Rehabilitation Center At Jefferson Hills, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Jefferson Hills, Pennsylvania.
- Location
- 540 Coal Valley Road, Jefferson Hills, Pennsylvania 15025
- CMS Provider Number
- 395948
- Inspections on file
- 23
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Rehabilitation Center At Jefferson Hills, The during CMS and state inspections, most recent first.
Surveyors found that multiple residents lived in rooms with dusty taped ceiling vents, baseboard molding pulled away from walls along their full length, and an in-use electrical outlet junction box with a visible hole near the floor by a bed. The affected resident and family reported these conditions had existed since admission. Additional issues included a cracked, partially patched, and unpainted ceiling area in a hallway, unpainted patched spots on hallway handrails, and a large dust-covered vent in the PT department. The NHA confirmed these environmental problems and that the facility did not provide a safe, clean, comfortable, and homelike environment as required by policy and state regulations.
The facility failed to ensure residents could anonymously file grievances by maintaining grievance boxes in three locations (lobby, north unit, south unit) at heights above ADA-recommended ranges and in positions visible to staff and sometimes blocked by furniture or equipment. Residents reported they could not reach some boxes, that they were not suitable for wheelchair users, and that staff visibility and the need to ask for assistance discouraged anonymous written complaints, leading them to instead ask staff to file grievances verbally. The Nursing Home Administrator confirmed that the grievance boxes were not accessible to residents, constituting a failure to honor resident rights.
Surveyors found that the facility did not maintain an ongoing activity program to meet residents' physical, mental, and psychosocial needs. Activity calendars over several months showed only one daily group activity at 1 p.m. on weekdays, limited rotating activities on Saturdays, and no group activities on Sundays, with only a cart of independent items offered. During interviews, residents reported wanting more activities and social interaction, stating there was little to do on weekends. The Activities Director confirmed there was no weekend activity coverage since an activity assistant left months earlier and acknowledged that only one weekday group activity was provided, and the NHA confirmed the failure on one of five units.
Surveyors found that the facility’s activities program was being directed by an individual who lacked required qualifications, including prior activities experience, therapeutic services education, social work or OT training, or a recreational services background. The Activities Director confirmed this lack of relevant education and experience. The facility’s OT reported having no oversight or involvement with the activities program, and the COTA/rehab director stated her role was limited to completing the mobility portion of the activities assessment without further involvement in activities programming or supervision. The NHA acknowledged that the facility did not have a qualified professional overseeing the activities department.
Surveyors found that the facility did not follow ordered pressure ulcer prevention and treatment interventions for three residents with existing pressure ulcers or identified risk. One resident with hemiplegia and a Stage III ulcer was repeatedly observed in bed without heel offloading or the ordered palm guard, despite care plan and physician orders, and an LPN confirmed these devices were not in place. Another resident with Parkinson’s disease and a Stage IV ulcer, assessed as high risk and needing assistance to roll, was observed multiple times lying on her back without the ordered wedge cushion in use, while the wedge sat unused in a nearby chair, and the resident indicated staff did not assist with wedge positioning. A third resident with hemiplegia, aphasia, and moderate risk for pressure ulcers was observed on several occasions without the ordered positioning wedge, and an LPN confirmed the resident did not have one, while leadership acknowledged the failure to provide the prescribed pressure ulcer care and prevention services.
Surveyors found that medications and medical supplies were not stored and managed according to policy. In one medication room, numerous expired items were present, including blood collection tubes, vacutainers, IV start kits, IV extension sets, syringes, antibiotic ointment, cleansing towelettes, and oral fluid collection devices, along with a partially used, undated vial of tuberculin solution in the refrigerator. On a medication cart, open multi-dose ophthalmic medications (Timolol, Dorzolamide/Timolol, and Latanoprost) were found without open dates on the bottles or storage containers. An LPN and the DON confirmed the presence of expired supplies and unlabeled, open medications.
The facility did not ensure residents had reasonable access to mail services by failing to provide Saturday mail delivery. Facility policy required mail to be delivered to residents and outgoing mail sent within 24 hours of postal service delivery or availability, but activity calendars for several months showed mail delivery only Monday through Friday. During a group interview, residents reported that mail and mail services were not provided on Saturdays. The Activities Director stated she does not deliver mail on weekends because she is not present and is the only staff member in the activity department, and the Business Office Manager reported there is no Saturday postal delivery to the facility. The NHA and DON confirmed that residents were not provided mail delivery on Saturdays, contrary to policy and resident rights requirements.
Surveyors found that the facility failed to maintain a safe environment when the biohazardous waste room was repeatedly left unlocked with multiple sharps containers and biohazard bags accessible, and the beauty shop was left unlocked with an environmental services cart containing cleaning supplies and a large putty knife. The staff restroom door was not fully closed and lacked an emergency call light or call cord, yet remained unlocked and accessible to residents. An LPN confirmed these conditions during interview, and the administrator acknowledged the failure to provide a safe environment on one nursing unit.
Surveyors found that the facility did not display required written information in common posting areas, such as the lobby and hallways near nursing units, explaining how residents and their representatives can apply for and use Medicare and Medicaid benefits and obtain refunds for previous payments covered by those programs. During an interview, the NHA confirmed that this information was not posted anywhere in the building, resulting in noncompliance with state requirements for licensee responsibility and management.
The facility failed to follow its own staff development policy requiring ongoing education on resident needs and rights. Review of training records showed that multiple nurse aides, LPNs, an RN, and therapy staff did not receive resident rights education at hire or during required annual in-service periods. In total, nine of thirteen reviewed direct care staff members lacked documented training on resident rights, a deficiency confirmed by the Nursing Home Administrator during surveyor interview.
Surveyors found that the facility did not provide required Quality Assurance and Performance Improvement (QAPI) education to most of the sampled staff. Review of the staff development policy showed an expectation for ongoing coordinated education, but records revealed that multiple nurse aides, LPNs, an RN, therapy staff, a dietary worker, and an environmental services worker lacked documented QAPI training either at hire or during required annual in-service periods. The administrator confirmed that eleven of fifteen reviewed employees had not received the mandated QAPI training.
A resident with cognitive impairment and a history of wandering exited the facility unsupervised after staff failed to monitor the front entrance and did not implement elopement prevention interventions in the care plan. The resident was later found by police in a nearby neighborhood and taken to the ED. The incident exposed lapses in supervision, documentation, and adherence to elopement protocols.
The facility did not maintain emergency lighting as required, as observed when the battery back-up light in the generator room failed to illuminate during a test. This was confirmed by interviews with the facility's Owner, Administrator, and Maintenance Director.
The facility was found to be non-compliant with building construction requirements as it is a two-story, Type III (200), unprotected ordinary structure with a basement and attic, which is fully sprinklered. This type of construction is not permitted to exceed one story in height. An interview with the facility's Owner, Administrator, and Maintenance Director confirmed the non-compliance.
A resident with specific hygiene preferences and medical conditions did not receive the required number of showers or baths, as per facility policy. Despite expressing the importance of choosing their bathing method, the resident received mostly bed baths, with many months lacking any showers. The DON confirmed this inconsistency in care.
The facility failed to assess, document, and notify physicians of abnormal blood glucose levels for two residents, leading to a deficiency in care. One resident had critically low CBG levels, while another had a high CBG level, yet the facility did not follow care plans or notify physicians. Interviews revealed inconsistencies in staff actions, and the DON confirmed the failures.
A facility failed to ensure accurate documentation of a resident's cognitive assessment. The resident's MDS assessments showed a decline in BIMS scores, indicating cognitive impairment, but progress notes consistently recorded a higher score. The DON confirmed the documentation was inaccurate and incomplete, and the facility lacked a specific policy for clinical record documentation.
A facility failed to notify a resident's family of a change in condition in a timely manner. The resident, admitted with dementia and a fractured leg, developed a possible pressure ulcer. Despite facility policy requiring notification of skin integrity changes, there was no evidence the family was informed. The DON confirmed this oversight.
A facility failed to maintain accurate medical records for a resident admitted with dementia and a leg fracture. A physician's order for wound care on the resident's feet was incorrectly documented, as confirmed by LPNs and the DON. The resident's TAR showed treatment was applied, but weekly skin checks indicated no wounds. The error was due to documentation being entered on the wrong chart.
Failure to Maintain Safe, Clean, and Homelike Resident Environment
Penalty
Summary
The facility failed to honor residents' rights to a safe, clean, comfortable, and homelike environment on one of two nursing units (North Nursing Unit). Surveyors observed that two residents had tape surrounding their ceiling air vents, with dust collected on both the vents and the tape. Four residents had rubber baseboard molding pulled away from the wall for the entire length of the wall in their rooms. One of these residents also had an approximately 30.61-millimeter hole in the wall at an outlet junction box that was in use, located near the floor between the head of the bed and the outside wall. The resident and his parents confirmed that the room conditions had been present since admission. Additional environmental deficiencies were identified in common areas. In the hallway outside a resident room, the ceiling had a cracked, partially patched, and unpainted area. Handrails in the North Hallway had unpainted patched spots on both sides of the hall. In the Physical Therapy Department, a large vent in the middle of the room had dust woven throughout the vent. During rounds and interview, the Nursing Home Administrator confirmed these findings and acknowledged that the facility failed to provide a safe, clean, comfortable, and homelike environment, in violation of facility policy and applicable state regulations (28 Pa. Code 207.2(a) and 201.29(k)).
Inaccessible and Non-Private Grievance Boxes Limit Anonymous Resident Complaints
Penalty
Summary
The facility failed to honor residents' rights to voice grievances without discrimination or reprisal by not providing accessible grievance boxes in three locations: the main lobby, and the north and south nursing units. Facility policy on grievances/complaints, reviewed on 1/16/25, allows grievances to be submitted orally or in writing and filed anonymously. During a resident group interview, residents reported they did not feel they could anonymously file grievances in the grievance boxes. They stated that some boxes were too high to reach, not designed for people in wheelchairs, and that the boxes were in view of staff, requiring them to ask staff for help, leading them to instead verbally ask staff to file grievances for them. On observation and measurement conducted with the Nursing Home Administrator, the grievance box in the lobby was found to be mounted at 54 inches from the floor, the north nursing unit box at 53 inches, and the south nursing unit box at 57 inches, all above the ADA-recommended operable part height range of 15 to 48 inches. The lobby box was in view of the reception desk and partially blocked by a chair, the north nursing unit box was in view of the nursing station, and the south nursing unit box was blocked by a cart with a cooler and also in view of the nursing station. During an interview, the Nursing Home Administrator confirmed that the facility failed to make the grievance boxes accessible to residents, in violation of 28 PA Code: 201.18(e)(4) Management and 28 PA Code: 201.29(a)(b)(c) Resident rights.
Failure to Provide Ongoing, Resident-Centered Activity Program
Penalty
Summary
The facility failed to provide an ongoing program of activities to meet the interests of and support the physical, mental, and psychosocial well-being of residents. Review of activity calendars from September 2025 through February 2026 showed that there were no group activities scheduled on Sundays and that, on weekdays, only one group activity was scheduled at 1:00 p.m. following lunch. The calendars indicated daily 9:30 a.m. one-on-one visits consisting of distributing a written Daily Chronicle for residents to read, 11:30 a.m. lunch, and a single 1:00 p.m. group activity Monday through Friday. On Saturdays, the 1:00 p.m. activity rotated among puzzles, coloring, and games, and on Sundays the only listed offering was a 1:00 p.m. "residents' choice" cart with books, magazines, and items for residents to use independently in their rooms. During a group interview, residents reported that they would like additional activities and stated there was only one activity during the week at 1:00 p.m. They expressed that they wanted to participate in activities rather than just having a cart brought around for independent use in their rooms, and they specifically noted that they enjoyed the socialization of group activities and that there was not much to do on weekends. The Activities Director stated there was no activity department coverage on weekends since the activity assistant left approximately six months earlier and confirmed there was only one group activity during the week at 1:00 p.m. The Activities Director also reported not being in the building to confirm weekend activities. The Nursing Home Administrator confirmed that the facility failed to provide an ongoing program of activities to meet residents' interests and support their physical, mental, and psychosocial well-being on one of five nursing units, in violation of 28 Pa. Code 201.18(b)(3) and 207.2(a).
Unqualified Individual Directing Activities Program
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the activities program was directed by a qualified professional. The Activities Director’s job description stated that the position’s primary purpose was to plan, organize, implement, evaluate, and direct activity programs in accordance with federal, state, and local standards, and as directed by the administrator, to meet residents’ emotional, recreational, and social needs on an individual basis. Review of the Activities Director’s (Employee E1) personnel record showed she was hired on 1/9/25, but there was no documentation of prior experience as an Activities Director, education in therapeutic services, education as a social worker or occupational therapist, or a background in recreational services. During interviews, the Activities Director (E1) confirmed she did not have education in therapeutic services, social work, occupational therapy, or recreational services. The facility’s Occupational Therapist (E3) confirmed she had no oversight or involvement with the activity program and that she was the only regularly scheduled OT for the facility. The Certified Occupational Therapy Assistant and Rehabilitation Services Director (E2) stated she only completed the mobility portion of the activities assessment in the clinical record and had no other involvement or oversight of the activities department programming or staff. The Nursing Home Administrator confirmed that the facility failed to ensure the Activities Department had a qualified director to oversee the activities program, in violation of 28 Pa Code 201.18(b)(3) and 201.189(e)(6).
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide prescribed treatments and services for pressure ulcer care and prevention for three residents identified as being at risk or already having pressure ulcers. Facility policy required residents to receive skin care, repositioning, and nutritional support to prevent avoidable pressure ulcers, and the Braden Scale was used to identify risk levels. For one resident with hemiplegia, diabetes, hypertension, and a documented Stage III pressure ulcer, the care plan and physician orders required offloading both heels while in bed, turning and repositioning every two hours, and wearing a palm guard on the left hand except during hygiene. The treatment administration record showed the palm guard was only documented as applied on two days, and multiple observations over several days found the resident lying on his back with heels not offloaded and without the palm guard in place. The resident reported that staff only sometimes assisted with heel elevation or palm guard application, and an LPN confirmed during interview that the resident’s heels were not offloaded and the palm guard was not in place. A second resident, with Parkinson’s disease, diabetes, muscle weakness, and a documented Stage IV pressure ulcer, was assessed as high risk for pressure ulcer development and required assistance to roll in bed. The care plan and physician orders directed that heel pillow boots be on when in bed, that the resident be turned and repositioned every two hours, and that a wedge cushion be used every four hours to offload the buttocks. During multiple observations on consecutive days, the resident was seen lying on her back without the wedge in place, while the wedge was observed in a chair next to the bed. When asked if staff assisted with positioning the wedge, the resident indicated negatively, and there was no indication in the report that the ordered offloading with the wedge was being implemented as prescribed. A third resident, with hemiplegia, aphasia, a history of stroke, and identified as at moderate risk for pressure ulcer development, required assistance to roll in bed. The care plan and physician orders required turning and repositioning every two hours and obtaining a wedge for offloading while in bed. Across several observations on different days, this resident was repeatedly observed in bed without a wedge in place. An LPN confirmed that the resident did not have a positioning wedge, despite the existing order. In a subsequent interview, the Nursing Home Administrator and the Director of Nursing acknowledged that the facility failed to provide the prescribed treatments and services related to pressure ulcer care and prevention for three of six residents reviewed, in violation of applicable state regulations regarding resident rights, resident care policies, and nursing services.
Failure to Properly Store, Label, and Remove Expired Medications and Supplies
Penalty
Summary
Surveyors identified that medications and related medical supplies were not stored and managed according to facility policy and regulatory requirements. Review of the facility’s “Storage of Medications” policy stated that medications must be stored in a safe, secure, and orderly manner in accordance with federal and state regulations. During an observation of the North Unit medication room, surveyors found multiple expired items, including blood collection tubes, vacutainers, IV start kits, IV extension sets, syringes, antibiotic ointment packets, cleansing towelettes, and oral fluid collection devices, all with past expiration dates. In addition, a partially used vial of tuberculin solution was found in the medication room refrigerator without any date indicating when it had been opened. A nurse (LPN) confirmed these observations at the time of the survey. Further observations of the South Unit medication cart revealed that several multi-dose ophthalmic medications were open and undated. Specifically, bottles of Timolol eye drops, Dorzolamide/Timolol, and Latanoprost were found open with no dates on either the bottles or their storage containers to indicate when they had been opened. The LPN using the cart acknowledged that these undated multi-dose medications were already present on the cart when medication administration began. In a subsequent interview, the DON confirmed that the facility failed to ensure that unlabeled medications were present on one of two medication carts and that out-of-date supplies were not properly stored or disposed of in one of two medication storage rooms.
Failure to Provide Residents with Saturday Mail Delivery and Access to Mail Services
Penalty
Summary
The facility failed to provide residents with reasonable access to mail services comparable to those available in the community by not delivering mail on Saturdays. The facility’s mail policy, last reviewed on 12/5/25, required delivery of incoming mail or other materials to residents within 24 hours of postal service delivery (or to the facility post office box) and delivery of outgoing mail to the postal service within 24 hours when there is no regularly scheduled postal delivery and pick-up service. During a resident group interview on 2/11/26, residents reported that mail was not delivered and mail services were not provided on Saturdays. Review of facility activity calendars for the six-month period from 9/25 through 2/26 showed that mail delivery was listed as occurring Monday through Friday only. The Activities Director stated she does not deliver mail on Saturdays because she is not in the building on weekends and is the only employee in the activity department. The Business Office Manager reported that the facility does not receive mail delivery from the postal service on Saturdays. The Nursing Home Administrator and Director of Nursing confirmed that the facility failed to ensure mail was delivered to residents on Saturdays, in violation of resident rights and applicable state regulations.
Unlocked Hazardous Areas and Lack of Call System in Staff Restroom
Penalty
Summary
Surveyors identified that the facility failed to ensure certain areas were free from accident hazards and adequately supervised. On multiple observations over several days, the biohazardous waste room was found unlocked, with 13 sharps containers on a shelf and two large biohazardous waste bags containing multiple sharps containers on the floor. The beauty shop was also observed unlocked, with an environmental services cart containing cleaning supplies and a large putty knife on top. Additionally, the staff restroom door was observed not fully closed, and the room lacked an emergency call light or call cord for emergency use. Further observations confirmed that on subsequent days the biohazardous waste room and staff restroom remained unlocked and accessible to residents. During interviews, an LPN acknowledged that the biohazardous waste room was unlocked and then engaged the locking mechanism, and also confirmed that the staff restroom was unlocked, accessible to residents, and did not have a call light available. The Nursing Home Administrator confirmed that the facility failed to provide a safe environment for residents on one of two nursing units, in violation of applicable Pennsylvania regulations regarding management, staff development, and resident rights.
Failure to Post Required Medicare/Medicaid Information for Residents
Penalty
Summary
The facility failed to display required written information for residents and/or their responsible persons on how to apply for and use Medicare and Medicaid benefits and how to receive refunds for previous payments covered by those benefits. During observations on 2/11/26 at approximately 11:30 a.m., surveyors inspected the first-floor lobby and hallways in and around the nursing units, where postings are typically available, and found that information on applying for Medicare and Medicaid and obtaining refunds for prior payments covered by these programs was not posted. In a subsequent interview on 2/12/26 at 9:00 a.m., the Nursing Home Administrator confirmed that the facility had not displayed this required written information anywhere in the building. The deficiency was cited under 28 Pa. Code: 201.14(a) Responsibility of licensee and 28 Pa. Code: 201.18(e) Management.
Failure to Provide Required Resident Rights Training to Direct Care Staff
Penalty
Summary
The deficiency involves the facility’s failure to provide required training on resident rights as part of its staff development program. The facility’s policy, last reviewed on 12/5/25, states that there shall be an ongoing, coordinated education program for facility personnel, including training related to the needs and rights of residents. Review of facility documents and in-service training records showed that multiple staff members lacked documented education on the resident rights program, either at the time of hire or during the required annual in-service period. Specifically, a nurse aide hired on 10/24/25 and another nurse aide hired on 11/23/25 did not receive resident rights education upon hire or thereafter. Additional nurse aides, LPNs, an RN, and therapy staff did not have documented resident rights in-service education during the applicable annual periods following their hire dates. In total, nine of thirteen reviewed staff members, including nurse aides, LPNs, an RN, and therapy employees, were found without the required resident rights training. During an interview on 2/13/26, the Nursing Home Administrator confirmed that the facility failed to provide resident rights training for these nine staff members, in violation of 28 Pa Code: 201.14(a), 201.18(b)(1), and 201.20(a)(c).
Failure to Provide QAPI Training to Majority of Staff
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide required Quality Assurance and Performance Improvement (QAPI) training to the majority of sampled staff. Review of the facility’s Staff Development Program policy, last reviewed on 12/5/25, showed that the facility was to maintain an ongoing, coordinated education program for personnel, including training related to residents’ problems, needs, rights, and technology. However, review of facility documents and personnel in-service training records revealed that eleven of fifteen staff members lacked documented QAPI education as required by this program. The missing QAPI training affected multiple disciplines and hire dates. Several nurse aides (employees E5, E6, and E7) did not receive QAPI education upon hire or within the specified annual in-service periods. Two LPNs (employees E9 and E10) and one RN (employee E11) similarly lacked QAPI in-service education during their respective annual review periods. Therapy staff (employees E12 and E13), a dietary employee (E14), and an environmental services employee (E15) also had no documented QAPI training either upon hire or within the designated annual timeframes. During an interview on 2/13/26, the Nursing Home Administrator confirmed that the facility failed to provide QAPI training for eleven of the fifteen reviewed staff members, in violation of 28 Pa Code sections 201.14(a), 201.18(b)(1), and 201.20(a)(c).
Failure to Prevent Elopement Due to Inadequate Supervision and Care Planning
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident who was identified as being at risk for wandering and exit-seeking behaviors. The resident had a history of cognitive impairment, poor decision-making skills, and demonstrated wandering and exit-seeking behaviors, as documented in an Elopement Risk Assessment. Despite these findings, the resident's care plan did not include any interventions to address elopement risk, and there were no physician orders for elopement prevention measures. On the day of the incident, the resident was last seen by staff in a recliner in the community room and later in another resident's room before being returned to his own room around 7:30 p.m. The resident was left unsupervised, and staff failed to monitor the front door, which allowed the resident to exit the facility without detection. The absence of supervision at the front desk was confirmed by video footage, contradicting an initial staff statement. The facility did not document the resident's wandering behaviors in the progress notes, and there was no immediate notification to local authorities by the facility when the resident was discovered missing. The resident was found by police in a nearby residential area without shoes and with no memory of how he arrived there. The police were alerted by a passer-by, not the facility, and the resident was subsequently taken to the emergency department for evaluation. The incident revealed gaps in supervision, documentation, and adherence to elopement prevention protocols, resulting in an immediate jeopardy situation for the resident.
Removal Plan
- Complete a root cause analysis to validate the cause of the resident elopement.
- Complete a head count to ensure all residents are accounted for.
- Reassess the resident upon return from the hospital and implement frequent checks.
- Audit all elopement books to ensure accuracy.
- Review and assess all residents for elopement risk, wandering, and update care plans and orders to include appropriate interventions.
- Assess all residents in house for elopement risk by the Director of Nursing or designee.
- Review and update care plans for residents identified with elopement risks with interventions to prevent elopement by the Director of Nursing or designee.
- Add all residents identified to be elopement risk to Elopement Binder per protocol.
- Conduct a house audit on all doors and exit points to ensure that facility is secure and alarms are functional by Maintenance.
- Conduct education to all facility staff regarding dementia/behavior in LTC residents, elopement risk and mitigation, and elopement policy and procedures to include keeping doors secure.
- Educate all staff on elopement interventions such as responding to alarms, reorienting wandering patients, encouraging activities, monitoring the front lobby and sign in sheet, code 10, and safety checks.
- Educate staff that all residents assessed as an elopement risk will have their picture and face sheet in the elopement book.
- Place elopement books with identified resident photos on all nurses' stations in addition to the current one at the receptionist's desk by the Administrator or designee.
- Screen newly admitted residents for elopement risk on admission, quarterly and as needed, and update care plans appropriately.
- Place new admissions and any resident assessed as an elopement risk in the elopement book that includes photograph and face sheets. Book is available for staff to review and monitor at all times.
- Investigate all incidents, perform root cause analysis and follow up with appropriate interventions by the DON or designee.
- Review elopement interventions and update as required by the QAPI team.
- Ensure the front door is monitored 24 hours 7 days a week by the RN supervisor until the wander guard system is installed.
- Review the lobby monitoring sign in sheet regularly.
- Audit door alarms daily by maintenance.
- Conduct elopement drills monthly on all shifts.
- Monitor the plan of correction by QAPI including all door audits, elopement book, elopement drills and all new admissions will be audited for elopement risk.
- Monitor the plan of correction at the Quality Assurance and Process Improvement meeting until consistent substantial compliance has been met.
Failure to Maintain Emergency Lighting
Penalty
Summary
The facility failed to maintain emergency lighting as required. During an observation on March 17, 2025, at 10:00 a.m., it was noted that the battery back-up light in the generator room did not illuminate when tested. This deficiency was confirmed through an interview with the Owner of the facility, the Facility Administrator, and the Maintenance Director on the same day at 1:00 p.m.
Plan Of Correction
I. The back-up battery light in the generator was turned back on at the time of the surveyors observation. II. No other emergency lights failed to illuminate when tested. III. Nursing Home Administrator will re-educate Director of Maintenance on the requirement to maintain emergency lighting. IV. Director of Maintenance will conduct 5 audits weekly for 8 weeks to ensure the back-up battery light in the generator illuminates when tested. Audit results will be taken through Quality Assurance Committee Meeting for tracking and trending purposes.
Non-compliance with Building Construction Requirements
Penalty
Summary
The facility was found to be non-compliant with building construction requirements as it is a two-story, Type III (200), unprotected ordinary structure with a basement and attic, which is fully sprinklered. According to the NFPA 101 standards, this type of construction is not permitted to exceed one story in height. This deficiency was identified during an observation on March 17, 2025, at 8:45 a.m. An interview with the facility's Owner, Administrator, and Maintenance Director later confirmed that the building construction type did not meet the necessary requirements for an existing health care building.
Plan Of Correction
I. New owner will have an architect review the blueprint and construction plan of the building in order to determine a solution to correct the deficiency for building construction. II. After architectural review, the facility will be able to determine a date for correction of deficiency. III. Director of Maintenance/Designee will monitor progress of correcting the deficiency for building construction. IV. Progress will be reported to the Quality Assurance Committee monthly for tracking and trending purposes. V. Facility will be submitting a request for a one time waiver.
Failure to Provide Adequate Hygiene Care
Penalty
Summary
The facility failed to ensure that a resident, who was unable to carry out activities of daily living, received the necessary services to maintain personal hygiene. Specifically, the facility did not consistently provide showers or baths for a resident identified as R37. The facility's policy required residents to have two baths or showers per week unless otherwise stated by the resident. However, documentation revealed that Resident R37 received significantly fewer showers than required, with many months showing no showers at all and only bed baths documented. Resident R37, admitted with diagnoses including repeated falls, diabetes, and low blood pressure, expressed that choosing between a tub bath, shower, bed bath, or sponge bath was somewhat important. Despite this preference, the resident reported being unable to recall the last time they had a shower. The Director of Nursing confirmed the facility's failure to consistently provide the necessary showers or baths for Resident R37, which was a violation of the resident's rights and the facility's care policies.
Plan Of Correction
I. Resident R37 received a shower on 3/17/2025. Moving forward, all residents will be offered a shower twice a week. II. Director of Nursing/Designee will conduct a full facility sweep to ensure all residents have been offered and received a shower if requested. III. Director of Nursing/Designee will re-educate all licensed nursing and CNA on the policy that care will be provided to residents, as needed 24-hours a day to attain and maintain the highest level of functioning; to include residents are to have two bath/showers/week unless the resident states otherwise. IV. Director of Nursing/Designee will conduct a random audit of 10 showers weekly for 8 weeks to ensure residents are being offered and receiving a shower if requested. Audit results will be taken through Quality Assurance Committee meeting for tracking and trending purposes.
Failure to Manage Abnormal Blood Glucose Levels
Penalty
Summary
The facility failed to properly assess, document, and notify physicians of abnormal capillary blood glucose (CBG) levels for two residents, leading to a deficiency in quality of care. Resident R20, who was re-admitted with diagnoses including diabetes, dementia, and high blood pressure, had instances where glucagon was administered, and CBG levels were recorded as low as 50 and 52. Despite these critical readings, the facility did not assess for hypoglycemia, monitor the effectiveness of treatment, or notify the physician as required by the care plan. Similarly, Resident R24, admitted with diabetes, high blood pressure, and depression, had a CBG level recorded at 438. The facility failed to assess for hyperglycemia, did not recheck the blood sugar, and did not notify the physician of this abnormal result, contrary to the care plan's interventions. The facility's policies on diabetic care and physician notification were not followed, contributing to the deficiency. Interviews with LPNs revealed inconsistencies in the actions taken when abnormal CBG levels were detected, with some staff indicating they would notify the doctor and recheck blood glucose, while others did not follow through with these steps. The Director of Nursing confirmed the facility's failure to notify the doctor, document assessments, and follow physician orders for the residents involved.
Plan Of Correction
I. R 20 and R24 were assessed with no negative outcomes found. II. A facility sweep of all residents on CBG's will be reviewed to ensure proper hypoglycemic protocol is in place. III. Director of Nursing/Designee will re-educate all licensed nursing staff on notification of change and hypoglycemic protocol policies and procedures. IV. Director of Nursing/Designee will conduct random audits of 10 residents weekly for 8 weeks to ensure proper hypoglycemic protocols and notifications are in place and documented. Audit results will be taken through Quality Assurance Committee meeting for tracking and trending purposes.
Inaccurate Documentation of Cognitive Assessment
Penalty
Summary
The facility failed to ensure that the clinical records for a resident, identified as R37, were complete and accurately documented. The resident was admitted with diagnoses including repeated falls, diabetes, and low blood pressure. The Minimum Data Set (MDS) assessments, which are mandated to evaluate a resident's abilities and care needs, showed discrepancies in the Brief Interview of Mental Status (BIMS) scores over time. Initially, the BIMS score was recorded as 15, indicating the resident was cognitively intact. However, subsequent MDS assessments showed a decline in the BIMS score to 12 and then to 10, suggesting moderate cognitive impairment. Despite these changes in the MDS assessments, the clinical record progress notes consistently documented a BIMS score of 15, indicating no cognitive impairment. This inconsistency was confirmed by the Director of Nursing (DON) during an interview, who acknowledged the failure to ensure accurate and complete documentation for the resident. The facility did not have a specific policy for documentation in clinical records, contributing to the deficiency.
Plan Of Correction
I. R37 BIMS score was updated by the Nurse Practitioner under the Palliative Care Note. II. Facility Nurse Practitioner(s) will conduct a full facility sweep to ensure all residents BIMS scores are updated and correctly documented. Moving forward, facility nurse practitioner(s) will ensure their documentation is current and updated in the resident charts. III. Director of Nursing/Director will re-educate the facility Nurse Practitioner(s) on clinical records are complete and accurate. IV. Director of Nursing/Designee will conduct random audits of 10 residents weekly for 8 weeks to ensure nurse practitioner(s) are documenting the correct BIMS score on residents. Audit results will be taken through Quality Assurance Committee meeting for tracking and trending purposes.
Failure to Notify Family of Change in Resident's Condition
Penalty
Summary
The facility failed to notify the family of a change in condition for one of four residents in a timely manner. The facility's policy, dated 5/1/24, requires that the responsible party or guardian be notified of any break in the resident's skin integrity. Resident R1, who was admitted with dementia and a fractured left leg, had a skin alteration to the coccyx noted upon admission. On 7/8/24, a nurse progress note indicated a possible pressure ulcer to the coccyx, measuring 6.5 cm by 7 cm, with a dressing applied and a CRNP involved in the treatment plan. However, there was no evidence in the clinical record that the resident's family was informed of this change in condition. The Director of Nursing confirmed this failure during an interview on 8/22/24.
Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure that medical records for each resident were complete and accurately documented, as evidenced by the case of a resident who was admitted with diagnoses including dementia and a left leg fracture. A physician's order was documented for wound care on both feet, which was incorrectly recorded in the resident's Treatment Administration Record (TAR) for July. The TAR indicated that the treatment was applied on two specific dates, but the resident was discharged shortly thereafter. Weekly skin check documentation prior to these dates showed no open areas on the resident's feet. Interviews with facility staff, including two Licensed Practical Nurses (LPNs) and the Director of Nursing (DON), confirmed that the documentation was incorrect. The LPNs revealed that the resident did not have wounds on the feet during their stay, and the DON confirmed that the physician order and TAR documentation were mistakenly entered on the wrong resident's chart. This error led to the facility's failure to maintain complete and accurate medical records for the resident, violating specific state code requirements for clinical records.
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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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