Pine View Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Broomall, Pennsylvania.
- Location
- 50 North Malin Road, Broomall, Pennsylvania 19008
- CMS Provider Number
- 395078
- Inspections on file
- 27
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 44
Citation history
Health deficiencies cited at Pine View Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
Two residents did not receive accurate, comprehensive wound assessments or timely pressure ulcer treatments as required by facility policy. For one resident, a buttock wound noted on readmission lacked description and measurements, and was not fully assessed until a wound physician visit days later, when it was identified as MASD and treated with Medihoney. For another resident, a sacral pressure ulcer present on admission was documented by the wound nurse and had an order for daily Medihoney, but the TAR showed no treatments for several days, and a wound NP first documented intact skin before later describing a Stage 3 sacral pressure ulcer present on admission. The DON confirmed gaps in assessment, documentation, and treatment for both residents.
Surveyors observed that a nurse performed wound care on two residents without following basic infection control practices. For each resident, the nurse placed wound care supplies directly on the bed, including on a used incontinence brief, and positioned clean items next to soiled dressings. During both wound treatments, the nurse failed to change gloves or perform hand hygiene between steps, despite handling contaminated materials and then applying Medihoney and clean bordered dressings to the wounds. In a later interview, the nurse admitted placing supplies on the bed due to lack of side tables and acknowledged forgetting to change gloves and perform hand hygiene, even though they knew these actions were required.
Two residents who required assistance with bathing did not receive scheduled showers, and there was no documentation of showers being provided or refused, despite physician's orders and care plans. Both residents were cognitively intact and required help due to incontinence and other medical conditions, but records and staff interviews confirmed the absence of both care and documentation over several months.
The facility did not follow physician orders for medication administration for two residents, including administering insulin and metoprolol when clinical parameters required the medications to be held, and failed to promptly act on an outside physician's antibiotic recommendation for another resident following a consult appointment.
The facility did not complete required safety assessments before placing air mattresses for several residents with cognitive and physical impairments, and failed to provide leg rests during wheelchair transport for a resident whose feet were observed dragging on the floor. Staff and administration confirmed that these safety measures were not in place as required.
The facility did not ensure proper documentation and accountability for controlled medications for two residents. In one case, doses of Oxycodone were signed out but not documented as administered in the MAR. In another case, Fentanyl patches were applied as ordered, but there was no evidence that two staff members witnessed and signed for the destruction of old patches, as required by policy.
Two residents with cognitive impairment and mobility needs were observed seated at a dining room table with their wheelchair brakes engaged, restricting their ability to move away from the table. Staff, including an LPN and the DON, confirmed that wheelchairs were routinely locked for residents at risk of falls, despite facility policy requiring residents to be free from restraints unless medically necessary.
The facility did not complete comprehensive MDS assessments and Care Area Assessments within the required regulatory time frames for multiple residents. Several assessments were completed one to three days late, and in one instance, a resident did not have an MDS completed in over a year. Staff confirmed these delays during interviews.
Quarterly MDS assessments were not completed within the required time frames for two residents. The ARD for each assessment exceeded the allowed completion window, as confirmed by the RNAC during staff interviews.
The facility did not complete and transmit required MDS assessments within the mandated 7-day timeframe for several residents, with both entry and discharge assessments being finalized weeks late. This was confirmed through review of records and staff interviews.
The facility failed to accurately complete MDS assessments for several residents, resulting in incorrect documentation of antipsychotic, opioid, anticonvulsant, and anti-anxiety medication use, as well as immunization status. These errors were confirmed by review of clinical records and staff interviews.
A resident with hepatic encephalopathy and a physician's order for long-term Rifaximin therapy did not have an individualized care plan addressing these needs. Review of clinical records, facility policy, and staff interviews confirmed that no care plan was developed or implemented for the resident's condition or ongoing antibiotic use.
The facility did not update care plans for two residents to accurately reflect their current clinical status, including the presence of pressure ulcers, use of IV fluids, antibiotics, and contact precautions. Clinical records and staff interviews confirmed that the care plans contained outdated interventions and did not match the residents' actual care needs.
A resident with cognitive impairment, bladder incontinence, and a history of UTIs was observed with an indwelling urinary catheter collection bag in direct contact with the floor, in violation of facility policy. Both an LPN and the ADON confirmed the improper placement of the catheter bag.
Two medication administration errors occurred when an LPN failed to have two residents rinse their mouths after receiving Fluticasone-Salmeterol (Advair) inhalation, as required by physician orders and manufacturer instructions. This resulted in a medication error rate of 8%, exceeding the acceptable threshold.
Surveyors found that an opened multidose vial of Aplisol TB solution was not dated when opened, and that narcotic boxes in two medication refrigerators, including one containing lorazepam intensol concentrate for a resident, were not permanently affixed, allowing the entire shelf to be removed. Staff confirmed these lapses in medication labeling and secure storage.
The facility did not obtain an FBI background clearance for an employee who had not lived in Pennsylvania for the past two years, as required. This oversight was identified during a personnel file review and confirmed in an interview with a staff member.
A resident with Alzheimer's and psychosis, known for combative behavior, fell and sustained a minor skin tear. The next day, a bruise above the right eye was reported by the resident's spouse, but the facility failed to conduct a thorough investigation. Only one staff statement was taken, and the DON incorrectly attributed the bruise to the fall, despite records indicating the resident did not hit their head.
A resident experienced a delay in treatment for a urinary tract infection due to the facility's failure to timely obtain a urine specimen as ordered by the physician. The resident showed signs of lethargy and confusion, prompting a urinalysis order on August 2, but the specimen was not collected until August 4. This delay postponed the start of antibiotic treatment until August 6, as confirmed by the DON.
A resident with multiple health conditions, including diabetes and impaired mobility, developed a Stage II pressure ulcer at the gastrostomy tube site due to inadequate monitoring and treatment by the facility. Despite being at risk for skin integrity issues, the facility failed to properly assess and treat the resident's condition, leading to the ulcer's development.
A facility failed to monitor a resident's significant weight loss, as required by its policy. The resident lost 14.4 pounds, or 8.8%, between two recorded weights. A note questioned the accuracy of this loss and recommended further weights, but no additional weights were obtained. The DON confirmed that a re-weight should have been completed.
A facility failed to document appropriate diagnosis and indications for the use of psychotropic medications for a resident. Lorazepam was administered without documented non-pharmacological interventions, and Seroquel was given without an appropriate diagnosis. The Director of Nursing confirmed the lack of documentation.
A resident with Atrial Fibrillation awaiting hip surgery was given a breakfast tray despite an NPO order before a scheduled TEE procedure. The resident consumed some food and drink, leading to the rescheduling of the procedure. The facility failed to provide documented evidence that the kitchen was informed of the NPO order.
Failure to Accurately Assess and Timely Treat Pressure-Related Wounds
Penalty
Summary
The facility failed to accurately and comprehensively assess and timely treat pressure-related skin impairments for two residents following readmission. For one resident, the readmission skin assessment documented a skin impairment on the right buttock but did not include a description of the wound or its size, contrary to facility policy requiring documentation of location, stage, length, width, and depth. A physician progress note later indicated a new small wound on the buttock with a request for wound care follow-up, yet the wound, identified on February 9, 2026, was not comprehensively assessed until the wound physician evaluated it on February 18, 2026. At that time, the wound was identified as MASD on the right buttock, measuring 2.0 x 1.4 x 0.1 cm, partial thickness, and a Medihoney treatment was ordered. The DON confirmed that this wound, identified upon readmission, was not comprehensively assessed until the wound physician visit. For the second resident, the readmission skin assessment noted scattered scabs on the abdomen and left leg. A subsequent skin assessment by the wound nurse documented a Stage 2 pressure ulcer to the sacrum present on admission. The wound nurse reported that they recheck residents' skin within 24 hours of admission to identify and address all skin impairments and confirmed that this resident was admitted with a Stage 2 sacral ulcer. A physician order for daily topical Thera Honey (Medihoney) to the sacrum was written, but the November Treatment Administration Record showed no evidence that the sacral wound was treated until several days later. Additionally, a wound NP note documented intact skin on one date, followed two days later by a note from the same NP describing a Stage 3 sacral pressure ulcer present on admission, measuring 3.0 x 2.0 x 0.2 cm, with continuation of Medihoney ordered. The DON confirmed there was no documented evidence of treatment for the sacral wound during the initial days after readmission and was unaware of the NP’s earlier inaccurate documentation of intact skin.
Improper Infection Control During Wound Care for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement proper infection prevention and control practices during wound care treatments for two residents. For one resident with a physician’s order dated March 8, 2026, to cleanse a right buttock wound with NSS, pat dry, apply Medihoney, and secure with a silicone border twice daily, a wound care observation on March 9, 2026, at 10:40 a.m. showed that the nurse placed tissue paper on the bed and laid wet gauze, Medihoney in a cup, and a bordered dressing on top of it. The nurse then cleansed the right buttock wound with wet gauze and discarded the gauze in a trash can, but continued the procedure by applying Medihoney and a newly opened border dressing without changing gloves or performing hand hygiene. For a second resident with a physician’s order dated November 13, 2026, to cleanse the sacrum with NSS and apply Medihoney daily, an observation of sacral wound care on March 9, 2026, at 10:50 a.m. revealed that the same nurse opened the resident’s incontinence brief, repositioned the resident, and placed a cup with wet gauze, Medihoney in a medicine cup, and bordered gauze on top of the resident’s used incontinence brief in the bed. The nurse removed the old sacral dressing and placed it beside the clean supplies on the soiled brief, then cleaned the sacral wound with wet gauze from the cup and discarded the used gauze back into the same cup. The nurse proceeded to apply Medihoney and cover the wound with bordered gauze without changing gloves or performing hand hygiene at any point during the procedure. In a subsequent interview, the nurse acknowledged placing wound supplies on the bed due to lack of side tables and confirmed not changing gloves or performing hand hygiene, stating they forgot despite knowing it should have been done.
Failure to Provide and Document Scheduled Showers for Dependent Residents
Penalty
Summary
The facility failed to provide scheduled showers to two residents who required assistance with activities of daily living, specifically bathing. One resident, who was cognitively intact and required help with bathing and toileting due to an indwelling catheter and frequent bowel incontinence, had physician's orders and a care plan indicating scheduled showers twice weekly. However, a review of clinical records, nurse aide bathing reports, and the Treatment Administration Record (TAR) showed no documentation that the resident received showers as scheduled or that refusals were documented, as required. The Director of Nursing confirmed the absence of documentation for both the provision and refusal of showers over several months. Another resident, also cognitively intact and requiring assistance with bathing and toileting due to a history of cerebral vascular accident and frequent incontinence, reported not receiving a shower since admission and stated that showers were never offered. Physician's orders indicated scheduled showers twice weekly with instructions to document refusals. Review of the nurse aide bathing report and TAR revealed no evidence that the resident received or refused showers, nor that bed baths were provided as an alternative. The Director of Nursing confirmed the lack of documentation for this resident as well.
Failure to Follow Physician Orders for Medication Administration and Consult Recommendations
Penalty
Summary
The facility failed to follow physician's orders regarding medication administration for multiple residents. For one resident with severe cognitive impairment and insulin-dependent diabetes, staff administered Insulin Lispro on numerous occasions when the resident's blood glucose was below the threshold specified in the physician's orders. The orders clearly stated that insulin should be held if blood glucose was less than 110 mg/dl, but the medication was given repeatedly when readings were below this level, as documented in the Medication Administration Record. The Director of Nursing confirmed that insulin was not administered as ordered on the specified dates. Another resident, who was cognitively intact and had a diagnosis of prostate cancer, returned from a radiology oncology/urology appointment with a recommendation for Bactrim DS to treat a urinary tract infection. The consult note indicated that the antibiotic should be started and adjusted based on culture results. However, there was no documented evidence that the facility obtained or acted upon these recommendations in a timely manner. The consult note was not sent to the facility until several days after the appointment, and the Director of Nursing confirmed that the consult sheet with the antibiotic recommendation was not received or acted upon promptly. A third resident, who was cognitively impaired and had a history of stroke with dysphagia, was prescribed metoprolol tartrate with instructions to hold the medication if blood pressure was less than 130/80. Despite this, the Medication Administration Record showed that the medication was administered multiple times when the resident's blood pressure was below the specified threshold. The Director of Nursing confirmed that the medication was given when it should have been held according to the physician's orders.
Failure to Assess Air Mattress Safety and Provide Wheelchair Leg Rests
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards by not completing air mattress safety assessments for multiple residents prior to the use of air mattresses. Specifically, for eleven residents, including those with cognitive impairments, pressure ulcers, and other significant medical conditions, there was no documented evidence that an assessment was performed to identify potential safety hazards associated with the use of air mattresses. Physician orders and care plans indicated the use of air mattresses for pressure relief and skin integrity, but the required safety assessments were not completed before these devices were put in place. Observations confirmed that these residents were using air mattresses, and interviews with facility staff, including the Nursing Home Administrator, verified that no bed safety assessments had been conducted prior to the placement of the air mattresses. The residents involved had varying degrees of cognitive impairment and physical dependency, with some being at risk for falls, having pressure ulcers, or requiring bariatric equipment. Despite these risks, the facility did not document any evaluation of the safety of air mattress use for these individuals. Additionally, the facility failed to provide appropriate assistance devices during wheelchair transport for one resident. An LPN was observed pushing a resident in a wheelchair without leg rests, resulting in the resident's feet dragging on the floor. The LPN stated that leg rests were not used because the resident could self-propel, but acknowledged that they were not in place during transport. The Nursing Home Administrator confirmed that leg rests should have been used if the resident's feet were dragging, but that they were not routinely kept on wheelchairs for residents who could self-propel.
Failure to Maintain Accountability for Controlled Medications
Penalty
Summary
The facility failed to maintain proper accountability for controlled medications for two residents. For one resident who was cognitively intact and required assistance with care needs, there were multiple instances where doses of Oxycodone HCL were signed out on the controlled drug record, but there was no documented evidence in the clinical record or Medication Administration Record (MAR) that these doses were actually administered. This lack of documentation was confirmed by the Assistant Director of Nursing, who acknowledged the absence of records indicating administration of the signed-out doses. For another resident with cognitive impairment and a history of dysphagia following a stroke, physician orders required the application of a Fentanyl patch every three days. Although the MAR and controlled drug count record showed that the patches were applied as ordered, there was no documented evidence that two staff members signed for the destruction of the old patches after removal, as required by facility policy. The Director of Nursing confirmed that she was unaware of the requirement for two nurse signatures for the destruction of Fentanyl patches and acknowledged the lack of witness signatures for the relevant dates.
Failure to Prevent Unnecessary Use of Physical Restraints
Penalty
Summary
The facility failed to ensure that two residents were free from the use of physical restraints not required for medical treatment. Both residents were cognitively impaired, required staff assistance for daily care, and used wheelchairs for mobility. According to their care plans and MDS assessments, they were at risk for falls. Observations revealed that both residents were seated at a dining room table with their wheelchair brakes engaged, preventing them from moving away from the table. The residents attempted to move or push away from the table but were unable to do so due to the locked wheelchairs. Staff interviews confirmed that it was common practice to lock the wheelchairs of residents at risk for falls while they were in the dining room. An LPN stated that this was done to prevent falls, and the DON indicated she did not consider this a restraint, despite the restriction of movement. The facility's policy stated that residents should be free from restraints unless needed for medical treatment, but there was no evidence that the use of locked wheelchairs in this context was medically necessary.
Failure to Complete MDS Assessments Within Required Time Frames
Penalty
Summary
The facility failed to complete comprehensive Minimum Data Set (MDS) assessments and Care Area Assessments (CAA) within the required time frames for nine residents. According to the Resident Assessment Instrument (RAI) User's Manual, admission MDS assessments and CAAs must be completed no later than 13 days after admission, and comprehensive MDS assessments must be completed at least every 92 days. Review of clinical records and the CMS MDS validation report revealed that for several residents, the MDS assessments were completed one to three days late. In one case, there was no MDS completed in the prior 366 days for a resident. Staff interviews, including with the Registered Nurse Assessment Coordinator Consultant, confirmed that the comprehensive MDS assessments for the identified residents were not completed within the required time frames. The findings were based on documentation and assessment dates in the residents' clinical records, as well as the facility's adherence to the regulatory requirements outlined in the RAI User's Manual and state code.
Failure to Complete Quarterly MDS Assessments Within Required Time Frames
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed within the required time frames for two residents. According to the Resident Assessment Instrument (RAI) User's Manual, the assessment reference date (ARD) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment, and the assessment must be completed within 14 days after the ARD. For one resident, the quarterly MDS assessment had an ARD of August 2, 2025, but was not completed until August 19, 2025. For another resident, the quarterly MDS assessment had an ARD of May 8, 2025, but was not completed until May 26, 2025. These findings were confirmed by the Registered Nurse Assessment Coordinator Consultant during an interview.
Failure to Timely Complete and Transmit MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were encoded and transmitted to the State within the required 7-day timeframe for five residents. Specifically, review of the Resident Assessment Instrument (RAI) Manual, clinical records, and staff interviews revealed that both entry and discharge MDS assessments for several residents were not completed within the mandated period. For example, discharge and entry assessments for multiple residents were finalized well beyond the 7-day window after the assessment reference date (ARD), with some delays extending to several weeks. The Registered Nurse Assessment Coordinator Consultant confirmed that these comprehensive MDS assessments were not completed as required by regulation.
Inaccurate MDS Assessments for Medication and Immunization Documentation
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for four residents, as required by the Resident Assessment Instrument (RAI) User's Manual. For one resident receiving Risperdal for a chronic psychiatric illness, psychiatric consults documented that a gradual dose reduction (GDR) was clinically contraindicated, but the MDS assessment was incorrectly coded to indicate that no such documentation existed. Another resident received Tramadol, an opioid, for pain management throughout the assessment period, but the corresponding MDS section was not coded to reflect opioid administration. Similarly, a third resident received both Tramadol and Lamotrigine (an anticonvulsant) during the assessment period, but the MDS assessment failed to indicate the administration of these medications. Additionally, a resident who was offered and declined the influenza vaccine was incorrectly coded in the MDS as not having been offered the vaccine. Another resident received Lorazepam (an anti-anxiety medication) and oxycodone (an opioid) during the assessment period, but the MDS assessment did not reflect the administration of these medications. These inaccuracies were confirmed through interviews with the regional Registered Nurse Assessment Coordinator, who acknowledged the coding errors in the residents' MDS assessments.
Failure to Develop and Implement Individualized Care Plan for Hepatic Encephalopathy
Penalty
Summary
The facility failed to develop and implement an individualized care plan for one resident who was reviewed. According to the facility's policy, a comprehensive, person-centered care plan with measurable objectives and timetables should be created and updated for each resident, especially when there are significant changes in condition or new clinical needs. For the resident in question, clinical records showed a diagnosis of hepatic encephalopathy and a physician's order for long-term antibiotic therapy with Rifaximin. Despite these documented needs, there was no evidence that a care plan was created to address the resident's hepatic encephalopathy or the ongoing requirement for antibiotic treatment. This deficiency was confirmed through review of the resident's clinical records, facility policies, and staff interviews. The DON acknowledged that no care plan was in place for the resident's hepatic encephalopathy or long-term antibiotic use. The lack of a care plan was found during a review of the resident's quarterly MDS assessment and physician's orders, which indicated the need for such interventions.
Failure to Update Care Plans to Reflect Current Resident Needs
Penalty
Summary
The facility failed to ensure that care plans were updated or revised to accurately reflect the current care needs of two residents. For one resident, multiple care plans indicated the presence of a stage three pressure ulcer, use of intravenous fluids, a midline intravenous catheter, administration of oral vancomycin, and the need for contact precautions. However, a review of the resident's clinical record, including the Medication Administration Record and physician's orders, showed no evidence that the resident had an active stage three pressure ulcer, was receiving intravenous fluids, had a midline catheter, was taking oral vancomycin, or was on contact precautions. The Director of Nursing confirmed that the care plans should have been updated to reflect the resident's current status. For another resident, the care plan documented that the individual was receiving intravenous antibiotics for sepsis and an ESBL infection and was on contact precautions. Review of the clinical record, including the Medication Administration Record and physician's orders, revealed no evidence that the resident was receiving intravenous antibiotics for sepsis/ESBL infection or required contact precautions. The Director of Nursing confirmed that the care plan should have been updated to reflect the resident's current care needs. These findings indicate that the facility did not revise care plans as required when residents' conditions changed.
Catheter Bag Improperly Positioned on Floor
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary catheter was observed with their catheter collection bag in direct contact with the floor, contrary to the facility's policy requiring catheter drainage bags to be kept off the floor. The resident was cognitively impaired, incontinent of bladder, and had a history of urinary tract infections. This observation was confirmed by both an LPN and the Assistant Director of Nursing, who acknowledged that the catheter bag should not have been on the floor. The failure to maintain proper catheter care was determined through review of policies, clinical records, direct observation, and staff interviews.
Medication Administration Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication administration error rate of less than five percent, as required. During medication administration observations, two errors were identified out of 25 opportunities, resulting in an 8% error rate. Specifically, a Licensed Practical Nurse (LPN) administered Fluticasone-Salmeterol (Advair) Inhalation Aerosol Powder to two residents without ensuring they rinsed their mouths after use, as directed by both the physician's orders and the manufacturer's instructions. The omission of this step was observed during the morning medication pass. Both residents had physician orders specifying the use of Fluticasone-Salmeterol for asthma and COPD, with explicit instructions to rinse the mouth after each administration to reduce the risk of side effects such as oral thrush. The LPN confirmed during an interview that she did not have the residents rinse their mouths after administering the medication. The Director of Nursing also confirmed that the mouth rinsing step should have been completed for both residents following administration of the inhaled medication.
Failure to Properly Label and Securely Store Medications
Penalty
Summary
Surveyors identified that the facility failed to properly label and store drugs and biologicals in accordance with professional standards. Specifically, an opened multidose vial of Aplisol TB solution was found in a medication storage refrigerator without a date indicating when it was opened, contrary to the manufacturer's instructions that require vials in use for more than 30 days to be discarded. Staff interviews confirmed that the vial was not dated upon opening. Additionally, the narcotic box in the refrigerator, although fixed to a shelf, could be removed from the refrigerator because the shelf itself was not permanently affixed, and the box did not contain any narcotic medications at the time of observation. Further observations revealed that a second medication refrigerator contained a separate box with two boxes of lorazepam intensol concentrate, a controlled liquid antianxiety medication prescribed to a resident. This box was also not permanently affixed, as the entire shelf it was mounted on could be removed from the refrigerator. Staff interviews, including with the DON, confirmed that the narcotic boxes in both refrigerators were not permanently affixed as required for the secure storage of controlled substances.
Failure to Obtain FBI Clearance for Employee
Penalty
Summary
The facility failed to obtain an FBI background clearance for an employee, identified as Employee E6, who was hired on April 24, 2024. Employee E6 had not resided within the Commonwealth of Pennsylvania during the previous two years, which necessitated an FBI clearance as per regulatory requirements. A review of Employee E6's personnel file revealed the absence of this clearance. This deficiency was confirmed during an interview with Employee E3 on August 28, 2024, and the information was subsequently conveyed to the Nursing Home Administrator and Director of Nursing.
Failure to Investigate Unknown Injury
Penalty
Summary
The facility failed to comprehensively investigate an unknown injury for a resident with Alzheimer's disease and psychosis, who had a severe cognitive impairment and was known for combative behavior and wandering. The resident, who was independent with ambulation, was observed to have fallen while attempting to walk, resulting in a minor skin tear on the left leg. However, the following day, the resident's spouse reported a bruise above the right eye, which was not initially documented or communicated. The facility's documentation and investigation into the bruise were inadequate, as only one staff statement was taken, and no thorough investigation was conducted to determine the bruise's origin. The Director of Nursing (DON) indicated that the bruise was from the fall, despite clinical records showing the fall was witnessed and the resident did not hit their head. The facility's policy required a comprehensive investigation of injuries of unknown origin, which was not followed in this case. The lack of a thorough investigation and failure to gather statements from all relevant staff members who had contact with the resident contributed to the deficiency, as the facility did not ensure the injury was properly investigated.
Delay in Obtaining Urine Specimen Leads to Treatment Delay
Penalty
Summary
The facility failed to timely obtain a urine specimen for testing according to physician orders for a resident, leading to a delay in treatment. The resident, who was noted to be lethargic and more confused than their regular baseline, was observed to occasionally jerk without awareness. A call was placed to the medical doctor, and the nurse practitioner was informed, but there was a delay in receiving a callback. The physician ordered a urinalysis and culture and sensitivity test to be conducted as soon as possible on August 2, 2024. Despite the order, the urine specimen was not obtained until August 4, 2024, during the day shift, which delayed the diagnosis and treatment of a urinary tract infection. The resident eventually received an order for the antibiotic Cipro on August 6, 2024, indicating a delay in the initiation of treatment. The Director of Nursing confirmed that the facility did not obtain the urine specimen in a timely manner, which resulted in the delay of treatment from July 31, 2024, until August 6, 2024.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to provide adequate care and services to prevent the development and worsening of a pressure ulcer for a resident. The resident, who was admitted with multiple diagnoses including muscle weakness, dysphagia, hemiplegia, and diabetes, was at risk for skin integrity issues due to impaired mobility and incontinence. Despite these risks, the facility did not properly monitor or treat the resident's skin condition, particularly around the gastrostomy tube site, from April 29, 2024, to May 7, 2024. This lack of attention led to the development of a Stage II pressure ulcer at the peg tube site. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the failure to assess and treat the resident's peg tube site appropriately. The resident's care plan included interventions such as monitoring skin integrity and conducting weekly full-body checks, but these measures were not effectively implemented. The pressure ulcer was eventually resolved by June 18, 2024, but the initial lack of proper care and documentation contributed to the development of the ulcer.
Failure to Monitor Resident's Weight Loss
Penalty
Summary
The facility failed to obtain and monitor weights for a resident, identified as Resident 83, which led to a deficiency in maintaining the resident's nutrition and hydration status. According to the facility's policy on Weight and Weight Change Management, residents are to be weighed monthly or more frequently if necessary. Resident 83's weight was recorded as 164.4 pounds on July 3, 2024, and then as 150.0 pounds on August 1, 2024, indicating a significant weight loss of 14.4 pounds or 8.8%. A weight change note on August 16, 2024, questioned the accuracy of this weight loss and recommended further weights to assess the validity of the weight status. However, no additional weights were obtained by August 28, 2024, despite the recommendation. An interview with the Director of Nursing confirmed that a re-weight should have been completed but was not.
Failure to Document Appropriate Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure appropriate diagnosis and documentation for the administration of psychotropic medications to a resident. Specifically, the resident was prescribed Lorazepam, an anti-anxiety medication, to be administered as needed for agitation. However, the clinical records did not provide appropriate indications for its use beyond agitation, nor did they document any attempts at non-pharmacological interventions prior to administering the medication. This lack of documentation was confirmed during an interview with the Director of Nursing. Additionally, the resident was prescribed Seroquel, an antipsychotic medication, upon discharge from the hospital to promote sleep and reduce agitation. The facility's records showed that the resident was administered Seroquel multiple times over two months. However, there was no documentation of an appropriate diagnosis for the use of this antipsychotic medication. The Director of Nursing was unable to provide such documentation during an interview, indicating a failure to ensure the resident had an appropriate diagnosis for the use of antipsychotic medication.
Failure to Follow NPO Order for Resident
Penalty
Summary
The facility failed to ensure an NPO (nothing per mouth) order was followed for a resident scheduled for a Transesophageal Echocardiogram (TEE). The resident, who had a diagnosis of Atrial Fibrillation and was awaiting hip surgery, was aware of the NPO order but forgot about it on the day of the procedure. On the morning of the procedure, an agency nurse aide provided the resident with a breakfast tray, and the resident consumed a cup of orange juice and 2-3 spoons of cereal before being reminded of the NPO order by a nurse. This resulted in the rescheduling of the TEE procedure. The Director of Nursing (DON) reported that a communication form should have been sent to the kitchen to inform them of the NPO order, but the facility was unable to provide documented evidence that this was done. Interviews with the resident and staff confirmed the sequence of events, and the nursing progress notes corroborated the failure to follow the NPO order. This deficiency led to a delay in the resident's scheduled medical procedure.
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Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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