Oak Hill Center For Rehabilitation And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Middletown, Pennsylvania.
- Location
- 1020 North Union Street, Middletown, Pennsylvania 17057
- CMS Provider Number
- 395347
- Inspections on file
- 36
- Latest survey
- April 7, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Oak Hill Center For Rehabilitation And Nursing during CMS and state inspections, most recent first.
Surveyors found that staff failed to follow physician orders for daily weights for two residents with conditions including CHF, CKD, GERD, HTN, MDD, pain, and elevated BMI. Both residents had care plans identifying risk for nutrition/hydration problems and interventions to monitor weight as ordered, yet review of weight documentation showed multiple missed daily weights on ordered days. The NHA confirmed that the residents were not weighed on the identified dates.
Surveyors identified failures in psychotropic medication management, including missing 14-day stop dates for PRN orders, lack of side effect monitoring for two residents on psychotropic drugs, absence of informed consent for one resident started on an antipsychotic, and inadequate documentation of behavioral interventions and monitoring for a resident switched to Lorazepam gel after refusing oral medication.
The facility did not ensure that physician orders and professional standards were followed for four residents, including missed laboratory tests, delayed implementation of medication monitoring, incomplete weekly skin assessments, and failure to notify a physician of critical blood glucose levels. These deficiencies involved residents with dementia, cerebrovascular disease, diabetes, and other chronic conditions.
A resident with chronic pain and multiple diagnoses did not receive timely comprehensive pain assessments, and pain management interventions were not consistently aligned with the resident's stated goals. Documentation showed frequent administration of prn Tylenol and oxycodone, sometimes simultaneously and without clear parameters, with several instances of unknown or ineffective outcomes. Staff confirmed the lack of appropriate medication parameters and improper administration practices.
Two residents with renal failure did not have proper documentation or communication between the facility and the dialysis provider, despite physician orders and care plans specifying scheduled dialysis treatments. Required dialysis communication sheets were missing or incomplete, and the Nursing Home Administrator confirmed these records were not consistently maintained.
Annual performance evaluations were not completed for five nurse aides, as required by facility policy. Personnel records lacked documentation of these reviews, and the administrator confirmed that evaluations should have been conducted around each employee's hire date.
Two residents' care plans were not updated to include the use of enabler bars, a trapeze, or pacemaker safety precautions, despite physician orders and facility policy requiring comprehensive, person-centered care planning. Staff confirmed that these interventions and safety measures were in use but not documented in the care plans or Kardex.
A resident with dementia and hypertension, who was care planned for bilateral fall mats to prevent falls, was observed on multiple occasions without the required fall mats in place. The absence of these devices was confirmed by the NHA, indicating a failure to follow the resident's fall prevention interventions.
A resident with a Foley catheter did not receive proper catheter care as required by facility policy and physician orders. The catheter bag was observed in contact with the floor on multiple occasions, and documentation of catheter care was missing for several days and not completed every shift as ordered. Staff confirmed these lapses in care and documentation.
A resident with Alzheimer's disease and other mental health diagnoses did not receive timely dental services for denture replacement, despite multiple scheduled visits and documented need for assistance with dentures. The resident missed a key denture fitting appointment, and the dentist was unable to locate her during a scheduled visit, resulting in a delay in necessary dental care.
A resident with dementia suffered a femur fracture that was not promptly acted upon after confirmation by x-ray. Despite ongoing high pain scores and repeated administration of PRN oxycodone, there was a significant delay in notifying the provider and transferring the resident to the hospital. Documentation failed to show timely pain assessments or interventions after the fracture was identified, resulting in the resident not receiving adequate pain management or timely hospital care.
A resident with type II diabetes had a physician's order for Ozempic, but the medication was not administered on two occasions, and there was no documentation of follow-up with the pharmacy or physician regarding its absence. The DON confirmed the medication was never dispensed, and the clinical record lacked evidence of any actions taken to address the missing medication.
A resident with dysphagia, dementia, and muscle weakness was given a thin liquid by a volunteer, despite physician orders for nectar thickened fluids. The volunteer did not consult nursing staff before providing the drink, contrary to facility policy. The resident began coughing and was later diagnosed with bilateral lobe pneumonia and a small left-sided effusion.
Two residents with dysphagia did not receive drinks in the prescribed nectar thickened consistency. One resident was given thin liquids by a volunteer, resulting in coughing and subsequent bilateral lobe pneumonia with a small pleural effusion. Another resident was observed with thin water and a straw at bedside, despite orders for nectar thickened liquids and no straws. Facility staff and volunteers did not follow physician orders or facility policy regarding fluid consistency.
Oak Hill Center for Rehabilitation and Nursing failed to provide meals in the correct texture for residents requiring mechanical soft and pureed diets. A resident with swallowing difficulties was served a mechanical soft meal instead of a pureed diet due to outdated dietary slips and miscommunication. The error was identified during meal service and corrected, but it highlighted a lapse in following dietary orders.
The facility failed to meet the required nurse aide (NA) staffing ratios on several occasions, as evidenced by staffing documents and staff interviews. The facility did not maintain the minimum NA-to-resident ratios on the day shift for four days, on the evening shift for two days, and on the night shift for one day. The Nursing Home Administrator confirmed the accuracy of the staffing information and acknowledged the facility's failure to meet the required NA ratios.
The facility did not meet the required LPN staffing ratios on specific shifts. On an evening shift, the facility had a census of 127 residents but only maintained an LPN ratio of 4.0, below the required 4.23. On two night shifts, the facility had the same census but only maintained an LPN ratio of 3.0, below the required 3.18. The Nursing Home Administrator confirmed the staffing deficiencies.
The facility did not meet the required minimum of 3.2 hours of direct nursing care per resident in a 24-hour period. On three separate days, the facility provided less than the required hours, with 3.18 hours on two days and 3.17 hours on another. This was confirmed by the Nursing Home Administrator.
The facility failed to ensure resident participation in the care planning process for two residents, as required by their New Admission Introduction & Handbook. Both residents, with conditions such as muscle weakness, chronic kidney disease, anemia, and pain, were not documented as having been invited to their care plan meetings. The Director of Social Services confirmed the absence of a process to ensure resident invitations to these meetings.
The facility did not provide the SNF-ABN form to two residents whose Medicare A coverage had ended, despite their plans to continue receiving skilled services. The Nursing Home Administrator acknowledged the error, which will be corrected.
The facility failed to ensure accurate resident assessments, leading to deficiencies in documenting significant weight loss and medication management for four residents. A resident with Parkinson's Disease experienced significant weight loss, which was not reflected in MDS assessments. Another resident's recommendation for a gradual dose reduction of Quetiapine was not documented due to a delay in scanning the consult. Additionally, a resident's physician-ordered GDR of Seroquel was not reflected in the MDS assessment. Lastly, a resident at risk for severe protein-calorie malnutrition was not marked as such in the MDS assessment.
The facility failed to provide adequate wound care for two residents with pressure ulcers. A resident with severe malnutrition and a stage 4 ulcer did not receive timely updated wound care orders, while another resident with paraplegia and a recurring ulcer experienced lapses in hand hygiene, barrier precautions, and unauthorized use of wound care products. These deficiencies were confirmed by the DON and NHA.
Two residents with limited mobility did not receive appropriate services to maintain or improve their mobility. One resident with a hand contracture had inconsistent documentation for prescribed splint and ROM exercises, while another resident with hemiplegia reported difficulty receiving assistance for daily ambulation. The facility's documentation practices were inadequate, as noted by the NHA.
The facility failed to provide appropriate care for two residents with feeding tubes, leading to deficiencies in monitoring and syringe changes. One resident lacked orders for G-tube site care, while another had insufficient orders for PEG tube syringe changes. These oversights were acknowledged by the facility's administration.
The facility failed to conduct timely trauma assessments and develop individualized care plans for two residents with PTSD. One resident's care plan lacked details on PTSD triggers, while another's records did not reflect her PTSD diagnosis or personalized interventions, despite her request for continued therapy and identification of specific triggers.
The facility failed to assess and obtain informed consent for the use of enabler bars/side rails for two residents. One resident with paraplegia and morbid obesity had side rails without documented consent or risk review. Another resident with COPD and CHF had an enabler rail without proper assessment, despite an initial evaluation indicating no need for side rails. Consent forms for both residents were signed after the observation.
The facility failed to store medications securely, leaving them at the bedside of three residents without self-administration orders. Medications, including a powder for a rash and discontinued creams, were found in resident rooms for staff convenience, contrary to policy. The DON confirmed these should have been stored in locked compartments.
The facility failed to implement enhanced barrier precautions (EBP) correctly, as observed when a nurse aide was seen handling soiled linen without a gown, despite EBP signage on the resident's door. Interviews revealed staff confusion about EBP application, leading to incorrect signage and lack of PPE use. The Infection Control Professional confirmed the oversight, and the Nursing Home Administrator and DON acknowledged the need for proper EBP implementation.
The facility failed to inspect side rails for two residents, leading to potential entrapment risks. One resident had bilateral enabler bars installed without timely safety measurements, while another had a side rail installed with no inspection documentation. The Nursing Home Administrator confirmed the lack of evidence for these inspections.
The facility failed to follow professional standards in medication administration and wound care for two residents. One resident did not receive prescribed eye drops due to a lack of physician orders, and another resident received unauthorized collagen with silver during wound care. Additionally, there was a delay in starting NPWT as ordered by a wound care specialist.
A facility failed to provide appropriate respiratory care for a resident with bipolar disorder and hypertension. The resident was observed using oxygen at 4 liters per minute, contrary to the physician's order of 2 liters per minute. Additionally, the facility did not document the maintenance of the resident's oxygen equipment as required, including changing the humidifier bottle and cleaning the oxygen concentrator filter.
A resident with ESRD did not receive appropriate dialysis care as the facility failed to avoid using the arm with the dialysis graft for blood pressure measurements and did not weigh the resident before dialysis sessions. Additionally, the dialysis order was not entered timely, and a communication sheet was missing. Interviews confirmed these documentation and care deficiencies.
A resident with CHF and vitamin deficiency did not receive necessary dental services as recommended by a dental consult. Despite the resident's concern about the lack of routine dental care, there was no evidence of follow-up dental services after a recommended cleaning and checkup. The facility acknowledged the need for a system to track dental appointments.
A resident with a history of UTIs and other conditions suffered harm due to the facility's failure to provide catheter care, administer antibiotics, and obtain timely lab results. The resident's condition worsened, leading to hospitalization for septic shock. Additionally, the facility failed to document wound treatments and obtain weekly weights as ordered.
The facility failed to adhere to care plans for two residents, resulting in missed showers and weights. One resident with heart failure and hypertension did not receive the ordered showers and was weighed only once instead of weekly. Another resident with heart failure and dementia was weighed only twice instead of weekly as ordered. The DON and Nursing Home Administrator confirmed these discrepancies.
Failure to Follow Physician Orders for Daily Weights
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for daily weights for two residents, despite active orders and care plan interventions directing that weights be monitored as ordered. For one resident with diagnoses including heart failure, GERD, stage 3 chronic kidney disease, and elevated BMI, the physician had ordered daily weights with instructions to report a 2–3 lb overnight gain or a 5 lb gain in one week, starting March 10, 2026. The resident’s care plan identified risk for nutrition/hydration problems related to anxiety, chronic heart failure, kidney disease, fluid restriction, diuretic use, and weight changes caused by fluid, and included an intervention to monitor weight as ordered. Review of the weight summary task showed that no weights were obtained on multiple specified dates, indicating that the ordered daily weights were not consistently performed. For a second resident with hypertension, major depressive disorder, pain, and overweight BMI, the physician had ordered daily morning weights for six weeks beginning February 17, 2026, and the care plan included an intervention to monitor weight as ordered due to risk for nutrition/hydration problems. Review of this resident’s weight summary task showed that weights were not obtained on two specified dates, again demonstrating that the physician’s orders for daily weights were not followed. During an interview, the Nursing Home Administrator confirmed that the residents were not weighed on the identified dates.
Deficiencies in Psychotropic Medication Management and Monitoring
Penalty
Summary
The facility failed to comply with regulatory requirements regarding the use and monitoring of psychotropic medications for several residents. For one resident with major depressive disorder and dementia, PRN (as needed) psychotropic medication orders for ABH Gel and Seroquel were issued without a documented 14-day stop date or rationale for continued use, contrary to facility policy. Interviews with the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that such orders should have a 14-day stop date documented and followed. Additionally, two residents receiving psychotropic medications, including antipsychotics and anxiolytics, did not have documented monitoring for side effects as required. One resident with dementia, agitation, and depression had multiple psychotropic medications ordered, but there was no documentation of side effect monitoring in the clinical record. The NHA confirmed that side effect monitoring should have been in place. Another resident with major depressive disorder and anxiety disorder was prescribed Lorazepam gel after previously refusing the oral form, but there was no documentation of side effect or behavior monitoring, nor evidence of nonpharmacological interventions or care planning for medication refusal. Furthermore, the facility failed to obtain proper informed consent for the initiation of psychotropic medication for a resident with anxiety disorder and paranoid schizophrenia. The clinical record lacked a signed informed consent form from the resident or their representative for the use of olanzapine. The NHA stated that it was the facility's expectation to obtain such consent. These deficiencies were identified through policy reviews, clinical record reviews, and staff interviews.
Failure to Follow Physician Orders and Professional Standards of Care
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards and physician orders for four residents. For one resident with dementia, laboratory tests including a complete blood count, metabolic profile, lipid panel, hemoglobin A1C, and anticonvulsant drug levels were ordered to be performed every six months starting on a specific date, but there was no evidence these labs were obtained or results documented. The Nursing Home Administrator confirmed the labs were not completed as ordered. Another resident with dementia, hypertension, and atrial fibrillation had a consultant pharmacist's recommendation for digoxin drug level monitoring, basic metabolic profile, and daily pulse checks, which was signed by the provider. However, there was a delay of approximately nine weeks before the pulse monitoring order was implemented, and no order for a digoxin level was found in the clinical record. The Director of Nursing confirmed that these interventions should have been implemented when the recommendation was signed. A third resident with cerebrovascular disease and major depressive disorder had physician orders and care plan interventions for weekly skin assessments due to risk of skin breakdown. Documentation showed that several weekly skin assessments were missing over a three-week period. Additionally, a resident with diabetes and anxiety disorder had orders for twice-daily blood glucose checks with physician notification required for results above 400 or below 60. The Medication Administration Record showed multiple instances of blood glucose readings above 400, but there was no documentation that the physician was notified as required.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with a history of pain, osteoarthritis, and multiple sclerosis. Facility policy required comprehensive pain assessments upon admission, quarterly, with significant changes, and with new or worsening pain, as well as documentation of pain management interventions consistent with the resident's goals. However, the resident did not receive a comprehensive pain assessment for over eight months, despite ongoing pain management issues. When an assessment was completed, the resident reported almost constant pain and set a pain goal, but there was no evidence that pain management interventions were consistently aligned with this goal. Medication administration records revealed that the resident received as-needed (prn) Tylenol and oxycodone for varying pain levels, including instances where both medications were given simultaneously on multiple occasions. There were also several doses where the effectiveness of the medication was either unknown or documented as ineffective. Additionally, prn medications were administered without clear parameters, and some doses were given for pain levels of zero or for fever when the resident did not have an elevated temperature. Staff interviews confirmed that prn pain medications lacked appropriate parameters and that the two medications should not have been administered together.
Failure to Document and Communicate Dialysis Care for Residents
Penalty
Summary
The facility failed to ensure that residents requiring dialysis received care and services consistent with professional standards, the comprehensive person-centered care plan, and the residents' goals and preferences. For two residents with diagnoses including end stage renal disease and chronic kidney disease, physician orders and care plans specified scheduled dialysis treatments. However, documentation of communication between the facility and the dialysis provider was either missing or incomplete. Specifically, for one resident, there were no dialysis communication sheets available for review, and for the other, there was a lack of documented communication for a period during which the resident attended multiple dialysis sessions. Interviews with the Nursing Home Administrator confirmed that dialysis communication sheets were not consistently completed or available for review, and that these records were not uploaded to the electronic health record. The facility's own policy required immediate communication with the attending physician, resident or representative, and dialysis staff regarding significant changes in the resident's status, but there was no evidence that this communication occurred or was documented as required.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance evaluations for five nurse aides, as required by policy. Personnel records for these nurse aides, who were hired between December 2021 and February 2024, did not contain documentation of annual performance reviews. During an interview, the Nursing Home Administrator confirmed that there was no additional documentation available and acknowledged that annual performance reviews should be completed around each employee's hire date.
Failure to Update and Revise Care Plans for Assistive Devices and Pacemaker Precautions
Penalty
Summary
The facility failed to review and revise the care plans for two residents as required by both facility policy and regulatory standards. For one resident with dementia, hypertension, and atrial fibrillation, the clinical record showed the use of bilateral enabler bars and a pacemaker monitoring unit, but the care plan did not include interventions or safety precautions related to the enabler bars or the pacemaker. Documentation confirmed the enabler bars were ordered and placed, and the resident had a pacemaker since 2018, yet these were never addressed in the care plan or its revision history. The Nursing Home Administrator and Director of Nursing confirmed that these items should have been included in the care plan. Another resident with morbid obesity and lumbar spondylolisthesis used bilateral enabler bars and a trapeze for bed mobility and transfers, with staff performing safety checks as ordered by the physician. Although there was a signed consent and risk-benefit form for the use of bed rails, the care plan and Kardex did not document the use of the enabler bars or trapeze. The Nursing Home Administrator confirmed via email that these devices were not documented in the care plan or Kardex, despite their use and the associated physician orders.
Failure to Provide Required Fall Prevention Devices
Penalty
Summary
The facility failed to provide adequate supervision and assistance devices to prevent accidents for one resident. According to the facility's policy on managing falls and fall risk, staff are required to implement interventions based on each resident's specific risks, including the use of bilateral fall mats as indicated in the care plan. Review of the clinical record for a resident with dementia and hypertension showed that fall mats were to be in place at both sides of the bed, as documented in the care plan. However, during observations on two separate occasions, the resident was found lying in bed without any fall mats present, and none were found in the room. In a subsequent interview, the Nursing Home Administrator confirmed that the fall mats were not in place as required by the care plan.
Failure to Provide Proper Catheter Care and Documentation
Penalty
Summary
The facility failed to provide appropriate catheter care and services to prevent urinary tract infections for a resident with a Foley catheter. Facility policy required that catheter tubing and bags be kept off the floor and that catheter care be documented with the date, time, and staff providing care. Observations on two separate occasions showed the resident's catheter bag in direct contact with the floor, contrary to policy. Staff interviews confirmed that the catheter bag should not have been on the floor. Additionally, review of the resident's clinical record revealed a lack of documentation for catheter care from the time of hospital readmission with a Foley catheter until several days later. Although there was a physician order for catheter care every shift, documentation was missing for multiple days and, when initiated, was only recorded for the day shift. The DON confirmed that catheter care should have been provided every shift, and the NHA acknowledged that the orders for catheter care were not re-populated until several days after the resident's return.
Failure to Provide Timely Dental Services and Denture Fitting
Penalty
Summary
The facility failed to provide routine and emergency dental services for a resident diagnosed with Alzheimer's disease, adjustment disorder with mixed anxiety, and depression. According to the facility's policy, selected dentists must be available for follow-up care, and social services are responsible for assisting residents with appointments. The resident, who had Medicaid managed care coverage, reported not having seen a dentist for the replacement of two missing upper right teeth. Documentation showed that the resident was in the process of receiving new dentures, with several dental visits scheduled and impressions taken for fabrication. However, the resident's care plan required assistance with inserting and removing dentures, and records indicated that both upper and lower dentures were ill-fitting and had plaque buildup. Despite being scheduled for a step 4 denture fitting, the resident was not seen by the dentist as planned. On one occasion, the dental provider made four attempts to see the resident during a scheduled visit but was unable to locate her. The dentist visits the facility approximately every six weeks, and the resident should have been seen prior to the next scheduled visit for her denture fitting. This lapse resulted in the resident not receiving timely dental care as required by facility policy and regulatory standards.
Delayed Hospital Transfer and Inadequate Pain Management Following Fracture
Penalty
Summary
A resident with Alzheimer's Disease and dementia, residing on a locked memory care unit, experienced a fall and subsequently complained of right thigh pain. An initial x-ray of the right hip was negative for fracture, and the resident was prescribed oxycodone for pain as needed. Over the following days, the resident continued to report significant pain, with documented pain scores ranging from 4 to 8, and received several doses of pain medication. Despite ongoing pain and difficulty ambulating, a second x-ray was not ordered until the next day, which revealed an acute right femur fracture late in the evening. After the positive fracture diagnosis, there was no documentation that the physician was notified promptly, nor was there evidence of further pain assessment or administration of pain medication throughout the night. The provider was not made aware of the x-ray results until the following morning, at which point the resident was assessed and orders were given for hospital transfer. This resulted in a delay of approximately 9.5 hours from the time the fracture was confirmed to the time the resident was sent to the hospital. There was also no documentation of when EMS was called or when the resident was actually transferred. During this period, the resident did not receive additional pain management or documented assessments for pain or discomfort. Upon hospital admission, the resident required surgical intervention for the fracture and was administered IV morphine for pain control. The facility failed to provide timely transfer to the hospital following confirmation of the femur fracture and did not adequately monitor or manage the resident's pain prior to transfer.
Failure to Provide Ordered Diabetes Medication Due to Lack of Pharmacy Follow-Up
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident with diagnoses including type II diabetes mellitus and muscle weakness. The resident had a physician's order for Ozempic, to be administered subcutaneously every Sunday for diabetes management. Review of the Medication Administration Record (MAR) for June 2025 showed that on two Sundays, nursing staff documented 'other/see note,' but there was no further documentation in the progress notes or clinical record to indicate that the medication was administered on those dates. Additionally, there was no evidence that the facility received the medication or that any follow-up was conducted regarding its absence. An interview with the Director of Nursing (DON) confirmed that the pharmacy had never dispensed the Ozempic to the facility, and the DON could not provide additional information about the missing medication. Further review of the clinical record revealed no documentation that the physician was notified about the unavailability of the medication or that any follow-up actions were taken. The Nursing Home Administrator stated that staff are expected to follow up with the pharmacy and physician when medications are not available, but this was not documented in the resident's record.
Neglect Resulting in Harm Due to Improper Fluid Consistency Provided by Volunteer
Penalty
Summary
The facility failed to protect a resident from neglect when a volunteer provided a drink of thin liquid to a resident with physician orders for nectar thickened fluids. The resident, who had diagnoses including dysphagia, dementia, and muscle weakness, was in the activity room when the volunteer, without consulting nursing staff, gave the resident a thin liquid beverage. Facility policy and volunteer guidelines specifically instructed that volunteers should not provide food or drink to residents without first asking the resident's nurse, and that pre-thickened liquids should be provided per physician orders. As a result of receiving the incorrect liquid consistency, the resident began coughing and subsequently developed bilateral lobe pneumonia with a small left-sided effusion, as confirmed by a chest X-ray. The incident was documented in the clinical record and facility investigation, with staff interviews confirming that the volunteer did not follow established protocols regarding dietary restrictions and fluid consistencies for residents with swallowing difficulties.
Failure to Provide Prescribed Fluid Consistencies Results in Resident Harm
Penalty
Summary
The facility failed to ensure that residents with physician-ordered thickened liquids received drinks in the appropriate consistency, resulting in actual harm to one resident. One resident with diagnoses including dysphagia, dementia, and muscle weakness had a physician order for nectar thickened fluids. Despite this, the resident was given a thin liquid drink by a volunteer during an activity, which led to the resident coughing immediately after ingestion. The incident was documented in the clinical record and confirmed by the volunteer, who admitted to providing the thin liquid without thickening it first. A subsequent chest x-ray revealed the resident developed bilateral lobe pneumonia with a small left-sided effusion, and the resident required antibiotic treatment. Another resident, also diagnosed with dysphagia, dementia, and muscle weakness, had a physician order for nectar thickened liquids and no straws. However, observation revealed a Styrofoam cup with a straw containing thin liquid water at the resident's bedside. The nurse aide responsible for passing the water was unaware of the thickened liquid order and confirmed that the resident was dependent on staff for drinking. The speech language pathologist also confirmed that the resident should be receiving nectar thickened liquids per the current order. Facility policy required that pre-thickened liquids be provided per physician orders and that volunteers not provide food or drink to residents without consulting nursing staff. Despite these policies, both a volunteer and a nurse aide failed to follow the prescribed fluid consistencies for residents with dysphagia, resulting in one resident suffering actual harm and another being placed at risk.
Failure to Provide Appropriate Meal Textures
Penalty
Summary
Oak Hill Center for Rehabilitation and Nursing failed to meet the requirements for providing meals in a form designed to meet individual needs, specifically for residents requiring mechanical soft and pureed diets. On April 22, 2025, during lunch service, the facility served a mechanical soft meal that did not adhere to the planned menu textures. The chicken enchilada casserole was served with a whole flour tortilla instead of being chopped, and the black beans were served whole rather than ground. This was confirmed by the Nursing Home Administrator during a staff interview. Additionally, a resident with diagnoses including diabetes type II and essential hypertension was affected by this deficiency. The resident had been downgraded to a pureed diet due to difficulty swallowing, as noted by a speech therapist. However, the resident was served a mechanical soft diet instead of the required pureed diet. The dietary slip used during meal tray-line service was outdated and incorrectly listed the resident's diet, leading to the resident receiving the wrong meal texture. The error was identified and corrected during the meal service, but it highlighted a failure in communication and adherence to dietary orders.
Plan Of Correction
1) Facility cannot retroactively correct. Updated diet tickets were immediately printed for current residents. 2) Director of Nursing/Dietary Manager/Designee conducted an audit of current residents' diet orders to ensure they were accurate on newly printed diet slips and to ensure that no other residents received an inaccurate diet. No other concerns were identified. 3) NHA/Designee reeducated the dietary manager and dietary staff on the components of this regulation with an emphasis on ensuring that dietary tickets are printed daily so that they may accurately reflect the residents' most recent diet order. 4) NHA/Designee will conduct random audits of 5 residents' meal trays and tray tickets 3x a week x 4 weeks, then once a week x 2 months to ensure that tickets have been printed daily, and that residents have received the correct physician-ordered meal. The findings of these audits will be brought to the QAPI committee monthly or until substantial compliance is met and maintained. Auditing schedule to be modified if needed.
Failure to Meet Required Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) staffing ratios on multiple occasions, as evidenced by a review of staffing documents and staff interviews. Specifically, the facility did not maintain the minimum required NA-to-resident ratios on the day shift for four out of seven days reviewed, on the evening shift for two out of seven days, and on the night shift for one out of seven days. The specific dates of non-compliance were December 29, 2024, January 2, 3, and 4, 2025, for the day shift; December 31, 2024, and January 3, 2025, for the evening shift; and January 1, 2025, for the night shift. The facility's census and staffing ratio information revealed that on these dates, the NA ratios were below the required levels. For instance, on December 29, 2024, the day shift had a NA ratio of 12.0 instead of the required 12.30 for 123 residents. Similarly, on January 1, 2025, the night shift had a NA ratio of 7.0 instead of the required 8.47 for 127 residents. The Nursing Home Administrator confirmed the accuracy of the staffing information and acknowledged the facility's failure to meet the required NA ratios during an interview on January 9, 2025.
Plan Of Correction
1) Facility cannot retroactively correct. 2) NHA/designee will review CNA staffing ratios for the last 4 weeks to ensure compliance and adherence to regulation. 3) NHA/Designee will re-educate staff scheduler and DON on regulation of CNA staffing ratios to ensure ongoing compliance. Facility will conduct daily staffing meeting to review CNA ratios to ensure ongoing compliance and systematic change. Facility will educate nursing staff on call off policy and hold weekly meeting to review call offs and enforce disciplinary action per call off policy. 4) NHA/Designee will conduct audit of projected CNA ratios 3 x a week x 4 weeks and once a month x 2 months to ensure compliance with regulation. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until substantial compliance is met.
Failure to Meet LPN Staffing Ratios
Penalty
Summary
The facility failed to meet the required minimum staffing ratios for Licensed Practical Nurses (LPNs) on specific shifts. On December 31, 2024, during the evening shift, the facility had a census of 127 residents but only maintained an LPN ratio of 4.0, falling short of the required 4.23. Additionally, on the same date and the night shift of January 1, 2025, the facility had the same census of 127 residents but only maintained an LPN ratio of 3.0, below the required 3.18. These deficiencies were confirmed by the Nursing Home Administrator during an interview on January 9, 2025, who acknowledged the accuracy of the staffing information and the failure to meet the required LPN ratios on the specified shifts.
Plan Of Correction
1) Facility cannot retroactively correct. 2) NHA/designee will review LPN staffing ratios for the last 4 weeks to ensure compliance and adherence to regulation. 3) NHA/Designee will re-educate staff scheduler and DON on regulation of LPN staffing ratios to ensure ongoing compliance. Facility will conduct daily staffing meeting to review LPN ratios to ensure ongoing compliance and systematic change. Facility will educate nursing staff on call off policy and hold weekly meeting to review call offs and enforce disciplinary action per call off policy. 4) NHA/Designee will conduct audit of projected LPN ratios 3 x a week x 4 weeks and once a month x 2 months to ensure compliance with regulation. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until substantial compliance is met.
Deficiency in Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident in a 24-hour period. This deficiency was identified during a review of staffing documents and confirmed through staff interviews. Specifically, on January 1, 2025, the facility provided only 3.18 hours of direct care per resident, 3.17 hours on January 2, 2025, and 3.18 hours on January 3, 2025. The Nursing Home Administrator confirmed the accuracy of the staffing information during an interview on January 9, 2025.
Plan Of Correction
1) Facility cannot retroactively correct. 2) NHA/designee will review PPDs for the last 4 weeks to ensure compliance and adherence to regulation. 3) NHA/Designee will re-educate staff scheduler and DON on regulation of PPD to ensure ongoing compliance. Facility will conduct daily staffing meeting to review PPDs to ensure ongoing compliance and systematic change. Facility will educate nursing staff on call off policy and hold weekly meeting to review call offs and enforce disciplinary action per call off policy. 4) NHA/Designee will conduct audit of projected PPDs 3 x a week x 4 weeks and once a month x 2 months to ensure compliance with regulation. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until substantial compliance is met.
Failure to Include Residents in Care Planning Process
Penalty
Summary
The facility failed to ensure that residents were included and provided the right to participate in the person-centered care planning process. This deficiency was identified for two residents, Resident 25 and Resident 31, during a review of 32 residents. The facility's New Admission Introduction & Handbook states that care plans are created for each resident upon admission and reviewed quarterly, with an expectation that residents will be invited to participate in care plan meetings routinely. However, interviews with both residents revealed that they did not recall being invited to their recent quarterly care plan meetings. Resident 25, who has diagnoses including muscle weakness and chronic kidney disease, and Resident 31, who has diagnoses including anemia and pain, both lacked documentation in their clinical records regarding their invitation and participation in care plan meetings. An interview with the Director of Social Services confirmed that there was no process in place to ensure residents were invited to participate in their care plan meetings, despite the expectation that all residents who can participate should be invited.
Failure to Provide SNF-ABN Forms to Residents
Penalty
Summary
The facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice of non-coverage (SNF-ABN) form to two residents, which is necessary to inform them of items and services no longer deemed eligible for coverage under Medicare A. For Resident 2, the clinical record indicated that the last covered day of Medicare A services was September 1, 2024, yet the facility did not offer the SNF-ABN form as the resident planned to remain in the skilled nursing facility and receive skilled services. Similarly, for Resident 108, the clinical record showed the last covered day of Medicare A services was August 9, 2024, and the facility again failed to provide the SNF-ABN form as the resident intended to continue receiving skilled services in the facility. An interview with the Nursing Home Administrator confirmed the facility's acknowledgment of providing the incorrect document, which will be corrected going forward. This deficiency was identified under the regulation 28 Pa. Code 201.14 (a) Responsibility of licensee.
Inaccurate Resident Assessments and Documentation Errors
Penalty
Summary
The facility failed to ensure accurate resident assessments for four residents, leading to deficiencies in the documentation of significant weight loss and medication management. Resident 33, diagnosed with Parkinson's Disease and moderate protein-calorie malnutrition, experienced significant weight loss over several months. However, the Minimum Data Set (MDS) assessments conducted in August and November 2024 did not reflect this weight loss, as confirmed by the Registered Dietician and acknowledged by the Nursing Home Administrator (NHA). Resident 37, with diagnoses including dementia and major depressive disorder, had a recommendation for a gradual dose reduction (GDR) of Quetiapine, which was not documented in the MDS assessment. The NHA revealed that the Registered Nurse Assessment Coordinator inaccurately coded the MDS assessment due to a delay in scanning the consult into the electronic health record. Similarly, Resident 46, diagnosed with dementia and anxiety disorder, had a physician's order for a GDR of Seroquel, which was not reflected in the October 2024 MDS assessment. Resident 67, diagnosed with dementia, hypertension, and dysphagia, was assessed to be at risk for severe protein-calorie malnutrition. However, the MDS assessment in September 2024 did not indicate this risk, despite a care plan focus on malnutrition and dehydration. The Regional Director of Clinical Services confirmed that the MDS assessment should have marked the resident as at risk for malnutrition, a point acknowledged by the NHA.
Deficient Wound Care Practices for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary treatment and services for residents with pressure ulcers, as evidenced by the care provided to two residents. Resident 64, who had severe protein calorie malnutrition and a stage 4 pressure ulcer, did not receive updated wound care orders in a timely manner. The Director of Nursing acknowledged that the new order recommendation from October 11, 2024, should have been updated by October 12, 2024, but the nurse failed to include the +Ag (silver) in the order. This oversight resulted in the resident not receiving the appropriate wound care treatment as recommended by the wound care consult. Resident 84, diagnosed with paraplegia and a recurring stage 4 sacral pressure ulcer, also experienced deficiencies in wound care. During a wound care observation, the wound nurse did not perform hand hygiene before, during, or after the procedure, and did not wear a gown despite the resident being on enhanced barrier precautions. Additionally, the soiled dressing was not dated, and collagen with silver was applied without an order. The Nursing Home Administrator confirmed these lapses in protocol, indicating a failure to adhere to professional standards of practice in wound care management.
Failure to Provide Mobility Assistance and Document Care
Penalty
Summary
The facility failed to provide appropriate services and assistance to maintain or improve mobility for two residents with limited mobility. Resident 37, who has a contracture of the left hand and is dependent on a wheelchair, had physician orders for a splint and active range of motion (ROM) exercises. However, documentation revealed that these interventions were frequently marked as not applicable or left blank over several months, indicating a lack of consistent implementation of the prescribed care. The Nursing Home Administrator acknowledged that refusals should be documented and evaluated for tolerance, but this was not reflected in the records. Resident 55, diagnosed with hemiplegia and hemiparesis following a cerebral infarction, reported difficulty in receiving assistance for daily ambulation with a walker, as prescribed. The resident's care guide indicated a requirement for ambulation to and from the dining room, but there was no documented evidence that this program was being carried out. The Nursing Home Administrator noted that the task was not entered correctly for documentation, which led to a lack of recorded evidence of the ambulation assistance being provided.
Deficiencies in Enteral Feeding Care for Residents
Penalty
Summary
The facility failed to ensure that a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications. For Resident 53, who has diagnoses of hemiplegia, hemiparesis, and dysphagia, the clinical record revealed an order for bolus feeding via a gastrostomy tube five times daily. However, there were no orders for G-tube site monitoring and care or syringe changes, which are necessary to prevent complications such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. During an interview, the Nursing Home Administrator, Director of Nursing, and Employee 1 acknowledged that orders should have been in place for these aspects of care. Similarly, for Resident 67, who has a gastrostomy with PEG tube, dementia, and dysphagia, the physician orders indicated that the PEG tube syringe was to be changed weekly, which was insufficient. The resident receives bolus enteral feedings five times a day via an open system. The Director of Nursing later revealed that the order for syringe changes should have been daily, not weekly, indicating a lapse in ensuring proper care and monitoring for residents with feeding tubes.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to complete timely trauma assessments and develop individualized care plans for trauma-informed care for two residents diagnosed with PTSD. Resident 10's clinical record showed a diagnosis of PTSD and traumatic brain injury, but there was no evidence of trauma-informed care assessments or follow-up care related to the PTSD diagnosis. The care plan for Resident 10 included a focus area for PTSD but lacked details on the source of PTSD or known triggers. Interviews with facility staff, including the Nursing Home Administrator and Director of Nursing, confirmed that no trauma assessment had been completed for Resident 10. Resident 105, who also had a PTSD diagnosis, expressed a desire to continue therapy sessions with a VA counselor. Her clinical records, however, did not reflect a PTSD diagnosis or any personalized interventions to prevent re-traumatization. Despite her request for continued counseling and her identification of specific triggers, such as the sounds of gunfire and being approached from behind, these were not documented in her care plan. The Director of Nursing was unable to find any information regarding Resident 105's PTSD diagnosis in her clinical records, although the VA confirmed her past services for PTSD. The Nursing Home Administrator acknowledged that social services should have conducted an initial trauma assessment and included this information in the resident's care plan.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to properly assess and obtain informed consent for the use of enabler bars/side rails for two residents, leading to a deficiency. For Resident 84, who has paraplegia and morbid obesity, bilateral side rails were observed attached to the bed without any documentation of a signed consent or a review of the risks and benefits with the resident or their representative. The Bed Rail Safety and Informed Consent Form for this resident was not signed until the day after the observation. Similarly, for Resident 105, who has COPD and CHF, an enabler rail was observed on the left side of the bed. Although the initial evaluation indicated that side rails were not necessary, a physician's order for a side rail was effective the same day. However, there was no additional evidence of an assessment to determine the appropriateness and safety of the enabler rail for this resident. The Bed Rail Safety and Informed Consent Form for Resident 105 was also not signed until the day after the observation. The Nursing Home Administrator confirmed the lack of timely consent and assessment for both residents.
Improper Storage of Medications in Resident Rooms
Penalty
Summary
The facility failed to ensure that prescription medications and treatments were stored in locked compartments and only accessible by authorized personnel for three residents. Resident 2 had a medication cup with a powder substance at the bedside, which was used for a rash but was not authorized for self-administration. The Assistant Director of Nursing confirmed that the powder should not have been stored at the bedside, and the Director of Nursing reiterated that Resident 2 had no orders for self-administration. Resident 80 had a tube of Nystatin-Triamcinolone cream and a bottle of Nystatin powder left in a wash basin on the bed, despite the cream being discontinued earlier. The resident did not self-administer these medications, and the Director of Nursing confirmed they should have been stored in the treatment or medication cart. Resident 84 had a medication cup with Triad cream at the bedside, which was left there for staff convenience, despite the resident having no self-administration orders. The Director of Nursing confirmed that the cream should not have been left at the bedside.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) appropriately, as observed during a tour of the nursing units. EBP signage was present on the doors of three residents, but there was no personal protective equipment (PPE) storage bin located outside of the rooms or on a door hanger. Employee 14, a nurse aide, was observed at the bedside of a resident with open wounds, bagging soiled linen without wearing a gown. This indicates a lack of adherence to the facility's policy on EBP, which requires the use of gowns and gloves during high-contact resident care activities. Interviews with staff revealed a lack of understanding and implementation of EBP. Employee 14 and Employee 13, an LPN, could only provide a reason for EBP for one resident, who had open wounds. The Infection Control Professional confirmed that PPE should have been available and used, and subsequently removed the EBP signage from the doors of two residents for whom EBP did not apply. The Nursing Home Administrator and Director of Nursing acknowledged that only residents on EBP should have signage, and that staff should be aware of the reasons for EBP and use appropriate PPE.
Failure to Inspect Side Rails for Entrapment Risks
Penalty
Summary
The facility failed to conduct regular inspections of side rails/enabler bars to identify areas of possible entrapment for two residents. For Resident 43, who has diagnoses including abnormalities of gait and hypertension, bilateral enabler bars were installed on the bed. However, the safety measurements for these rails were not documented until five days after installation. This delay in documentation indicates a lapse in the facility's adherence to its policy on the proper use of side rails, which requires assessment of the space between the mattress and side rails to reduce entrapment risk. Similarly, for Resident 105, who has chronic obstructive pulmonary disease and congestive heart failure, a side rail was installed on the left side of the bed. Despite an order for this installation being effective for nearly two months, there was no evidence of any inspection or measurement of the side rail to identify possible entrapment areas. The Nursing Home Administrator confirmed the absence of documentation for these inspections, further highlighting the facility's failure to comply with safety protocols for side rail usage.
Medication Administration and Wound Care Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of practice in medication administration for two residents. For one resident with dry eye syndrome, the facility did not include the prescribed eye drops in the resident's medication orders, despite a consultation indicating the need for Systane ophthalmic solution. The resident expressed concern about not receiving the eye drops, and it was confirmed by the Director of Nursing that the medication was not added to the orders until a later date. For another resident with paraplegia and a stage 4 sacral pressure ulcer, the facility did not follow the physician's order for negative pressure wound therapy (NPWT). During an observation, a Licensed Practical Nurse applied collagen with silver to the wound without a physician's order. Additionally, the NPWT was not initiated on the date specified by the wound care specialist, and no explanation was provided for the delay. The Nursing Home Administrator confirmed that there should have been a physician's order for the use of collagen with silver.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for a resident who was reviewed for respiratory care. The resident, who has diagnoses including bipolar disorder and hypertension, was observed using oxygen at 4 liters per minute, despite a physician's order for oxygen at 2 liters per minute. The resident's care plan indicated an intervention of oxygen via nasal prongs at 2 liters as ordered, but observations on two separate occasions revealed the resident using oxygen at a higher rate. Additionally, the facility did not document the maintenance of the resident's oxygen equipment as required. The resident's clinical record showed a new order to change the humidifier bottle, clean the oxygen concentrator filter, and change the oxygen tubing, all starting on a specific date. However, the treatment administration records for October and November failed to show that these tasks were completed prior to the specified date. An interview with the Director of Nursing revealed that the resident should have a titrate oxygen order, with a baseline of 2 liters per minute, increasing to 4 liters per minute during activities.
Deficiency in Dialysis Care and Documentation
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for a resident with End Stage Renal Disease (ESRD), hypertension, and diabetes mellitus. The resident's care plan included an intervention to avoid drawing blood or taking blood pressure in the arm with the dialysis graft. However, blood pressure was repeatedly documented in the resident's left arm, which had the dialysis access, on multiple occasions. Additionally, there was a missing communication sheet for dialysis on a specific date, and the resident's dialysis order was not entered in a timely manner upon admission. Furthermore, the facility did not weigh the resident prior to dialysis on several occasions, as required by the resident's care plan. The resident had been attending dialysis sessions three times a week since admission, but the dialysis order was only entered two weeks later. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed these deficiencies, acknowledging the lack of timely documentation and incorrect recording of blood pressure measurements.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to provide or obtain necessary dental services for a resident with dental concerns. The resident, who has congestive heart failure and a vitamin deficiency, expressed concern about the lack of routine dental care, despite having her own teeth and being accustomed to maintaining them. A dental consult form from December 1, 2023, recommended a dental cleaning and checkup in six months, but there was no evidence in the resident's clinical record of any additional dental services being received since that date. The Nursing Home Administrator acknowledged that the dental provider is responsible for tracking and scheduling follow-up appointments, but also noted the need for the facility to implement a system to track these appointments.
Failure to Implement Proper Care Leads to Resident Harm
Penalty
Summary
The facility failed to implement treatment and care in accordance with professional standards of practice, resulting in actual harm to a resident who developed a urinary tract infection and septic shock. The resident, who had a history of urinary tract infections and other medical conditions, had orders for foley catheter care every shift. However, the Treatment Administration Record (TAR) showed that catheter care was not completed on several occasions. Additionally, a urinalysis ordered stat was delayed, and the specimen was contaminated, leading to a lack of timely and appropriate treatment. The resident's antibiotic medication, Doxycycline, was not administered as ordered due to unavailability in the facility's backup supply, and there was no documentation of physician notification for the missed dose. The delay in obtaining the urine specimen and administering the antibiotic contributed to the resident's deteriorating condition, as evidenced by elevated white blood cell counts and subsequent hospitalization for septic shock. The resident's condition worsened, with symptoms including decreased responsiveness, low blood pressure, and increased respiratory rate, leading to emergency medical intervention. Further deficiencies were noted in the facility's failure to document wound treatments and obtain weekly weight measures as ordered. The lack of documentation and adherence to physician orders for wound care and weight monitoring further exemplified the facility's failure to provide comprehensive care. Interviews with the Director of Nursing and Nursing Home Administrator revealed awareness of these issues, but the deficiencies resulted in significant harm to the resident, necessitating hospitalization.
Failure to Adhere to Care Plans for Two Residents
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for two residents, leading to deficiencies in meeting their physical needs. Resident 3, diagnosed with heart failure and hypertension, was admitted to the facility and had physician orders for twice-weekly showers and weekly weights for four weeks. However, the resident only received one shower and was weighed only once during the specified period, contrary to the orders. The Director of Nursing confirmed the discrepancies, attributing the missed showers to an incorrect entry of the bath/shower order. Resident 10, diagnosed with heart failure and dementia, also experienced a deficiency in care. The resident had orders for weekly weights for four weeks following admission. Despite this, the resident was weighed only twice, once on the admission date and once several weeks later. The Director of Nursing and the Nursing Home Administrator both acknowledged that the resident should have been weighed weekly as per the physician's orders. These failures indicate a lack of adherence to the prescribed care plans for both residents.
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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