for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to follow established infection control guidelines from CMS and CDC regarding Enhanced Barrier Precautions (EBP) for a resident with pressure ulcers. According to the facility's policy and updated federal guidance, residents with chronic wounds, such as pressure ulcers, require EBP, which includes the use of gowns and gloves during high-contact care activities to prevent the spread of multidrug-resistant organisms (MDROs). Review of clinical records showed that a resident had unstageable pressure ulcers on the left heel and foot, with physician orders for daily wound care. However, there was no evidence that EBP was ordered or care planned for this resident until several days after the wounds were documented. Observations revealed that there was no signage or notification indicating EBP in the resident's room, nor was any personal protective equipment (PPE) available in or around the room during the survey. Staff interviews confirmed that the requirement for EBP was missed for this resident, despite the presence of pressure ulcers. The deficiency was cited under state regulations for failure to implement appropriate infection prevention and control measures.
Failure to Follow Physician Orders for PRN Pain Medication
Penalty
Summary
The facility failed to ensure that physician's orders for as needed (prn) pain medications were followed for one resident. According to the clinical record review, the resident was cognitively intact, required supervision with daily care, and had diagnoses including right arm fracture, osteoporosis, and a pathological lumbar spine fracture. Physician's orders specified that acetaminophen (Tylenol) was to be administered for mild pain (pain level 1-3) and oxycodone for moderate to severe pain (pain level 4-10). However, the Medication Administration Record showed that oxycodone was given for a pain level of 3, and Tylenol was given for a pain level of 5, both of which were outside the prescribed parameters. The DON confirmed that the medications were not administered according to the physician's orders.
Failure to Follow Enhanced Barrier Precautions and Medication Administration Protocols
Penalty
Summary
The facility failed to follow established infection control guidelines and its own policies regarding Enhanced Barrier Precautions (EBP) and medication administration for a resident with an indwelling urinary catheter. Observations revealed that a Licensed Practical Nurse (LPN) did not wear gloves or a gown while administering medications, applying and removing medicated patches, and providing insulin injections to the resident, despite the resident being on EBP due to the presence of an indwelling catheter. The LPN also handled spilled medications with bare hands, including picking up pills from the medication cart and administering them to the resident, contrary to facility policy that prohibits touching tablets or capsules with fingers. The resident involved was cognitively impaired, required assistance with care, and had an indwelling catheter, as well as orders for insulin and topical/transdermal medications. The LPN stated she was unaware that the resident was on EBP and confirmed she did not use gloves during medication administration or when handling spilled medications. The Director of Nursing confirmed that the resident was on EBP and that appropriate PPE should have been used during care. These actions were not in compliance with CDC and CMS infection control guidelines, as well as facility policy.
Infection Control Deficiency in Linen Handling
Penalty
Summary
The facility failed to adhere to proper infection control practices concerning the handling of soiled linen for two residents. Observations revealed that a nurse aide exited the room of a resident carrying soiled laundry with bare hands, contrary to the facility's infection control policy that mandates the use of gloves. The nurse aide confirmed the requirement to wear gloves when handling soiled laundry. Additionally, during a bed bath for another resident, two nurse aides were observed throwing soiled gowns, briefs, and bed linens on the floor instead of placing them in bags for proper disposal. The aides acknowledged that the soiled items should not be thrown on the floor and should be bagged and taken to the dirty linen bins. The facility's infection control policy, dated May 8, 2024, specifies that staff should handle soiled linen using standard precautions, such as wearing gloves. The Nursing Home Administrator confirmed that gloves should be worn when carrying soiled laundry out of resident rooms and that soiled items should not be placed on the floor. The deficiency was identified during a review of facility policies, clinical records, observations, and staff interviews, highlighting a failure to follow established infection control protocols.
Delayed Completion of MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive admission and annual Minimum Data Set (MDS) assessments within the required time frame for four residents. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, an admission MDS assessment must be completed no later than 14 days following admission. However, the assessments for Residents 32, 128, 204, and 225 were completed 15, 18, 21, and 19 days after admission, respectively. This delay in completing the assessments was confirmed through interviews with the Nursing Home Administrator and the Assistant Director of Nursing. The deficiency was identified during a review of the Resident Assessment Instrument User's Manual, clinical records, and staff interviews. The manual specifies that the Assessment Reference Date (ARD) must be set within 366 days after the ARD of the previous comprehensive assessment, and the assessment should be completed no later than the ARD plus 14 calendar days. The facility's failure to adhere to these guidelines resulted in the late completion of the MDS assessments for the mentioned residents, as confirmed by the facility's staff.
Failure to Complete Quarterly MDS Assessments on Time
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed within the required timeframe for four residents. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, the assessment reference date (ARD) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type, and the assessment must be completed no later than 14 calendar days after the ARD. However, the facility did not adhere to these guidelines for Residents 33, 147, 157, and 159. For Resident 33 and Resident 147, the quarterly MDS assessments were completed 15 days after the ARD, exceeding the 14-day requirement. Resident 157's assessment was completed 19 days after the ARD, and Resident 159's assessment was completed 17 days after the ARD. These delays were confirmed during an interview with the Nursing Home Administrator, indicating a failure to complete the assessments on time as required by the regulations.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for eight residents, as required by the Resident Assessment Instrument (RAI) User's Manual. The deficiencies were identified through a review of clinical records and staff interviews. For several residents, the MDS assessments did not accurately reflect the administration of medications or the use of medical devices. For instance, one resident was administered an antibiotic for a urinary tract infection, but the MDS assessment did not indicate this. Similarly, another resident was using a wander/elopement alarm, but the MDS assessment failed to record its use. In other cases, the facility did not accurately document the use of respiratory support devices and dialysis treatments. One resident was using a BIPAP device and receiving dialysis, but these were not recorded in the MDS assessment. Another resident was using a CPAP device for sleep apnea, yet this was not reflected in the assessment. Additionally, the use of antipsychotic medication for a resident with schizophrenia was not documented, despite being administered daily during the assessment period. The facility also failed to document hospice care and oxygen use for residents who were receiving these services. One resident was admitted to hospice care for chronic obstructive pulmonary disease, but the MDS assessment did not indicate hospice care was being provided. Another resident was receiving oxygen therapy, yet this was not recorded in the assessment. These inaccuracies were confirmed by the Nursing Home Administrator during an interview, highlighting a significant lapse in the facility's assessment processes.
Medication Administration Failures for Two Residents
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by the physician for two residents. Resident 2, who had a diagnosis of heart failure, was prescribed an as-needed diuretic, Lasix, and Potassium to be administered if there was a significant weight increase. Despite documented weight increases, there was no evidence that these medications were given. Additionally, Resident 2 was prescribed Midodrine for hypotension, which was to be withheld if the systolic blood pressure exceeded 130 mmHg. However, the medication was administered on multiple occasions when the resident's blood pressure was above this threshold. Resident 143, who was cognitively intact and had diagnoses of diabetes and renal failure, was supposed to receive Insulin Aspart, Renvela, and Insulin Glargine. These medications were not administered on specific dates because the resident was at dialysis, and there was no documentation that they were given upon the resident's return. Interviews with the Assistant Director of Nursing confirmed these lapses in medication administration for both residents.
Failure to Administer Enteral Feedings as Ordered
Penalty
Summary
The facility failed to administer enteral feedings in accordance with physician's orders for two residents, leading to deficiencies in their care. Resident 20, who was usually understood and had a feeding tube, was supposed to receive Jevity 1.5 if she consumed less than 50% of her meal. However, the Medication Administration Record (MAR) showed that the resident did not receive the prescribed 237 ml of Jevity 1.5 on several occasions when her meal intake was below 50%, and conversely, she received it when her intake was above 50%. This inconsistency was confirmed by the Assistant Director of Nursing. Similarly, Resident 56, who was cognitively impaired and dependent on staff for eating, had orders to receive a 240 ml bolus of Isosource 1.5 if she consumed less than 50% of her meal. The MAR revealed that the resident did not receive the bolus on multiple occasions when her intake was below 50%, and she received it when her intake was above 50%. Additionally, there was no documentation of staff checking residuals before administering the tube feeding, as required by the facility's policy. This was also confirmed by the Assistant Director of Nursing.
Infection Control Deficiencies in Equipment Cleaning and PPE Use
Penalty
Summary
The facility failed to adhere to proper infection control practices, as evidenced by multiple observations and staff interviews. During a medication administration, a Licensed Practical Nurse (LPN) used a blood pressure cuff on two residents without cleaning it between uses, which was confirmed by both the LPN and the Assistant Director of Nursing. This action violated the facility's infection control policy, which mandates cleaning of medical equipment between residents to prevent cross-contamination. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices or chronic wounds, as required by updated CMS guidelines. For instance, a resident with a urinary catheter did not have appropriate signage or personal protective equipment (PPE) available outside their room. Interviews with the LPN Manager and Infection Preventionist confirmed the oversight. Similarly, another resident with a feeding tube and tracheostomy did not receive care with the necessary PPE, as observed when a nurse aide provided incontinence care without gloves or a gown. Further deficiencies were noted in the handling of soiled linen and the administration of enteral feedings. A nurse aide was observed carrying soiled linen with bare hands, contrary to the facility's policy requiring gloves. Moreover, an LPN administered a bolus feeding to a resident with a feeding tube while only wearing gloves, omitting the required gown. These actions were confirmed through interviews with the involved staff and the Nursing Home Administrator, highlighting a pattern of non-compliance with infection control protocols.
Failure to Facilitate Resident Dining Choices Due to Broken Air Conditioner
Penalty
Summary
The facility failed to ensure that residents could make choices about significant aspects of their lives, such as dining in the main dining room. This deficiency affected nine residents who expressed their desire to eat in the main dining room but were unable to do so due to a broken air conditioner. The facility decided to close the dining room, citing high temperatures and the need to wait for a part to fix the air conditioner. Interviews with residents and staff confirmed that the dining room remained closed, and no alternative measures were taken to allow residents to dine there. The Nursing Home Administrator and Maintenance Director confirmed that the air conditioning units were not functioning, and a vendor was consulted to assess the situation. However, the facility did not monitor the temperatures in the dining room and opted to close it as a precaution. The decision to close the dining room was made without attempting other interventions to maintain its operation, thus limiting the residents' ability to exercise their right to choose where to dine.
Failure to Provide Timely and Accurate Medicare Coverage Notices
Penalty
Summary
The facility failed to provide the required notice to residents or their representatives regarding the end of Medicare coverage and potential liability for services not covered. Specifically, for Resident 201, the facility did not issue a Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form or an Advance Beneficiary Notice (ABN) in a timely manner. The resident's Medicare A services began on March 1, 2024, and ended on April 22, 2024, but the verbal notification to the resident's responsible party was only given on May 1, 2024, which was not 48 hours in advance as required. Additionally, the ABN notice provided did not specify the items and services covered or not covered under Medicaid or by the facility's per diem rate, nor did it include the cost of those items and services. For Resident 228, the facility also failed to provide a complete ABN notice. The resident began Medicare A services on February 7, 2024, and the last covered day was April 1, 2024. Although the SNF Beneficiary Protection Notification Review form and ABN were signed on March 29, 2024, the ABN notice did not include necessary details about coverage and costs. An interview with the Nursing Home Administrator confirmed these deficiencies, acknowledging that the ABN forms for both residents were not completed accurately and should have been.
Failure to Provide Written Notices for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents and their representatives regarding the reasons for hospital transfers, as required by regulations. This deficiency was identified through clinical record reviews and staff interviews, affecting six residents. For Resident 85, who was cognitively intact and dependent on staff for personal care, there was no documented evidence of written notice provided for a hospital transfer due to elevated troponin levels and sepsis. Resident 96, who had cancer and dementia, was transferred multiple times to the hospital for various reasons, including chest pain, sepsis, and septic shock. Despite these significant medical events, there was no documented evidence of written notices provided to the resident or their representative for any of these transfers. Similarly, Resident 157, who was cognitively intact and had osteomyelitis, was transferred to the hospital twice for elevated white blood cell count and other symptoms, but again, no written notices were documented. Other residents, including Resident 171 with cancer and end-stage renal disease, Resident 192 with a suprapubic catheter, and Resident 218 with acute kidney injury, were also transferred to hospitals without documented written notices to them or their representatives. Interviews with the Nursing Home Administrator and the Assistant Director of Nursing confirmed the lack of awareness and compliance with the requirement to provide written notices for hospital transfers.
Failure to Complete Timely MDS Assessments for Hospice Admissions
Penalty
Summary
The facility failed to complete comprehensive significant change Minimum Data Set (MDS) assessments within the required time frame for two residents who experienced significant changes in their conditions. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, the Assessment Reference Date (ARD) and the significant change comprehensive MDS assessment must be completed no later than the 14th calendar day after a significant change in the resident's status is determined. However, for Resident 96, who was admitted to hospice care due to an end-stage illness on July 26, 2024, there was no documented evidence of a completed significant change in status MDS assessment within the required time frame. This was confirmed by the Nursing Home Administrator during an interview on August 27, 2024. Similarly, Resident 171, who was admitted to hospice care with a terminal diagnosis of chronic obstructive pulmonary disease (COPD) on January 31, 2024, also lacked documented evidence of a completed significant change in status MDS assessment within the required time frame. This deficiency was confirmed by the Nursing Home Administrator during an interview on August 26, 2024. The failure to complete these assessments as required by the RAI User's Manual and 28 Pa. Code 211.5(f) Clinical Records indicates a lapse in the facility's compliance with mandated assessment protocols.
Failure to Develop Individualized Care Plan for CPAP Use
Penalty
Summary
The facility failed to develop a care plan to address the individualized care needs of a resident who was cognitively impaired and required assistance for daily care. The resident had a physician's order to use a CPAP machine at bedtime for sleep apnea, as documented in the Medication Administration Record from August 1 through 26, 2024. However, there was no documented evidence of a care plan that included interventions for the use of the CPAP machine. This deficiency was confirmed during an interview with the Assistant Director of Nursing, who acknowledged that a care plan should have been developed for the resident's CPAP use.
Failure to Update Care Plans for Two Residents
Penalty
Summary
The facility failed to ensure that care plans were updated to reflect changes in residents' care needs for two residents. For Resident 125, a significant change Minimum Data Set (MDS) assessment indicated that she was cognitively intact and dependent on staff for personal hygiene needs, with a diagnosis of a left hip fracture. Her care plan, however, noted that she was receiving anticoagulant therapy for atrial fibrillation, but the Medication Administration Record (MAR) showed no evidence of anticoagulant medication being administered. An interview with the Assistant Director of Nursing confirmed that Resident 125 was no longer taking an anticoagulant, and her care plan should have been revised accordingly, but it was not. For Resident 191, an admission MDS assessment revealed cognitive impairment, dependency on staff for all care needs, a diagnosis of dementia, and the use of a feeding tube. Physician's orders specified a 260 ml bolus feeding of Jevity 1.2 every four hours, but the care plan indicated a different feeding regimen of 65 ml per hour. The Assistant Director of Nursing acknowledged that Resident 191's care plan was not updated when her tube feeding orders changed, which it should have been. These deficiencies were identified through a review of policies, clinical records, and staff interviews.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure a safe environment for Resident 165, who had a history of falls and was cognitively impaired, requiring extensive assistance for daily care and transfers. The resident's quarterly Minimum Data Set (MDS) assessment indicated diagnoses including lower back pain, difficulty walking, and dementia. Despite these needs, the facility did not implement new interventions after the resident experienced falls on two separate occasions. On August 22, 2024, Resident 165 fell from her wheelchair to the side of her bed, resulting in a red, swollen right wrist, although an X-ray showed no injuries. No new interventions were documented to prevent future falls. Again, on August 25, 2024, the resident fell to the right side of her bed while the bed alarm was sounding, but no injuries were reported. Despite these incidents, the facility did not document any new interventions to prevent further falls, as confirmed by interviews with the Assistant Director of Nursing and the Nursing Home Administrator.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of Post Traumatic Stress Disorder (PTSD) received trauma-informed care to mitigate or eliminate triggers. A quarterly Minimum Data Set (MDS) assessment for the resident indicated moderate cognitive impairment and diagnoses of depression and PTSD. However, the resident's care plan lacked documented evidence of identified specific triggers that could re-traumatize the resident or measures to prevent or minimize these triggers. An interview with the Assistant Director of Nursing revealed that the facility was not completing trauma-informed care assessments.
Failure to Conduct Annual Nurse Aide Evaluations
Penalty
Summary
The facility failed to ensure that annual performance evaluations for nurse aides were completed as required. Specifically, the personnel files of three nurse aides were reviewed, revealing that their evaluations were not conducted in accordance with their hire dates. Nurse Aide 1, hired on August 11, 1998, did not have a documented evaluation for August 2023. Similarly, Nurse Aide 2, hired on July 2, 2008, lacked documentation for a July 2023 evaluation. Nurse Aide 3, hired on August 12, 2018, also did not have a documented evaluation for August 2023. An interview with the Nursing Home Administrator confirmed the absence of these evaluations, indicating a lapse in the facility's adherence to required staff performance review protocols. The deficiency was identified through a review of personnel files and staff interviews, highlighting the facility's failure to comply with regulations regarding the timely evaluation of nurse aide performance. This oversight was confirmed by the Nursing Home Administrator, who acknowledged the lack of documented evidence for the required annual evaluations.
Medication Security and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that controlled medications were properly secured and labeled according to their policies and professional standards. For one resident, a controlled medication, Clonazepam, was found unsecured in a medication cart without a label. The medication was intended for a resident with an order to receive 0.5 mg every eight hours for anxiety. The medication was prepared ahead of time and stored in a cart that did not have a controlled medication drawer, violating the facility's policy that requires controlled drugs to be stored under double lock and key. Additionally, the facility did not ensure proper labeling of medications for another resident. The resident was ordered to receive 17 grams of Miralax daily via a peg tube, but the medication was administered orally. The label on the Miralax had not been updated to reflect the change in administration route, as the resident no longer had a peg tube. This discrepancy was confirmed by the Assistant Director of Nursing, indicating a failure to update medication labels in accordance with the facility's policy and procedures.
Failure to Maintain Sanitary Conditions in Kitchen
Penalty
Summary
The facility failed to ensure that food was served under sanitary conditions, as observed during a lunch meal tray line in the main kitchen. Several dietary workers, identified as Dietary Worker 6 through Dietary Worker 11, were noted to have beards that were not covered with beard nets, contrary to the facility's policy. Additionally, Dietary Worker 12 and Dietary Worker 13 did not have their hair completely covered by hair nets during food preparation. The facility's policy, dated May 8, 2024, mandates that kitchen staff maintain personal hygiene by keeping hair clean and neatly tied or pinned back under a hair net, and facial hair such as beards must be covered with a beard net. Interviews with the Dietary Manager and the Nursing Home Administrator confirmed the requirement for dietary workers to have beards covered with beard nets and hair completely under hair nets while in the kitchen. This deficiency was identified under 28 Pa. Code 211.6(f) Dietary Services.
Incomplete Clinical Documentation for Resident
Penalty
Summary
The facility failed to ensure that clinical records for a resident were complete and accurately documented. Specifically, the clinical records for a resident, who required hemodialysis treatments and was at nutritional risk due to end-stage renal disease, lacked documentation of daily weights on specific dates. The resident's care plan included an intervention to monitor and report any significant weight changes to the physician, and a physician's order required daily weights to be recorded and reported if there was a significant weight gain. An interview with the Assistant Director of Nursing confirmed the absence of documented daily weights for the resident on the specified dates. Although facility staff were obtaining the weights, there was no designated area in the clinical record to chart these weights, nor were they entered into the vitals section. This oversight resulted in incomplete clinical documentation, as required by the facility's standards and regulations.
Failure to Obtain Required Hospice Documentation
Penalty
Summary
The facility failed to obtain the required information from the contracted hospice provider for a resident receiving hospice care. The hospice contract with Family Hospice, effective January 1, 2020, stipulated that the hospice agency must provide the facility with a copy of the most recent plan of care and the physician certification and recertification of the terminal illness for each hospice patient. However, for one resident, there was no documented evidence in the clinical records that the facility obtained the current hospice recertification of terminal illness or plan of care from the hospice provider for the certification period. The resident in question, who was rarely understood, had a memory problem, and was dependent on staff for daily care needs, was diagnosed with dementia and had been receiving hospice services since September 9, 2022. Despite the care plan indicating hospice care, as of August 27, 2024, the facility had not obtained the necessary hospice documentation for the certification period from June 30, 2024, through August 28, 2024. This deficiency was confirmed during an interview with the Nursing Home Administrator.
Repeated Deficiencies in QAPI Implementation
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations, as evidenced by repeated deficiencies identified in multiple surveys. These deficiencies included issues with the timely completion and accuracy of comprehensive assessments, development and revision of care plans, proper labeling and storage of medications, quality of care, food preparation and serving, and maintaining complete and accurate resident records. Despite having plans of correction that involved conducting audits and reporting results to the QAPI committee, the facility was unable to effectively address these recurring issues. The deficiencies were consistently identified across several surveys, including those ending in October 2023, April 2024, and August 2024. The facility's plans of correction, which were supposed to ensure compliance through audits and QAPI committee reviews, were not successfully implemented. This resulted in ongoing non-compliance with regulations related to comprehensive assessments, MDS assessments, care plan development and updates, medication management, food service, and medical record documentation.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to administer medication as ordered by the physician, resulting in a significant medication error for a resident. The resident, who was cognitively impaired and diagnosed with heart failure, was prescribed 40 mg of Torsemide twice a day. However, due to a failure in transcribing the physician's order into the medical record, the resident did not receive the medication from May 25 through June 7, 2024. The error was identified when a CRNP noted that the resident was fluid overloaded with severe swelling of the lower extremities, despite being on the prescribed medication regimen. An interview with the Director of Nursing confirmed that the registered nurse responsible for reviewing the laboratory results with the physician did not update the medical record with the new order, leading to the medication not being administered as required.
Failure to Transcribe Physician's Order Leads to Medication Error
Penalty
Summary
The facility failed to correctly transcribe a physician's order for a resident, leading to a medication administration error. The resident, who was cognitively impaired and diagnosed with heart failure, was supposed to receive 40 mg of Torsemide twice a day as per the physician's order. However, the registered nurse who reviewed the laboratory results with the physician did not transcribe this new order into the medical record. As a result, the resident did not receive the prescribed medication from May 25 through June 7, 2024. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the registered nurse failed to update the medical record with the new order. This oversight resulted in the resident not receiving the necessary medication to manage their condition, which included fluid overload and severe swelling of the lower extremities. The failure to transcribe the order was a violation of the Pennsylvania Code and the facility's obligation to maintain professional standards of quality care.
Oxygen Therapy Not Administered as Ordered
Penalty
Summary
The facility failed to provide oxygen therapy as ordered by the physician for a resident. The facility's policy, dated May 8, 2024, required that oxygen be administered according to the physician's orders. A quarterly Minimum Data Set (MDS) assessment for the resident, dated July 4, 2024, indicated that the resident was cognitively intact and received oxygen therapy. The care plan, dated February 22, 2024, and physician's orders from July 10, 2024, specified that the resident should receive oxygen at two liters per minute (lpm) every shift for hypoxia. However, observations on August 7, 2024, revealed that the resident was receiving oxygen at a flow rate of five lpm via a nasal cannula, contrary to the physician's order. An interview with a Licensed Practical Nurse confirmed the discrepancy in the oxygen flow rate.
Failure to Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to ensure that staff reported an allegation of verbal abuse in a timely manner for a resident who was cognitively impaired. The resident reported to the Area Agency on Aging that a family member had been verbally abusive, calling her derogatory names and expressing anger over a family matter. Despite the resident's visible distress and fear, as documented in nursing notes and staff witness statements, the facility did not report the allegation to the Department of Health as required by their policy. The Director of Nursing confirmed that the facility did not report the verbal abuse allegation, citing the lack of direct witness accounts and the resident's cognitive impairment as reasons. The facility's investigation revealed that the resident felt emotionally threatened by the family member, who was subsequently banned from visiting. However, there was no documented evidence that the incident was reported to the appropriate authorities, as mandated by state regulations.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans with specific and individualized interventions for two residents. Resident 3, who was cognitively intact, had a skin tear on his left shin that required specific wound care. Despite recommendations from a wound clinic to adjust the treatment frequency and type, the facility did not update the care plan to reflect these changes. The Treatment Administration Record did not show the recommended changes, and there was no documented evidence of a comprehensive care plan addressing the wound. Resident 7 was admitted with End Stage Renal Disease and required dialysis through a right subclavian dialysis catheter. Despite receiving dialysis on multiple occasions, there was no documented evidence of a comprehensive care plan that included specific interventions for managing the dialysis catheter and the dialysis process. Interviews with the Director of Nursing confirmed the absence of these care plans for both residents.
Failure to Obtain Physician's Orders for Dialysis Care
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis had an active physician's order to attend dialysis treatments and to obtain physician's orders for the care and monitoring of the dialysis site. The resident, who was admitted with End Stage Renal Disease (ESRD) and had a right subclavian dialysis catheter, received dialysis on multiple occasions without documented physician's orders for these treatments. This lack of documentation was confirmed through clinical record reviews and staff interviews. Additionally, there was no evidence of physician's orders for the care and monitoring of the resident's dialysis catheter and insertion site, nor for the emergency equipment to be available at the resident's bedside in case of an emergency related to the catheter. The Director of Nursing confirmed the absence of these necessary orders, indicating a lapse in the facility's protocol for managing dialysis care for the resident.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in the documentation of their medical treatments and medications. For one resident, the MDS assessment incorrectly indicated that the resident did not receive hypoglycemic medications during the assessment period, despite physician's orders and medication administration records showing that the resident was prescribed and received Metformin, Glimepiride, and Nesina for diabetes management. An interview with the Registered Nurse Assessment Coordinator (RNAC) revealed a misunderstanding, as the RNAC believed the resident did not receive hypoglycemic medications during this time. For another resident, the MDS assessment failed to document the receipt of oxygen therapy, non-invasive mechanical ventilation, and dialysis, despite physician's orders and treatment administration records confirming these treatments were administered. The RNAC confirmed that the MDS assessment should have reflected these treatments, indicating a lapse in accurately capturing the resident's care needs and treatments during the assessment period.
Failure to Follow Wound Care and Blood Sugar Monitoring Protocols
Penalty
Summary
The facility failed to provide care for wounds in accordance with professional standards of practice for one resident. Resident 3, who was cognitively intact, had a skin tear on his left shin. The wound clinic recommended specific treatment changes on two occasions, which were not followed by the facility. Initially, the wound was to be treated with Xeroform every other day, but the facility did not adhere to this schedule. Later, the clinic advised switching to medical grade honey, but the facility continued using Xeroform alongside the new treatment, contrary to the recommendations. The Director of Nursing confirmed these discrepancies in treatment. Additionally, the facility did not notify the physician about elevated blood sugar levels for another resident, Resident 7, as required by the physician's orders. The resident's blood sugar levels exceeded the threshold for notification on multiple occasions, yet there was no documented evidence that the physician was informed. This oversight was confirmed by the Director of Nursing, indicating a failure to follow the physician's orders regarding blood sugar monitoring and communication.
Incomplete Documentation for Residents' Clinical Records
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented for two residents. For Resident 2, a quarterly Minimum Data Set (MDS) assessment indicated cognitive impairment and a history of falls. On February 7, 2024, Resident 2 experienced an unwitnessed fall, and although a registered nurse assessed the resident and documented the assessment in the investigation documents, this information was not included in the resident's clinical record. The Director of Nursing confirmed that the assessment should have been documented in the clinical record. For Resident 9, an admission MDS assessment revealed diagnoses of schizophrenia and Parkinson's disease. Staff statements indicated that Resident 9 frequently rang his call bell, leading to an incident where a non-working call bell was given to him to prevent frequent interruptions. However, there was no documentation in Resident 9's clinical record to reflect his behavior of constantly ringing the call bell. The Director of Nursing confirmed the absence of this documentation in the clinical record.
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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