Oak Ridge Rehabilitation & Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Taylor, Pennsylvania.
- Location
- 500 West Hospital Street, Taylor, Pennsylvania 18517
- CMS Provider Number
- 395564
- Inspections on file
- 43
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Oak Ridge Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
Staff failed to consistently follow care-planned fall-prevention interventions for three residents. One resident with a history of intracerebral hemorrhage and left-sided weakness had a care plan requiring bilateral fall mats while in bed, but one mat was folded and stored between equipment instead of on the floor. Another resident with dementia and chronic respiratory failure had a care plan requiring a bathroom door alarm and accessible call light, yet observations showed the bathroom door open with the alarm off and the call light placed behind the resident, out of reach, on two occasions. A third resident with a femur fracture and muscle weakness had a care plan requiring the call light within reach, but it was attached to the opposite side of the bed and not accessible. Nursing staff and leadership acknowledged that these fall-prevention interventions were not implemented as care planned.
A resident with post-polio syndrome and malignant neoplasm of the major salivary gland, who was cognitively intact per BIMS, was not afforded the right to participate in a required quarterly person-centered care plan conference. A care plan meeting was scheduled with the resident and the resident’s daughter, but the daughter requested to reschedule on the day of the meeting. Social Services left a voicemail offering alternative dates and times, yet there was no further documented follow-up, no rescheduled conference, and no evidence that the care plan meeting was conducted with the resident alone. The NHA and DON confirmed there was no documentation that the quarterly care plan conference was completed for this resident.
A resident with severe cognitive impairment and an elopement risk was left unattended at an outside medical appointment by a nurse aide, resulting in the resident attempting to leave the facility unsupervised. The incident was reported verbally to an LPN and documented, but was not escalated to administration or investigated according to policy, and the administration only became aware of the event during a survey.
The facility did not provide two residents with the required written notice and explanation of Medicare coverage termination, including information about the SNF-ABN and the right to appeal, prior to ending Medicare Part A services. One resident's responsible party was not contacted or informed, and another resident with moderate cognitive impairment signed the form without receiving an explanation or being told about appeal rights.
Two residents with significant medical and mobility issues experienced falls related to toileting, and the facility failed to implement or document required three-day bowel and bladder assessments as outlined in their care plans. Despite planned interventions for fall prevention and toileting support, the care plans were not revised in a timely manner to reflect post-fall needs, and the necessary assessments were not completed, as confirmed by the DON.
The facility did not follow its abuse prohibition policy by failing to obtain required references from previous employers for two newly hired staff members, as confirmed by a review of personnel files and administrator interview.
A resident with Alzheimer's dementia and hyperlipidemia experienced a significant decline and began hospice care, but the facility did not complete the required significant change MDS assessment to document this change, as confirmed by the DON.
A nurse administered Novolog insulin to a resident with diabetes when the resident's blood glucose did not meet the sliding scale criteria, and failed to provide the ordered Basaglar insulin, which was not available on the medication cart. The nurse also documented administration of Basaglar when only Novolog was given, and admitted to not verifying the medication type against physician orders. The DON confirmed these failures to follow professional standards.
A resident with osteoarthritis and intact cognition received PRN opioid pain medication for moderate to severe pain on multiple occasions without documented attempts of non-pharmacological interventions, contrary to facility policy. The DON confirmed that no evidence existed of alternative pain management strategies being tried before administering the opioid.
A resident with severe dementia exhibited increased behavioral symptoms, including anxiety and restlessness, but the facility did not update the care plan to include individualized, person-centered interventions or non-pharmacological approaches based on the resident's preferences and history.
A registered nurse administered expired Novolog insulin to a resident with diabetes and parkinsonism, failing to verify the medication label and disregarding physician orders. The nurse documented giving Basaglar insulin but actually gave Novolog, which was not indicated by the resident's blood glucose level at the time. The DON confirmed the nurse did not follow proper procedures, resulting in a significant medication error.
The facility failed to maintain sanitary food storage and service practices, leading to potential contamination. Observations revealed unsanitary conditions, such as juice dispensing guns in contact with bulk juice boxes, uncovered dishware, and flies in the dish room. Additionally, food particles and debris were found in dining areas, and chocolate shakes were not dated. The NHA confirmed these deficiencies.
The facility did not have the Medical Director or a designated physician present at the QAPI Committee meetings for four consecutive months. This was confirmed through sign-in sheets and an interview with the administrator, highlighting a failure to meet regulatory requirements for physician attendance.
The facility failed to maintain an effective pest control program, as evidenced by observations of flies in the kitchen and dead bugs in the dining area. A resident reported frequent insect sightings, and the maintenance director confirmed a lack of documented pest treatments and unaddressed pest control recommendations.
The facility failed to maintain a clean environment on the third floor dementia unit. Observations revealed sticky, dirty floors with dried liquid stains in the dining room and resident rooms. A strong urine odor was noted from a resident's mattress, and a room had a broken floor tile and damaged, soiled walls. The interim Nursing Home Administrator confirmed that these areas should be kept clean and sanitary.
The facility failed to resolve grievances from two residents, one regarding dietary preferences and the other about delayed call bell response, leading to a deficiency in grievance handling. A resident with gastroesophageal reflux disease was not consulted about her dietary preferences despite a grievance filed, while another resident with irritable bowel syndrome experienced prolonged incontinence due to staff's delayed response to her call bell. The facility lacked documentation of efforts to address these grievances.
A facility failed to implement individualized measures for a resident with declining continence, despite policy requirements. The resident, with diagnoses including congestive heart failure and dysphasia, was identified as incontinent. The care plan included evaluating urination patterns and assisting with toileting, but no retraining program was in place. The resident developed a stage 2 pressure ulcer, and the facility lacked evidence of interventions to address the decline in continence.
The facility failed to provide timely behavioral health services to two residents, one with adjustment disorder and major depressive disorder, and another with schizoaffective disorder. The first resident did not receive psychiatric services since February, despite expressing dissatisfaction with previous telehealth sessions and ongoing mental health struggles. The second resident, requiring specialized mental health services, experienced a significant delay in receiving psychological follow-up, contrary to recommendations.
The facility failed to attempt a gradual dose reduction (GDR) of psychoactive medications for two residents. One resident was on Trazadone and Lexapro, and the other on Depakote, Olanzapine, and Escitalopram Oxalate. Despite pharmacist recommendations for GDR, the physician disagreed without providing clinical rationale, and the facility lacked documentation to support continued dosages or GDR attempts.
The facility failed to comply with pharmacy supplies expiration and labeling policies on two resident units. Expired and improperly labeled items were found, including Foley catheter devices, povidone/iodine swabs, needles, and wound dressings. Opened items lacked dates, and the medication refrigerator was improperly maintained. An LPN confirmed these findings, and the NHA and DON acknowledged the issues.
The facility did not routinely offer evening snacks to residents, resulting in a 15-hour gap between dinner and breakfast. Residents reported receiving snacks only upon request, and there was no evidence of snacks being offered to those on the Dementia unit. The administrator could not provide documentation of routine snack offerings.
The facility failed to update its facility-wide assessment to address the needs of its Dementia/Memory care unit, affecting 61 residents with Dementia/Alzheimer's and 43 residents on a locked unit. Previous surveys had identified deficiencies in dementia care and behavioral health services, including resident-to-resident abuse. The facility did not ensure necessary staff resources to meet licensure and certification standards.
The facility failed to maintain dignity and privacy for two residents. One resident with dementia was left without window coverings, compromising privacy, while another was left incontinent for 15 hours after a delayed response to a call bell. The latter also experienced anxiety from being manhandled during transfers. Interviews confirmed the facility's failure to treat residents with dignity and respect.
A resident with a history of aggressive behavior physically abused another resident in the Dementia Unit Dayroom. Despite staff attempts to manage the aggressor's escalating behaviors, the incident occurred, resulting in the victim being pulled to the ground by her hair. The facility was aware of the aggressor's history but failed to prevent the altercation, highlighting a deficiency in ensuring resident safety.
A facility failed to implement its abuse policy and conduct a thorough assessment after a resident-to-resident altercation. Resident 60 pulled Resident 85 by her hair, causing her to fall. The RN's assessment of Resident 85 was inadequate, lacking comprehensive documentation as required by the facility's policy. The Director of Nursing confirmed the failure to document a complete assessment.
A registered nurse failed to administer scheduled medications to five residents, signing the MAR as if they had been given. The facility did not conduct a thorough investigation into this potential neglect, as required by their policy, and there was no documentation in the residents' records about the missed medications.
A facility failed to include necessary interventions in a resident's care plan to monitor respiratory status and oxygen use. The resident, with shortness of breath and cognitive impairment, frequently turned off the oxygen concentrator, but staff did not ensure continuous oxygen delivery. The care plan lacked specific actions for monitoring oxygen saturation or guidelines for staff intervention.
A resident with a history of stroke and severe cognitive impairment had a physician's order for oxygen therapy at 2 L/min. However, observations revealed the oxygen concentrator was set to 3 L/min, not following the prescribed order. This was confirmed by an LPN and acknowledged by the NHA and DON, indicating a deficiency in nursing services.
A facility failed to provide person-centered care for a resident with ESRD requiring hemodialysis. The care plan did not include the resident's specific schedule preferences or provisions for transportation and meal accommodations related to the dialysis schedule. The DON confirmed the care plan's inadequacy in addressing these needs, resulting in a deficiency.
The facility failed to maintain accurate clinical records for two residents. One resident had an undocumented skin injury, while another had a boil with no documented healing progress. The DON confirmed the lack of documentation for both cases.
A facility failed to provide a working call system for a severely cognitively impaired resident. During an observation, it was found that there was no call bell connected or available in the resident's room, and no alternative method for summoning assistance was present. Interviews with an LPN and the Nursing Home Administrator confirmed that call bells should be accessible at each resident's bedside.
The facility did not implement procedures to ensure safe smoking for a resident with COPD, despite having a non-smoking policy. The resident was allowed to smoke without a care plan or revised smoking policy, as confirmed by the Nursing Home Administrator and DON during a survey.
The facility failed to protect residents from being disenrolled from Medicare health plans without informed consent. Residents were disenrolled without proper documentation of their requests or understanding of the implications, and cognitive assessments were not conducted prior to signing disenrollment forms. The facility lacked policies and procedures for assisting residents with health plan changes.
The facility failed to implement individualized care plans for two residents with dementia, leading to repeated falls and inappropriate behaviors. Despite having care plans, interventions were not effectively applied, resulting in safety concerns and incidents. The facility did not adequately address specific behaviors or provide necessary diversional activities.
The facility's QAPI committee failed to correct deficiencies related to abuse and dementia care. A resident exhibited inappropriate behavior towards cognitively impaired residents, and another resident experienced multiple falls due to unmanaged dementia-related behaviors. The facility did not revise care plans or implement effective interventions, leading to repeated issues.
A resident with severe cognitive impairment was not protected from sexual abuse by another resident, also cognitively impaired, in an LTC facility. The facility's policy to protect residents lacking capacity to consent was not followed, as evidenced by incidents of physical affection between the two residents. The care plan for the resident exhibiting these behaviors did not address or prevent such incidents, leading to a substantiated case of abuse.
A facility failed to justify the increase of an antipsychotic medication for a resident with dementia and Parkinsonism. After the resident became verbally aggressive, the dosage of Quetiapine Fumarate was increased without documented clinical rationale or evidence of considering less restrictive alternatives. The facility did not address potential underlying causes of the behavior, as confirmed by the DON.
Failure to Implement Care-Planned Fall-Prevention Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to consistently implement person-centered fall-prevention care plan interventions for three residents. For a resident with nontraumatic intracerebral hemorrhage and left-sided hemiplegia/hemiparesis, the comprehensive care plan dated March 14, 2024, required bilateral fall mats to be placed on the floor next to the bed while the resident was in bed. During observation, the resident was in bed and the left fall mat was folded in half and propped between the PTAC unit and the wheelchair, rather than positioned on the floor as directed. A registered nurse confirmed that the fall mats were a fall-prevention intervention and acknowledged that the left mat was not in place as required by the care plan. A second resident, admitted with dementia and chronic respiratory failure, had a care plan dated December 29, 2025, identifying fall risk related to weakness, unsteady gait, and urinary incontinence, with interventions including use of a bathroom door alarm and maintaining the call light within reach. On two separate observations, the resident was seated alone in a wheelchair next to the bed with the bathroom door open, the bathroom door alarm not sounding, and the call light draped over a bedside chair behind the resident, out of reach. A third resident, admitted with a right femur fracture and muscle weakness, had a care plan dated March 30, 2026, that included keeping the call light within reach due to decreased strength, decreased endurance, and a history of falls. Observation showed this resident seated in a wheelchair on the left side of the bed while the call light was attached to the right side of the bed near the pillow, not within reach. A nurse aide confirmed the call light was not accessible, and the Nursing Home Administrator and Director of Nursing later acknowledged that staff failed to consistently implement the fall-prevention interventions identified in the care plans for these three residents.
Failure to Conduct Required Quarterly Care Plan Conference With Cognitively Intact Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a cognitively intact resident was afforded the right to participate in the development and implementation of a person-centered plan of care, including completion of a required quarterly care plan conference. Facility policy required the interdisciplinary team, in conjunction with the resident and the resident’s family or legal representative, to develop and review a comprehensive care plan at least quarterly with the MDS assessment and after significant changes. The resident involved was admitted with post-polio syndrome and malignant neoplasm of the major salivary gland and had a BIMS score of 15, indicating intact cognition and ability to participate in care planning. A quarterly care plan conference was scheduled with the resident and the resident’s daughter for a specific date and time, but on the day of the meeting the daughter requested that it be rescheduled. Social Services documented leaving a voicemail for the daughter offering alternative dates and times, but there was no further documented follow-up, no evidence that the meeting was rescheduled, and no evidence that the care plan conference was conducted with the resident alone despite the resident’s ability to participate. During interviews, the Social Services Director, Nursing Home Administrator, and DON confirmed that no additional attempts were made to contact the daughter and that there was no documentation that a quarterly care plan conference had been completed for this resident, resulting in the failure to provide the resident the right to participate in the care planning process.
Failure to Investigate Resident Neglect After Unattended Medical Appointment
Penalty
Summary
The facility failed to thoroughly investigate an incident in which a resident with severe cognitive impairment and a known risk for elopement was left unattended during an outside medical appointment. The resident, who had a diagnosis of dementia and heart failure, was accompanied to a cardiology appointment by a nurse aide. After the appointment, the nurse aide left the resident alone in a lobby area while she used the restroom. During this time, the resident was observed by a transportation driver and another individual attempting to leave the facility, and was stopped outside by a driver who questioned her about her caregiver's whereabouts. Upon returning to the facility, the nurse aide verbally reported the incident to an LPN, who provided immediate education to the aide and wrote a witness statement, which was then given to an RN Supervisor. However, the RN Supervisor did not report the incident to the Nursing Home Administrator or the Director of Nursing, believing the information to be a rumor. The transportation driver, who also witnessed the incident, informed the RN Supervisor but did not escalate the report to facility administration. As a result, the facility did not follow its written abuse policy, which requires immediate reporting and investigation of any allegations of abuse or neglect. The administration was not made aware of the incident until it was discovered during a survey investigation. No immediate investigation was initiated, and statements from all involved parties were not collected as required by policy and federal regulations.
Failure to Provide Required Medicare Coverage Termination Notices and Appeal Rights
Penalty
Summary
The facility failed to provide required written notice of Medicare coverage termination, including an explanation of the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) and the right to appeal, to residents and/or their representatives prior to the end of Medicare Part A services. For one resident with Parkinson's disease, muscle weakness, and diabetes, the clinical record showed that the SNF-ABN form was completed and the responsible party's information was documented, but there was no evidence that the resident or her responsible party received the notice, reviewed the form, or were informed of the opportunity to appeal. The resident's daughter confirmed during an interview that she was not contacted regarding the SNF-ABN and was not advised of the right to appeal. For another resident with Parkinson's disease and a history of falls, who had moderate cognitive impairment, the SNF-ABN form was signed by the resident, and the social worker documented no appeal. However, there was no evidence that the resident was provided with an explanation of the form or informed of the right to appeal. The resident stated in an interview that he was asked to sign the form without any explanation or information about the right to appeal the denial of coverage. The Nursing Home Administrator acknowledged the findings when reviewed by the surveyor.
Failure to Implement and Revise Individualized Care Plans for Toileting and Safety Needs
Penalty
Summary
The facility failed to fully develop and implement person-centered, comprehensive care plans to address the individualized toileting and safety needs of two residents. For one resident with a history of hemiplegia, hemiparesis, gait abnormalities, and narcolepsy, the care plan included scheduled toileting and fall prevention interventions. However, after multiple falls in the bathroom, including incidents resulting in a laceration and a hematoma, the facility did not complete or document a three-day bowel and bladder assessment as required by the care plan. Additionally, the care plan was not revised in a timely manner to reflect post-fall interventions or assessment results. Another resident with diagnoses including diabetes mellitus and congestive heart failure, and moderate cognitive impairment, experienced a fall with injury while attempting to go to the bathroom. The care plan for this resident included interventions such as a three-day bowel and bladder tracking assessment and a bed alarm to alert staff of unsafe transfers. Despite these planned interventions, the facility did not complete the required bowel and bladder assessment following the fall. Interviews with the Director of Nursing confirmed that the planned fall interventions, including the three-day bowel and bladder assessments, were not implemented for either resident. The clinical records and care plans did not reflect timely or complete documentation of these interventions, resulting in a failure to meet the residents' individualized care needs as required.
Failure to Obtain Required Employment References During Staff Hiring
Penalty
Summary
The facility failed to fully implement its abuse prohibition procedures by not adequately screening two of five newly hired employees. According to the facility's Resident Abuse policy, screening potential employees requires obtaining references from their most recent or previous employers. A review of personnel files showed that for one Dietary Manager and one Housekeeping staff member, there was no documentation that the facility had contacted their previous employers for references or employment verification. The Nursing Home Administrator confirmed that there was no evidence of such contact for these two employees, indicating the facility did not follow its own established policy for employee screening.
Failure to Complete Significant Change MDS Assessment After Hospice Election
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment for a resident who experienced a notable decline in condition and elected to receive hospice care. The resident, admitted with diagnoses including Alzheimer's dementia and hyperlipidemia, began hospice services on July 1, 2024. Despite federal requirements mandating a significant change MDS assessment within 14 days of such an event, there was no documented evidence that this assessment was completed to reflect the initiation of hospice services. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the required comprehensive assessment had not been performed.
Failure to Administer Insulin According to Physician Orders and Professional Standards
Penalty
Summary
A registered nurse failed to provide nursing services consistent with professional standards of quality by not following physician's orders and not ensuring accurate medication administration for a resident diagnosed with Type 2 Diabetes Mellitus and parkinsonism. During a medication administration observation, the nurse checked the resident's blood sugar, which was 169 mg/dL, and administered 10 units of Novolog insulin. However, the physician's sliding scale order for Novolog required administration only when blood glucose readings exceeded 200 mg/dL, and the resident's blood sugar did not meet this criterion. Additionally, the nurse was supposed to administer Basaglar, a long-acting insulin, as per the active physician order, but this medication was not available on the medication cart at the time of inspection. A review of medication usage showed that Novolog insulin had been administered multiple times without qualifying blood sugar levels, and the nurse documented that Basaglar was given when it was not. The nurse admitted to failing to verify the medication type against the physician's orders prior to administration. The Director of Nursing confirmed that the nurse did not verify the insulin type, administered the incorrect medication, and failed to provide nursing services in accordance with professional standards of practice.
Failure to Attempt Non-Pharmacological Pain Interventions Prior to PRN Opioid Administration
Penalty
Summary
The facility failed to follow its own policy regarding pain management for a resident with osteoarthritis of the right knee, who was cognitively intact and able to report pain levels. The facility's policy, last reviewed on April 8, 2025, required that non-pharmacological interventions be considered and attempted, either alone or in conjunction with medications, prior to administering pharmacological pain relief. Examples of such interventions included environmental adjustments, physical interventions, exercise, and cognitive or behavioral strategies. A review of the resident's clinical record and medication administration record (MAR) revealed that, over a period from March 1, 2025, through April 24, 2025, opioid pain medication (Oxycodone HCl 5mg) was administered on an as-needed (PRN) basis for reported moderate to severe pain on multiple occasions. On each of these occasions, there was no documented evidence that non-pharmacological interventions were attempted prior to the administration of the opioid medication, despite the resident's pain levels being within the range specified for PRN use. An interview with the Director of Nursing (DON) confirmed the absence of documentation regarding the use of non-pharmacological pain management strategies before administering opioid medication. This lack of documented attempts to use alternative pain management methods prior to pharmacological intervention constituted a failure to comply with both facility policy and regulatory requirements.
Failure to Develop Individualized Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan to address the dementia-related behavioral symptoms of a resident diagnosed with severe cognitive impairment. The resident, who was admitted with a diagnosis of dementia, exhibited increased behaviors such as self-rising, anxiety, and restlessness almost daily during the month of April 2025. Despite these documented changes in behavior, the resident's care plan, last revised in June 2024, did not include any new interventions or strategies to address these emerging symptoms. A review of the clinical record and care plan revealed no evidence that the facility assessed the resident's preferences, social history, routines, or interests to create individualized, non-pharmacological interventions. There was also no documentation of purposeful or meaningful activities tailored to the resident's needs to enhance well-being. An interview with the Nursing Home Administrator confirmed that the facility could not provide evidence of having developed or implemented a person-centered plan for the resident's dementia care.
Significant Medication Error Due to Improper Insulin Administration
Penalty
Summary
A registered nurse failed to properly verify and administer insulin to a resident with Type 2 Diabetes Mellitus and parkinsonism. The nurse administered 10 units of Novolog insulin using a pen that had expired beyond the manufacturer-recommended 28-day usage period. The nurse did not check the expiration date on the insulin pen prior to administration, as required by facility policy. Additionally, the nurse documented that Basaglar insulin was given, but in reality, Novolog was administered instead. Review of the resident's physician orders showed that Basaglar was to be administered once daily, and Novolog was to be given only per a sliding scale for elevated blood glucose levels. At the time of administration, the resident's blood glucose did not meet the threshold for Novolog per the sliding scale, and Basaglar was not available on the medication cart as required. Documentation revealed that Novolog had been administered multiple times without corresponding elevated blood sugar readings, and the nurse admitted to not following the physician's orders or verifying the medication label. The Director of Nursing confirmed these findings, resulting in a significant medication error.
Unsanitary Food Storage and Service Practices
Penalty
Summary
The facility failed to maintain acceptable practices for food storage and service, leading to potential contamination and microbial growth in food. During an initial tour of the dietary department, unsanitary practices were observed, including juice dispensing guns in contact with bulk juice boxes and a buildup of a red, gel-like substance inside the nozzles. Clean dishware and beverage pitchers were left uncovered in the dry storage room. Clean thermal bowls and cups were placed next to dirty dishes, and cleaned cooking equipment was stored next to dirty items. Additionally, small black flies were observed in the dish room, indicating poor sanitation. Further observations in the 2nd floor dining area revealed food particles and debris on the floor, dirt accumulation around the room's perimeter, and a brown substance on the wall. Nine chocolate shakes in the refrigerator were not dated, making it impossible to determine their thaw dates. In the Memory Care Unit's pantry, dirt and debris were found on the floor, and the outside of a refrigeration door was sticky with food splatters. Cleaned thermal mugs were placed on a visibly dirty tray. The Nursing Home Administrator confirmed these deficiencies, acknowledging the failure to maintain sanitary conditions and proper food labeling.
Medical Director Absence at QAPI Meetings
Penalty
Summary
The facility failed to ensure that the Medical Director or a designated physician attended the Quality Assurance Process Improvement (QAPI) Committee meetings for four consecutive months, from January 2024 through April 2024. This was identified through a review of the QAPI Committee meeting sign-in sheets, which showed the absence of the Medical Director or any other physician at these meetings, whether virtually or in-person. An interview with the facility administrator on May 9, 2024, confirmed the absence of a physician at the monthly/quarterly QAPI meetings during this period.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple observations and interviews. During an initial tour of the kitchen, several small black flies were observed flying around clean cooking equipment, and the Certified Dietary Manager (CDM) confirmed that drain flies were frequently present due to the damp environment. Additionally, in the 2nd floor dining area, small dead black bugs were found on the floor, windowsills, and air-conditioning units, with a loose windowsill allowing gaps to the outside. A dead, large-winged insect was also observed on the floor. The Director of Maintenance admitted that while pest treatments were performed on floor drains, there was no documented evidence of regular treatments in the kitchen area. A cognitively intact resident reported that small dark insects were a common sight in the facility, particularly during meals, which was bothersome. The facility's most recent pest control report indicated routine pest control for rodents and insects, but also noted issues such as door gaps and building exterior cracks that allowed pest access. The maintenance director confirmed that the facility had not acted on the pest control company's recommendations to secure these areas, nor could they provide evidence of routine preventative measures to deter pests.
Failure to Maintain Clean Environment in Dementia Unit
Penalty
Summary
The facility failed to provide adequate housekeeping services to maintain a clean environment on the third floor dementia unit. Observations on May 8, 2024, revealed that the large dining room floor was sticky, dirty, and soiled with dried liquid stains, and dirt, dried liquid stains, and food crumbs were present on the window sills. In several resident rooms, the floors were dirty and sticky, with one room emitting a strong urine odor from the resident's mattress. Another room had a broken floor tile under the bed and a wall with deep gouges and heavily soiled wallpaper. These conditions were confirmed during an interview with the interim Nursing Home Administrator, who acknowledged that resident rooms and dining/activity areas should be maintained in a clean and sanitary manner.
Failure to Address Resident Grievances in a Timely Manner
Penalty
Summary
The facility failed to adequately address and resolve grievances filed by two residents, leading to a deficiency in honoring residents' rights to voice grievances without discrimination or reprisal. Resident 76, who was admitted with diagnoses including gastroesophageal reflux disease and muscle weakness, expressed dissatisfaction with her full liquid diet and the lack of a bedtime snack. Despite a grievance filed by her guardian, the resident reported that no staff had visited her to discuss her dietary preferences, indicating a lack of timely follow-up by the facility. Resident 90, admitted with irritable bowel syndrome and requiring extensive assistance with activities of daily living, filed a grievance regarding the staff's failure to respond promptly to her call bell during the night shift, resulting in her being left incontinent for 15 hours. The facility did not provide evidence of investigating or addressing this grievance, nor did they follow up with the resident to determine if her concerns were resolved. Interviews with the Nursing Home Administrator and Director of Nursing confirmed the absence of documented efforts to resolve these grievances, highlighting a deficiency in the facility's grievance handling process.
Failure to Implement Individualized Continence Care
Penalty
Summary
The facility failed to assess and implement individualized measures to meet the toileting needs of a resident who experienced a decline in continence. The facility's policy on urinary incontinence required the physician and staff to review the progress of individuals with impaired continence and document responses to interventions. However, the facility did not develop or implement interventions for the resident, who was admitted with diagnoses including congestive heart failure, abnormal gait, and dysphasia, and was identified as incontinent of bowel and bladder. The resident's care plan included evaluating urination patterns, applying barrier cream, and assisting with toileting. Despite a decline in bladder continence noted in the resident's assessments, no bladder or bowel retraining program was in place. The resident developed a stage 2 pressure ulcer, and the facility's documentation showed no evidence of interventions to address the decline in continence. The Director of Nursing confirmed the lack of evidence for measures to decrease urinary incontinence and prevent related complications.
Failure to Provide Timely Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to two residents, leading to deficiencies in maintaining their highest practicable physical, mental, and psychosocial well-being. Resident 90, who was admitted with diagnoses including adjustment disorder, major depressive disorder, and acute stress reaction, reported not receiving psychiatric services since February 2024. The resident expressed dissatisfaction with previous telehealth services, citing distractions and a lack of engagement from the psychologist. Despite the resident's ongoing struggles with anxiety and depression, there was no documented follow-up on her psychological needs from February 20, 2024, to the survey's conclusion on May 10, 2024. Similarly, Resident 28, diagnosed with schizoaffective disorder and requiring specialized mental health services, did not receive timely psychological follow-up. Although a psychological evaluation in October 2023 recommended individual psychotherapy within four weeks, the resident was not seen by psychological services until March 25, 2024. The Director of Nursing and Nursing Home Administrator confirmed the lack of timely psychological services for both residents, acknowledging the failure to adhere to recommended follow-up care.
Failure to Attempt Gradual Dose Reduction of Psychoactive Medications
Penalty
Summary
The facility failed to attempt a gradual dose reduction (GDR) of psychoactive medications for two residents, which was identified through clinical record reviews and staff interviews. Resident 52 was admitted with diagnoses including dementia and had physician orders for Trazadone and Lexapro, both antidepressants. A pharmacist consult requested a GDR for these medications, but the physician disagreed without providing an individualized clinical rationale. The facility could not provide documented evidence supporting the continued use of the current doses or any GDR attempts in the past year. Resident 77, also diagnosed with dementia and bipolar disorder, had physician orders for Depakote, Olanzapine, and Escitalopram Oxalate. The pharmacist recommended dose reductions for these medications, but the physician disagreed, citing potential clinical deterioration without documented evidence of behaviors. The facility lacked documentation to support the continued dosages or any GDR attempts for Resident 77 in the past year. The Nursing Home Administrator and Director of Nursing confirmed the absence of GDR attempts for both residents.
Medication Storage and Expiration Compliance Issues
Penalty
Summary
The facility failed to adhere to pharmacy supplies expiration and use-by dates on two of its resident units, specifically the First and Second Floors. During a review of the facility's policies and observations in the medication room on the second floor, several expired and improperly labeled items were found. These included expired Foley catheter securement devices, povidone/iodine swab sticks, BD Eclipse Needles, needleless sterile connectors, safety needles, central line trays, Opti foam heel wound dressings, urostomy pouches, urine BD vacutainer kits, sterile urine cups, Comfort foam Ag wound dressings, and Bisacodyl medicated laxative suppositories. Additionally, there were opened items without dates, such as Santyl Collagenase, Normal Saline Irrigation Solution, alcohol, hydrogen peroxide, and an Apisol injection vial, which did not comply with the facility's policy for multidose medications. The medication refrigerator was found to have a thick layer of ice, scattered dark substances, and frozen paper towels, with no evidence of temperature monitoring as required by the facility's policy. Employee 1, an LPN, confirmed these findings. During an interview, the Nursing Home Administrator and the Director of Nursing acknowledged that expired pharmacy products should have been removed and discarded, and the medication refrigerator should have been defrosted, cleaned, and monitored for temperature. These deficiencies indicate a failure to maintain medication storage and preparation areas in a clean, safe, and sanitary manner, as per the facility's policies.
Failure to Provide Routine Evening Snacks
Penalty
Summary
The facility failed to provide a nourishing evening snack for residents when more than 14 hours elapsed between the supper meal and breakfast the next day. This deficiency was observed in four residents out of a sample of 23. The facility's policy, last reviewed in February 2024, mandates the provision of adequate nutrition, yet the scheduled meal times revealed a 15-hour gap between dinner and breakfast. During a group interview, residents reported that snacks were not routinely offered in the evenings, and they only received snacks upon request. Additionally, residents on the Dementia unit also experienced a 15-hour gap without evidence of being offered a nourishing snack. The facility administrator could not provide documented evidence that residents were routinely offered and provided with a bedtime snack.
Failure to Update Facility-Wide Assessment for Dementia Care
Penalty
Summary
The facility failed to timely review and update its facility-wide assessment to identify the specific personnel and resources necessary to care for its current resident population. The assessment, last reviewed on April 15, 2024, did not address the needs of the locked third-floor Dementia/Memory care unit, which houses 61 residents with documented diagnoses of Dementia/Alzheimer's disease and 43 residents residing on the locked dementia unit. This oversight was identified during a survey ending on May 10, 2024, when the facility provided an assessment tool that lacked documentation on the specific needs of these residents. Previous surveys conducted on January 25, 2024, and February 27, 2024, had already identified deficiencies related to inadequate dementia care and behavioral health services, including instances of resident-to-resident abuse. During the current survey, the facility was also cited for failing to provide behavioral health services to meet the mental health needs of a resident with a diagnosed mental disorder. The facility did not update its assessment to ensure that it had the necessary staff resources with the required skills and competencies to care for its resident population, thus failing to meet minimum licensure and certification standards.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain the personal dignity, privacy, and quality of life for two residents. Resident 49, who has dementia and exhibits behaviors such as moving furniture and removing window coverings, was observed in a room without curtains, shades, or blinds, leaving him visible from the street. Despite the resident's behavior of removing window coverings, the facility did not replace them or explore alternative solutions to ensure his privacy. Resident 90, who is cognitively intact, reported that a nurse aide did not assist her after she rang the call bell, leaving her incontinent for 15 hours. Additionally, she experienced anxiety due to being manhandled during transfers with a mechanical lift, following a previous traumatic transfer incident that resulted in a broken leg and surgery. Interviews with the Nursing Home Administrator and Director of Nursing confirmed the facility's failure to consistently treat residents with dignity and respect, including timely responses to requests for assistance.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect Resident 85 from physical abuse by Resident 60, despite being aware of Resident 60's history of aggressive behavior. Resident 85, who was severely cognitively impaired with Alzheimer's disease and other mental health disorders, was involved in an altercation with Resident 60 in the Dementia Unit Dayroom. Resident 60, also severely cognitively impaired, had been exhibiting increased agitation and aggressive behaviors prior to the incident. On the day of the incident, Resident 60 was observed pacing and insisting on going home, which staff attempted to manage by redirecting her to her room. The incident occurred when Resident 60 approached Resident 85, who was seated at a different table, and pulled her by the hair, causing her to fall to the ground. Staff intervened by separating the residents, and an RN assessment found no injuries to either resident. Despite the lack of physical injuries, the facility's failure to prevent the altercation highlights a deficiency in ensuring a safe environment for Resident 85, who was supposed to be protected from abuse. The facility's awareness of Resident 60's escalating behaviors and history of aggression, combined with the failure to effectively manage these behaviors, contributed to the incident. The Director of Nursing confirmed the facility's awareness of Resident 60's behaviors and acknowledged the failure to protect Resident 85 from physical abuse. The incident was reported to the local police and the Aging Agency, and both residents' families and physicians were notified.
Failure to Implement Abuse Policy and Conduct Thorough Assessment
Penalty
Summary
The facility failed to implement its established abuse prohibition policy and procedures in response to an incident involving two residents. Resident 60, who was observed packing her clothes and insisting she was going home, engaged in a physical altercation with Resident 85 in the Dementia Unit Dayroom. Resident 60 pulled Resident 85 by her hair, causing her to fall to the ground. Staff intervened by separating the residents and notifying the responsible parties and physicians. However, the RN's assessment of Resident 85 was inadequate, as it did not include a thorough physical assessment or documentation of the required assessment data as outlined in the facility's Abuse Policy. The RN's documentation only noted that there were no signs of injury or distress and that vital signs were within normal limits. The RN failed to document a comprehensive assessment, including pain assessment, current behavior, medications, behaviors over the past 24 hours, active diagnoses, and recent labs. This lack of thorough documentation and assessment was confirmed during an interview with the Director of Nursing, who acknowledged the failure to provide documented evidence of a complete physical assessment following the incident of physical abuse.
Failure to Investigate Medication Errors
Penalty
Summary
The facility failed to thoroughly investigate potential neglect involving five residents who did not receive their scheduled medications on April 27, 2024. Employee 10, a registered nurse, signed the Medication Administration Records (MAR) indicating that all medications had been administered, but the medications were later found in the medication cart. The residents affected included those with diagnoses such as dementia, diabetes, and cerebral infarction, and they missed medications like atorvastatin, metropolol, Sevelamer, dipyridamole, memantine, Eliquis, metformin, and Toresmide. The facility's policy requires a complete investigation into such incidents, but there was no documented evidence of an investigation into the potential neglect by Employee 10. The facility did not obtain witness statements from staff or cognitively intact residents, and there was no documentation in the residents' clinical records indicating the missed medications. Interviews with the administrator and director of nursing confirmed the lack of a thorough investigation, violating several Pennsylvania Code regulations related to the responsibility of the licensee, management, resident rights, and nursing services.
Failure to Monitor Resident's Respiratory Status and Oxygen Use
Penalty
Summary
The facility failed to identify and implement necessary interventions in the care plan of a resident who required monitoring of respiratory status and oxygen use. The resident, who was admitted with diagnoses including shortness of breath and urinary retention, exhibited behaviors such as unplugging and removing oxygen, which were not addressed in the care plan. The care plan included interventions for the resident's behaviors but did not specify actions to monitor respiratory status, such as checking oxygen saturation levels or guidelines for when to notify nursing staff if the oxygen therapy was interrupted. Observations revealed that the resident was frequently found with the oxygen concentrator turned off, despite wearing a nasal cannula, and staff did not intervene to ensure continuous oxygen delivery as prescribed. The resident was noted to be severely cognitively impaired, and a physician's order required continuous oxygen at four liters per minute. The Director of Nursing and Nursing Home Administration confirmed the omission of respiratory monitoring measures in the care plan, which contributed to the deficiency.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to consistently administer oxygen therapy as ordered for a resident, leading to a deficiency. The resident, who was admitted with a history of falling and hemiplegia following a stroke, had a physician's order for oxygen therapy at 2 liters per minute via nasal cannula as needed for shortness of breath. However, observations on two separate occasions revealed that the resident's oxygen concentrator was set to 3 liters per minute, which was not consistent with the physician's orders. The deficiency was confirmed through observations and staff interviews. On both occasions, the oxygen concentrator was observed running at an incorrect flow rate, and this was confirmed by an LPN. Further confirmation came from interviews with the Nursing Home Administrator and the Director of Nursing, who acknowledged that the physician's order for supplemental oxygen was not followed for the resident. This failure to adhere to the prescribed oxygen therapy regimen constitutes a deficiency in the facility's provision of nursing services.
Deficiency in Person-Centered Dialysis Care Coordination
Penalty
Summary
The facility failed to provide person-centered care and coordination of individualized services for a resident with end-stage renal disease (ESRD) who required hemodialysis. The resident, who also had dementia, was admitted with a care plan that included interventions to coordinate care with a dialysis center and monitor the dialysis access site. However, the care plan did not reflect the resident's specific schedule preferences or provisions for transportation and meal accommodations related to the dialysis schedule. A physician order indicated that the resident's dialysis was scheduled for 4:00 a.m. on specific days, and the resident's wife was allowed to transport him. Despite this, the care plan lacked details on the resident's transportation preferences and meal schedule adjustments needed for dialysis days. The Director of Nursing confirmed that the care plan did not adequately address these aspects, leading to a deficiency in providing comprehensive and individualized care for the resident.
Deficiency in Clinical Record Documentation
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for two residents, as identified during a survey. For one resident, who was admitted with a history of falling and hemiplegia following a stroke, a skin injury was observed on the left lower extremity during an inspection. However, there was no documentation in the clinical record regarding the assessment or cause of this injury. The Director of Nursing confirmed the absence of any documentation related to the injury. For another resident, who was admitted with type 2 diabetes mellitus and a history of boils, a boil on the left inner labia majora was noted to have burst. Although treatment was administered as per the physician's order, there was no documentation in the clinical record regarding the healing progress, status, or resolution of the boil. The Director of Nursing and Nursing Home Administrator confirmed the lack of documentation tracking the healing and resolution of the resident's boil.
Call Bell Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a working call system was available and accessible in the room of Resident 52, who is severely cognitively impaired. During an observation on May 9, 2024, it was noted that there was no call bell connected to the wall outlet or present anywhere in the room. Additionally, there was no alternative method for the resident to summon assistance, such as a tap bell. Instead, two plugs were inserted into the wall outlet call bell unit to circumvent the alarm when the outlet is unplugged. An interview with a licensed practical nurse confirmed that Resident 52 did not have access to a call bell while in bed, and verified that call bells are supposed to be placed within reach of residents at their bedside. The Nursing Home Administrator also confirmed that call bells should be placed at each resident's bedside, in accordance with 28 Pa. Code 205.67 (j) Electric Requirements for existing and new construction.
Failure to Implement Safe Smoking Procedures for Resident
Penalty
Summary
The facility failed to implement established procedures to ensure safe smoking practices for a resident identified as a current smoker. During an onsite survey, it was observed that the facility had a policy indicating it was a non-smoking facility, prohibiting smoking within the facility or on its grounds. However, the Nursing Home Administrator acknowledged that one resident, identified as a current smoker, was allowed to smoke. A review of the resident's clinical record showed that the resident was admitted with a diagnosis of chronic obstructive pulmonary disease (COPD), but there was no care plan addressing the resident's smoking until the surveyor's inquiry. The facility lacked a smoking policy to address the decision to allow the resident to smoke, and the issue was only brought to attention during the survey. Interviews with the Nursing Home Administrator and Director of Nursing confirmed the absence of a care plan and a revised smoking policy for the resident.
Failure to Ensure Informed Consent for Medicare Plan Changes
Penalty
Summary
The facility failed to develop and implement policies and procedures to protect residents from being disenrolled from their Medicare health plans without their informed consent. This deficiency was identified through a review of clinical records, CMS guidance, facility documentation, and staff interviews. The facility did not ensure that residents were competent to make informed decisions about their health plan changes, nor did they provide adequate explanations of the risks involved in disenrollment, both verbally and in writing. Resident 11, who was cognitively intact with a BIMS score of 13, was disenrolled from a Medicare Advantage Plan without documented evidence of her initiating the request or understanding the implications. The facility did not assess her cognitive abilities before having her sign the disenrollment form. Similarly, Resident 16, who was moderately cognitively impaired with a BIMS score of 10, was disenrolled without involving his health care decision maker, his daughter, and without providing her with a written explanation of the risks involved. Resident 17, who was cognitively intact, was also disenrolled without documented evidence of initiating the request. Resident 21, who was moderately cognitively impaired, was disenrolled without assessing his current cognitive function or involving his responsible party, his daughter. Interviews with facility staff revealed that the facility lacked policies and procedures for assisting residents with health plan changes and failed to ensure residents' cognitive abilities were assessed before signing disenrollment forms.
Failure to Implement Individualized Dementia Care Plans
Penalty
Summary
The facility failed to develop and implement individualized plans to manage dementia-related behavioral symptoms for two residents, leading to multiple incidents and falls. Resident 14, who was severely cognitively impaired and had a history of falls, experienced several incidents due to poor safety awareness and wandering behavior. Despite having a care plan that included diversional activities and safety checks, these interventions were not effectively implemented, resulting in repeated falls and injuries. Resident 14's care plan included activities such as music, television shows, and pet visits to manage her dementia-related behaviors. However, the facility did not consistently provide these activities, and the resident continued to experience falls, including unwitnessed incidents in the dayroom and her bedroom. The facility's reliance on 15-minute safety checks proved ineffective, as evidenced by the resident's repeated falls and injuries, including a laceration that required hospital evaluation. Resident 19, also severely cognitively impaired, exhibited intrusive wandering and inappropriate sexual behaviors. The facility's care plan for Resident 19 did not address these specific behaviors or provide interventions for staff to manage them. This oversight led to incidents where Resident 19 engaged in inappropriate interactions with other residents, which were not adequately addressed in the care plan. The facility's failure to implement person-centered, interdisciplinary care plans for these residents resulted in ongoing behavioral issues and safety concerns.
Failure to Address Abuse and Dementia Care Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address and correct quality deficiencies related to abuse and dementia care, as identified in surveys conducted on January 25, 2024, and February 27, 2024. Despite having a plan of correction in place, the facility did not effectively implement or sustain the necessary changes. Specifically, the facility did not revise the care plan for a resident who exhibited inappropriate behavior, such as kissing cognitively impaired female residents, which was identified as a form of potential sexual abuse and harassment. This behavior was observed on two separate occasions, and the facility did not take adequate steps to protect other residents. Additionally, the facility failed to manage dementia-related behavioral symptoms effectively, as evidenced by a resident who experienced six falls in February 2024 due to dementia-related behaviors. The facility did not implement individualized interdisciplinary plans to manage these symptoms and ensure resident safety. The QAPI committee did not identify these ongoing deficiencies or develop effective plans to sustain corrections, leading to repeated issues in both abuse prevention and dementia care.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect Resident 18 from sexual abuse by another resident, Resident 19. Resident 18 was severely cognitively impaired with a BIMS score of 6, indicating an inability to consent to sexual activity. Despite this, Resident 18 was found in a situation with Resident 19, who also had severe cognitive impairment, where they were engaged in a kiss. The facility's policy requires that residents suspected of lacking the capacity to consent to sexual activity be protected from abuse, but this was not adequately ensured in this case. Resident 19, who was admitted with diagnoses including dementia and severe cognitive impairment, was observed on two occasions engaging in physical affection with other residents. The care plan for Resident 19 did not address these behaviors or include interventions to prevent such incidents. The facility's failure to identify and manage Resident 19's behaviors, and to ensure Resident 18's protection, resulted in a substantiated case of resident abuse. The Nursing Home Administrator confirmed the deficiency, acknowledging that Resident 18 was not free from sexual harassment by Resident 19.
Failure to Justify Increased Antipsychotic Dosage
Penalty
Summary
The facility failed to ensure that a resident was free from chemical restraints that were not required for medical treatment. Resident 19, who was admitted with diagnoses including Parkinsonism, dementia with behavioral disturbances, and adult failure to thrive, was prescribed Quetiapine Fumarate (Seroquel) 25 mg. Following an incident where the resident became verbally aggressive after being redirected from a female resident, the CRNP discussed increasing the dosage to 75 mg. However, the facility did not provide physician documentation of the clinical rationale for this increase. The facility did not demonstrate that less restrictive alternatives were considered or attempted, nor did it provide evidence of an appropriate assessment and care planning by the interdisciplinary team. The clinical record lacked documentation that the facility staff or physician had identified and addressed potential underlying causes of the resident's behavior, such as environmental factors. The Director of Nursing confirmed the absence of documentation justifying the increased dosage of the antipsychotic drug to control the resident's behavior.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
