Mountain Laurel Healthcare And Rehabilitation Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Clearfield, Pennsylvania.
- Location
- 700 Leonard Street, Clearfield, Pennsylvania 16830
- CMS Provider Number
- 395331
- Inspections on file
- 41
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 32
Citation history
Health deficiencies cited at Mountain Laurel Healthcare And Rehabilitation Ctr during CMS and state inspections, most recent first.
Staff failed to follow physician orders and correctly identify residents during medication administration, leading to multiple medication errors. In one case, an LPN gave Metoprolol without first obtaining ordered vital signs. Another resident’s medications were administered at a time different from the physician’s order and the MAR was not updated to reflect the correct times. Additional errors included an LPN giving vitamins to the wrong cognitively impaired resident after relying on the resident’s incorrect self-identification and an outdated photo, a resident receiving Clonazepam instead of Morphine, and another resident receiving Hydrocodone/APAP instead of Oxycodone/APAP. The administrator acknowledged these errors and the failure to update the MAR.
Surveyors observed an LPN leaving an unlocked med cart unattended in a hallway with drawers ajar and multiple pre-poured medication cups, labeled only with first names, sitting unsecured on top while a resident sat nearby. The pre-poured meds included clonazepam, metformin HCl, magnesium oxide, vitamin C, potassium chloride, lactulose, atorvastatin, Pepcid, Ranexa, metoprolol tartrate, and senna for four different residents, including one who was out at the hospital. The LPN reported that she pre-pours meds to accommodate residents going to the dining room and to mix lactulose into a resident’s milk, and acknowledged that the meds and cart should not have been left unsecured or out of her direct line of sight, in violation of facility policy requiring meds to be locked or under direct observation.
An LPN failed to follow facility infection control and medication administration policy by handling oral medications with bare hands during administration to two residents. In one instance, the LPN popped a pill directly into her bare hand before placing it into a medication cup and giving it to a resident. In another instance, when a pill fell from a medication cup onto the medication cart, the LPN picked it up with her bare hand, returned it to the cup, and administered it. The LPN and the Nursing Home Administrator later acknowledged that medications should not have been touched with bare hands before administration.
Two residents experienced deficient wound and pressure ulcer care when staff failed to follow wound vac orders and manufacturer instructions for a Stage 4 pressure ulcer, including not documenting required dressing changes, not routinely checking that the NPWT device was functioning, and not performing timely RN wound assessments while the device was nonfunctional, leading to documented deterioration of the wound. Another resident with paraplegia and diabetes had physician orders for a wound care consult and buttock wound treatment, but there was no evidence the consult was scheduled or completed for several weeks, despite ongoing documentation of moisture-associated skin damage and preventative measures, and the DON confirmed the lack of timely wound consultant involvement and documentation.
The facility did not maintain adequate staffing with appropriate competencies in its food and nutrition services, as the Assistant Dietary Manager lacked full required training and the Certified Dietary Manager position was vacant. There was also a period without a Registered Dietician until a contracted RD began, as confirmed by staff interviews.
Facility management failed to maintain employee health insurance coverage, continuing to deduct premiums from staff paychecks even after the insurance was cancelled for non-payment. Staff were unaware of the cancellation and did not know the status of the deducted funds.
The facility did not meet the required nurse aide-to-resident staffing ratios during the overnight shift for three consecutive days. With resident censuses of 117 and 116, the facility consistently had fewer nurse aides than required, with no additional higher-level staff to compensate. The Nursing Home Administrator confirmed these deficiencies.
The facility failed to pay outstanding invoices to a staffing agency, leading to the withdrawal of essential nursing staff. Interviews confirmed the facility's inability to maintain required staffing levels without agency support, jeopardizing resident care.
The facility failed to meet the required nurse aide-to-resident staffing ratios on several occasions due to call-offs, as confirmed by the Nursing Home Administrator. On multiple days, the facility did not have enough nurse aides during the evening and overnight shifts, with no additional staff available to compensate for these shortages.
The facility failed to administer medications as ordered for two residents. One resident did not have their blood pressure checked before receiving Midodrine for hypotension, and another did not have their blood pressure or heart rate checked before receiving Metoprolol for hypertension. The DON confirmed these oversights.
A facility failed to document catheter care for a resident with an indwelling urinary catheter, leading to a urinary tract infection. Despite the facility's policy requiring regular catheter care, there was no evidence of care being provided during night shifts on several occasions. The resident, who was cognitively impaired and required assistance, developed a UTI, and the lack of documentation was confirmed by the DON.
A facility failed to provide trauma-informed care for a resident with PTSD, who had a history of significant traumatic events. Despite the resident's cognitive impairment and known trauma history, there was no documented assessment to identify triggers that could re-traumatize the resident. The DON confirmed the absence of such an assessment, highlighting a deficiency in care.
A resident with dementia exhibited wandering and rummaging behaviors, leading to multiple altercations with other residents. Despite documented care plans, interventions like redirection and stop signs were ineffective, resulting in physical altercations. Staff interviews indicated that strategies to manage the resident's behaviors were not consistently effective, and there was no documented evidence of revised interventions when initial measures failed.
The facility failed to provide enough dietary staff to keep the main dining room open during meal times, leaving residents unable to dine there. Several residents expressed their desire to eat in the dining room for socialization and hot meals, but staffing shortages prevented this. The Dietary Manager and Nursing Home Administrator confirmed the closure due to insufficient staff.
The facility failed to maintain sanitary conditions in the second floor kitchenette's ice machine and the first floor kitchenette's refrigerator. The ice machine's drain pipe lacked an air gap, and the refrigerator contained an expired sherbet, unlabeled popsicles, and a dark substance. These issues were confirmed by the Maintenance Director and Nursing Home Administrator.
The facility's QAPI committee failed to address recurring deficiencies, including providing an environment free from abuse, developing comprehensive care plans, and ensuring quality care. Despite previous plans of correction involving audits and QAPI reviews, the same issues were repeatedly cited, indicating ineffective implementation of corrective measures.
A resident's rights were violated when staff removed personal food items from her room without her knowledge or consent. The resident, who was cognitively intact and able to communicate, was taken to the dining room, during which time her belongings were removed. Interviews with staff confirmed that the resident was not informed prior to the removal, violating the facility's policy on resident rights.
A resident with dementia was subjected to abuse by an agency nurse aide, who was reported by the resident's wife for being rough and causing fear during care. The aide's actions were confirmed through an investigation, leading to her termination and placement on the Do Not Return list.
The facility failed to provide written notification to the state ombudsman, residents, and/or their representatives regarding the reasons for hospital transfers for five residents. These residents, with varying cognitive and medical conditions, were transferred to the hospital without the required documentation. The Nursing Home Administrator confirmed the lack of written notices.
The facility failed to develop and implement care plans for three residents, neglecting to address PTSD, dialysis catheter care, and smoking needs. A resident with PTSD had no care plan despite a significant trauma history. Another resident with a central venous catheter for dialysis lacked a care plan for catheter care, and a resident with metastatic lung cancer had no care plan for smoking needs. The DON confirmed these oversights.
The facility failed to update care plans for three residents, leading to outdated care instructions. A resident's care plan still included potential complications for a PICC line and urinary catheter that were removed, while another resident's care plan was not updated after a PICC line removal. Additionally, a resident's care plan required 15-minute checks due to cognitive impairment, but there was no evidence these checks were conducted.
A facility failed to ensure a safe smoking environment for a resident who was cognitively impaired and required supervision. The resident's ability to smoke was not re-evaluated quarterly as per facility policy, with the last evaluation conducted several months prior. The DON confirmed the oversight in completing the required smoking assessment.
A facility failed to maintain a medication administration error rate below five percent, with an error rate of eight percent observed. An LPN did not follow the manufacturer's instructions when administering Fluticasone nasal spray to a resident, as confirmed by the DON.
A facility failed to document that a resident was offered the influenza vaccine for the 2022-2023 season. The resident, who was cognitively impaired and dependent on staff, had a history of receiving the vaccine annually. However, there was no evidence of an offer for the current season, as confirmed by the DON.
The facility did not notify the responsible parties of two residents about changes in their medication and treatment. One resident, with dementia, was prescribed Macrobid for a UTI and Tamiflu for flu exposure without notifying their responsible party. Another resident, who tested positive for the flu, was given Tamiflu and guaifenesin without notification. The DON confirmed the lack of documentation for these notifications.
A resident with moderately impaired cognition and on a mechanically altered diet experienced a choking incident with pizza due to inadequate assessment of swallowing ability. Despite previous reports of difficulty, the resident was served pizza, leading to a Heimlich maneuver intervention. Communication lapses prevented timely assessment by the Speech Therapist.
Medication Administration Errors and Failure to Follow Physician Orders
Penalty
Summary
The deficiency involves failures to follow physician medication orders and to ensure correct resident identification during medication administration, resulting in multiple medication errors. For one cognitively intact resident who required assistance with all daily care needs, the physician had ordered Metoprolol Tartrate 50 mg twice daily with instructions to hold the dose if systolic blood pressure was less than 100 or heart rate was less than 60. During an observed medication pass, an LPN administered the Metoprolol without obtaining the resident’s blood pressure or heart rate beforehand, contrary to the order and facility policy requiring vital signs to be obtained and medications held when parameters were not met. Another cognitively impaired resident who required assistance with all daily care needs had physician orders for Synthroid 25 mg at 8:00 a.m. and Oxycodone 10 mg at 8:00 a.m. and 4:00 p.m. A nursing note documented that this resident became upset when the 8:00 a.m. medications were given at 6:00 a.m., stating he had requested medications at 8:00 a.m. and 8:00 p.m., and the MAR was not updated to reflect the ordered administration times. Additional medication errors occurred when medications were administered to the wrong residents or the wrong medications were given. A cognitively impaired resident with dementia, anxiety, and depression was sitting in a wheelchair outside another resident’s room and, when asked her name, identified herself as that other resident. An LPN, unfamiliar with the resident, relied on this verbal identification and a computer photo that did not resemble the resident’s current appearance, assumed it was an old picture, and did not seek staff assistance to verify identity. As a result, calcium with Vitamin D and magnesium intended for another resident were administered to this resident in pudding. In another incident, a cognitively impaired, dependent resident was given 0.5 mg Clonazepam instead of the ordered 60 mg Morphine during a morning medication pass. In a separate case, a cognitively intact, independent resident was given Hydrocodone/APAP 5-325 mg instead of the ordered Oxycodone/APAP 5-325 mg. The Nursing Home Administrator confirmed that these medication errors should not have occurred and that the MAR for the resident with time-specific medication orders had not been updated to reflect the correct administration times.
Unsecured and Pre-Poured Medications Left on Unlocked Med Cart
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medications were properly secured and not pre-poured in advance, contrary to facility policy and professional standards. The facility’s medication policy dated March 19, 2026, required all drugs and biologicals to be stored in locked compartments and to remain under the direct observation of the person administering them or locked in the storage area/cart during medication pass. During an observation of medication administration on April 28, 2026, five pre-poured medication cups containing pills and liquids, labeled only with first names, were found sitting unsecured on top of an unlocked medication cart with three drawers ajar. These medications corresponded to physician orders for four residents: one receiving clonazepam, metformin hydrochlorothiazide, magnesium oxide, and Vitamin C; another receiving potassium chloride and lactulose; a third receiving atorvastatin, Pepcid, and Ranexa; and a fourth receiving metoprolol tartrate and senna. During the observation period, the LPN responsible for the cart left it unattended and out of her direct line of sight multiple times while a resident sat near the unsecured cart. She administered pre-poured medications to two residents at different times, and also left the cart in the hallway with pre-poured medications on top and drawers ajar while entering residents’ rooms to administer medications. In an interview, the LPN stated that she pre-pours medications for some residents because they like to go to the dining room for supper and that she prepared lactulose in advance to mix it into a resident’s milk because the resident does not like to take it. She also acknowledged that she had prepared medications for a resident who was out at the hospital before realizing the resident had not yet returned. The LPN and the Nursing Home Administrator both confirmed that medications should not have been pre-poured or left unsecured and that the medication cart should have been locked with all drawers closed when not in the nurse’s direct sight.
Improper Handling of Oral Medications During Administration
Penalty
Summary
Facility staff failed to follow its infection prevention and control and medication administration policy, which required staff to remove medications from their source without touching them with bare hands. During medication administration for Resident 2, an LPN preparing the medications was observed popping a pill into her bare hand and then dropping it into a medication cup before administering it to the resident. In a separate observation during medication administration for Resident 3, while the LPN was popping medications into a medication cup, a pill fell out of the cup onto the medication cart; the LPN picked up the pill with her bare hand, placed it back into the cup, and then administered it to the resident. In a subsequent interview, the LPN acknowledged that she should not have touched the pills with her bare hands before administering them, and the Nursing Home Administrator confirmed that the LPN should not have handled the pills in this manner, in violation of the facility’s policy and 28 Pa. Code 211.12(d)(1) regarding nursing services.
Failure to Provide Timely and Appropriate Wound and Pressure Ulcer Care
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary treatment and services for an existing Stage 3/4 pressure ulcer for one resident and failure to follow physician orders in a timely manner for another resident. Facility policies required physician orders for wound care, detailed documentation of each treatment, weekly head-to-toe skin assessments, and adherence to negative pressure wound therapy (NPWT/wound vac) orders and manufacturer instructions, including frequent monitoring of the pump and changing dressings at least every 72 hours. The wound vac manufacturer’s instructions specified that the machine should be frequently checked to ensure it was on and delivering negative pressure and that dressings should not remain in place longer than 72 hours. Resident 4, who was cognitively intact, dependent for care, frequently bowel incontinent, and diagnosed with paraplegia, had a Stage 4 pressure ulcer on the right buttock/ischium. Physician orders and a wound clinic consultation directed cleansing with soap and water, placement of white foam in tunnels, black foam to the wound bed, wound vac pressure at 125 mmHg, and dressing changes on specified days. Documentation showed the wound vac treatment was completed at the wound clinic on one date, and the resident later requested that wound vac changes be done in the morning instead of the evening. However, there was no documented evidence that the wound vac treatment was completed on the specified mornings following the resident’s requests. There was also no documentation that the wound vac was changed between several consecutive days, no evidence of routine checks to ensure the wound vac was functioning, and no RN wound assessment documented during that period, despite the wound vac not charging and ultimately going completely dead. By the next wound clinic visit, the wound on Resident 4’s right buttock/ischium was documented as significantly worse, with markedly increased measurements, tunneling, undermining, and the presence of necrotic tissue, slough, and exudate requiring debridement. Interviews with wound clinic staff, LPNs, an RN, and the DON confirmed that the resident did not arrive at the clinic with a wound vac, that the wound vac had not been functioning properly, that there were necrotic areas and foul odor, that the wound was the worst it had ever been, and that no wound assessment had been completed during the time the wound vac was not working. Staff also confirmed that the wound clinic physician was not informed that the wound vac was not in use, that wet-to-dry dressings were being used instead, or that the wound condition had changed. Resident 3 was admitted with an abrasion on the left calf, a friction area on the left buttock, and reddened heels requiring elevation. Physician orders included cleansing the left buttock wound with soap and water and applying zinc barrier cream every shift. The resident was cognitively intact, required extensive assistance, and had diagnoses including paraplegia and diabetes, and was care planned as being at risk for skin breakdown. A physician order for a wound care consultation was entered, and nursing documentation noted that the rounding provider updated orders, including the wound care consult. Subsequent clinical notes over several days documented moisture-associated skin damage to the buttocks with preventative skin measures in place. Despite the physician’s order for a wound care consultation for Resident 3, there was no documented evidence that the resident was seen by a wound consultant from the date the consult was ordered until several weeks later, when a wound care consultation finally occurred and new treatment orders for bilateral buttocks were written. There was also no documentation that an appointment had been made for the consult or that the resident refused to be seen. The DON confirmed that Resident 3 was not seen by a wound consultant during that interval and that there was no documentation of scheduling or refusal. These omissions reflect the facility’s failure to follow physician orders in a timely manner for wound care consultation and treatment for Resident 3.
Insufficient Qualified Staffing in Food and Nutrition Services
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. The Assistant Dietary Manager, who was originally hired as a dietary aide, was promoted to the assistant manager position after the previous dietary manager resigned, despite not having completed all required training and only having finished one Serve Safe training course. The Certified Dietary Manager position remained vacant during this period. Additionally, the facility did not have a Registered Dietician from October 11, 2025, through November 17, 2025, with the current Registered Dietician only starting on November 17, 2025, through a contracted agency. These findings were confirmed through interviews with the Assistant Dietary Manager and the Director of Nursing.
Failure to Maintain Employee Health Insurance and Mismanagement of Payroll Deductions
Penalty
Summary
The governing body and owners failed to ensure effective management of the facility by not maintaining compliance with state regulations regarding employee health insurance. Interviews with the Assistant Director of Nursing and a Registered Nurse Supervisor revealed that although money was being deducted from staff paychecks for health insurance premiums, the insurance had actually been cancelled due to non-payment by the facility. Staff were unaware of the cancellation and did not know where the deducted funds were going. Facility records confirmed that deductions continued for several months after the insurance was cancelled, and the Director of Nursing was unable to specify when payments to the insurance company had stopped.
Failure to Meet Overnight Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide-to-resident staffing ratios during the overnight shift for three consecutive days. On January 28, 2025, with a census of 117 residents, the facility required 7.80 nurse aides but only had 7.25 on duty. On January 29, 2025, with a census of 116 residents, 7.73 nurse aides were needed, but only 7.09 were present. Similarly, on January 30, 2025, with the same census of 116, 7.73 nurse aides were required, but only 7.17 were available. No additional higher-level staff were available to compensate for these deficiencies. The Nursing Home Administrator confirmed the failure to meet the staffing requirements during an interview on January 31, 2025.
Plan Of Correction
1. The administrator and/or designee will conduct a review of the last 14-days of nursing schedules to determine compliance with proper nursing hours. 2. The administrator and/or designee will conduct reviews for least 5-days per week for two weeks then 3-days per week for one month to ensure compliance. In the event of extensive call-offs, higher level nursing will staff fill, if possible, we ask for volunteers with bonuses, then in extreme case, we will mandate and will stop admissions. We continue to recruit all levels of staff, Registered Nurses, Licensed Practical Nurses, Certified Nurser's Aides. We also have a schedule/staffing meeting each day to discuss staffing and census. We have created a shift differential for evenings and night shifts and a weekend differential - this program is for all our nursing staff. We have increased our Registered Nurse Licensed Practical Nurse wages. We continue a bonus for: Open Shift Bonus 4hrs 8hrs Registered Nurses, Licensed Practical Nurses, Certified Nurser's Aides. Referral and Sign on Bonuses for: Registered Nurses, Licensed Practical Nurses, Certified Nurser's Aides. While we continue recruitment, we have established a Certified Nurse's Aide class thru an outside contractor to develop more Certified Nurse's Aide. 3. The results of the audits, along with a Root Cause Analysis of any identified issues, will be brought to the Quality Assurance and Performance Improvement Committee for further analysis and corrective action.
Failure to Pay Staffing Agency Jeopardizes Resident Care
Penalty
Summary
The facility failed to pay bills incurred for services essential to the residents' health and safety in a timely manner. A review of unpaid invoices from the National Healthcare Staffing agency revealed significant outstanding balances dating from September 2024 to January 2025. The total amount owed was $324,648.00, with individual invoices ranging from $10,817.18 to $46,143.11. The facility's inability to settle these debts led to the staffing agency withdrawing their personnel from the facility. Interviews with the Nursing Home Administrator and the owner of the staffing agency confirmed the outstanding balance and the agency's decision to pull their staff due to non-payment. The Nursing Home Administrator acknowledged that the facility could not maintain the required nursing staff levels without the agency's support. A payment was sent for the oldest invoice, but the remaining invoices remained unpaid, jeopardizing the facility's ability to provide adequate care to its residents.
Plan Of Correction
National Healthcare Staffing has agreed to a payment schedule. The facility Scheduler will receive, review and process each National Healthcare Staffing invoice and forward to the Nursing Home Administrator for approval. Then the Business Office Manager/designee will forward electronically to the Accounts Payable for payment. Facility administrator will review the Accounts Payable relative to National Healthcare Staffing to ensure timely payments as follows: weekly x2, monthly x2 for timely processing of National Healthcare Staffing with results to the facility Quality Assessment and Assurance Committee.
Staffing Deficiency Due to Inadequate Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required nurse aide-to-resident staffing ratios on multiple occasions, as evidenced by a review of nursing schedules and staffing information. On December 20, 2024, the facility had a census of 119 residents, necessitating 10.82 nurse aides for the evening shift, but only 9.37 nurse aides were available. Similarly, on December 19, 2024, with a census of 120 residents, the overnight shift required 7.93 nurse aides, yet only 7.07 were present. This pattern continued over the following days, with the facility consistently falling short of the required number of nurse aides during the overnight shifts. The deficiency was confirmed through an interview with the Nursing Home Administrator, who acknowledged that the facility did not meet the staffing ratios due to call-offs. No additional higher-level staff were available to compensate for these deficiencies, indicating a lack of contingency planning to address unexpected staff shortages. The report highlights specific instances where the facility's staffing levels were inadequate, leading to non-compliance with the regulatory requirements for nurse aide-to-resident ratios.
Plan Of Correction
1. The administrator and/or designee will conduct a review of the last 14-days of nursing schedules to determine compliance with proper nursing hours. 2. The administrator and/or designee will conduct reviews at least 5-days per week for two weeks, then 3-days per week for one month to ensure compliance. In the event of extensive call-offs, higher level nursing will staff fill, if possible. We ask for volunteers with bonuses, then in extreme cases, we will mandate and will stop admissions. We continue to recruit all levels of staff: Registered Nurses, Licensed Practical Nurses, Certified Nurse's Aides. We also have a schedule/staffing meeting each day to discuss staffing and census. We have created a shift differential for evenings and night shifts and a weekend differential - this program is for all our nursing staff. We have increased our Registered Nurse and Licensed Practical Nurse wages. We continue a bonus for: Open Shift Bonus 4hrs 8hrs Registered Nurses, Licensed Practical Nurses, Certified Nurse's Aides. Referral and Sign on Bonuses for: Registered Nurses, Licensed Practical Nurses, Certified Nurse's Aides. While we continue recruitment, we have established a Certified Nurse's Aide class through an outside contractor to develop more Certified Nurse's Aides. 3. The results of the audits, along with a Root Cause Analysis of any identified issues, will be brought to the Quality Assurance and Performance Improvement Committee for further analysis and corrective action.
Failure to Administer Medications Per Physician Orders
Penalty
Summary
The facility failed to administer medications as ordered by the physician for two residents. Resident 55, who was cognitively intact and dependent on staff for daily care, had a physician's order to receive Midodrine for hypotension, with specific instructions to hold the medication if the systolic blood pressure exceeded 130. However, the staff did not obtain or record the resident's blood pressure before administering the medication, as confirmed by the Director of Nursing. Similarly, Resident 84, who was cognitively impaired and also dependent on staff, had a physician's order to receive Metoprolol Succinate Extended Release for hypertension, with instructions to hold the medication if the systolic blood pressure was less than 100 or the heart rate was less than 60. The staff failed to obtain or record the resident's blood pressure or heart rate prior to administering the medication. This oversight was also confirmed by the Director of Nursing.
Failure to Document Catheter Care Leads to UTI
Penalty
Summary
The facility failed to provide appropriate care to prevent urinary tract infections for a resident with an indwelling urinary catheter. The facility's policy required that the resident's care plan be reviewed for any special needs related to the urinary catheter. The resident, who was cognitively impaired and required assistance for daily care activities, had a diagnosis of obstructive uropathy and a physician's order for a 20 French urinary catheter with a 5 cc balloon for urinary retention. Despite these requirements, there was no documented evidence of catheter care being provided during the night shift on multiple dates across July, August, and September 2024. A nursing note from September 7, 2024, indicated that the resident developed a urinary tract infection, and orders were given to start antibiotic treatment and maintain proper Foley catheter care. However, the lack of documentation for catheter care during the night shifts was confirmed by the Director of Nursing, indicating a failure to adhere to the facility's policy and potentially contributing to the resident's urinary tract infection.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident diagnosed with Post Traumatic Stress Disorder (PTSD) received trauma-informed care to mitigate triggers associated with their condition. The resident, who was cognitively impaired, had a history of significant traumatic events, including witnessing a friend's death in war, his wife's suicide, and abuse from his father. Despite these known factors, there was no documented evidence that the facility conducted an assessment to identify specific triggers that could re-traumatize the resident. An interview with the resident revealed the emotional impact of these traumatic events, with the resident expressing feelings of guilt and distress. The Director of Nursing confirmed the absence of a documented trauma history assessment for the resident, indicating a lapse in the facility's responsibility to provide appropriate care for individuals with PTSD. This deficiency was identified during a review of clinical records and interviews with the resident and staff.
Inadequate Management of Dementia-Related Behaviors
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident diagnosed with dementia, leading to multiple incidents of resident-to-resident altercations. Resident 109, who has Alzheimer's disease and dementia, exhibited wandering and rummaging behaviors, entering other residents' rooms and taking their belongings. Despite these behaviors being documented in care plans, interventions such as redirection and the use of stop signs were ineffective in preventing the resident from entering others' rooms, resulting in several altercations with other residents. On multiple occasions, Resident 109 was involved in physical altercations with other residents who reacted negatively to her entering their personal spaces. For instance, Resident 94 hit Resident 109 after she entered his room, and Resident 70 struck her in the common area. These incidents highlight the facility's failure to adequately assess and adjust interventions for Resident 109's wandering behaviors, as the measures in place did not prevent her from entering other residents' rooms or protect her from harm. Interviews with staff revealed that while they attempted to redirect Resident 109 and used stop signs to deter her from entering rooms, these strategies were not consistently effective. The facility's documentation lacked evidence of a thorough assessment or revision of person-centered interventions when initial strategies failed. This oversight contributed to ongoing safety risks for Resident 109 and other residents, as her behaviors continued to disrupt the unit and lead to altercations.
Dining Room Closure Due to Insufficient Dietary Staff
Penalty
Summary
The facility failed to provide sufficient dietary staff to operate the main dining room during meal times, resulting in residents being unable to eat there. Observations on September 23, 2024, revealed that the dining room was empty during lunch hours. Multiple residents expressed their desire to eat in the dining room for socialization and to enjoy hot meals, including coffee, but were unable to do so due to staffing shortages. Interviews with residents confirmed their preference for dining room meals, highlighting the impact of the deficiency on their dining experience. The Dietary Manager acknowledged the issue, stating plans to reopen the dining room in the future but confirming the current closure due to insufficient staff. The Nursing Home Administrator also confirmed the dining room's closure, acknowledging awareness of residents' wishes to have it open, particularly for lunch. The deficiency was noted under several Pennsylvania Code regulations, indicating a failure in management, staff development, and dietary services.
Sanitation Deficiencies in Ice Machine and Refrigerator
Penalty
Summary
The facility failed to maintain sanitary conditions in the preparation and storage of food and ice, as evidenced by deficiencies found in the second floor kitchenette's ice machine and the first floor kitchenette's refrigerator. The ice machine's drain pipe was observed to be in direct contact with the floor drain due to a clear tube installed over the pipe, eliminating the necessary air gap required for sanitary conditions. This was confirmed by the Maintenance Director, who acknowledged the absence of the air gap. Additionally, the refrigerator in the first floor kitchenette was found to contain a dark, removable substance at the bottom of the freezer, an expired carton of orange sherbet, and several popsicles that were undated, unlabeled, and one that was open to air. The Nursing Home Administrator confirmed that these items should have been discarded and that the freezer should have been clean. These findings indicate a failure to adhere to the facility's policy for resident personal food storage, which mandates labeling and dating of all food and beverages.
Repeated Deficiencies in Quality Assurance and Care
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address recurring deficiencies effectively, as evidenced by repeated citations in multiple surveys. The deficiencies identified in the current survey include failure to provide an environment free from abuse, inadequate development and revision of comprehensive care plans, and failure to provide quality care. Additionally, the facility was cited for not maintaining a safe environment free of accident hazards, improper management of indwelling urinary catheters, and inappropriate food preparation and serving. The facility had previously developed plans of correction for these deficiencies, which included conducting audits and reporting the results to the QAPI committee. However, the current survey results indicate that these plans were not successfully implemented, as the same issues were repeatedly cited. The QAPI committee's inability to maintain compliance with regulations highlights a significant gap in the facility's quality assurance processes.
Resident Rights Violation: Unauthorized Removal of Personal Items
Penalty
Summary
The facility failed to protect the rights of a resident, identified as Resident 47, by removing personal food items from her room without her knowledge or consent. According to the facility's policy on resident rights, residents have the right to retain and use personal possessions, including food items, and should be informed in advance of any changes to their care plan. Resident 47, who was cognitively intact and able to communicate her needs, was taken to the dining room by a nurse aide on August 20, 2024. During her absence, staff removed all food items from her room, including non-perishable items, without notifying her beforehand. Interviews with staff members, including a nurse aide, the Director of Nursing, and the Nursing Home Administrator, confirmed that the resident was not informed prior to the removal of her belongings. The nurse aide stated that she was instructed by the Director of Nursing to remove the food items, and both the Director of Nursing and the Nursing Home Administrator acknowledged that they did not notify the resident before the action was taken. This incident was found to be in violation of the resident's rights as outlined in the facility's policy and the 28 Pa. Code 201.29(j) regarding resident rights.
Resident Abuse by Agency Nurse Aide
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a resident with dementia who was sometimes understood and could sometimes understand others. The resident's care plan indicated that they were resistive to care and required extensive assistance with dressing. On a particular shift, the resident's wife reported witnessing Agency Nurse Aide 2 being rough with the resident, pushing him over, causing fear, and handling him in a manner that resulted in his arm getting caught and his head stuck while changing his shirt. The aide's actions were so forceful that a TV was knocked off its stand, and the resident attempted to hit the aide out of fear. The investigation confirmed the abuse allegations after reviewing interviews with residents, families, and staff. The resident's wife also noted that another resident was dissatisfied with the care provided by the same aide. The facility's policy on abuse and neglect emphasizes the residents' right to be free from abuse and neglect, which was violated in this instance. The investigation substantiated the abuse, leading to the termination of Agency Nurse Aide 2's contract and her placement on the Do Not Return list for the facility.
Failure to Notify Ombudsman and Representatives of Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to the state ombudsman, residents, and/or their representatives regarding the reasons for hospital transfers for five residents. Resident 30, who had dementia, was transferred to the hospital for a femur fracture without documented notification. Resident 44, who was cognitively intact and had respiratory failure, requested a transfer due to breathing difficulties, but no written notice was provided. Similarly, Resident 48, also with respiratory failure, requested a transfer to the emergency department without documented notification. Resident 56, who was moderately cognitively impaired and had obstructive uropathy, was transferred to the hospital with symptoms of sepsis and a urinary tract infection, yet no written notice was documented. Resident 118, who was cognitively impaired and had dementia, was transferred to the hospital for an open fracture on his finger without documented notification. The Nursing Home Administrator confirmed that the facility did not provide the required written notices for these transfers.
Failure to Develop Resident-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement resident-centered care plans for three residents, leading to deficiencies in addressing their specific care needs. Resident 4, who was cognitively impaired and diagnosed with PTSD, did not have a care plan addressing his PTSD despite a psychological evaluation indicating significant trauma history. The Director of Nursing confirmed the absence of a care plan for PTSD, acknowledging it should have been in place. Similarly, Resident 47, who required dialysis and had a central venous catheter, lacked a care plan addressing the catheter's care needs. Despite physician orders for post-dialysis weighing and the presence of an emergency kit, no documented care plan was found. Additionally, Resident 111, diagnosed with metastatic lung cancer and requesting to smoke, did not have a care plan addressing her smoking needs, even though staff reviewed the smoking policy with her. The Director of Nursing confirmed the absence of care plans for both residents, acknowledging the oversight.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update and revise care plans to reflect the current care needs of three residents. For Resident 44, the care plan was not updated to remove references to a PICC line and an indwelling urinary catheter after these devices were removed on September 3, 2024. Despite the removal, the care plan continued to indicate potential complications related to these devices. This oversight was confirmed by the Director of Nursing during an interview. Similarly, Resident 90's care plan was not updated to reflect the removal of a PICC line, which had been removed without issues as noted in a nursing entry dated March 14, 2024. Observations confirmed the absence of the PICC line, yet the care plan still included potential complications related to it. Additionally, Resident 109's care plan required 15-minute checks due to cognitive impairment and behavior issues, but there was no documented evidence that these checks were conducted from August 8, 2024, through September 26, 2024. Interviews with staff confirmed that the care plan was not revised to reflect the current status of the checks.
Failure to Re-evaluate Smoking Ability for Resident
Penalty
Summary
The facility failed to ensure a safe environment related to smoking for a resident, identified as Resident 46. According to the facility's policy, a resident's ability to smoke should be re-evaluated quarterly, upon a significant change, or as determined by staff. However, there was no documented evidence that Resident 46's ability to smoke was evaluated quarterly as required. The resident, who was cognitively impaired and required supervision for daily care needs, was last evaluated for smoking in March 2024, indicating she was an at-risk smoker needing supervision or physical support. The Director of Nursing confirmed that a smoking assessment was not completed with the quarterly Minimum Data Set (MDS) assessment, which was a mandated assessment of the resident's abilities and care needs.
Medication Administration Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to maintain a medication administration error rate of less than five percent, as evidenced by observations during medication administration. On September 25, 2024, two medication administration errors were identified during 25 opportunities for error, resulting in an error rate of eight percent. Specifically, the administration of Fluticasone nasal spray to Resident 60 did not adhere to the manufacturer's instructions. The instructions required the user to blow their nose before use and to close off the other nostril during administration, which was not done. Licensed Practical Nurse 7 administered the Fluticasone nasal spray to Resident 60 without instructing the resident to blow his nose or close off the other nostril, as confirmed by an interview with the nurse. The Director of Nursing also confirmed that the nurse should have followed the manufacturer's instructions. This oversight contributed to the facility's failure to maintain the required medication administration error rate.
Failure to Document Influenza Vaccine Offer
Penalty
Summary
The facility failed to ensure that each resident was offered and/or received the influenza immunizations, specifically for one resident reviewed. The facility's policy, dated October 2023, stated that the Infection Preventionist is responsible for promoting and administering the seasonal influenza vaccine. However, a review of the Minimum Data Set (MDS) assessment for a resident, dated August 3, 2024, indicated that the resident, who was cognitively impaired and dependent on staff for daily care tasks, did not receive the influenza vaccine for the current season due to being offered but declining it. Despite this, there was no documented evidence that the resident was offered the vaccine for the 2022-2023 flu season, as confirmed by the Director of Nursing. The resident had a history of receiving the influenza vaccine annually from 2017 to 2022, but there was a lack of documentation for the 2022-2023 season.
Failure to Notify Responsible Parties of Medication Changes
Penalty
Summary
The facility failed to notify the responsible parties of two residents about changes in their treatment and medication, as required by their policy. Resident 2, who had moderately impaired cognition and a diagnosis of dementia, experienced a decline in condition, leading to a urinalysis and subsequent prescription of Macrobid for a urinary tract infection. Additionally, Resident 2 was exposed to Influenza A and was prescribed Tamiflu. In both instances, there was no documented evidence that the resident's responsible party was informed of these changes in medication. Similarly, Resident 5, who also had moderately impaired cognition, tested positive for the flu and was prescribed Tamiflu and guaifenesin. Again, there was no documented evidence that the responsible party was notified of these new medication orders. The Director of Nursing confirmed the lack of documentation regarding the notification of responsible parties for both residents, which was a requirement according to the facility's policy and state regulations.
Failure to Assess Resident's Swallowing Ability Leads to Choking Incident
Penalty
Summary
The facility failed to ensure a safe environment for a resident by not adequately assessing the resident's ability to safely consume certain foods, specifically pizza. The resident, who had moderately impaired cognition and was on a mechanically altered diet, experienced a choking incident during dinner when a piece of pizza obstructed his airway. Despite being on a mechanical soft, ground texture diet, the resident was served pizza, which led to the incident where a Licensed Practical Nurse had to perform the Heimlich maneuver to dislodge the food. Prior to the incident, there were indications that the resident had difficulty eating pizza, as noted by a Nurse Aide who had observed the resident's struggles and communicated this to the kitchen and a nurse. However, there was no documented assessment of the resident's ability to safely eat pizza in the months leading up to the incident. The Speech Therapist, who was responsible for the resident's case, was not informed of these difficulties, indicating a breakdown in communication and assessment processes within the facility.
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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