Rehab At Shannondell
Inspection history, citations, penalties and survey trends for this long-term care facility in Audubon, Pennsylvania.
- Location
- 5000 Shannondell Drive, Audubon, Pennsylvania 19403
- CMS Provider Number
- 396101
- Inspections on file
- 21
- Latest survey
- April 28, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Rehab At Shannondell during CMS and state inspections, most recent first.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
A resident with a right hip fracture and a right artificial hip joint, who was cognitively intact per BIMS, left the facility with a visitor without informing nursing staff and was later located by police at a church and returned to the unit. Nursing staff discovered the resident missing during routine checks, initiated a search, and contacted 911, while CNAs assigned to the unit reported they were unaware the resident had left at the time. The front desk process allowed visitors and some residents to sign in and out at a kiosk, and a concierge observed the resident leaving but was not required to notify unit staff. The administrator confirmed the resident left without staff knowledge, and the DON acknowledged she did not investigate the event or obtain statements and did not report the incident to the state health department because she did not consider it an elopement, resulting in a failure to report an alleged violation as required.
A resident with a right femur fracture and right hip prosthesis, who was cognitively intact per BIMS, left the facility with a visitor without staff knowledge and was later located off-site by law enforcement and returned. Unit CNAs reported they were unaware the resident had left at the time, and one only learned of the incident the next day. The front desk process allowed visitors and residents to sign in and out at a kiosk, and a concierge observed the resident leaving but was not required to notify nursing staff, treating residents similarly to those in assisted living. The DON did not initiate an investigation, did not obtain staff or witness statements, and did not report the incident to the state, as she did not consider the event to be an elopement, resulting in a failure to thoroughly investigate and report the alleged violation as required.
A resident with a right femur fracture and right hip prosthesis, who was cognitively intact per BIMS, left the facility with a visitor without staff knowledge. CNAs assigned to the unit were unaware the resident had left, and the concierge at the front desk observed the resident exit but did not notify nursing, reportedly allowing residents to come and go for fresh air and treating them as if in assisted living. The facility’s elopement policy requires supervision when residents leave and management of situations where patients leave without staff knowledge, but the DON did not investigate the incident, obtain staff statements, or report it to the health department, as it was not considered an elopement.
A resident admitted with wound infection and bacteremia received IV vancomycin via a midline catheter, but staff failed to follow facility policy and physician orders requiring measurement and documentation of the external catheter length. The care plan identified risk for complications related to the midline and called for measuring and documenting the external catheter length during dressing changes, yet the admission external length was left blank and no subsequent measurements were recorded. Observation confirmed the resident had IV access for antibiotic administration, and the DON acknowledged that the external catheter length was never documented and no insertion-length information was obtained from the hospital.
Two residents with significant respiratory conditions, including COPD, CHF, pulmonary embolism with cor pulmonale, pleural effusion, asthma, and acute/chronic respiratory failure, were observed receiving oxygen via nasal cannula at specific flow rates, but their physician orders only directed oxygen via nasal cannula to maintain SpO2 above 92% with titration or weaning as tolerated, without specifying flow rate or complete device parameters as required by facility policy. Their care plans identified risk for altered breathing patterns and referenced “oxygen as ordered” but did not provide further instructions for oxygen therapy. The DON later acknowledged that the oxygen orders for these residents were unclear and incomplete.
A resident experienced a fall during the overnight shift and was assisted by a nurse aide, who failed to report the incident to nursing staff. The fall was only discovered when the resident self-reported it to an LPN during the next shift, resulting in delayed physician notification and assessment. The resident sustained pain and a skin tear, and the DON confirmed the reporting failure.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in increased risk for resident accidents.
A facility failed to inform a resident and her family of their right to formulate an advanced directive upon admission and did not verify her code status, leading to confusion during a medical emergency. The resident, admitted after a hospital stay for serious conditions, was considered Full Code by default, despite hospital documentation indicating a DNR/DNI status. This oversight resulted in CPR being administered without confirmation of the resident's wishes, highlighting a significant deficiency in the facility's admission process.
The facility failed to maintain accurate records for controlled drugs on two medication carts, with missing and pre-signed entries in the narcotic book. Staff interviews revealed that nurses sometimes pre-signed or failed to sign the narcotic book, leading to incomplete records and a lack of accountability for controlled substances.
The facility had a medication error rate of eight percent due to incorrect administration of Cyanocobalamin to two residents. Both residents were prescribed the medication sublingually, but it was administered orally by a registered nurse and an LPN. This error was confirmed by the DON.
The facility failed to store and label medications according to professional standards. An expired Glucagon injection was found in a medication cart, and an open vial of Tuberculin PPD lacked a date opened label in the medication room. These issues were confirmed by the respective licensed nurses.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Recognize and Report Resident Elopement Incident
Penalty
Summary
The deficiency involves the facility’s failure to recognize and report an elopement incident as an alleged violation in accordance with §483.12(c). The facility’s elopement policy, dated September 2022, states that it is intended to ensure that patients who leave the facility without staff knowledge or without adequate supervision/safety are managed appropriately. Resident R125 was admitted on March 16, 2026, with diagnoses including an intertrochanteric fracture of the right femur and a right artificial hip joint. An MDS dated March 26, 2026, documented a BIMS score of 14, indicating the resident was cognitively intact. On April 4, 2026, progress notes show that at approximately 7:25 a.m. on April 5, 2026, shortly after a shift change, a nurse entered the resident’s room and found the resident was not there and had not informed nursing staff of his departure. The nurse reported last seeing the resident at approximately 3:45 p.m. at the beginning of the prior shift. After discovering the resident missing, the nurse alerted a nurse aide, who searched the unit but did not find the resident, and 911 was called. It was known that the resident had a visitor and had been seen leaving the facility at approximately 4:22 p.m. Law enforcement obtained information on the resident and the visitor, checked their homes without finding them, and later contacted the resident’s former wife, who reported that the visitor was very religious. Police ultimately located the resident and the visitor at a local church, and the resident returned to the unit at approximately 10:30 p.m. Nurse aides assigned to the resident’s unit on the day of the incident reported they were not aware the resident had left the building at the time and only learned of the event later; one aide recalled that the resident may have had a visitor but did not know the time and stated she did not pay attention. The front desk receptionist supervisor described that visitors are expected to sign in at a kiosk, indicate who they are and where they are going, and that residents going on a leave of absence (LOA) may be signed out either when the visitor arrives or when the resident comes downstairs, with some residents signing themselves out and back in. The supervisor stated that residents going to a doctor’s appointment do not have to sign out because the nurse already knows about it. The Nursing Home Administrator confirmed that the resident left the facility with a friend without staff knowledge and that a concierge at the front desk saw the resident leave but is not required to inform staff when residents leave, explaining that some residents go out for fresh air and are treated as if they are in assisted living. The DON stated she did not investigate the incident or obtain staff or witness statements and did not report the incident to the Department of Health because she did not consider it an elopement, despite the resident leaving the facility without staff knowledge, which led to the failure to report the incident as required under §483.12(c).
Plan Of Correction
1. The DON or designee will report all violations in accordance with guidelines. 2. R125 is alert and oriented. R125 was in our facility for short term rehab, was completely independent with ambulation when using his walker. R125 regularly exercised by walking throughout the nursing unit on his own. 3. R125 exited the facility without notifying any staff members. He left after a friend picked him up so that they could attend Church services on Easter weekend. 4. When R125 returned from Church, he was educated on the importance of notifying staff members prior to leaving the facility. R125 acknowledged that he should have discussed his plan with staff prior to leaving. 5. Our residents are informed of the expectations of notifying facility staff when they are admitted to the facility as those directives are included in the residence and care agreement. 6. The facility policy for non-medical outings will be modified to include the addition of a "check out and check in" process for all patients electing to leave the facility for non-medical reasons. 7. The nursing staff and concierge staff will be in-serviced on policy changes and expectations with non-medical outings. 8. The charge nurse will complete a "Non-Medical Outing Pass" when the patient leaves and returns from an outing. These passes will be kept in the patient's chart. 9. The ADON or designee will audit each non-medical outing to verify that necessary documents have been completed. These audits will be completed for 120 days. 10. The results of the ADON audits will be reported to QA and any pattern or trend of non-compliance will be reviewed and addressed accordingly.
Failure to Investigate and Report Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to conduct a timely and thorough investigation of an elopement incident involving one resident. The resident was admitted with an intertrochanteric fracture of the right femur and a right artificial hip joint, and an MDS assessment showed a BIMS score of 14, indicating the resident was cognitively intact. According to progress notes, the resident was last seen by the nurse at approximately 3:45 p.m. and was later discovered missing around 7:25 a.m. the following day, at which time staff initiated a search, called 911, and learned that the resident had left the facility with a visitor. Police ultimately located the resident and the visitor at a local church, and the resident returned to the unit at approximately 10:30 p.m. Interviews with staff revealed that direct care staff on the unit were not aware that the resident had left the building at the time of departure. One nurse aide reported leaving the unit around 7 p.m. to work on another unit and only learned the resident was missing when a nurse later asked about the resident. Another nurse aide who worked the day shift on the unit stated she did not know the resident had left and only heard about the incident the next day; she recalled the resident may have had a visitor but did not pay attention to the time. The front desk receptionist supervisor explained that visitors are expected to sign in at a kiosk and may sign residents out for a leave of absence either upon arrival or after bringing the resident downstairs, and that residents or visitors are expected to sign the resident back in upon return, except for pre-arranged medical appointments. The facility’s administrative staff confirmed that the resident left the facility with a friend without staff knowledge and that a concierge at the front desk saw the resident leave with the visitor. The administrator stated that the concierge does not have to inform staff when residents leave the building and that some residents are allowed to go out for fresh air, with the concierge treating all residents as if they were in assisted living. The DON acknowledged that she did not investigate the incident, did not obtain staff or witness statements, and did not report the incident to the Department of Health because she did not consider it an elopement. This lack of investigation and reporting occurred despite regulatory requirements and the facility’s own elopement policy intended to ensure appropriate management of residents who leave the facility without staff knowledge or adequate supervision.
Plan Of Correction
1. All elopement incidents will be thoroughly investigated. 2. The policy for incident investigation will be reviewed and updated as needed. 3. The Nursing staff will be in-serviced on policy changes. 4. The DON or designee is responsible for ensuring that alleged violations are thoroughly investigated. 5. The DON or designee will complete an audit, to verify that all alleged violations are thoroughly investigated. This audit will be completed for 60 days and patterns or trends requiring follow-up will be reported to facility Quality Assurance committee.
Resident Leaves Facility Without Staff Knowledge or Elopement Response
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and monitoring of a resident, resulting in the resident leaving the building without staff knowledge. The facility’s Patient Elopement policy states that patients who are not at risk of elopement are free to move throughout the facility and leave with supervision, and that patients who leave without staff knowledge or adequate supervision are to be managed appropriately. In this case, the resident’s departure occurred without staff awareness, and the event was not managed as an elopement under the facility’s own policy. The resident involved, identified as R125, was admitted with an intertrochanteric fracture of the right femur and a right artificial hip joint. An MDS assessment showed a BIMS score of 14, indicating the resident was cognitively intact. Progress notes documented that on the morning after the incident, nursing staff discovered the resident was not in the room; the nurse last recalled seeing the resident at the beginning of the prior shift. After an unsuccessful search of the unit, 911 was called. It was later learned that the resident had left the facility with a visitor and was ultimately located at a local church and returned to the unit that night. Interviews with staff revealed that the CNAs assigned to the resident’s unit during the day shift were not aware that the resident had left the building and only learned of the incident later. The front desk receptionist supervisor explained that visitors are expected to sign in at a kiosk and that residents going on leave of absence are to be signed out and back in, either by themselves or by their visitors, except for pre-arranged medical appointments. The Nursing Home Administrator confirmed that a concierge at the front desk saw the resident leave with a visitor but did not notify nursing staff, and stated that the concierge allows residents to leave for fresh air and treats all residents as if they are in assisted living. The DON acknowledged that she did not investigate the incident, did not obtain staff or witness statements, and did not report the event to the Department of Health because she did not consider it an elopement.
Plan Of Correction
1. The DON or designee will report all violations in accordance with guidelines. 2. R125 is alert and oriented. R125 was in our facility for short term rehab, was completely independent with ambulation when using his walker. R125 regularly exercised by walking throughout the nursing unit on his own. 3. R125 exited the facility without notifying any staff members. He left after a friend picked him up so that they could attend Church services on Easter weekend. 4. When R125 returned from Church, he was educated on the importance of notifying staff members prior to leaving the facility. R125 acknowledged that he should have discussed his plan with staff prior to leaving. 5. Our residents are informed of the expectations of notifying facility staff when they are admitted to the facility as those directives are included in the residence and care agreement. 6. The facility policy for non-medical outings will be modified to include the addition of a "check out and check in" process for all patients electing to leave the facility for non-medical reasons. 7. The nursing staff and concierge staff will be in-serviced on policy changes and expectations with non-medical outings. 8. The charge nurse will complete a "Non-Medical Outing Pass" when the patient leaves and returns from an outing. These passes will be kept in the patient's chart. 9. The ADON or designee will audit each non-medical outing to verify that necessary documents have been completed. These audits will be completed for 120 days. 10. The results of the ADON audits will be reported to QA and any pattern or trend of non-compliance will be reviewed and addressed accordingly.
Failure to Measure and Document External Midline Catheter Length for IV Therapy
Penalty
Summary
The facility failed to administer IV therapy in accordance with professional standards of practice and physician orders for one resident with a midline catheter. Facility policy for central venous catheter dressing changes, dated May 2011, required an RN to measure the external portion of the catheter, document this measurement in the electronic medical record, ensure it matched the IV insertion records, and notify the physician of any discrepancies. The resident’s comprehensive care plan, initiated shortly after admission, identified risk for complications related to the midline and included an intervention to measure and document the length of the external catheter during dressing changes; however, the external length on admission was left blank in the care plan. The resident was admitted with diagnoses of wound infection and bacteremia and had a physician order for IV vancomycin every 12 hours for 21 days, as well as a subsequent order to measure the external catheter length with each weekly dressing change. The MDS indicated the resident received IV therapy for antibiotic medications while in the facility. Observation confirmed the resident had IV access for antibiotic administration. Review of the clinical record revealed no documented evidence that the external catheter length was measured and documented on admission or with any dressing changes thereafter. The DON confirmed that the facility did not document the resident’s external catheter length and did not have documentation from the hospital regarding the external catheter length at the time of insertion.
Plan Of Correction
1. All PICC lines will be measured in accordance with facility policy 2. The policy on Central Venous Catheter Dressing Change (PICC Line) will be updated as needed. 3. The licensed nursing staff will be in-serviced by the ADON or designee on policy changes. 4. As part of routine clinical review meeting, the ADON will verify PICC line measurements are being completed according to policy 5. For the next 60 days, the ADON or designee will complete an audit to verify compliance. 6. Results of the audit will be reported to facility QA team.
Incomplete Oxygen Therapy Orders and Documentation for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that oxygen therapy was provided in accordance with professional standards of practice and physician orders for two residents who required respiratory care. Facility policy on oxygen utilization and storage required that physician orders for oxygen include the device, flow rate, and duration, including clear parameters for PRN use. For one resident admitted with acute and chronic respiratory failure, pneumonia, CHF, and COPD, observation showed oxygen being administered via nasal cannula at three liters per minute. However, the corresponding physician order only stated to provide oxygen via nasal cannula to keep pulse oximetry greater than 92% and allowed titration or weaning as tolerated, without specifying a flow rate or fully detailing the delivery device. The resident’s care plan addressed risk of altered breathing patterns related to multiple respiratory conditions and oxygen use, but the only intervention related to oxygen was “oxygen as ordered,” with no further instructions. For a second resident admitted with pulmonary embolism with cor pulmonale, pleural effusion, asthma, and acute and chronic respiratory failure, observation showed oxygen being administered via nasal cannula at six liters per minute. The physician order for this resident was similarly limited to oxygen via nasal cannula to keep pulse oximetry greater than 92% with titration or weaning as tolerated, again without specifying a flow rate or complete delivery parameters. The care plan for this resident also identified risk of altered breathing patterns related to multiple respiratory diagnoses and oxygen use, but listed only “oxygen as ordered” as the intervention, with no additional directions for oxygen therapy. The surveyor later notified the DON that complete oxygen orders could not be found for these two residents, and the DON confirmed that the oxygen orders were not clear and needed to be updated.
Plan Of Correction
1. The policy on Oxygen Utilization and Storage will be modified to ensure physician orders for oxygen include flow rate. 2. The licensed nursing staff will be in-serviced on policy changes. 3. All new oxygen orders will be completed in accordance with new policy. 4. As part of routine clinical meeting, the ADON will verify that oxygen orders are accurate and completed according to policy. 5. For the next 60 days, the ADON will complete an audit on all oxygen orders verifying accuracy. 6. The residents of the audits will be reported to the facility QA team.
Failure to Immediately Notify Physician of Resident Fall and Injury
Penalty
Summary
The facility failed to immediately notify the attending physician of an accident resulting in injury for one resident. According to the facility's policy, the charge nurse is responsible for promptly informing the physician of any changes in a resident's condition, including accidents or incidents, and for documenting the details and any instructions received. In this case, a resident experienced a fall at 5:00 a.m. while ambulating to the bathroom. The nurse aide on duty at the time assisted the resident after the fall but did not report the incident to the nursing staff or document it. The fall was only discovered when the resident self-reported the incident to a licensed nurse during the following shift. Subsequent review of the clinical and hospital records indicated that the resident sustained pain in the left elbow, hip, and knee, as well as a left shin skin tear, and reported hitting her head. The physician was eventually notified and ordered x-rays and pain medication, along with treatment for the skin tear. Interviews confirmed that the nurse aide failed to report the fall as required, resulting in a delay in physician notification and assessment. The Director of Nursing verified that the incident was not reported until the resident disclosed it during the next shift.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Verify Code Status and Inform of Advance Directive Rights
Penalty
Summary
The facility failed to inform a resident and/or her responsible party of their right to formulate an advanced directive upon admission, and did not clarify the resident's code status to ensure her end-of-life care wishes would be honored. The facility's policy required social services to verify a patient's code status within one business day of admission, but this was not done for the resident in question. The resident was admitted to the facility after a hospital stay for serious medical conditions, including a fall and multiple types of brain hemorrhages, and was assessed as alert and oriented to person and time but not to place or situation. Upon admission, the facility did not attempt to determine if the resident had an advanced directive or wanted to create one. The resident's hospital discharge summary indicated a DNR/DNI status, but this information was not verified or documented by the facility. When the resident experienced a medical emergency, CPR was initiated without confirmation of her code status, leading to a situation where emergency medical technicians had to contact the resident's son to confirm whether CPR should continue. Interviews with facility staff revealed that the resident was considered Full Code by default upon admission, as the social services assessment to confirm code status had not yet been completed. The facility's failure to verify the resident's code status and inform her of her rights regarding advanced directives resulted in a lack of clarity during a critical medical event, ultimately leading to the continuation of CPR against the resident's documented wishes.
Plan Of Correction
1. R1 is no longer in our facility. 2. A baseline audit will be completed to verify that all patients have an opportunity to formulate an advanced directive, including code status. 3. The Advanced Directive P&P will be updated. 4. The DON or designee will create an Advanced Directive assessment. 5. The Advanced Directive assessment will be completed by the admitting nurse when each patient arrives. 6. The licensed nurses will be in-serviced on the newly created AD Assessment. 7. For the next sixty (60) days, the DON or designee will complete random audits to ensure that the Advanced Directive Assessment is being completed correctly. 8. The DON or designee will report patterns and trends from these audits to the facility QA Committee. 9. The DON or designee will monitor for compliance.
Inadequate Record-Keeping for Controlled Drugs
Penalty
Summary
The facility failed to maintain an accurate system of records for the receipt and disposition of controlled drugs between shifts, leading to discrepancies in the narcotic book for two medication carts on the 3rd Floor B. During an observation on July 10, 2024, it was found that the narcotic book for Medication Cart 3rd Floor B Front had a pre-signed entry by a nurse who was going off duty, which was confirmed by the nurse himself. Additionally, several entries in the narcotic book for both Medication Cart 3rd Floor B Front and Back were missing signatures from either the nurse going off duty or the nurse coming on duty on various dates in June and July 2024. Interviews with the involved staff revealed that the outgoing and incoming nurses are supposed to count the narcotics together and sign the narcotic book accordingly. However, it was discovered that some nurses pre-signed the narcotic book, and others failed to sign it altogether, resulting in incomplete records. This lack of proper documentation and accountability for controlled substances was observed during medication administration on the 3rd floor unit, indicating a systemic issue in the facility's management of pharmaceutical services.
Medication Administration Error: Incorrect Route
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in an error rate of eight percent based on 25 medication opportunities with two errors. The errors involved the administration of Cyanocobalamin (Vitamin B-12) to two residents, R9 and R244. According to the physician's orders, both residents were to receive Cyanocobalamin 1,000 mcg via the sublingual route once daily. However, during a medication administration pass, Registered Nurse Employee E3 and Licensed Practical Nurse Employee E4 administered the medication orally instead of sublingually to Residents R9 and R244, respectively. This deviation from the prescribed route of administration was confirmed by the Director of Nursing during an interview.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored and labeled according to professional standards. During an observation of the medication cart on the 3rd floor unit, a Glucagon injection with an expired date was found in the top drawer. This was confirmed by Licensed Nurse, Employee E6, who acknowledged the presence of the expired medication. Additionally, in the third-floor medication room, an open vial of Tuberculin PPD 5TU/0.1ml was found in the refrigerator without a date opened affixed to the vial or the box. This was confirmed by Licensed Nurse, Employee E7, who acknowledged the lack of proper labeling. These findings indicate a failure to adhere to the facility's policy for medication administration, which requires checking expiration dates and labeling multi-dose vials with the date they were opened.
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Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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