Northampton County-gracedale
Inspection history, citations, penalties and survey trends for this long-term care facility in Nazareth, Pennsylvania.
- Location
- Gracedale Avenue, Nazareth, Pennsylvania 18064
- CMS Provider Number
- 395476
- Inspections on file
- 30
- Latest survey
- October 17, 2025
- Citations (last 12 mo.)
- 11 (3 serious)
Citation history
Health deficiencies cited at Northampton County-gracedale during CMS and state inspections, most recent first.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Surveyors found that two residents had inaccurate MDS assessments. One resident with dementia and a history of falls had an MDS indicating no falls since the prior assessment, despite nursing documentation of a fall during that period, which the DON confirmed should have been captured. Another resident with Alzheimer's disease and chronic kidney disease had an MDS indicating they were receiving dialysis, although the clinical record contained no dialysis documentation and the DON confirmed the resident was not on dialysis. These issues were cited under CFR 483.20(g) for accuracy of assessments.
Surveyors found that staff did not follow multiple physician orders for several residents, including not obtaining ordered occult blood stool tests for a resident with ESRD, failing to notify a physician when a diabetic resident’s blood glucose repeatedly exceeded 300 mg/dL, administering carvedilol to a resident with dementia and HTN despite heart rates below the ordered parameter, and not applying ordered Prevalon boots for a resident at risk for skin breakdown while in bed. The DON confirmed these lapses in implementing the prescribed treatment and monitoring.
The facility did not meet required NA staffing ratios on one reviewed day shift. Review of nursing schedules over a multi-week period showed that on a specific day shift, the number of NAs scheduled did not meet the mandated minimum of one NA per ten residents. During a subsequent interview, the DON confirmed that the facility failed to comply with the required NA-to-resident ratio for that shift.
The facility did not implement adequate interventions for residents with known aggressive and wandering behaviors, leading to one resident being physically assaulted and injured after entering another's room, and another resident experiencing sexual abuse. The lack of monitoring and preventive measures resulted in actual harm and distress to the affected residents.
A resident with significant cognitive and physical impairments was allowed to leave AMA without a documented capacity assessment or timely provider notification. The resident left in a wheelchair, without medications, a confirmed destination, or social support, and staff did not notify the provider until two days later. This failure to follow policy and ensure resident safety resulted in Immediate Jeopardy.
A resident with dementia and a history of wandering, who was identified as high risk for elopement, was left unsupervised when assigned 1:1 staff failed to remain with them as required by care plan and physician order. The resident used a door code to exit the building undetected, and staff had not received required elopement prevention training. The facility also failed to change door codes after discovering the resident had obtained them, and did not immediately respond to the resident's alert bracelet alarm, resulting in the resident's unwitnessed elopement.
A resident with dementia and a history of wandering, identified as an elopement risk, was left without required 1:1 supervision after the assigned staff member left and was not replaced. This lapse in supervision resulted in the resident eloping from the facility. Facility records also showed that required nurse aide ratios and direct care hours were not met on the day of the incident.
The NHA and DON failed to ensure effective management and supervision, resulting in two residents eloping—one after removing a roam alert bracelet and another despite a physician's order for 1:1 supervision. Required staff education on elopement prevention was not completed as indicated in the Immediate Jeopardy action plan, affecting 29 residents at risk for elopement. Documentation did not show that assigned staff received necessary training prior to their shifts.
Two residents with dementia and complex needs did not have comprehensive care plans addressing their identified risks and barriers. One resident with memory impairment and wandering behavior had no documented interventions for elopement risk or use of an alert device, while another Spanish-speaking resident with communication difficulties lacked care plan interventions to address language barriers.
A resident with dementia and a history of wandering was able to repeatedly remove his alert bracelet and elope from the facility due to the lack of a stronger tamper-resistant band, absence of 1:1 observation, and failure to update the care plan as required by facility policy. The resident was eventually found by police off facility grounds, and staff confirmed that necessary interventions were not implemented.
Three residents were subjected to physical and mental abuse by an LPN, who was observed hitting a resident, inserting fingers and wash cloths into the resident's mouth, and restricting the movement of two other residents. One resident sustained physical injuries requiring ER evaluation, while the others experienced significant distress. Staff failed to intervene promptly, and the incident was only addressed after a resident called 911.
A resident with severe protein calorie malnutrition, bipolar disorder, and dementia was inaccurately documented on the MDS as receiving an antipsychotic medication, despite no clinical record or orders supporting this. The inaccuracy was confirmed by the Administrator.
A resident with diabetes and a stage 4 sacral pressure ulcer did not receive physician-ordered wound care treatments as documented in the treatment administration record, with multiple dates showing missing documentation. The DON confirmed the lack of evidence that the required wound care was completed as ordered.
A resident with cognitive impairment and multiple medical conditions did not receive ordered podiatry care for mycotic toenails. Despite a physician's order and the weekly availability of a podiatrist, the resident was not scheduled for a podiatry visit, and observation showed the toenails remained discolored, thick, long, and jagged.
Two residents with limited ROM did not receive prescribed restorative nursing programs as ordered. One resident with upper limb paralysis and cognitive impairment did not receive active or passive ROM exercises despite therapy and physician orders. Another resident with lower extremity weakness was not offered passive ROM exercises on most days, and staff documentation confirmed the deficiency.
A medication cart on one nursing unit was observed to be unlocked and unattended in a common area, contrary to facility policy requiring secure storage of drugs and biologicals. The cart was accessible to anyone nearby during multiple observation periods.
Food items in two nourishment rooms were found improperly stored without required labeling or dating, and an LPN was observed distributing meal trays without changing gloves or performing hand hygiene after touching various surfaces, in violation of facility policies.
The facility failed to implement physician's orders for a resident with acute cystitis, Alzheimer's disease, and chronic kidney disease. The resident was observed without the prescribed Darco Flat, roam alert bracelet, or chair alarm on multiple occasions.
The facility failed to provide adequate catheter care for a resident with an indwelling urinary catheter, as staff repeatedly positioned the catheter drainage bag above the bladder level and allowed it to touch the floor, contrary to facility policy.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
Inaccurate MDS Assessments for Falls and Dialysis Status
Penalty
Summary
The deficiency involves inaccurate completion of Minimum Data Set (MDS) assessments for two residents, contrary to regulatory requirements that assessments accurately reflect a resident's status and be properly certified. One resident with dementia and a history of falls had an MDS assessment dated February 2, 2026, that indicated there had been no falls since the prior assessment dated November 3, 2025. However, a nurse's note documented that this resident experienced a fall on November 24, 2025. In an interview, the DON confirmed that this MDS assessment was inaccurate and should have captured the fall that occurred in November. For the second resident, who had diagnoses including Alzheimer's disease and chronic kidney disease, the MDS assessment dated February 10, 2026, indicated that the resident was receiving dialysis while in the facility. Review of the clinical record revealed no documentation that the resident was receiving dialysis at that time. In an interview, the DON confirmed that this MDS entry was inaccurate and that the resident was not on dialysis. The survey cites these inaccuracies under CFR 483.20(g) Accuracy of Assessments, which had been previously cited on 4/16/25.
Plan Of Correction
Lead RNAC will pull list of residents who have had any falls in last quarter and ensure falls are listed on the MDS. RNAC secretary will check list of residents with MDSs due and weekly and will check each name to see if any of the residents had a fall and will communicate that to the RNAC/LNAC. RNACs/LNACs will audit the nursing sections of two MDSs done by another team member weekly x 4 weeks, then two MDSs biweekly x 1 months, two monthly. Two monthly will continue as a routine quality indicator. Schedule will be adjusted based on results. (I.e. increase if errors are found or continue with two monthly as routine quality indicator if no errors are found.) Lead RNAC will report results of audits to QAPI.
Failure to Follow Physician Orders for Diagnostics, Monitoring, Medications, and Pressure Injury Prevention
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physician orders for multiple residents. One resident with end stage renal disease and on dialysis had a physician order dated March 27, 2026, for an occult blood stool test to be obtained for three days; review of the clinical record showed no documentation that this test was ever obtained. Another resident with type 2 diabetes mellitus with diabetic kidney complications and acute respiratory failure had an order dated August 29, 2025, for blood sugar checks before meals and at bedtime, with instructions to notify the physician if blood sugar was below 70 mg/dL or above 300 mg/dL. The Medication Administration Records showed that this resident’s blood sugar exceeded 300 mg/dL once in January 2026, seven times in February 2026, and seven times in March 2026, with no documented evidence that the physician was notified of these elevated readings. A third resident with hypertension and dementia had a physician order dated March 24, 2026, for carvedilol to be administered twice daily, with a specific parameter not to administer the medication if the resident’s heart rate was less than 60 beats per minute. Review of the MAR revealed that carvedilol was administered twice in March 2026 and six times in April 2026 when the resident’s heart rate was below 60 beats per minute. A fourth resident with cerebral infarction, vascular dementia, and muscle weakness had a physician order dated June 24, 2025, for Prevalon boots to be applied while in bed, and the care plan identified the resident as being at risk for skin breakdown. Multiple observations on April 28 and 29, 2026, showed this resident in bed without the ordered Prevalon boots applied. In interviews on April 30, 2026, the DON confirmed that the occult blood test was not done, the physician was not notified of the high blood sugars, and the medication was administered outside ordered parameters.
Plan Of Correction
Infection Control Nurse will educate providers on how to enter hemoccult order into treatment instead of into lab orders by 5/16/26. Infection Control Nurse will educate charge nurses to move hemoccult order from lab order into treatment order if it has been mistakenly entered into lab order by 5/16/26. Charge nurses will run order listing report daily and check for incorrect lab orders. Staff Development will educate nurses re: physician notifications by . ADONs will audit random events that required notification weekly x 4 weeks, biweekly for 4 weeks, then monthly. ADON completed audit on 5/7/26 regarding all Prevalon boot orders - all care plans and tasks updated. Charge nurses will audit that boots are in place for all residents with order for boots- weekly x 4 weeks, then randomly monthly. Root cause analysis revealed that nurse did not understand greater than and less than symbols. ADON completed audit of all meds with parameters utilizing greater than or less than symbols. Wording was corrected / symbols were removed to ensure clarity. Order template was update to include words, not symbols. Charge nurses will audit medication parameters weekly x 4 weeks, biweekly for 4 weeks, then monthly. Staff development will educate charge nurses will on the importance of running their order listing report and reviewing all new/updated orders for follow up. All audits will be reviewed monthly at QAPI.
Failure to Meet Minimum NA-to-Resident Ratio on a Day Shift
Penalty
Summary
The facility failed to meet state-required minimum nurse aide (NA) staffing ratios for one of 22 reviewed days. Review of nursing schedules covering March 1 to 17, 2026, and April 26 to 30, 2026, showed that on March 8, 2026, during the day shift (7:00 a.m. to 3:00 p.m.), the facility did not provide the required minimum of one NA per ten residents. For all other reviewed days and shifts, the report does not identify additional ratio failures. In an interview on May 1, 2026, at 9:25 a.m., the Director of Nursing (DON) acknowledged that the facility failed to meet the required NA-to-resident ratio on that specific day shift. No additional information is provided in the report regarding specific residents, their medical conditions, or any clinical events occurring as a result of the staffing shortfall. The deficiency is based solely on the documented staffing schedules and the DON’s confirmation of noncompliance with the mandated NA staffing ratio for the identified day shift.
Plan Of Correction
Sufficient staff was originally scheduled but dropped due to call outs. DON will educate schedulers and supervisors to add open shift to staff and agency requests when staff call out. Supervisors and / or schedulers round the units and ask additional staff to work as needed as call outs occur. Schedulers will monitor staffing numbers and report to DON daily.
Failure to Prevent Resident-to-Resident Abuse Resulting in Harm
Penalty
Summary
The facility failed to protect residents from abuse, resulting in physical and sexual harm to two residents. One resident with a history of mood disorder, anxiety, alcohol-induced dementia, and psychosis was known to be verbally and physically aggressive, often refusing care and exhibiting behavioral disturbances. Despite these ongoing behaviors and documented refusal to allow others into his room, there was no evidence that interventions were implemented to prevent other residents from entering his room. This lack of intervention led to an incident where another resident, who had cognitive communication deficits, dementia, and a tendency to wander, entered the aggressive resident's room and sustained multiple injuries, including skin tears, bruising, and a fractured coccyx, after being assaulted. Additionally, another resident with a history of wandering and confusion entered the room of a resident without cognitive impairment and engaged in inappropriate sexual contact. The affected resident reported the incident, expressing agitation and anxiety, and requested medication for anxiety. Documentation showed that there were no interventions implemented to increase monitoring of the resident with wandering behaviors to prevent such incidents. The report highlights that the facility did not follow its own abuse prevention and resident-to-resident altercation policies, which required monitoring for aggressive behaviors and implementing care plan changes to prevent further incidents. The failure to provide adequate supervision and interventions for residents with known behavioral issues directly resulted in physical and sexual abuse, causing actual harm to at least one resident.
Failure to Notify Provider and Assess Capacity During AMA Discharge
Penalty
Summary
The facility failed to ensure timely notification of a provider when a resident left the facility against medical advice (AMA), and did not confirm the resident's capacity to make such a decision. The facility's policy required prompt notification of the resident's physician or provider if a resident or representative requested discharge AMA. However, documentation showed that the provider was not notified until two days after the resident had left the facility. There was also no evidence that a capacity evaluation was performed prior to the resident's discharge, despite the resident having a history of altered mental status, cognitive deficits, and a recent stroke. The resident in question had multiple diagnoses, including problems related to living alone, altered mental status, muscle weakness, cognitive communication deficit, metabolic encephalopathy, and a below-the-knee amputation. The care plan indicated performance deficits in activities of daily living, limited mobility, impaired cognitive function, and short-term memory loss. The resident's physician had documented that decision-making capacity needed to be re-evaluated before discharge, as the resident seemed unable to understand the potential problems after leaving the facility, such as not having a home or transportation. Despite this, there was no documentation of a capacity assessment being completed, and staff allowed the resident to sign out AMA without confirming capacity or ensuring a safe discharge plan. Staff interviews confirmed that no capacity evaluation was performed, and the provider was not notified at the time of discharge. The resident left the facility in a wheelchair, without medications, a confirmed destination, or social support. Facility documentation showed that the AMA discharge form was signed by the resident and nursing supervisors, but there was no evidence of timely provider notification or interventions to ensure the resident's safety. This series of actions and omissions resulted in an Immediate Jeopardy situation.
Removal Plan
- The facility policy, Discharging a Resident Without a Physician's Approval, was updated and compliance with the updated policy will be implemented. The updates included that when a resident desires to leave AMA, staff will reference the resident's capacity in the medical record for consideration with management of the discharge and any AMA discharge will now require an incident report that will prompt staff to contact the provider.
- Physicians will be notified of AMA discharges immediately. The incident reports are audited by the risk management nurse. Compliance with the policy will be audited through High Risk Event and Quality Assurance and Performance Improvement (QAPI) meetings.
- Nursing staff onsite were re-educated on the updated policy, and notification to the Pennsylvania Department of Health and the local Area Agency on Aging at the time of an AMA discharge. The remainder of nursing staff will be educated.
- A new physician's order set was implemented to clearly communicate to the interdisciplinary team when a resident lacks capacity, has capacity, or if capacity is to be determined. Resident capacity will be documented with the order set. Nursing supervisors will audit new admissions for implementation of the order set.
- The interdisciplinary team will be educated on the new order set, and to document resident capacity based only on physician documentation. Compliance will be reviewed at QAPI meetings.
Failure to Provide Adequate Supervision and Elopement Prevention
Penalty
Summary
The facility failed to provide adequate supervision and monitoring to prevent the elopement of a resident who was identified as being at high risk for elopement. The resident, who had diagnoses including dementia, insomnia, wandering, restlessness, and agitation, was assessed as having memory impairment and was able to ambulate independently. The care plan and physician orders required 1:1 supervision and the use of a roam alert bracelet due to the resident's history and ongoing behaviors such as exit-seeking, attempting to use elevators, and previously eloping from another facility. Despite these interventions, there were multiple documented incidents where the resident was found attempting to access elevators, standing by exit points, and even obtaining and hiding door codes, yet the facility did not consistently implement or evaluate the recommended 1:1 supervision in a timely manner. On the day of the incident, the assigned 1:1 staff member left their post and was not replaced, leaving the resident unsupervised in violation of the care plan and physician's order. During this period without supervision, the resident was able to use a previously obtained door code to exit the facility through a stairwell door, as later confirmed by camera footage. The facility also failed to change the door codes after discovering the resident had obtained them, and did not provide required elopement prevention training to the staff assigned to the resident at the time of the incident. Additionally, the facility did not immediately initiate a search when the resident's alert bracelet alarmed, and there was no evidence that staff on the unit had received the necessary training as outlined in the facility's Immediate Jeopardy action plan. Further review revealed that 29 residents on the same unit were assessed as being at risk for elopement, yet there was no documentation that staff had received the required education on elopement prevention prior to their shifts. The facility's failure to provide adequate supervision, implement timely interventions, and ensure staff were properly trained directly resulted in the resident's unwitnessed elopement from the building, which was only discovered after the resident could not be located and was later found offsite by police.
Removal Plan
- Resident 2's room was changed to a secure unit.
- The facility changed all the door and elevator codes.
- The facility updated the 1:1 policy to include that staff is never to walk away from the assigned resident until another staff member takes their place.
- The facility educated all staff regarding the new 1:1 policy and not sharing door codes.
- The facility educated staff that a search should occur immediately if a door alarm is sounding.
- The facility instructed staff not to utilize fire alarm doors for everyday use to decrease alarm fatigue.
- The facility will continue to assess residents' risk of elopement upon admission, quarterly, and with events.
- The Nursing Home Administrator will update the pre-admission review of elopement risk to ensure the facility can safely manage a resident at risk of elopement.
- Monthly department head meetings will be held for the leadership team to discuss elopement events.
- Staff members observed to be giving out door and elevator codes to visitors or residents will receive disciplinary action.
Failure to Provide Required 1:1 Supervision and Adequate Staffing
Penalty
Summary
The facility failed to provide sufficient and competent staff to implement a resident's care plan interventions. Clinical record review showed that a resident with dementia, insomnia, wandering, restlessness, and agitation was assessed as having memory impairment and was able to walk without assistance. The resident was identified as an elopement risk, and the care plan included 1:1 observation as an intervention. On September 17, 2025, a physician ordered 1:1 supervision for this resident. However, facility documentation revealed that the staff member assigned to provide 1:1 supervision left the assignment at 8:00 p.m. on September 20, 2025, and was not replaced, leaving the resident without required supervision. As a result, the resident eloped from the facility later that night. Additionally, staffing documentation indicated that the facility did not meet the state-required nurse aide ratios and minimum direct care hours per resident on that day.
Failure to Prevent Resident Elopement and Ensure Staff Training
Penalty
Summary
The Nursing Home Administrator (NHA) and Director of Nursing (DON) did not effectively manage the facility to ensure adequate interventions and supervision were provided to prevent the elopement of two residents. One resident was able to self-remove a roam alert bracelet and exit the facility, resulting in an Immediate Jeopardy situation. The facility's action plan required that all nurses receive education on elopement prevention before their next shift and that all staff be educated by a specified date. However, documentation showed that this education was not completed as required. A second resident, who had a physician's order for one-to-one supervision due to exit-seeking behavior, also eloped after being left unsupervised by the staff assigned to provide this supervision. There was no documented evidence that the nurse aide assigned to supervise the resident or the LPN overseeing the aide had received the necessary elopement training prior to their shifts, as required by the facility's Immediate Jeopardy action plan. Additionally, 29 residents on one unit were identified as being at risk for elopement, but the required staff education was not completed for that unit. The NHA and DON failed to fulfill their responsibilities to ensure compliance with federal and state regulations, contributing to these Immediate Jeopardy situations.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed the specific needs of two residents as identified in their comprehensive assessments. For one resident with vascular dementia, syncope, and a history of stroke, clinical records showed memory impairment and wandering behavior, with an elopement risk assessment indicating the use of an alert bracelet. However, there was no documented evidence that the care plan included interventions to monitor elopement risk, wandering, or the use of the alert device. For another resident with dementia, insomnia, wandering, restlessness, and agitation, who primarily spoke Spanish and rarely understood English, the MDS Care Area Assessment summary indicated that communication should be addressed in the care plan. Despite this, there was no documentation of interventions to address the resident's communication barrier in the care plan.
Failure to Prevent Elopement Due to Inadequate Supervision and Policy Noncompliance
Penalty
Summary
The facility failed to provide adequate supervision and monitoring to prevent an elopement for a resident identified as being at risk. The resident, who had diagnoses including vascular dementia, syncope, and cerebral infarction, was independently ambulatory and had documented memory impairment. Despite being assessed as a wanderer at risk for elopement, the resident was able to repeatedly remove his alert bracelet, which was intended to prevent unauthorized exits. Facility policy required that residents capable of removing their alert bracelets be issued a stronger, tamper-resistant band and, if still able to remove it, be placed on one-to-one observation. However, after the resident removed his alert bracelet on multiple occasions, there was no documented evidence that a stronger band was provided or that one-to-one observation was implemented as required by policy. Additionally, there was no documentation that the resident's care plan was updated to include interventions addressing his elopement risk, wandering behavior, or alert bracelet use. On one occasion, the resident was found off the unit and returned, but later the same day, he was able to leave the facility undetected and was found by police walking along a road a mile away. Staff interviews confirmed the lack of appropriate interventions and care plan updates, and the failure to follow facility policy led to an Immediate Jeopardy situation.
Removal Plan
- Resident 1's room was changed to a secure unit, and a new alert bracelet was placed on the resident. The resident's care plan was updated to include risk for elopement. Resident 1 was placed on 1:1 observation.
- The facility conducted an immediate audit of all residents with alert bracelets to ensure they were intact and with the appropriate band.
- The facility conducted an audit to ensure all residents with an alert bracelet had an appropriate care plan in place.
- The facility created a log to monitor each alert bracelet and band to ensure the correct band is in place, and that the policy regarding stronger bands is being followed.
- The receptionists will review the binder of at risk residents at the start of their shifts for changes and initial a log.
- The facility will update the template for 1:1 orders in the electronic health record.
- The facility educated all staff in the facility on the facility's procedure for alert bracelets, stronger bands, and resident care plans. All staff that were available were immediately educated. Other staff will be re-educated prior to the start of their next shift.
- Weekly audits of alert bracelets, bands, logs, and care plans will be completed and the results discussed at QAPI (Quality assurance, performance improvement) committee.
- Signs are posted with instructions to not share door codes and to be aware of residents who may try to exit.
Failure to Prevent Resident Abuse by LPN
Penalty
Summary
The facility failed to protect three residents from physical and/or mental abuse, as evidenced by an incident involving an LPN and three residents. According to facility documentation and staff and resident statements, the LPN was observed in a resident's room wearing full PPE, tapping one resident on the chest and back, and inserting her fingers into the resident's mouth. Blood-stained wash cloths were found on the floor, and two other residents in the room were shouting for help. One nurse aide reported that the LPN prevented her from entering the room and did not report the incident immediately. Resident interviews revealed that the LPN instructed them to put on PPE gowns, restricted their movement, and physically abused one resident by hitting and forcing wash cloths and towels into her mouth. One resident called 911 for help. As a result of the incident, the abused resident was transferred to the emergency room and was found to have petechial hemorrhages on the hard palate, periorbital edema, swollen lips, and difficulty closing her mouth. Nursing documentation noted that the resident expressed fear for her life. The other two residents also reported being frightened and subjected to inappropriate actions by the LPN, such as being sprinkled with water and being prevented from leaving the room. The facility's failure to intervene promptly and ensure the residents' safety resulted in actual physical harm to one resident and mental distress to all three involved.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to complete an accurate Minimum Data Set (MDS) assessment for one resident. Clinical record review showed that the resident had diagnoses of severe protein calorie malnutrition, bipolar disorder, and dementia. The resident's MDS assessment indicated the use of an antipsychotic medication, but a review of the clinical record revealed no orders for or evidence that the resident received such medication. This inaccuracy was confirmed by the Administrator during an interview.
Failure to Document and Administer Physician-Ordered Pressure Ulcer Treatments
Penalty
Summary
The facility failed to provide physician-ordered wound care treatments for one of five sampled residents with pressure ulcers. Clinical record review showed that a resident with diabetes mellitus and hidradenitis suppurativa had a stage 4 pressure sore on the sacrum. The physician had ordered wound care involving cleansing with wound cleanser, application of a collagen sheet, filling with silver alginate, and covering with an Optifoam gentle dressing every shift. However, the treatment administration record for March 2025 lacked documentation that these treatments were completed on six specific dates. The Director of Nursing confirmed there was no documented evidence that the wound treatments were performed as ordered on those dates.
Failure to Provide Ordered Foot Care and Podiatry Services
Penalty
Summary
A deficiency was identified when a resident with diagnoses including encephalopathy and ischemic cardiomyopathy, who was dependent on staff for care and had mild cognitive impairment, did not receive appropriate foot care as ordered. The resident had a physician's order for nursing staff to schedule a podiatry clinic visit for mycotic toenails, but there was no documented evidence that this was done. Observation revealed the resident's toenails were discolored, thick, long, and jagged, and the Director of Nursing confirmed the resident was not scheduled with the podiatrist despite the podiatrist being available weekly at the facility. This failure to provide the ordered foot care and schedule the resident for podiatry services resulted in the resident not receiving necessary treatment for their mycotic toenails.
Failure to Implement Restorative Nursing Programs for Residents with Limited Range of Motion
Penalty
Summary
The facility failed to implement prescribed restorative nursing programs (RNP) to maintain or improve range of motion (ROM) for two residents with limited mobility. One resident with monoplegia, muscle weakness, and lack of coordination had an occupational therapy recommendation and physician's order for active assisted and passive ROM exercises for the upper extremities. Despite these orders, there was no evidence that staff provided the required RNP, as confirmed by the Director of Nursing and the Program Director of Rehabilitation. The resident was dependent on staff for activities of daily living and had cognitive impairment, with a noted limitation in upper extremity ROM. Another resident with diagnoses including atrial fibrillation and cauda equina syndrome was care planned for passive ROM exercises to the lower extremities. The resident reported that staff did not perform the exercises and that he would not refuse them if offered. Review of the RNP task flowsheet showed that the resident was not offered restorative ROM on 19 out of 30 days. The Director of Nursing confirmed the lack of documented evidence that the RNP was provided as required.
Unlocked and Unattended Medication Cart in Common Area
Penalty
Summary
Facility staff failed to ensure that medications and biologicals were securely stored on one of twelve nursing units. According to the facility's policy, all compartments containing drugs and biologicals, including medication carts, must be locked when not in use and should not be left unattended if unlocked. However, observations on Tower 5 revealed that a medication cart was left unlocked and unattended in a common area, making it accessible to anyone in the vicinity during two separate observation periods on the same day.
Food Storage and Meal Distribution Lapses
Penalty
Summary
The facility failed to store food in a sanitary manner on two nursing units, Northwest 1 and Northwest 2. During observations, multiple food items in the nourishment room refrigerators and cabinets were found without proper labeling or dating, including packages of strawberries, blueberries, shrimp, crawfish tail meat, pepperoni, chili sauce, and bulk containers of cookies. Some items were labeled with use-by dates, but several perishable items lacked both resident names and dates, contrary to facility policy which requires perishable foods to be labeled with the resident's name, the item, and a use-by date. Staff confirmed that the nourishment rooms were intended for resident use only. Additionally, the facility failed to distribute resident meal trays in a sanitary manner on the Northeast 1 unit. An LPN was observed serving food while wearing the same gloves after touching door knobs, keypads, and her jacket, without changing gloves or performing hand hygiene between tasks. This practice was inconsistent with the facility's policy on standard precautions, which requires staff to change gloves and wash hands between resident contacts and tasks.
Failure to Implement Physician's Orders
Penalty
Summary
The facility failed to ensure that physician's orders were implemented for one of the 37 sampled residents. Resident 5, who had diagnoses including acute cystitis without hematuria, Alzheimer's disease, and chronic kidney disease, was observed without the prescribed Darco Flat, roam alert bracelet, or chair alarm on multiple occasions. Specifically, on April 30, 2024, and May 1, 2024, Resident 5 was seen in his wheelchair in the dining room area without these prescribed items in place, despite the physician's order dated April 23, 2024.
Inadequate Catheter Care for Resident
Penalty
Summary
The facility failed to ensure adequate catheter care for a resident with an indwelling urinary catheter. The facility's policy required that the urinary drainage bag be positioned lower than the bladder at all times to prevent backflow and that the catheter tubing and drainage bag be kept off the floor. However, observations revealed multiple instances where these guidelines were not followed. On one occasion, the resident was seen in a wheelchair with the catheter drainage bag hanging on the armrest, above the level of the bladder. On another occasion, the catheter was observed on the mattress while the resident was in bed, and later, the catheter bag was placed directly on the floor. Additionally, a registered nurse and a nurse aide were observed placing the catheter bag on the resident's lap and wheelchair armrest, respectively, both of which were above the bladder level. The resident involved had diagnoses including acute cystitis without hematuria, Alzheimer's disease, chronic kidney disease, and urine retention. The physician had ordered a Foley catheter for the resident every shift. Despite this, the facility staff failed to maintain the proper positioning of the catheter drainage bag, as evidenced by multiple observations over two days. These actions were in direct violation of the facility's urinary catheter care policy and contributed to the deficiency noted in the report.
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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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