Pavilion At St Luke Village, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Hazleton, Pennsylvania.
- Location
- 1000 Stacie Drive, Hazleton, Pennsylvania 18201
- CMS Provider Number
- 395265
- Inspections on file
- 32
- Latest survey
- September 22, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Pavilion At St Luke Village, The during CMS and state inspections, most recent first.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
Multiple residents repeatedly reported long wait times for care and delayed meal distribution, with meal trays left sitting and food becoming cold. Despite these ongoing concerns being raised in Resident Council meetings, the facility failed to file or document grievances as required and did not keep residents informed of any actions taken, leaving the issues unresolved.
The facility did not ensure that MDS assessments accurately reflected the clinical status of three residents. One resident's MDS failed to document ongoing tracheostomy care, continuous oxygen therapy, and suctioning as ordered. Another resident's MDS inaccurately recorded PASARR status, omitting the need for specialized mental health services. A third resident was incorrectly assessed as having an indwelling catheter, which was not present upon observation. These inaccuracies were confirmed by the NHA and were not consistent with clinical records or direct observations.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a failure to meet the resident's individualized care needs.
A resident with COPD and chronic kidney disease, receiving IV antibiotics for MRSA, had seven scheduled doses of Cefazolin lacking documentation in the MAR. The NHA confirmed that nursing staff omitted these entries, and an RN attested to administering the medication but failing to document it in the EHR.
A resident with a history of schizophrenia, depression, and anxiety was hospitalized for psychiatric reasons and later readmitted with updated behavioral health needs. The facility did not revise the resident's care plan to include new diagnoses, recent behavioral episodes, or interventions identified by the behavioral hospital, and failed to document a review or update of the care plan to reflect the resident's current condition.
A resident receiving continuous enteral nutrition via PEG tube did not have the feeding container labeled with the date and time it was opened and hung, as required by facility policy. Additionally, the resident's wheelchair and feeding pole were observed to be coated with dried residue and were not maintained in a sanitary condition.
A resident with a diagnosis of PTSD and anxiety did not have an individualized, person-centered care plan that identified symptoms, triggers, or interventions to minimize re-traumatization, despite facility policy requiring trauma-informed, culturally competent care. The facility was unable to demonstrate that care was provided in accordance with professional standards and the resident's preferences.
A resident identified as at moderate risk for pressure injuries developed worsening pressure ulcers due to the facility's failure to consistently implement and document preventive interventions such as scheduled turning, repositioning, and nutritional support. Despite care plans and physician orders, staff did not provide evidence of performing required tasks, and the resident's wounds progressed from Stage II to unstageable, leading to actual harm and hospital evaluation.
The facility failed to enforce its compliance and ethics program when two employees accepted or failed to report offers of monetary compensation from an insurance vendor in exchange for resident referrals. Despite required training and clear policies, staff did not report the vendor's actions or their own involvement, resulting in violations of the Anti-Kickback statute and facility policy.
The facility did not meet the required nurse aide to resident ratios on six shifts, as per Pennsylvania regulations effective July 2024. Staffing records showed shortfalls in the number of nurse aides on night and evening shifts in January 2025, with no additional staff available to compensate. This was confirmed by the Nursing Home Administrator.
The facility did not meet the required LPN-to-resident ratio on a day shift, with only 3.40 LPNs available for 108 residents, instead of the required 4.32. This staffing shortfall was confirmed by the Nursing Home Administrator.
The facility did not meet the required minimum of 3.2 hours of direct resident care per resident per day on several occasions in January 2025. Staffing levels were insufficient, providing only 3.13, 3.00, and 3.06 hours on specific days. This deficiency was confirmed by the Nursing Home Administrator.
The facility failed to meet the required nurse aide to resident ratios on 18 out of 48 shifts reviewed, as mandated by the regulation effective July 1, 2024. The staffing records showed multiple instances where the number of nurse aides was insufficient, with no higher-level staff available to compensate for the deficiency. The Nursing Home Administrator confirmed the shortfall during an interview.
The facility failed to meet the required LPN-to-resident ratios on six shifts, as evidenced by staffing records and staff interviews. On several occasions, the number of LPNs was below the required minimum for the resident census, with specific deficiencies noted on the evening and night shifts. The Nursing Home Administrator confirmed these deficiencies.
The facility did not consistently provide the required 3.2 hours of direct nursing care per resident per day. On multiple occasions, the nursing care hours fell short, ranging from 2.88 to 3.19 hours. The Nursing Home Administrator confirmed the shortfall in staffing levels.
The facility failed to implement a comprehensive infection control program, resulting in a scabies outbreak among residents and staff. Inadequate tracking and documentation of infections, along with poor environmental conditions in the central supply room, contributed to the spread of infections. A resident with heart disease and chronic kidney disease developed a persistent rash, later confirmed as scabies, highlighting the facility's failure to maintain proper infection control practices.
The facility failed to respond promptly to residents' call bells, affecting their dignity and quality of life. Two residents reported waiting 20 minutes to two hours for assistance, while five others expressed similar concerns during a group interview. The NHA and DON acknowledged the issue but could not explain the delays.
The facility failed to prevent pressure ulcers in two residents. One resident developed a Stage II pressure injury on her ear due to inadequate padding of oxygen tubing, despite having a care plan. Another resident, with reduced mobility and Alzheimer's, developed pressure areas on her buttock and sacrum due to lack of scheduled repositioning and incontinence care. The sacral wound worsened to an unstageable pressure area. The DON confirmed the facility's failure to implement consistent preventive measures.
A facility failed to provide a resident with restorative nursing services to maintain mobility, despite a program being in place. The resident, with chronic kidney disease and pulmonary embolism, was cognitively intact and had a good prognosis with therapy. However, documentation showed missed sessions, and the resident reported not receiving the necessary services. The NHA confirmed the oversight but lacked evidence of service delivery.
A facility failed to provide individualized incontinence care for a resident with Alzheimer's and severe cognitive impairment, leading to the development of a Stage II pressure ulcer. Despite the resident's documented incontinence and need for substantial assistance, the facility did not implement a tailored continence management program or perform frequent incontinence checks, as required by their policy.
A resident did not receive six doses of Pregabalin for neuropathic pain management due to a delay in medication delivery from the pharmacy. Despite a STAT delivery request and confirmation of the prescription, the medication was not provided until two days later. The DON confirmed the facility's responsibility to ensure timely pharmaceutical services.
A facility failed to document the clinical rationale for continuing an antipsychotic medication for a resident with Alzheimer's and anxiety. Despite no maladaptive behaviors being recorded, the resident's medication dosage was increased without proper justification. The care plan lacked identification of anxiety as a problem and did not include non-pharmacological interventions. Interviews with the NHA and DON revealed an inability to provide evidence for the medication's necessity or attempts at alternative interventions.
A resident reported that her soiled clothing was not being taken to the laundry, leading to dirty clothes accumulating in her closet. An LPN confirmed the issue and removed the dirty clothing. The Nursing Home Administrator acknowledged the facility's responsibility to maintain a clean and homelike environment.
A resident with cellulitis did not receive timely antibiotic treatment due to a known allergy to the prescribed medication, Doxycycline. The facility failed to contact the medical director when the attending physician did not respond to clarify the order, resulting in a delay in treatment.
A resident was administered Macrodantin for a UTI without meeting the criteria for antibiotic therapy, as per the facility's antibiotic stewardship policy. Despite no documented symptoms, the medication was given following family insistence, highlighting a failure to adhere to the policy.
A resident with a pressure ulcer on the right heel experienced deterioration due to the facility's failure to implement necessary care and interventions. The resident's condition worsened, leading to osteomyelitis, as the facility did not follow recommendations for repositioning and use of Prevalon boots. Additionally, the facility delayed notifying the physician of critical x-ray results, contributing to the resident's declining health.
A resident with multiple wounds, including venous ulcers and a necrotic pressure ulcer, did not receive adequate wound assessments and documentation from the nursing staff. Critical details such as drainage and wound description were missing, and the differentiation between pressure and non-pressure wounds was not made. This led to delayed identification of osteomyelitis in the resident's heel, with the attending physician not being notified promptly, resulting in the resident's condition worsening.
A resident with a PICC line and diagnosed with a septic knee and diabetes did not receive the prescribed IV antibiotic, Daptomycin, for three consecutive days. The facility's policy on timely medication administration was not followed, and the attending physician was not notified of the missed doses. Interviews with the DON and the administrator confirmed these failures.
The facility failed to provide appropriate pain management for two residents by not attempting non-pharmacological interventions before administering opioid medication and not following physician orders. One resident received medication without prior non-pharmacological attempts, while another received medication for pain levels below the prescribed threshold.
A resident with a septic knee and diabetes did not receive the prescribed antibiotic, Daptomycin, for three consecutive days due to the facility's pharmacy failing to deliver the medication on time. This was confirmed by the NHA.
The facility failed to document the results of monthly drug regimen reviews conducted by a pharmacist for several residents with various diagnoses, including diabetes and COPD. Despite completing reviews, there was no evidence of identified irregularities, recommendations, or physician actions, as confirmed by the Nursing Home Administrator.
The facility failed to maintain a comprehensive infection prevention and control program for two months. The last recorded data for monitoring infections was completed in late May, with no evidence of surveillance activities thereafter. The Infection Preventionist transitioned roles in early June, and the NHA confirmed the lack of a functional system to analyze infection trends during this period.
The facility failed to provide sufficient nursing staff, resulting in long wait times for resident care. Residents reported delays in call bell responses, particularly during evening shifts and meal times, leading to frustration and unmet care needs. Staffing records confirmed the facility did not meet state-required nurse aide and LPN ratios, and the Nursing Home Administrator acknowledged the issue.
The facility failed to provide an accessible smoking area for two residents who smoked prior to a new non-smoking policy. The policy required residents to smoke offsite without staff assistance, posing challenges for residents with mobility issues. Both residents expressed dissatisfaction, and the facility acknowledged the difficulties but did not provide a safe smoking area.
A resident with spinal stenosis and hypertension reported being slapped by another resident who entered her room uninvited. The facility failed to notify the resident's representative, who holds medical and financial Power of Attorney, about the incident. This deficiency was confirmed by the Nursing Home Administrator and violates Pennsylvania Code regarding nursing services and resident rights.
A resident with spinal stenosis reported discomfort due to a non-functioning cooling unit in their room, which had been an issue for over a month. Despite a maintenance request, no repairs were made, and the Nursing Home Administrator could not provide evidence of scheduled repairs, failing to ensure a comfortable environment.
A resident was physically abused by another resident who entered her room uninvited and slapped her. The facility's policy on abuse prevention was not effectively implemented, as the aggressive resident had a known history of entering rooms and becoming agitated. The RN Supervisor was aware of the behavior, but adequate measures were not in place to prevent the incident.
A facility failed to investigate an injury of unknown source for a cognitively impaired resident on anticoagulant therapy, despite multiple instances of unexplained vaginal bleeding. Additionally, the facility did not thoroughly investigate an allegation of physical abuse involving two residents, lacking a statement from the initial reporter and failing to substantiate the claim due to insufficient evidence.
A facility failed to ensure accurate MDS assessments for a resident, as the Discharge MDS indicated a discharge to a hospital, while records showed the resident was discharged home. This inaccuracy was confirmed by the Nursing Home Administrator.
A resident with Alzheimer's disease exhibited intrusive wandering and aggressive behavior, including entering other residents' rooms uninvited and slapping another resident. The facility failed to develop and implement a comprehensive, individualized care plan to manage these dementia-related behaviors, as confirmed by staff and the Nursing Home Administrator.
A resident with multiple ulcers and Type 2 diabetes had an x-ray revealing osteomyelitis, but the physician was not promptly notified. The x-ray was completed, and results were available, but the physician was informed only after a change in condition assessment five days later, leading to a delay in treatment.
A facility failed to document an incident where a resident with Alzheimer's disease intruded into another resident's room and committed physical abuse. Despite the report of the incident, there was no documentation in the clinical records of either resident, violating professional standards for nursing documentation.
A facility failed to coordinate care between the facility and a hospice agency for a resident with liver cancer. Despite a physician order for hospice services, the resident's care plan did not reflect the necessary coordination to meet their daily and terminal care needs. This deficiency was confirmed by the Nursing Home Administrator.
A facility failed to assess and evaluate a resident's bowel and bladder function, leading to a deficiency in care. The resident experienced frequent incontinence, and there was no documented evidence of required evaluations or interventions. The resident reported delays in receiving toileting assistance, resulting in accidents. The nursing home administrator confirmed the lack of action on the resident's increased incontinence.
The facility failed to ensure the timely disposition of discontinued and unused medications, leading to improper storage in medication rooms. Observations revealed various medications stored in drawers and cupboards, not in designated locations for discontinued medications. Staff confirmed that these medications should have been returned to the pharmacy, and the facility failed to implement procedures for timely disposition.
The facility failed to implement consistent infection control procedures in the third-floor medication room. Medications were stored alongside staff food and beverages in a small refrigerator, which was confirmed by an LPN and the DON.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Failure to Address and Resolve Resident Grievances Regarding Care and Meal Distribution
Penalty
Summary
The facility failed to adequately address and resolve ongoing resident complaints and grievances raised during Resident Council meetings, specifically regarding long wait times for care and delayed meal distribution. Despite multiple residents consistently voicing these concerns over several months, meeting minutes indicated that grievances were to be filed on their behalf, but a review of facility records revealed no documentation of such grievances being filed for the relevant periods. Residents reported that their requests for assistance were not responded to in a timely manner and that meal trays, although arriving on time, were left sitting for extended periods before being distributed, resulting in cold food. These issues were repeatedly marked as unresolved in the Resident Council meeting minutes. Interviews with residents confirmed that these problems persisted despite being brought up multiple times, and the Nursing Home Administrator was unable to provide evidence of any effective actions taken to resolve the concerns. The administrator also could not explain the lack of grievance documentation or demonstrate any follow-up or communication with residents regarding the status of their complaints. The facility's own policy requires prompt efforts to resolve grievances and to keep residents informed of progress, but these procedures were not followed, resulting in continued dissatisfaction and unresolved issues for the affected residents.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the clinical status of three residents. For one resident with respiratory failure, tracheostomy, and continuous oxygen needs, the quarterly MDS assessment did not indicate that the resident was receiving continuous oxygen therapy, as-needed suctioning, or tracheostomy care, despite physician orders and treatment records confirming these interventions were provided. Another resident with schizophrenia had an annual MDS assessment that inaccurately documented the resident's PASARR status, indicating no need for a Level II PASARR, even though clinical records and a determination letter confirmed the requirement for specialized services due to a mental condition. A third resident, admitted with quadriplegia, was assessed on the admission MDS as having an indwelling urinary catheter, but direct observation revealed no catheter was present. In each case, the inaccuracies were confirmed by the Nursing Home Administrator during interviews. These findings demonstrate that the facility did not follow the required procedures for accurate MDS completion, including direct observation and proper documentation, as outlined in the RAI User's Manual and state regulations.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
A deficiency was identified when appropriate treatment and care were not provided according to physician orders, as well as the resident's preferences and goals. The report notes a failure to ensure that care was delivered in alignment with the established plan, which is required to meet the individual needs and wishes of the resident. This lapse resulted in the resident not receiving care as intended, based on their documented preferences and medical orders.
Failure to Accurately Document Antibiotic Administration in Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for one resident who was admitted with chronic obstructive pulmonary disease and chronic kidney disease. The resident had a physician's order to receive Cefazolin, an antibiotic, intravenously every eight hours for 15 days to treat MRSA. Upon review of the medication administration record for the specified month, it was found that documentation was missing for seven scheduled administrations of the antibiotic on several dates and times. During an interview, the Nursing Home Administrator confirmed that nursing staff omitted the required documentation from the clinical record. An attestation from a registered nurse indicated that the medication was administered as ordered, but the nurse forgot to document these administrations in the electronic health record. The administrator acknowledged that it is the facility's responsibility to ensure that medical records are accurate and complete.
Failure to Update Comprehensive Care Plan After Psychiatric Hospitalization
Penalty
Summary
The facility failed to ensure that a resident's comprehensive care plan was reviewed and revised to accurately reflect the resident's current needs and services. Clinical record review showed that the resident, who had diagnoses including schizophrenia, depression, and anxiety, was transferred to a hospital for involuntary psychiatric commitment due to verbal and physical aggression. Upon readmission from a behavioral hospital, documentation from the hospital included specific red flags, warning signs, and internal coping strategies relevant to the resident's mental health status. However, the facility's care plan did not incorporate these updated findings, nor did it reflect the resident's recent psychiatric hospitalization or the escalation of behaviors that led to the hospital stay. The care plan, initially created years prior, was not updated to include the resident's current diagnosis of schizophrenia, recent behavioral episodes, or the interventions and strategies identified by the behavioral hospital. Interventions and goals in the care plan were outdated and did not address the resident's present mental health risks or needs. An interview with the director of nursing confirmed there was no documented evidence that the care plan had been reviewed or revised to reflect the resident's current condition and required interventions.
Failure to Label Enteral Feeding and Maintain Sanitary Equipment
Penalty
Summary
A resident with a history of dysphagia and Alzheimer's disease was admitted with a physician's order for continuous enteral feeding via a PEG tube. During observation, the enteral feeding container in use for this resident was found to be lacking a label indicating the date and time it was opened and hung, which is required to ensure safe administration within the recommended 48-hour timeframe as per facility policy. This omission was directly observed while the tube feeding and pump were running and delivering nutrition to the resident. Additionally, the resident's wheelchair and the attached feeding pole were observed to be coated with a dried tan residue, which was present on multiple surfaces including the seat cushion, seat support, back support, armrests, and wheels. The Nursing Home Administrator confirmed that housekeeping is responsible for scheduled cleaning of all wheelchairs and that all staff are expected to clean wheelchairs immediately when soiled. The facility failed to ensure proper labeling of enteral feeding containers and did not maintain the resident's equipment in a sanitary condition.
Failure to Provide Trauma-Informed, Person-Centered Care for Resident with PTSD
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered plan to provide trauma-informed care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). A review of the facility's policy on trauma-informed care indicated that care and services should be culturally competent, account for resident experiences and preferences, and address the needs of trauma survivors by minimizing triggers and re-traumatization. However, the clinical record for the resident, who was admitted with diagnoses including PTSD and anxiety, did not include identification of PTSD symptoms, triggers, or resident-specific interventions to address these needs. Additionally, an outside psychiatry consultation for the resident did not mention a history of PTSD, and the current care plan in effect at the time of review failed to address the resident's PTSD diagnosis or provide interventions to minimize triggers and re-traumatization. Interviews with the Nursing Home Administrator and Social Services Director confirmed that the facility could not demonstrate the provision of culturally competent, trauma-informed care in accordance with professional standards and the resident's preferences.
Failure to Prevent and Manage Pressure Ulcers Resulting in Actual Harm
Penalty
Summary
The facility failed to develop and implement care and services consistent with professional standards of practice to prevent the development of a pressure ulcer for a resident, resulting in actual harm. The resident was admitted with diagnoses including muscle weakness, dysphagia, and urinary retention, and was identified as being at moderate risk for pressure injury development. The care plan included interventions such as a pressure-reducing mattress, wheelchair cushion, encouragement of nutrition and hydration, weekly skin assessments, and repositioning every two hours. However, documentation and staff interviews revealed that these interventions, particularly scheduled turning and repositioning, were not consistently implemented or documented as ordered by the physician. Clinical records and task summary reports from the period in question failed to show evidence that staff performed the required pressure ulcer prevention tasks, specifically scheduled turning and repositioning. Additionally, licensed nursing staff did not develop or implement timely interventions to address the resident's decreased mobility and risk for pressure injuries. The facility was also unable to provide evidence of weight loss or treatment refusals by the resident, and there were inconsistencies in the administration of prescribed nutritional supplements. Over the course of several weeks, the resident developed new pressure ulcers on the buttocks and sacrum, which progressed from Stage II to unstageable ulcers with slough and eschar, eventually merging into a large ulceration. Despite updates to the care plan and new treatment orders, the lack of consistent implementation of preventive measures and documentation contributed to the worsening of the resident's condition, ultimately resulting in the resident being sent to the emergency room for evaluation due to the deterioration of the sacral wound.
Failure to Enforce Compliance and Ethics Program Regarding Vendor Kickbacks
Penalty
Summary
The facility failed to effectively implement and enforce its compliance and ethics program, as evidenced by the actions of two employees in the activity department and business office. The Code of Ethics manual required all employees to undergo compliance training and to report any unethical, illegal, or unprofessional behavior. Despite this, Employee 1, the Activities Director, accepted monetary payments from an insurance vendor in exchange for introducing the vendor to residents and/or their responsible parties, resulting in several residents being signed up for the vendor's insurance plan. Employee 1 admitted to accepting payments on multiple occasions, motivated by financial need and persistent encouragement from the vendor. Employee 2, the Business Office Manager, was aware of the vendor's offers to compensate staff for facilitating insurance enrollments, having witnessed such discussions at a staff party and being directly offered payment to intervene with a resident's family regarding insurance enrollment. Despite completing annual training on the Code of Ethics and Corporate Compliance, Employee 2 did not report these unethical solicitations to facility leadership or the compliance hotline, as required by facility policy. Other employees who witnessed the vendor's discussions also failed to report the behavior. The Nursing Home Administrator confirmed that she was unaware of the vendor's actions and the employees' involvement until the investigation was initiated. The lack of reporting by both Employee 1 and Employee 2, despite their training and the facility's mandatory reporting policy, demonstrated a failure in the facility's internal controls to monitor adherence to statutes, regulations, and program requirements. This deficiency resulted in the facility's inability to prevent and detect criminal, civil, and administrative violations related to the Anti-Kickback statute and the facility's own Code of Ethics.
Facility Fails to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios as stipulated by the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, §211.12 Nursing Services, effective July 1, 2024. Specifically, the facility did not provide the minimum number of nurse aides per resident on six out of twenty-one reviewed shifts. The regulation mandates a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight. However, on several dates in January 2025, the facility's staffing records showed a shortfall in the required number of nurse aides for the night and evening shifts, based on the facility's census. For instance, on January 5, 2025, the night shift had 6.30 nurse aides instead of the required 7.07 for a census of 106 residents. Similarly, on January 6, 2025, the evening shift had 9.07 nurse aides instead of the required 9.73 for a census of 107 residents. These deficiencies were confirmed during an interview with the Nursing Home Administrator on January 28, 2025. The report also noted that no additional higher-level staff were available to compensate for the staffing shortfall on the mentioned dates.
Plan Of Correction
The facility cannot retroactively correct the Nurse Aide Staff to resident ratios on previous shifts. The NHA/Designee educated the Nursing Staff Scheduler and Director of Nursing on minimum nurse aide to resident ratios on all shifts, ensuring continued proactive planning and follow up to address issues identified. Daily staffing meetings will be held with the NHA, Staff Scheduler, DON, and other team members as necessary to review per patient ratios 5 days per week to review projected staffing, reconcile prior days staffing, and follow up as needed for continued improvement and comprehensive team approach. The facility utilizes contracted nursing staff, incentives, and flexible schedules for current staff, focuses on recruitment of direct hire staff for continuity of care as well as employee engagement, feedback through town hall meetings, and individualized support to decrease absences. A call-in list is used to attempt to fill unexpected absences. Resident occupancy is reviewed and revised as needed with IDT during staffing meetings. The NHA/Designee will quality monitor Nurse Aide to resident ratios 5 days per week for 4 weeks, then one per week for 3 weeks, then monthly for 2 months to ensure minimum Nurse Aide to resident ratios are met. The NHA/Designee will quality monitor daily staffing meetings 5 days per week for 4 weeks, weekly for 3 weeks, then monthly for 2 months to ensure staffing meetings are occurring with required attendees.
LPN Staffing Deficiency on Day Shift
Penalty
Summary
The facility failed to meet the required minimum staffing levels for Licensed Practical Nurses (LPNs) during the day shift on one occasion. Specifically, on January 11, 2025, the facility did not provide the mandated ratio of one LPN per 25 residents, as evidenced by staffing records showing only 3.40 LPNs available for a resident census of 108, where 4.32 LPNs were required. This deficiency was confirmed during an interview with the Nursing Home Administrator on January 28, 2025.
Plan Of Correction
The facility cannot retroactively correct the Licensed Practical Nurse staff to resident ratios on previous shifts. The NHA/Designee educated the Nursing Staff Scheduler and Director of Nursing on minimum Licensed Practical Nurse staff to resident ratios on all shifts, ensuring continued proactive planning and follow-up to address issues identified. Daily staffing meetings will be held with the NHA, Staff Scheduler, DON, and other team members as necessary to review per patient hours 5 days per week to review projected staffing, reconcile prior days staffing, and follow up as needed for continued improvement and a comprehensive team approach. The facility utilizes contracted nursing staff, incentives, and flexible schedules for current staff, focuses on recruitment of direct hire staff for continuity of care, as well as employee engagement, feedback through town hall meetings, and individualized support to decrease absences. A call-in list is used to attempt to fill unexpected absences. Resident occupancy is reviewed and revised as needed with the IDT during staffing meetings. The NHA/Designee will quality monitor Licensed Practical Nurse staff to resident ratios 5 days per week for 4 weeks, then one per week for 3 weeks, then monthly for 2 months to ensure minimum Licensed Practical Nurse to resident ratios are met. The NHA/Designee will quality monitor daily staffing meetings 5 days per week for 4 weeks, weekly for 3 weeks, then monthly for 2 months to ensure staffing meetings are occurring with required attendees.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to consistently meet the required minimum of 3.2 hours of direct resident care per resident per day, as mandated by the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, effective July 1, 2024. A review of the facility's staffing levels revealed deficiencies on specific dates in January 2025, where the facility provided only 3.13, 3.00, and 3.06 direct care nursing hours per resident, respectively. This shortfall in nursing care hours was confirmed during an interview with the Nursing Home Administrator on January 28, 2025.
Plan Of Correction
The facility cannot retroactively correct the per patient hours on previous days. The NHA/Designee educated the Nursing Staff Scheduler and Director of Nursing on minimum 3.20 per patient hours per day, ensuring continued proactive planning and follow up to address issues identified. Daily staffing meetings will be held with the NHA, Staff Scheduler, DON, and other team members as necessary to review per patient hours 5 days per week to review projected staffing, reconcile prior days staffing, and follow up as needed for continued improvement and comprehensive team approach. The facility utilizes contracted nursing staff, incentives, and flexible schedules etc. for current staff, focuses on recruitment of direct hire staff for continuity of care as well as employee engagement, feedback through town hall meetings, and individualized support to decrease absences. A call-in list is used to attempt to fill unexpected absences. Resident occupancy is reviewed and revised as needed with IDT during staffing meetings. The NHA/Designee will quality monitor per patient hours 5 days per week for 4 weeks, then one per week for 3 weeks, then monthly for 2 months to ensure minimum 2.87 per patient hours are met. The NHA/Designee will quality monitor daily staffing meetings 5 days per week for 4 weeks, weekly for 3 weeks, then monthly for 2 months to ensure staffing meetings are occurring with required attendees.
Staffing Deficiency in Nurse Aide Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios on 18 out of 48 shifts reviewed. The regulation, effective July 1, 2024, mandates a minimum of 1 nurse aide per 10 residents during the day, 1 per 11 residents in the evening, and 1 per 15 residents overnight. However, the facility's staffing records revealed multiple instances where the number of nurse aides fell short of these requirements. For example, on December 17, 2024, the night shift had 5.5 nurse aides instead of the required 6.73 for a census of 101 residents. Similar deficiencies were noted on various dates, including December 22, 24, 25, 26, 27, 28, 29, 30, 31, 2024, and January 1, 2025, across different shifts. The Nursing Home Administrator confirmed during an interview on January 3, 2025, that the facility did not meet the required nurse aide to resident ratios on the specified dates. Additionally, there were no higher-level staff available to compensate for the staffing deficiencies. This lack of adequate staffing was consistent across several shifts, indicating a systemic issue in maintaining the mandated staffing levels.
Plan Of Correction
The facility cannot retroactively correct the Nurse Aide Staff to resident ratios on past shifts identified. The facility cannot retroactively correct the Nurse Aide Staff to resident ratios on previous shifts. The NHA/Designee educated the Nursing Staff Scheduler and Director of Nursing on minimum nurse aide to resident ratios on all shifts, ensuring continued proactive planning and follow up to address issues identified. Daily staffing meetings will be held with the NHA, Staff Scheduler, DON, and other team members as necessary to review per patient ratios 5 days per week to review projected staffing, reconcile prior days staffing, and follow up as needed for continued improvement and comprehensive team approach. The facility utilizes contracted nursing staff, incentives, and flexible schedules etc. for current staff, focuses on recruitment of direct hire staff for continuity of care as well as employee engagement, feedback through town hall meetings, and individualized support to decrease absences. A call-in list is used to attempt to fill unexpected absences. Resident occupancy is reviewed and revised as needed with IDT during staffing meetings. The NHA/Designee will quality monitor Nurse Aide to resident ratios 5 days per week for 4 weeks, then one per week for 3 weeks, then monthly for 2 months to ensure minimum Nurse Aide to resident ratios are met. The NHA/Designee will quality monitor daily staffing meetings 5 days per week for 4 weeks, weekly for 3 weeks, then monthly for 2 months to ensure staffing meetings are occurring with required attendees.
LPN Staffing Deficiency
Penalty
Summary
The facility failed to meet the required LPN-to-resident ratios on six shifts out of 48 reviewed, as evidenced by a review of nurse staffing records and staff interviews. Specifically, on December 21, 2024, the evening shift had 2.88 LPNs instead of the required 3.37 for a census of 101 residents. On December 22, 2024, the night shift had 2.38 LPNs instead of the required 2.53 for the same census. On December 25, 2024, the day shift had 3.19 LPNs instead of the required 4.16 for a census of 104, and the evening shift had 3.19 LPNs instead of the required 3.47. On December 30, 2024, the evening shift had 3.5 LPNs instead of the required 3.57 for a census of 107. Finally, on December 31, 2024, the night shift had 2.13 LPNs instead of the required 2.73 for a census of 109. The Nursing Home Administrator confirmed these deficiencies during an interview on January 3, 2025.
Plan Of Correction
The facility cannot retroactively correct the Licensed Practical Nurse Staff to resident ratios on past shifts identified. The facility cannot retroactively correct the Licensed Practical Nurse Staff to resident ratios on previous shifts. The NHA/Designee educated the Nursing Staff Scheduler and Director of Nursing on minimum Licensed Practical Nurse staff to resident ratios on all shifts, ensuring continued proactive planning and follow-up to address issues identified. Daily staffing meetings will be held with the NHA, Staff Scheduler, DON, and other team members as necessary to review per patient hours 5 days per week to review projected staffing, reconcile prior days staffing, and follow up as needed for continued improvement and comprehensive team approach. The facility utilizes contracted nursing staff, incentives, and flexible schedules, etc. for current staff, focuses on recruitment of direct hire staff for continuity of care as well as employee engagement, feedback through town hall meetings, and individualized support to decrease absences. A call-in list is used to attempt to fill unexpected absences. Resident occupancy is reviewed and revised as needed with IDT during staffing meetings. The NHA/Designee will quality monitor Licensed Practical Nurse Staff to resident ratios 5 days per week for 4 weeks, then one per week for 3 weeks, then monthly for 2 months to ensure minimum Licensed Practical Nurse to resident ratios are met. The NHA/Designee will quality monitor daily staffing meetings 5 days per week for 4 weeks, weekly for 3 weeks, then monthly for 2 months to ensure staffing meetings are occurring with required attendees.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to consistently meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day. A review of the facility's staffing levels revealed that on several dates, including December 22, 25, 27, 29, 30, 2024, and January 1, 2025, the facility provided less than the required nursing care hours, with figures ranging from 2.88 to 3.19 hours per resident. An interview with the Nursing Home Administrator confirmed the facility's inability to meet the mandated staffing levels on these dates.
Plan Of Correction
The facility cannot retroactively correct the per patient hours on past days identified. The facility cannot retroactively correct the per patient hours on previous days. The NHA/Designee educated the Nursing Staff Scheduler and Director of Nursing on minimum 3.20 per patient hours per day, ensuring continued proactive planning and follow up to address issues identified. Daily staffing meetings will be held with the NHA, Staff Scheduler, DON, and other team members as necessary to review per patient hours 5 days per week to review projected staffing, reconcile prior days staffing, and follow up as needed for continued improvement and comprehensive team approach. Facility utilizes contracted nursing staff, incentives, and flexible schedules etc. for current staff, focuses on recruitment of direct hire staff for continuity of care as well as employee engagement, feedback through town hall meetings, and individualized support to decrease absences. Call in list used to attempt fill unexpected absences. Resident occupancy reviewed and revised as needed with IDT during staffing meetings. The NHA/Designee will quality monitor per patient hours 5 days per week for 4 weeks, then one per week for 3 weeks, then monthly for 2 months to ensure minimum 2.87 per patient hours are met. The NHA/Designee will quality monitor daily staffing meetings 5 days per week for 4 weeks, weekly for 3 weeks, then monthly for 2 months to ensure staffing meetings are occurring with required attendees.
Inadequate Infection Control Program Leads to Scabies Outbreak
Penalty
Summary
The facility failed to develop and implement a comprehensive infection control program, which led to the spread of infectious diseases, including scabies, among residents and staff. The infection control tracking logs lacked detailed data collection necessary for monitoring and investigating infections, such as resident room location, infectious organism, treatment, infection start and resolution dates, symptoms, and culture information. This lack of documentation prevented the facility from identifying potential trends and implementing specific interventions to prevent the spread of infections. Resident 7, who was admitted with heart disease and chronic kidney disease, developed an itchy rash that persisted despite treatment with Triamcinolone cream and Cetirizine. The resident was placed on contact precautions, but the rash continued to spread, leading to a dermatology consult that confirmed scabies. The facility's infection control documentation revealed that 12 additional residents and several staff members also developed itchy rashes, indicating a scabies outbreak. However, there was no evidence of consistent nursing assessments or documentation regarding staff rashes and treatments. The facility's central supply room was found to be in poor condition, with visible dirt, debris, and unclean equipment, further indicating a failure to maintain an environment conducive to infection prevention. The Director of Nursing confirmed that infection control practices were not maintained, and the facility failed to implement proper infection control practices, including their established policy and procedures, to prevent and mitigate the spread of scabies.
Delayed Response to Call Bells Affects Resident Dignity
Penalty
Summary
The facility failed to provide timely responses to residents' requests for assistance, impacting their quality of life and dignity. This deficiency was identified through a review of clinical records, resident council meeting minutes, grievances, and interviews with residents and staff. Specifically, two residents out of 21 sampled, and five out of nine residents during a group interview, reported experiencing long wait times for staff to respond to call bells. Resident 25, who is moderately cognitively impaired, reported waiting 20 minutes or longer for assistance. Resident 74, who is cognitively intact, described waiting from 15 minutes to two hours for care, including a two-hour wait for pain medication. During a resident council group interview, several residents expressed distress over the long wait times. Resident 24 reported waiting 20 to 30 minutes for assistance, while Resident 28 noted that the wait time is particularly long in the evening. Resident 31 mentioned that staff sometimes turn off the call bell without returning promptly. Resident 55 shared an experience of being left on the toilet for 30 minutes, and Resident 57 indicated that she often waits 30 minutes for assistance, leading her to transfer herself to the bathroom unsafely. The Nursing Home Administrator and Director of Nursing acknowledged the importance of treating residents with dignity and respect but could not explain the untimely responses to residents' requests.
Failure to Prevent Pressure Ulcers in Residents
Penalty
Summary
The facility failed to consistently provide care and services to prevent the development of pressure sores for two residents. Resident 19, who was admitted with chronic obstructive pulmonary disease and was cognitively intact, developed a Stage II pressure injury on her left ear due to oxygen tubing. Despite having a care plan in place to prevent skin breakdown, the facility did not consistently implement effective interventions, such as padding the oxygen tubing, leading to the development of the pressure injury. Resident 26, who was readmitted with a left hip fracture, reduced mobility, and Alzheimer's disease, developed pressure areas on her left buttock and sacrum. The facility's records did not show that staff performed necessary pressure ulcer prevention tasks, such as scheduled turning and repositioning or frequent incontinence care. Additionally, there was no documentation of interventions being developed and implemented to prevent pressure areas related to the resident's declined mobility. The facility's failure to implement consistent and appropriate measures resulted in the worsening of Resident 26's sacral wound, which progressed from a Stage II to an unstageable pressure area. The Director of Nursing confirmed that the facility did not take consistent actions to prevent the development and worsening of pressure sores for the residents involved.
Failure to Provide Restorative Nursing Services
Penalty
Summary
The facility failed to ensure that a resident received appropriate services and assistance to maintain or improve mobility, as required by their restorative nursing program. Resident 74, who was admitted with chronic kidney disease and pulmonary embolism, was cognitively intact and had been placed on a restorative nursing program for ambulation and active range of motion. This program was initiated in April 2024 and discontinued in November 2024. However, documentation revealed that the resident did not receive or was not offered the scheduled restorative nursing program on 18 occasions between October and November 2024. Despite a physical therapy discharge summary indicating that the resident's prognosis to maintain their current level of function was excellent with participation in the restorative nursing program, the resident reported not receiving the necessary therapy or services. The Nursing Home Administrator confirmed the facility's responsibility to provide these services but could not provide documented evidence that the resident received the planned restorative nursing services. This lack of service delivery was confirmed through interviews and a review of the facility's policy and clinical records.
Failure to Provide Individualized Incontinence Care
Penalty
Summary
The facility failed to assess and implement individualized measures to meet the toileting needs of a resident, identified as Resident 26, who was part of a sample of 21 residents. The facility's policy required residents to be evaluated for continence upon admission, quarterly, and with significant changes in status. However, despite Resident 26's documented incontinence and cognitive impairment, the facility did not provide evidence of a tailored continence management program or frequent incontinence checks and care. This lack of individualized care was evident in the resident's care plan, which did not reflect necessary interventions to prevent skin breakdown due to incontinence. Resident 26, who had Alzheimer's disease and was severely cognitively impaired, was always incontinent of bowel and bladder and required substantial assistance with personal care. After being readmitted to the facility with additional diagnoses, including a hip fracture and reduced mobility, the resident developed a Stage II pressure ulcer on the sacrum. The facility's investigation revealed that staff did not perform more frequent incontinence checks and care, which contributed to the development of the pressure ulcer. The Nursing Home Administrator confirmed the facility's inability to provide evidence of consistent and timely incontinence management for Resident 26.
Failure to Provide Timely Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, identified as Resident 9, who was prescribed Pregabalin Oral Capsule 25 mg for neuropathic pain management. The deficiency occurred when the resident did not receive six doses of the medication from November 8, 2024, through November 10, 2024, due to the pharmacy not delivering the medication to the facility. Despite a physician order initiated on November 8, 2024, and communication between the facility and pharmacy services, the medication was not administered as required. The facility's policy requires that all controlled substance orders be communicated to the pharmacy, with specific instructions for timely delivery if needed before the next scheduled delivery. However, despite a STAT delivery request and confirmation of the prescription receipt by the pharmacy, the medication was not provided until November 10, 2024, at 9:00 PM. The Director of Nursing confirmed the failure to provide the medication as prescribed, acknowledging the facility's responsibility to ensure pharmacy services meet each resident's needs.
Lack of Documentation for Antipsychotic Use in Resident with Anxiety
Penalty
Summary
The facility failed to ensure proper documentation and justification for the continued use of an antipsychotic medication, quetiapine fumarate, for a resident diagnosed with Alzheimer's disease and generalized anxiety disorder. The resident, who was severely cognitively impaired, was prescribed quetiapine to manage anxiety. However, the clinical records lacked evidence of the physician's documentation of the clinical rationale for the continued administration of this medication. Despite behavior tracking indicating no maladaptive behaviors related to anxiety, the resident's quetiapine dosage was increased without adequate documentation of the necessity for such an increase. The facility's records did not show any individualized non-pharmacological interventions being developed or implemented to address the resident's anxiety-related behaviors. Furthermore, the resident's care plan did not identify anxiety or related behavioral symptoms as a problem, nor did it include any non-pharmacological strategies. Interviews with the Nursing Home Administrator and Director of Nursing revealed that they could not provide documented evidence justifying the use of the antipsychotic medication for the resident's anxiety. Additionally, they were unable to demonstrate that the facility had attempted to develop and implement non-pharmacological interventions to manage the resident's anxiety. This lack of documentation and failure to explore alternative interventions contributed to the deficiency identified in the report.
Failure to Maintain Clean Environment for Resident
Penalty
Summary
The facility failed to maintain a clean and homelike environment for Resident 76, as observed and reported during a survey. On October 16, 2024, Resident 76 reported that her soiled clothing was not being taken to the laundry, resulting in dirty clothes accumulating at the bottom of her closet. This was confirmed during an observation at the same time, where several dirty clothing articles were found crumpled on the bottom shelf of her closet. Employee 1, an LPN, acknowledged that the facility is responsible for washing Resident 76's clothing and confirmed that soiled clothing should be placed in a laundry receptacle for cleaning. The LPN also confirmed the presence of dirty clothing in the closet and removed them. The Nursing Home Administrator later confirmed the facility's responsibility to maintain a clean and homelike environment for all residents.
Failure to Administer Timely Antibiotic Treatment
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of practice by not ensuring that a physician-ordered antibiotic was timely obtained and administered to a resident diagnosed with cellulitis. The resident, who was admitted with a diagnosis including chronic atrial fibrillation, was noted to have a slight pink discoloration on her right lower extremity, leading to a physician's order for Doxycycline 100 mg twice a day. However, the pharmacy did not send the medication due to the resident's known allergy to tetracycline, which is contraindicated with Doxycycline. Despite this, the facility did not take timely action to address the issue. The nursing staff failed to implement the facility's policy for notification of change in condition, which required contacting the medical director if the attending physician did not respond in a reasonable time. The physician did not respond to the facility's attempts to clarify and confirm the order, resulting in the resident not receiving any doses of the prescribed medication or an alternative treatment for her cellulitis. Interviews with the resident and the Nursing Home Administrator confirmed the delay in treatment and the failure to contact the medical director to change the medication order.
Unnecessary Antibiotic Administration
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary antibiotics, as required by their antibiotic stewardship policy. The policy emphasizes the importance of prescribing antibiotics only when necessary to prevent issues such as gastrointestinal disease and drug-resistant pathogens. Despite this, a resident was prescribed and administered Macrodantin for a urinary tract infection without meeting the criteria for antibiotic therapy. The resident's clinical records showed no symptoms of a urinary tract infection, yet the medication was administered following the insistence of the resident's family. The resident, who was cognitively intact with a BIMS score of 14, had a urine culture showing E. coli growth, but no symptoms were documented to justify the antibiotic treatment. The facility's Nursing Home Administrator confirmed that the criteria for antibiotic therapy were not met, acknowledging the facility's responsibility to prevent unnecessary antibiotic use. This incident highlights a lapse in adhering to the facility's antibiotic stewardship program, as the decision to administer antibiotics was influenced by external pressure rather than clinical necessity.
Failure to Implement Pressure Ulcer Care and Timely Interventions
Penalty
Summary
The facility failed to provide necessary care to promote healing and prevent the worsening of a pressure sore for a resident, leading to deterioration and clinical complications. The resident, who was admitted with a pressure ulcer on the right heel, was at risk for developing pressure ulcers and had unhealed pressure ulcers. Upon admission, the resident's pressure wound was noted as unstageable and necrotic, but no further assessment details were documented. The care plan did not include measures to reduce pressure on the unstageable pressure ulcer, such as offloading pressure, turning, and repositioning. Subsequent assessments failed to document thorough details of the pressure wound, and the wound increased in size over time. A wound consult later revealed the pressure sore had worsened, with recommendations for a repositioning schedule and the use of Prevalon boots, which were not implemented by the facility. The resident's condition deteriorated further, with an x-ray revealing calcaneus erosion consistent with osteomyelitis, a bone infection. The facility did not timely notify the physician of the x-ray results, delaying prompt treatment. The resident was eventually sent to the hospital with worsening symptoms, including a non-healing wound and osteomyelitis. Hospital records indicated that the resident's wounds were extensive, and without debridement of dead bone, the chances of curing the osteomyelitis were minimal. The facility's failure to implement recommended measures and document thorough assessments contributed to the resident's declining condition.
Inadequate Wound Assessment and Documentation
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of quality, as evidenced by the inadequate evaluation and documentation of a resident's wounds. The resident, who was admitted with multiple wounds including venous ulcers and a necrotic pressure ulcer, did not have a complete assessment documented by the nursing staff. The assessments lacked critical details such as drainage, wound description, and the condition of surrounding tissue, which are essential for monitoring and treatment. The nursing staff also failed to differentiate between pressure and non-pressure wounds in their documentation, leading to incomplete and inaccurate records. This oversight was evident in multiple assessments where the type of wound was not identified, and the specific locations of wounds on the resident's body were not clearly documented. This lack of thorough documentation hindered the ability to monitor the resident's condition effectively and identify any deterioration in a timely manner. The deficiency was further highlighted when a wound consultant noted significant deterioration in the resident's right heel, recommending an X-ray that revealed osteomyelitis. Despite receiving the X-ray results, there was no documentation of the attending physician being notified until several days later, delaying necessary treatment. This delay in communication and action contributed to the resident's condition worsening, as confirmed by hospital records indicating a severe infection requiring intravenous antibiotics.
Failure to Administer Prescribed IV Antibiotics
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of physician-ordered intravenous (IV) medications for a resident. Specifically, Resident 148, who was admitted with a peripherally inserted central catheter (PICC line) and diagnosed with a septic left knee and diabetes, did not receive the prescribed IV antibiotic, Daptomycin, on three consecutive days. The facility's policy on administering medications, which requires medications to be administered within one hour of their prescribed time, was not followed. Interviews with the Director of Nursing and the nursing home administrator confirmed the failure to administer the IV antibiotic therapy as prescribed and the failure to notify the attending physician of the missed doses. This deficiency was identified during a review of the resident's Medication Administration Record and was corroborated by staff interviews, highlighting a lapse in the facility's adherence to its medication administration policy.
Failure in Pain Management Protocols
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents by not attempting non-pharmacological interventions before administering opioid pain medication and not adhering to physician orders. Resident 8, diagnosed with fibromyalgia, had a physician order for oxycodone to be administered as needed for pain levels between 4 and 10. However, the facility's records showed that on multiple occasions in May, June, and July 2024, the medication was given without first attempting non-pharmacological interventions. This lack of adherence to protocol was confirmed during an interview with the Nursing Home Administrator. Similarly, Resident 20, diagnosed with Multiple Sclerosis, had a physician order for oxycodone to be administered for pain levels between 7 and 10. Despite this, the facility's records indicated that the medication was administered for pain levels below the prescribed threshold on several occasions in May, June, and July 2024. The Nursing Home Administrator confirmed that there was no documented evidence of non-pharmacological interventions being attempted prior to administering the medication, and the facility did not follow the physician's orders for pain management.
Failure to Provide Timely Antibiotic Administration
Penalty
Summary
The facility failed to provide timely pharmacy services for Resident 148, who was admitted with a septic left knee and diabetes. A physician's order was in place for the administration of Daptomycin, an intravenous antibiotic, to be given daily in the morning until August 12, 2024. However, a review of the Medication Administration Record revealed that the antibiotic was not administered on July 12, 13, and 14, 2024. This lapse occurred because the facility's pharmacy did not deliver the medication on time, as confirmed by the Nursing Home Administrator during an interview on July 19, 2024.
Failure to Document Pharmacist Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a comprehensive monthly drug regimen review for residents, as required by their policies and procedures. Specifically, the pharmacist did not identify and report irregularities in the drug regimens of four residents, nor was there evidence that physicians acted upon any identified irregularities. The residents involved had various diagnoses, including type 2 diabetes, depression, anxiety, generalized anxiety disorder, major depressive disorder, viral hepatitis, and chronic obstructive pulmonary disease (COPD). Despite the pharmacist completing medication regimen reviews on multiple occasions, the facility could not provide documentation of the results, any noted irregularities, recommendations made, or physician responses. During the survey, it was confirmed through a staff interview that the facility lacked documented evidence of the pharmacist's recommendations or identification of irregularities in the drug regimens of the residents. The Nursing Home Administrator verified the absence of documentation, which is a violation of the facility's regulatory requirements under 28 Pa. Code 211.9 (k) Pharmacy services, 28 Pa. Code 211.12 (c) Nursing services, and 28 Pa. Code 211.2 (d)(3) Medical Director. This deficiency was identified for four out of the 24 residents sampled during the survey.
Inadequate Infection Control Program Implementation
Penalty
Summary
The facility failed to maintain and implement a comprehensive infection prevention and control program for two months, specifically June and July 2024. The facility's policy on infection control, last reviewed on May 9, 2024, outlines objectives to prevent, detect, investigate, and control infections, as well as maintain records of incidents and corrective actions. However, a review of the facility's infection control data revealed that the last recorded data for monitoring and managing healthcare-associated infections was completed on May 27, 2024. There was no documented evidence of infection control surveillance and data analysis activities from May 27, 2024, through July 19, 2024. During this period, the facility lacked a functional system to analyze infection clusters, changes in prevalent organisms, or increases in infection rates. Employee 6, the Infection Preventionist, indicated that she coordinated and implemented the infection control program until June 5, 2024, when she transitioned to a different role. She was unable to provide evidence of surveillance activities after May 27, 2024. The Nursing Home Administrator confirmed that the Infection Preventionist was not performing the required duties to implement an effective infection control program, resulting in the facility's failure to fully implement a comprehensive program during the specified months.
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by multiple grievances and interviews with residents and staff. Residents reported long wait times for call bell responses, with some waiting over 20 minutes for assistance. This issue was particularly prevalent during the evening shift and meal times when staff were occupied with other duties. Residents expressed feelings of frustration and anger due to the delays in receiving care, which sometimes resulted in accidents or unmet care needs. Clinical record reviews revealed that several residents, including those with chronic conditions such as COPD, heart failure, and coronary artery disease, were cognitively intact and aware of the staffing deficiencies. These residents reported that the facility was often short-staffed, especially on weekends, and that the number of new admissions had increased without a corresponding increase in nursing staff. This led to residents feeling rushed and dependent on staff for assistance with activities of daily living. Observations and interviews with staff confirmed the staffing shortages, with reports of nurse aides and LPNs calling off and not being replaced. The facility's staffing records showed that they failed to meet the required minimum state ratios for nurse aides and LPNs on numerous occasions. The Nursing Home Administrator acknowledged the staffing issues and confirmed that the facility did not provide additional direct care staff to accommodate the increased resident census.
Facility Fails to Provide Accessible Smoking Area for Residents
Penalty
Summary
The facility failed to uphold the residents' right to self-determination by not providing an accessible smoking area for residents who smoked prior to the implementation of a new non-smoking policy. Two residents, identified as Resident 21 and Resident 72, were affected by this change. Resident 21, who is cognitively intact and uses a wheelchair for mobility, expressed frustration as she could no longer smoke on facility grounds and required assistance to reach the designated smoking area across the street. Similarly, Resident 72, who has moderate cognitive impairment and requires substantial help for mobility, was unable to access the smoking area without assistance. The facility's new smoking policy, effective May 10, 2024, prohibited smoking on facility grounds and required residents to sign out and smoke offsite. This policy change was discussed in a Resident Council meeting, and residents were informed that staff would no longer assist with smoking. The designated smoking area was located across the street, which presented mobility challenges due to uneven terrain and potential hazards, making it difficult for residents in wheelchairs to access safely. During interviews, both residents expressed dissatisfaction with the lack of assistance and the inability to smoke as they had before. The Nursing Home Administrator confirmed the policy change and acknowledged the difficulties residents faced in reaching the smoking area. The facility offered smoking cessation programs and assistance with transferring to another facility for residents who wished to continue smoking, but failed to provide a safe and accessible smoking area for current residents who smoked.
Failure to Notify Resident Representative of Abuse Incident
Penalty
Summary
The facility failed to timely notify the resident representative of an allegation of physical abuse involving Resident 35. Resident 35, who was admitted with diagnoses including spinal stenosis and hypertension, reported an incident where another resident, Resident 87, entered her room uninvited and slapped her in the face. This incident occurred when Resident 35 asked Resident 87 to put down an orange. Despite the seriousness of the incident, there was no documented evidence that the facility informed Resident 35's representative, who holds medical and financial Power of Attorney, about the reported abuse. The incident was documented in a facility incident report dated July 9, 2024, and a grievance report dated July 11, 2024, highlighted the representative's dissatisfaction with not being informed. An interview with the Nursing Home Administrator confirmed the failure to notify the resident's representative in a timely manner. This deficiency is a violation of the Pennsylvania Code, specifically 28 Pa. Code 211.12 (d)(3)(5) regarding nursing services and 28 Pa. Code 201.29 (b) concerning resident rights.
Failure to Maintain Comfortable Environment for Resident
Penalty
Summary
The facility failed to provide a comfortable environment for Resident 89, who was admitted with a diagnosis of spinal stenosis and is cognitively intact with a BIMS score of 15. The resident reported that the temperature in his room was too warm and uncomfortable due to a non-functioning cooling unit, which had been an issue since his admission over a month ago. Despite the facility offering a room change, the resident preferred to stay in his current room with a functioning cooling unit. Observations and interviews revealed that the air cooling unit in the resident's room had not been functioning for over a month, with the room temperature recorded at 75.1 F. A maintenance request order dated May 24, 2024, indicated the issue, but no repairs had been made by the time of the survey ending July 19, 2024. The Nursing Home Administrator was unable to provide evidence of scheduled or in-progress repairs, confirming the facility's responsibility to ensure a comfortable environment for residents.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse and mental anguish, as evidenced by an incident involving two residents. Resident 35, who was cognitively intact, reported that Resident 87, who was severely cognitively impaired, entered her room uninvited and slapped her in the face after being told to return an orange she had taken. The incident report indicated that Resident 35 was assessed with no injuries noted, but she expressed upset over the incident and concern about Resident 87's potential for further aggression. The facility's policy on abuse prevention and investigation was not effectively implemented, as Resident 87 had a known history of entering other residents' rooms uninvited and becoming agitated. Despite this, adequate measures were not in place to prevent the incident. The RN Supervisor acknowledged being aware of Resident 87's behavior and potential for aggression, yet the facility did not ensure sufficient supervision or intervention to prevent the altercation. The nursing home administrator confirmed the facility's failure to protect Resident 35 from abuse.
Failure to Investigate Alleged Abuse and Injury of Unknown Source
Penalty
Summary
The facility failed to investigate an injury of unknown source for Resident 24, who was severely cognitively impaired and receiving anticoagulant therapy. Despite multiple instances of unexplained vaginal bleeding documented in nursing progress notes, there was no evidence that the facility conducted an investigation to rule out abuse, neglect, or mistreatment. The Nursing Home Administrator and Director of Nursing confirmed that no investigation or physical examination was conducted to determine the cause of the bleeding, which was a violation of the facility's abuse prohibition policy. Additionally, the facility did not thoroughly investigate an allegation of physical abuse involving Resident 35, who reported being slapped by another resident, Resident 87. The incident report noted that Resident 35 was assessed with no injuries, but the investigation lacked a statement from the staff member who initially reported the incident. Interviews revealed that Resident 87 had a history of entering other residents' rooms uninvited and becoming agitated, yet the facility did not substantiate the abuse allegation due to a lack of corroborating evidence. The facility's failure to conduct thorough investigations in both cases highlights a deficiency in adhering to their abuse prohibition policy. The policy mandates immediate reporting and investigation of any injury of unknown source or abuse allegation, which was not followed in these instances. This oversight potentially compromised the safety and well-being of the residents involved.
Inaccurate MDS Assessment for Discharged Resident
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) Assessments accurately reflected the status of a resident. Specifically, the MDS assessment for a resident who was discharged from the facility was found to be inaccurate. The resident's Discharge MDS assessment indicated that they were discharged to a short-term general hospital, whereas the Discharge Plan and Instructions showed that the resident was actually discharged home. This discrepancy was confirmed during an interview with the Nursing Home Administrator.
Failure to Implement Individualized Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement individualized plans to manage dementia-related behavioral symptoms for a resident, identified as Resident 87, who was diagnosed with Alzheimer's disease and was severely cognitively impaired. The deficiency was identified following an incident where Resident 87 entered another resident's room uninvited and slapped the resident when confronted. The care plan for Resident 87, initially dated April 10, 2024, did not adequately address the resident's behaviors of intrusive wandering, taking items that did not belong to her, and potential for agitation when confronted. Interviews with staff and residents revealed that Resident 87 had been exhibiting behaviors such as entering other residents' rooms uninvited and becoming agitated when told no. Despite these behaviors, the facility did not have a comprehensive, individualized person-centered plan to address and manage these dementia-related behaviors. The facility's failure to document and implement specific interventions to manage Resident 87's behaviors was confirmed by the Nursing Home Administrator, who acknowledged the lack of a comprehensive care plan to address these issues.
Failure to Notify Physician of Abnormal X-ray Results
Penalty
Summary
The facility failed to promptly notify the attending physician of abnormal x-ray results for a resident, leading to a delay in treatment. The resident, who was admitted with diagnoses including Type 2 diabetes and multiple ulcers, had a wound consult on July 10, 2024, which recommended an x-ray due to the deterioration of a pressure ulcer on the right heel. The x-ray, completed on July 11, 2024, revealed calcaneus erosion consistent with osteomyelitis. However, there was no documentation indicating that the physician was informed of these results on the same day. The deficiency was further highlighted when a change in condition assessment five days later noted increased pain and confirmed osteomyelitis, prompting the physician to be notified and the resident to be sent to the hospital. The Nursing Home Administrator confirmed the failure to notify the physician promptly, which was a breach of the facility's responsibility to ensure timely communication of critical health information.
Failure to Document Resident Incident and Abuse
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for two residents, as required by professional standards of practice. Resident 35, who was admitted with spinal stenosis and hypertension, reported an incident where Resident 87, diagnosed with Alzheimer's disease, entered her room uninvited and slapped her. Despite this report, there was no documentation in the clinical records of either resident regarding the incident of intrusive wandering and physical abuse. The deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the absence of documented evidence in the clinical records for both residents. This lack of documentation contravenes the American Nurses Association Principles for Nursing Documentation and the Title 49 Professional and Vocational Standards, which mandate timely and accurate record-keeping to ensure informed decisions and high-quality care.
Failure to Coordinate Hospice Services
Penalty
Summary
The facility failed to ensure proper coordination of care and services between the facility and the hospice agency for a resident diagnosed with malignant neoplasm of the liver and bile duct. The resident was admitted to the facility and had a physician order for hospice services to be provided at the facility. However, during a survey, it was found that the resident's care plan did not reflect the necessary coordination of services between the facility and the hospice agency to meet the resident's daily care needs and specific needs related to their terminal diagnosis. This lack of coordination was confirmed during an interview with the Nursing Home Administrator.
Failure to Evaluate and Address Bowel and Bladder Incontinence
Penalty
Summary
The facility failed to thoroughly assess and evaluate bowel and bladder function for a resident, leading to a deficiency in providing appropriate care. The facility's policy requires residents to be evaluated for continence upon admission, quarterly, and with significant changes in status. However, for one resident, there was no documented evidence of a Bowel and Bladder evaluation or Bowel and Bladder Elimination Pattern evaluation being completed upon admission or quarterly, despite the resident's frequent incontinence of bladder and bowel. The resident's condition declined, as noted in the Minimum Data Set (MDS) assessments, which showed an increase in bowel incontinence over time. The resident reported that nursing staff often took a long time to respond to call bells, resulting in delayed assistance with toileting. On one occasion, the resident waited over 15 minutes for help, leading to an accident due to bowel incontinence. The nursing home administrator confirmed that there was no documented evidence of the facility acting upon the resident's increased bowel incontinence or implementing any scheduled toileting programs in response to the decline in bowel function. This lack of timely evaluation and intervention contributed to the deficiency in care.
Failure to Implement Timely Disposition of Resident Medications
Penalty
Summary
The facility failed to implement a system to ensure the timely disposition of resident medications, leading to the improper storage of discontinued and unused medications. During an observation of the second-floor medication room, various medications, including antibiotics, pain medications, and diuretics, were found stored in drawers below the counter. These medications were in blister cards with preprinted pharmacy labels, some of which had the resident's name scratched off. Employee 2, a Registered Nurse, confirmed that these medications were not in a designated location for discontinued medications and should have been returned to the pharmacy for disposition. The RN was unable to explain the handwritten note found on top of the discontinued medications, which stated, 'all need to take turns.' Further observations in the third-floor medication room revealed similar issues, with medications stored in drawers and cupboards among resident care equipment. Medications such as heparin vials, Paxlovid, and Ipratropium-Albuterol solution were found improperly stored. Employee 1, an LPN, confirmed that these medications were not in a designated location for discontinued medications and should have been returned to the pharmacy. Both employees stated that pharmacy deliveries occur daily, and discontinued medications should be inventoried and placed in a pharmacy bag for return. Interviews with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) confirmed that discontinued medications should be picked up by the pharmacy or destroyed by nursing staff and not stockpiled in medication rooms. The NHA stated that the facility is to return discontinued medications to the pharmacy at least quarterly but was unable to explain why medications belonging to a resident discharged months earlier were still in the facility. The facility failed to implement procedures to ensure the timely disposition and secure storage of discontinued medications.
Infection Control Deficiency in Medication Room
Penalty
Summary
The facility failed to ensure the consistent implementation of infection control procedures in the third-floor medication room. During an observation on April 9, 2024, at approximately 9:28 AM, it was found that a small, dormitory-size medication refrigerator was located on the floor. Inside the refrigerator, resident medications were stored alongside two plastic, one-gallon containers of iced tea and six 16 fluid oz. bottles of salad dressings on the door. An interview with an LPN confirmed that the food and beverages stored in the medication refrigerator belonged to staff. The Director of Nursing also confirmed that the facility failed to store medications under sanitary conditions, which could potentially spread infection.
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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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.
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