Myerstown Nursing And Rehab Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Myerstown, Pennsylvania.
- Location
- 7 West Park Avenue, Myerstown, Pennsylvania 17067
- CMS Provider Number
- 395343
- Inspections on file
- 23
- Latest survey
- April 3, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Myerstown Nursing And Rehab Llc during CMS and state inspections, most recent first.
Two residents who were dependent on staff for toileting and incontinence care did not receive timely, dignified assistance. One resident with cervical disc disorder and cervicalgia activated the call bell multiple times for incontinence care; staff walked past the room, turned off the call light without assisting, and made a dismissive remark before the resident finally received help more than an hour after the initial request. Another resident with CHF and diabetes was observed in bed with the call bell placed out of reach in a bedside table drawer and repeatedly yelled out for help with urination, personal items, water, and food, while staff did not respond and the call bell remained inaccessible.
A resident with cervical disc disorder with myelopathy, cervicalgia, and a documented self-care deficit was dependent on staff for toileting and required prompt response to call bells per the care plan. The resident requested incontinence care using the call bell, which remained unanswered for an extended period while staff walked by, turned off the call light without providing care, and, in one instance, an NA refused to provide care and left the room. The resident had to reactivate the call bell multiple times and did not receive the requested incontinence care for over an hour after the initial request.
Surveyors found that the call bell system in multiple rooms on three units illuminated in the hallway but did not produce an audible alarm when activated. A resident with chronic pain and dysphagia, dependent on staff for toileting and dressing and care planned for fall risk with a call light intervention, reported his call bell had not worked properly for two days, which was confirmed on observation. Another resident with diabetes and insomnia, also care planned for fall risk with a call light intervention, reported that his call bell worked only sporadically. Staff and the Administrator acknowledged that the call bells had been lighting but not sounding since the previous day.
The facility failed to notify two residents or their responsible parties of physician-ordered changes in treatment and medications. For one resident with CHF and dementia, new orders for sacral wound care with triad paste and right heel wound care with calcium alginate were implemented without documented notification to the resident or representative. For another resident with dementia, new orders for Mucinex for a productive cough and hydrocortisone cream for a rash were also not accompanied by documented notification. The Administrator confirmed there was no documentation that these residents or their responsible parties were informed of the changes.
Surveyors found that a resident remained in the same hospital gown from the prior day because no clean gowns were available on the unit, and a NA confirmed the absence of gowns on hallway linen carts. Observations on all three nursing units showed linen carts and clean linen rooms with no or very few gowns, sheets, towels, and wash cloths, along with dirty floors, debris, and opened bags of clean linens placed directly on the floor. On one unit, multiple full, odorous bins of soiled linens were left in the hallway outside the clean utility room, and later checks the same day showed that these linen supplies had not been replenished.
A resident with multiple serious diagnoses, including kidney failure, COPD, respiratory failure, metabolic encephalopathy, and a UTI, was admitted and had an order for 0.25 ml of morphine solution (20 mg/ml) every four hours. The MAR showed that the resident did not receive the ordered morphine for two days because the medication was not available from the pharmacy. The DON confirmed that the resident did not receive the morphine as ordered until two days after admission, resulting in a cited deficiency in pharmacy and nursing services.
Surveyors observed damaged windowsills, chair rails, and walls in multiple rooms and the dining area, along with debris and a black substance on floors in several rooms and an elevator, indicating a failure to maintain a safe, clean, and comfortable environment.
The facility did not employ a full-time qualified dietitian or a qualified dietary services manager, as confirmed by both the dietary manager and the Administrator during staff interviews.
Surveyors found that food items in two nursing unit pantries were not labeled with resident names or dates, and refrigerators and freezers contained opened and undated items, as well as visible food debris and hair. The Administrator confirmed that staff were responsible for labeling and dating resident food, but this was not done according to facility policy.
A resident with significant mobility limitations and a history of amputation waited 29 minutes for staff to respond to their call bell after requesting assistance to the bathroom, despite facility policy requiring a response within 20 minutes. The delay caused the resident to miss an activity.
A resident with a known peanut allergy and moderate cognitive impairment was served a peanut butter bar for dessert, despite documentation of the allergy and care plan instructions to offer alternate food items. The DON confirmed the error after the resident identified the allergy when interviewed.
A resident with multiple medical conditions did not receive simethicone as ordered by the physician because the medication was not available from the pharmacy. The resident experienced severe gas pain over several days, and documentation confirmed the medication was not administered as prescribed. The DON verified the medication was unavailable and not given.
A resident with serious health conditions did not receive care according to physician's orders, including daily weight monitoring and medication administration. The facility failed to notify the physician of a significant weight change and did not administer several medications as prescribed, nor did they follow procedures for changing administration tubing and replacing antimicrobial caps.
A facility failed to provide adequate catheter care for a resident with an indwelling urinary catheter. Observations showed the catheter drainage bag hanging off the bed, uncovered, and touching the floor, contrary to facility policy. The resident, who required extensive assistance and was at increased risk for infection, had chronic obstructive pulmonary disease and congestive heart failure. The Nursing Home Administrator confirmed the catheter bag should not be uncovered and on the floor.
Failure to Provide Timely, Dignified Assistance With Toileting and Call Bell Access
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assistance with toileting and incontinence care in a manner that maintained resident dignity for two dependent residents. One resident had cervical disc disorder with myelopathy, cervicalgia, no cognitive impairment, and was care planned as dependent on staff for toileting with a need for prompt response to all requests for assistance. During an interview, this resident requested incontinence care and activated the call bell at 9:48 a.m. The call light remained on until 10:02 a.m., during which time a nurse aide walked past the room without assisting. At 10:02 a.m., a staff member turned off the call light and left the room without providing care. The resident reactivated the call bell at 10:11 a.m.; at 10:12 a.m., a nurse aide entered, stated, “What is it now?” turned off the call bell, and again did not provide assistance. The resident activated the call bell a third time at 10:41 a.m. and did not receive toileting assistance until 11:00 a.m., more than one hour after the initial request. The second resident had diagnoses including congestive heart failure and diabetes and was assessed as dependent on staff for toileting, with a care plan intervention for staff to keep the call bell within reach and answer promptly. Observation showed this resident in bed with the call bell placed in the bedside table drawer, out of reach. The resident subsequently yelled out that she was urinating and needed help, identifying her room number, and stated that she had to go to the bathroom and might need to again. Later, she stated she did not have her things and could not get to them, and she continued to yell out for assistance with the bathroom, water, and food. Throughout these observations, the call bell remained out of reach and staff did not respond to her verbal requests for assistance.
Failure to Provide Timely Incontinence Care and Assistance With ADLs
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assistance with activities of daily living, specifically incontinence care, to a resident who was unable to perform these tasks independently. The resident had diagnoses including cervical disc disorder with myelopathy and cervicalgia, had no cognitive impairment per the MDS, and was dependent on staff for toileting. The resident’s care plan identified a risk for falls, directed staff to encourage use of the call bell for assistance, required prompt response to all requests for assistance, and documented a self-care deficit requiring staff assistance with ADLs. On the morning of April 3, 2026, the resident requested incontinence care and activated the call bell at 9:48 a.m. The call light remained on until 10:02 a.m., during which time NA 1 walked past the room without assisting. At 10:02 a.m., a staff member turned off the call light and left the room without providing care. At 10:11 a.m., the resident reactivated the call bell; at 10:12 a.m., NA 1 entered, asked, “What is it now?”, turned off the call bell, refused to provide care, and walked away. The resident activated the call bell again at 10:41 a.m. and did not receive incontinence care until 11:00 a.m., more than one hour after the initial request, contrary to the care plan requirement for prompt response and assistance with ADLs.
Failure to Maintain Functioning Call Bell System on All Units
Penalty
Summary
Surveyors identified that the facility failed to provide a properly working call bell system in resident bathrooms and bathing areas on all three units. On multiple observations on March 19, 2026, call bells in rooms 103, 105, 203, and 316 illuminated in the corridor but produced no audible sound when activated. Staff interviews, including with a nurse and another employee, confirmed that the call bells were lighting up in the hallway but not sounding when used. The Administrator also confirmed that the call bell system had not been functioning properly and that this issue, with lights working but no audible alarm, had been occurring since the prior day. Clinical record review showed that one resident had chronic pain and dysphagia, was alert and oriented, and was dependent on staff for toileting and dressing. This resident’s care plan identified a risk for falls and included an intervention for staff to ensure the call light was within reach and to encourage its use; the resident reported that his call bell had not worked properly for two days, and observation confirmed there was no sound when the call bell was activated. Another resident with diabetes and insomnia, who was also alert and oriented and care planned as at risk for falls with the same call light intervention, reported that his call bell sporadically did not work properly. These findings demonstrated that the malfunctioning call system affected multiple rooms and residents whose care plans relied on a functioning call bell for fall-risk interventions.
Failure to Notify Residents/Responsible Parties of Physician-Ordered Treatment Changes
Penalty
Summary
The facility failed to notify residents or their responsible parties of physician-ordered changes in treatment for two of five sampled residents, as required. For one resident with diagnoses including congestive heart failure and dementia, the clinical record showed that on February 1, 2026, the resident complained of sacral pain and the physician ordered application of triad paste, and on February 4, 2026, the physician ordered application of calcium alginate to a right heel wound; there was no documented evidence that the resident or responsible party was notified of these new treatment orders. For another resident with dementia, the clinical record showed that on February 6, 2026, the physician ordered Mucinex for five days for a productive cough and hydrocortisone cream twice daily for a rash, with no documented evidence that the resident or responsible party was notified of these medication and treatment changes. In an interview on February 24, 2026, at 1:04 p.m., the Administrator confirmed there was no documented evidence that the residents or their responsible parties were notified of these physician-ordered changes, constituting a failure to immediately inform the resident, physician, and family of changes affecting the resident, in violation of 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Inadequate Linen Supply and Unclean Linen Areas Across All Nursing Units
Penalty
Summary
Surveyors identified a failure to maintain a safe, clean, comfortable, and homelike environment related to linen availability and cleanliness across all three nursing units and for one sampled resident. On the second floor, a resident reported remaining in the same hospital gown as the previous day due to a lack of clean gowns on the unit. At the same time, a nurse aide confirmed that there were no hospital gowns available on the hallway linen carts. Observation of the second floor linen carts showed no clean resident gowns, and the clean linen room on that unit contained only two clean gowns and no sheets, with the floor noted to be dirty and littered with debris, plastic cups, and dirt. Additional observations on the third and first floor units showed similar deficiencies in linen supply and environmental cleanliness. On the third floor, the linen cart had few gowns, sheets, and towels, and the clean linen room contained few clean gowns and sheets, with debris on the floor and two opened bags of clean linens placed directly on the floor. On the first floor, the clean linen room had no sheets, few clean gowns, and no wash cloths, and three full, odorous bins of soiled linens were located in the hallway outside the clean utility room. Follow-up observation later the same day confirmed that the linen carts and clean linen rooms on these units had not been replenished and remained sparse or empty.
Failure to Provide Ordered Morphine Due to Pharmacy Unavailability
Penalty
Summary
Surveyors identified that the facility failed to ensure a prescribed medication was available from the pharmacy for administration as ordered by the physician for one of three sampled residents. The resident was admitted on a specified date with diagnoses including kidney failure, COPD, respiratory failure, metabolic encephalopathy, and a urinary tract infection. On the day of admission, at 12:06 p.m., the physician ordered 0.25 ml of a morphine solution (20 mg/ml) to be administered every four hours. According to the Medication Administration Record, the resident did not receive any doses of the ordered morphine on two consecutive days because the medication was not available from the pharmacy. In an interview conducted on a later date at 10:45 a.m., the Director of Nursing confirmed that the resident did not receive the morphine as ordered until another specified date at 12:00 a.m. This failure to provide the ordered medication was cited under 28 Pa. Code 211.9(d) related to pharmacy services and 28 Pa. Code 211.12(d)(1)(3)(5) related to nursing services.
Environmental Deficiencies Noted in Facility
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment on one of its nursing units. During observations conducted on two separate days, surveyors noted multiple instances of physical damage and cleanliness issues. Specifically, the top left edge of the windowsills was found to be damaged in several resident rooms and in the dining room. Additional damage was observed to the chair rail under the television and to a wall beneath a wooden shelf in the dining room. Furthermore, debris and a black substance were present on the floors of several resident rooms and in an elevator. These findings indicate that the facility did not ensure the environment was properly maintained as required.
Failure to Employ Qualified Dietary Services Manager or Full-Time Dietitian
Penalty
Summary
The facility failed to employ a full-time qualified dietary services manager in the absence of a full-time qualified dietitian. During an interview, the dietary manager confirmed that there was no qualified dietary manager employed. Additionally, the Administrator verified that the facility did not have a full-time dietitian or a qualified dietary manager in place. These findings were based on staff interviews and a review of facility staffing, with no evidence provided to show compliance with the requirement for appropriate dietary service management.
Failure to Store Resident Food in a Sanitary and Labeled Manner
Penalty
Summary
The facility failed to store food in a sanitary manner on both Health Care 1 and Health Care 2 nursing units. According to facility policy, nursing staff are required to label and date resident food items that require refrigeration. However, observations revealed multiple instances of noncompliance. In Health Care 1, the resident pantry refrigerator contained an opened container of ice cream, two cans of soda, an opened bottle of soda, two opened jars of salsa, and a piece of candy, none of which were labeled with a resident name or date. Additionally, the refrigerator shelves had visible food debris, a strand of hair, and a piece of plastic tape with accumulated dust. In Health Care 2, the refrigerator contained a container of chopped fresh fruit, a bag of cherries, an uncovered dish of wilted sliced tomatoes, and a container of oat milk, all undated. Opened bottles of apple cider vinegar, salad dressing, and oat milk were also present without dates or resident names. The refrigerator shelves and bottom area were found to have sticky food debris and a hair strand. The freezer contained items such as a spicy breaded chicken sandwich and ice cream products, none labeled with a resident name. During an interview, the Administrator confirmed that the refrigerators are designated for resident food only and that items are to be labeled with the resident name and dated by staff, as per facility policy. The observations and staff interview demonstrate that the facility did not adhere to its own policies regarding the labeling, dating, and sanitary storage of resident food items, resulting in a deficiency under the cited regulations.
Delayed Response to Call Bell for Resident Requiring Extensive Assistance
Penalty
Summary
A resident with a right leg above the knee amputation, reduced mobility, and chronic pain syndrome, who was able to communicate needs and required extensive assistance with activities of daily living, was observed to have their call bell activated for 29 minutes without response from staff. The resident had a care plan indicating a risk for falls and dependence on staff for toileting, with interventions specifying that staff should encourage use of the call bell and respond promptly to requests for assistance. On the day of the incident, the resident reported waiting for assistance to use the bathroom and expressed concern about missing an activity due to the delay. Facility policy expected call bells to be answered within 20 minutes, but staff did not respond within this timeframe.
Failure to Accommodate Food Allergy in Resident Meal Service
Penalty
Summary
A resident with a documented peanut allergy and moderate cognitive impairment was served a peanut butter bar for dessert, despite clear documentation of the allergy in the clinical record, ongoing plan of care, and admission documentation. The resident required set-up assistance for feeding and was at nutritional risk due to vision problems, with instructions in the care plan to offer alternate food items as needed. On the observed date, staff served the resident a meal that included a peanut butter bar, and the resident identified his peanut allergy when interviewed. The Director of Nursing later confirmed that the resident had received the peanut butter bar, which was not appropriate given his documented allergy.
Failure to Administer Ordered Medication Due to Unavailability
Penalty
Summary
A deficiency occurred when a resident with diagnoses including cervical disc disorder with myelopathy, chronic pain, constipation, and muscle weakness did not receive simethicone as ordered by the physician. The physician's order, dated January 24, 2025, directed staff to administer simethicone twice daily. However, the medication was not available from the pharmacy, and nursing documentation confirmed that the resident did not receive the medication for four consecutive days. The resident reported experiencing severe gas pain during this period. The physician was notified of the unavailability, and a subsequent order was given to administer simethicone as needed, but the medication still was not administered as originally ordered. The Director of Nursing confirmed that the medication was not available and not given as prescribed.
Failure to Implement Physician's Orders and Administer Medications
Penalty
Summary
The facility failed to implement physician's orders for a resident diagnosed with bacteremia, congestive heart failure, and respiratory failure. The physician's order required the resident to be weighed daily, with a directive to notify the doctor if there was a weight gain of two or more pounds in one day. On one occasion, the resident's weight increased by two pounds, but there was no evidence that the staff notified the physician of this change as required. Additionally, the facility did not adhere to several medication administration orders for the resident. There were multiple instances where medications such as ampicillin, ceftriaxone sodium, florastor, heparin sodium, and normal saline were not administered as ordered. Furthermore, the staff failed to change administration tubing and replace antimicrobial caps as directed. These deficiencies were confirmed by the Director of Nursing during an interview.
Inadequate Catheter Care for Resident
Penalty
Summary
The facility failed to provide adequate catheter care for a resident with an indwelling urinary catheter. The facility's policy required that the urinary drainage bag be positioned below the bladder level, not on the floor, and covered at all times to prevent backflow of urine. However, observations on two consecutive days revealed that the resident's catheter drainage bag was hanging off the bed, uncovered, and directly touching the floor. The resident had chronic obstructive pulmonary disease and congestive heart failure, required extensive assistance for activities of daily living, and was at increased risk for infection. The Nursing Home Administrator confirmed that the catheter bag should not be uncovered and on the floor.
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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