River's Edge Rehabilitation & Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- 9501 State Road, Philadelphia, Pennsylvania 19114
- CMS Provider Number
- 395843
- Inspections on file
- 32
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at River's Edge Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
Surveyors found that an oxygen storage room on the second floor lacked the required precautionary signage stating, "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING," as mandated for gas cylinder storage areas. This deficiency was confirmed by facility leadership during the initial survey and again during a subsequent revisit, when the same room was still missing the required sign.
A cognitively intact resident with osteoarthritis, low back pain, and major depressive disorder was assisted out of bed and placed in a Geri-chair in the dayroom for breakfast and to await therapy. The resident became verbally agitated and repeatedly requested to return to their room, but staff, including a nurse aide and unit staff, attempted to redirect the resident and delayed honoring the request for approximately 30–40 minutes so the resident would remain up for therapy, despite the resident’s known preference for in-room therapy. The resident ultimately called the police, reporting they were being forced to stay in the dayroom, and was only taken back to their room when police arrived, demonstrating a failure to respect the resident’s right to make choices about daily activities.
The facility failed to keep its dish machine in safe working order, resulting in staff manually pushing dishware through a machine with a broken conveyor belt and missing curtains and jet caps. The Dietary Director reported the malfunction and requested repair approval from the Administrator, who approved the request, but the machine remained in disrepair while quotes for repair and replacement were obtained over several weeks.
The facility was found to have deficiencies in food storage and sanitation practices. Observations revealed unlabeled and undated ground beef, outdated deli meats, and improperly sanitized equipment in the kitchen. The Food Service Director confirmed these findings during a tour.
The facility did not ensure proper disposal of garbage and refuse, as observed during a kitchen tour with the FSD. Cigarette butts were found in the receiving area and loading dock, and the garbage was not covered. These issues were confirmed by the FSD.
A facility failed to conduct timely care plan meetings for a resident with dementia and hearing deficits. The last documented meeting was in June 2024, attended by the resident's daughter-in-law via phone, with no evidence of subsequent meetings. Interviews confirmed missed meetings in September and December 2024.
The facility did not provide timely written notification to residents and their representatives about hospital transfers and the reasons for these transfers. Two residents were transferred to the hospital without their representatives being informed in writing, in a language and manner they understood. The facility lacked a system for notifying residents' representatives in writing prior to transfers or discharges, as confirmed by the Nursing Home Administrator and DON.
A facility failed to follow a physician's order for a resident's catheter care. The order specified a Foley Catheter with a 16fr/10ml balloon, but the resident was found with a 16fr/5ml balloon. This discrepancy was confirmed by a licensed nurse, highlighting a lapse in adhering to the prescribed catheter care.
A resident with multiple health issues experienced a significant weight loss, which the facility failed to address appropriately. Despite policies requiring reweighing and nutritional evaluation, there was no documented reweight or physician evaluation. The dietitian did not implement timely nutritional interventions, and the food-first approach was deemed inappropriate by the physician.
A facility failed to create an individualized care plan for a resident with dementia, as required by their policy. The care plan lacked measurable goals and interventions for the resident's dementia care needs. This was confirmed by the DON, highlighting a deficiency in compliance with state regulations.
A resident's bed was found to have a mattress six inches smaller than the bed frame, exposing slats and increasing entrapment risks. The resident, with neurological and physical impairments, had been using this setup since admission. Staff interviews confirmed the mismatch, and it was noted that mattresses are purchased separately from bed frames, leading to this oversight.
The facility failed to follow physician orders for two residents, resulting in deficiencies. One resident experienced delays in insulin administration, with a nurse leaving the resident unsupervised with medication. Another resident did not receive ordered showers, with documentation not supporting a claimed refusal. Staff confirmed these deficiencies, acknowledging policy violations.
The facility did not ensure that residents and/or their responsible parties were notified or participated in care plan meetings, as required by policy. This was confirmed for four residents, with no documentation of notification or participation since their last meetings. An interview with a social worker confirmed the absence of such documentation.
A resident with diabetes continuously refused Lantus insulin injections for three months, but the facility failed to notify the physician. Despite the refusals, the physician's notes inaccurately stated that the resident's diabetes was controlled with Lantus. The Unit Manager confirmed the lack of communication, leading to a deficiency in resident care.
A resident with cognitive impairment and multiple health issues was found with bruises of unknown origin. The facility's investigation was incomplete, lacking interviews with staff and failing to confirm the resident's report of a therapy session. The Director of Rehabilitation noted the resident had been discharged from therapy months earlier, and the Director of Nursing acknowledged the investigation's shortcomings.
The facility failed to notify the State LTC Ombudsman of emergency transfers for four residents who required hospital care due to significant medical issues. Despite transferring 56 residents over three months, the facility did not provide the required notifications for these specific cases, as confirmed by the Nursing Home Administrator.
The facility did not develop care plans for three residents requiring oxygen therapy, despite physician orders for oxygen administration and maintenance. Observations revealed uncleaned oxygen concentrator filters, confirmed by staff, indicating non-compliance with care plan policy and nursing service regulations.
A facility failed to follow a physician's order for a neurology follow-up for a resident who was transferred to the hospital for right arm weakness. Hospital discharge instructions required a neurology appointment within two weeks, but no evidence of scheduling was found in the resident's records. This was confirmed with the Unit Manager.
The facility failed to maintain clean oxygen concentrator filters for three residents, as required by their physician orders and facility policy. Despite instructions to clean the filters weekly, it was observed that the filters were covered with thick dust, indicating non-compliance with the established standards of practice for respiratory care.
The facility failed to administer medications as ordered for two residents due to unavailability. One resident did not receive Betamethasone cream for eczema over several days, and another did not receive Oxycodone and Methocarbamol for pain management. The facility's policy requires notifying the physician and providing alternatives when medications are unavailable, which was not followed.
A facility failed to obtain timely laboratory services for a resident's digoxin levels as per physician orders. The resident, diagnosed with Atrial Fibrillation and prescribed Digoxin, had a care plan requiring serum digoxin level checks every six months. However, the last documented test was in April 2023, which was confirmed by the Unit Manager.
Failure to Post Required Oxygen Storage Room Cautionary Signage
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During an observation on the second floor, they found that the Oxygen Storage Room did not have the required precautionary signage on the door. Specifically, the room lacked a sign readable from 5 feet that stated: "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING," as required for oxygen cylinder storage areas. This absence was directly observed by surveyors during the inspection. In an exit interview conducted with the Administrator and the Maintenance Director following the initial observation, facility leadership confirmed the lack of required signage. During a subsequent onsite revisit, surveyors again observed that the same second-floor Oxygen Storage Room still lacked the mandated cautionary sign. In a second exit interview with the Administrator and a Maintenance Representative, they again confirmed that the signage remained absent at the time of the revisit.
Plan Of Correction
1. The facility immediately purchased and installed the required signage at the Oxygen Storage Room on the second floor. The signage was updated to include "Oxygen Storage No Smoking" in accordance with NFPA 99 requirements for compressed gas storage areas. 2. All residents have the potential to be affected by this issue. 3. The Director of Maintenance and facility leadership were in-serviced on the requirements for proper labeling and signage of medical gas storage areas, including oxygen storage rooms, in accordance with NFPA 99 and CMS Life Safety Code requirements. 4. The Director of Maintenance or designee will conduct routine environmental rounds to ensure all medical gas storage areas are properly labeled and compliant with NFPA 99 signage requirements. Audits will be conducted monthly for three months, with immediate correction of any identified deficiencies. Findings will be documented and reported to the Quality Assurance and Performance Improvement (QAPI) Committee as appropriate.
Failure to Honor Resident’s Choice to Return to Room Before Therapy
Penalty
Summary
The facility failed to honor a cognitively intact resident’s right to make choices regarding daily activities, specifically the resident’s repeated requests to return to their room. The resident, admitted with diagnoses including primary osteoarthritis, low back pain, and major depressive disorder, had a BIMS score of 15 on the March 20, 2026 MDS, indicating intact cognition. On the morning in question, staff assisted the resident out of bed around 7:30 a.m. in preparation for scheduled therapy and placed the resident in a Geri-chair in the dayroom for breakfast and to wait for therapy. The resident became verbally agitated in the dayroom and repeatedly shouted that they wanted to go back to their room. Staff attempted to redirect and reassure the resident, explaining that therapy was scheduled and that they should remain out of bed to attend. Despite the resident’s clear and repeated requests—reported as approximately four times after breakfast—to return to their room, staff did not immediately comply, instead keeping the resident in the dayroom for an estimated 30–40 minutes while waiting for therapy. During this time, the resident contacted the police, stating they were being forced to remain in the dayroom and not allowed to return to bed. When the police arrived, the resident was still in the Geri-chair, continuing to request to return to bed. The DON confirmed that the resident preferred to have therapy in their room, but staff encouraged the resident to remain out of bed for therapy and did not take the resident back to the room immediately, despite multiple requests, resulting in a failure to respect the resident’s right to self-determination and choice of daily activities.
Dish Machine Not Maintained in Safe and Functional Condition
Penalty
Summary
The facility failed to maintain the dish machine in safe and functional operating condition, resulting in staff having to manually operate malfunctioning equipment. On April 15, 2026, observation of the dish machine showed that the conveyor belt was broken, requiring staff to manually push dishware through the machine to initiate the wash cycle. The Director of Dietary confirmed that the dish machine was not functioning properly and that there were missing curtains and caps on the jets. Review of email communication dated March 12, 2026, showed that the Director of Dietary had requested approval from the Administrator for dish machine repair, stating it needed to be fixed as soon as possible, and that the Administrator approved the repair the same day. Further review revealed that the Administrator did not receive a quote from the repair company until April 2, 2026, and that a new quote for a replacement dish machine was submitted on April 13, 2026. Interview with the Administrator on April 15, 2026, confirmed that the dish machine remained in this condition while the facility was in the process of obtaining a new machine. No residents or specific patient conditions were mentioned in relation to this deficiency.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several deficiencies observed during a kitchen tour. The main refrigerator contained two 10-pound ground beef links that were unlabeled and undated, opened ham deli meat dated March 10, 2025, two 10-pound ready-to-eat roast beef labeled with a received date of March 17, 2025, and opened mozzarella cheese labeled with a received date of December 10, 2024. Additionally, the three-compartment sink was found to be improperly sanitized, as the pH test of the sanitation solution showed no change in the pH test strip, indicating the sanitizer was outside the acceptable pH range. These findings were confirmed by the Food Service Director during the kitchen tour.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed during a tour of the main kitchen conducted with the Food Service Director (FSD), Employee E6. During the inspection, hundreds of cigarette butts were found in the receiving area and loading dock, which are used by the facility to transport clean food. Additionally, it was observed that the garbage was not covered. These observations were confirmed by the FSD during the tour.
Failure to Conduct Timely Care Plan Meetings
Penalty
Summary
The facility failed to ensure that care plan meetings were held for a resident, identified as Resident R55, who was reviewed among 24 residents. Resident R55 had a decline in communication due to a hearing deficit and impaired cognition related to dementia. The clinical records showed that a care conference meeting was last documented in June 2024, attended by the resident's daughter-in-law via phone. However, there was no documented evidence of subsequent care conference meetings occurring after June 2024. Interviews with the facility Administrator and Social Worker confirmed that care conferences were not conducted in September 2024 and December 2024, as required.
Failure to Notify Residents' Representatives of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents and their representatives regarding hospital transfers and the reasons for these transfers. Specifically, two residents, identified as R31 and R102, were transferred to the hospital without their representatives being notified in writing, in a language and manner they understood. Resident R31 was admitted to the hospital with a diagnosis of hematoma of the left kidney and abdominal pain, while Resident R102 was transferred for evaluation of a gastrointestinal bleed. The clinical records lacked evidence of written notification to the residents' representatives. An interview with the Nursing Home Administrator and Director of Nursing confirmed the absence of a system for notifying residents' representatives in writing prior to transfers or discharges.
Failure to Implement Physician-Ordered Catheter Care
Penalty
Summary
The facility failed to implement appropriate treatment and services for incontinence management for one resident. A physician's order for the resident, dated March 24, 2025, specified the use of a urinary Foley Catheter with a size 16fr/10ml balloon, to be changed monthly and as needed based on clinical indications. However, on March 27, 2025, it was observed that the resident had a Foley Catheter with a 16fr/5ml balloon instead of the ordered 16fr/10ml balloon. This discrepancy was confirmed by a licensed nurse, indicating a failure to adhere to the physician's order for catheter care.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to adequately monitor and modify nutritional interventions for a resident, leading to a significant weight loss that was not addressed in a timely manner. The resident, who was admitted with conditions such as muscle wasting, high blood pressure, hyperlipidemia, depression, and dysphasia, experienced a clinically significant weight loss of 6.3% in one month. Despite the facility's policy requiring reweighing and nutritional evaluation for significant weight changes, there was no documented reweight or evidence of a physician's evaluation to address the resident's medical and nutritional issues related to the weight loss. Additionally, the Registered Dietitian failed to implement and monitor appropriate nutritional interventions, such as therapeutic supplements, to address the resident's impaired nutrition. Instead, the dietitian notified the Food Service Director, a non-medical professional, about the weight loss, and the resident was placed on a select menu with updated preferences. The physician acknowledged that the food-first approach was not suitable for the resident's condition, as the resident was very sick, had a dry mouth, and lacked appetite. The facility's documentation was also inconsistent, with a progress note indicating an evaluation for weight loss occurring after the fact.
Failure to Implement Individualized Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized person-centered care plan for a resident diagnosed with dementia, identified as Resident R84. The facility's dementia care policy, dated September 2024, mandates that care plans be individualized based on the assessment and diagnosis of each resident. However, upon reviewing Resident R84's care plan dated April 21, 2022, it was found that there were no measurable goals or interventions addressing the resident's dementia care needs. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that residents diagnosed with dementia should have a care plan in place. The deficiency was identified under the regulations 28 Pa Code 211.11(d) and 28 Pa Code 211.12 (d)(1)(3)(5).
Incompatible Mattress and Bed Frame Leads to Entrapment Concerns
Penalty
Summary
The facility failed to ensure compatibility between mattresses and bed frames for a resident, leading to a deficiency. Observations conducted on two consecutive days revealed that the mattress used by a resident was six inches smaller than the metal bed frame, exposing the bedframe slats on each side and increasing entrapment concerns. The resident, who was admitted with neurological conditions, a cerebrovascular accident, cognitive communication deficit, muscle weakness, and atrophy, had been using the mismatched bed frame and mattress since admission. Interviews with staff, including a nurse assistant and the maintenance director, confirmed the mismatch. The maintenance director acknowledged that the mattress applied was a 36-inch size, while the bed frame required a 42-inch mattress. It was revealed that bed audits were last conducted in the first week of February, and the incorrect mattress size was likely reapplied by housekeeping. The facility's practice of purchasing mattresses separately from bed frames contributed to the oversight.
Medication and Care Deficiencies
Penalty
Summary
The facility failed to adhere to physician orders regarding medication administration for two residents, resulting in deficiencies. Resident R3, diagnosed with type 2 diabetes mellitus and other conditions, was prescribed NovoLin R insulin at specific times. However, there were multiple instances where the insulin was administered late, including significant delays on several days. On one occasion, Resident R3 expressed symptoms of hypoglycemia due to the delay, and the nurse, Employee E5, left the resident unsupervised with medication, contrary to the facility's policy. Additionally, the facility did not follow physician orders for Closed Record CR2, who was supposed to receive showers twice a week. The documentation did not indicate that the resident refused a shower, yet the shower was not provided as ordered. A family member later inquired about the missed shower, prompting a late entry in the progress notes claiming the resident refused, which was not supported by the initial documentation. Interviews with the Director of Nursing and other staff confirmed these deficiencies, acknowledging the delays in insulin administration and the failure to provide a shower as ordered. The facility's policies on medication administration and resident care were not followed, leading to these documented deficiencies.
Failure to Involve Residents in Care Plan Meetings
Penalty
Summary
The facility failed to ensure that residents and/or their responsible parties were provided with the opportunity to participate in their care plan meetings. This deficiency was identified for four residents, specifically Residents R64, R54, R85, and R69. The facility's policy, revised in August 2023, mandates that residents and their families or legal representatives be part of the interdisciplinary team and participate in the development and ongoing review of the care plan. However, the clinical records for these residents showed no evidence of notification or participation in care plan meetings since their last documented meetings, which were held on various dates in 2023. During an interview with the social worker, Employee E14, it was confirmed that there was no documentation to prove that the facility had notified the residents or their responsible parties about the care plan meetings, provided them with the opportunity to participate, or given them a copy of their care plan. This lack of documentation and involvement is a violation of the facility's policy and the relevant Pennsylvania Code sections regarding clinical records and nursing services.
Failure to Notify Physician of Medication Refusal
Penalty
Summary
The facility failed to notify a physician about a resident's continuous refusal to take prescribed medication, Lantus, for diabetes management. The resident, who has a history of falling, hypertension, seizures, and diabetes, was prescribed 12 units of Lantus to be administered subcutaneously at bedtime. However, the Medication Administration Records (MAR) for March, April, and May 2024 indicated that the resident refused the majority of the scheduled injections, with refusals recorded for 28 out of 31 days in March, 28 out of 30 days in April, and 28 out of 31 days in May. Despite these refusals, the physician's progress notes for the same months documented that the resident's diabetes was being controlled with Lantus insulin and glipizide. Interviews and reviews of the clinical records revealed that the nursing staff did not notify the physician about the resident's refusal to take the Lantus insulin. The Unit Manager confirmed that there was no evidence to show that the physician was informed of the refusals, even though the physician continued to document that the resident's diabetes was being managed with the medication. This lack of communication between the nursing staff and the physician led to a deficiency in ensuring proper resident care and adherence to prescribed medication orders.
Incomplete Investigation of Resident's Bruising
Penalty
Summary
The facility failed to conduct a complete and thorough investigation into bruises of unknown origin found on a resident, identified as Resident R69. The resident, who was cognitively impaired and had a history of pain, delusional disorder, hypertension, and peripheral vascular disease, was observed with purplish areas on the left hand towards the wrist. The facility's policy on abuse, neglect, and exploitation requires considering factors such as physical injury of unknown source, but the investigation into the resident's bruising was inadequate. The investigation only included an interview with the resident, who reported having physical therapy exercises the day before noticing the bruises. However, the Director of Rehabilitation confirmed that the resident had been discharged from therapy months prior, and no evidence was found to confirm any therapy session on the day in question. The investigation lacked interviews with staff who might have interacted with the resident or witnessed the incident, and there was no documentation to rule out abuse or neglect. The Director of Nursing confirmed that no additional information was available to demonstrate a thorough investigation.
Failure to Notify Ombudsman of Emergency Transfers
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers for four residents. This deficiency was identified through a review of facility documentation, clinical records, and staff interviews. Specifically, the facility did not provide the required notification for emergency hospital transfers of four residents, each of whom experienced significant medical issues necessitating immediate hospital care. These issues included a swollen tongue, low blood sugar, signs of gastrointestinal bleeding, and altered mental status with intractable pain. The facility's documentation revealed that a total of 56 residents were transferred to the hospital over a three-month period, yet there was no indication that the Ombudsman was notified for the emergency transfers of the four residents in question. The Nursing Home Administrator confirmed during an interview that the required notifications were not made in a timely manner, as mandated by the regulations. This oversight highlights a failure in the facility's process for ensuring compliance with notification requirements for emergency transfers.
Failure to Develop Care Plans for Oxygen Therapy
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for three residents, which was identified during a review of 27 resident records. Specifically, Residents R40, R62, and R65 did not have care plans addressing their use and maintenance of oxygen therapy, despite having physician orders for oxygen administration. Resident R40 had an order for oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath, while Residents R62 and R65 had orders for continuous oxygen at the same rate. Additionally, all three residents had orders to clean their oxygen concentrator filters weekly and as needed. On observation, it was found that the oxygen concentrator filters for these residents were covered with thick dust, indicating they had not been cleaned as required. This was confirmed by a registered nurse, Employee E7. Further interviews with Unit Manager Employee E29 confirmed the absence of care plans related to the residents' oxygen use. This deficiency violates the facility's care plan policy, which mandates timely and adequate person-centered care plans for all residents, and contravenes specific nursing service regulations.
Failure to Schedule Neurology Follow-Up
Penalty
Summary
The facility failed to ensure that a physician's order for a neurology follow-up was followed for a resident. The resident, identified as R62, was transferred to the hospital due to right arm weakness. Upon discharge from the hospital, the instructions dated April 30, 2024, specified that a follow-up appointment with neurology should be scheduled within two weeks. However, a review of the resident's clinical records showed no documented evidence that this neurology appointment was scheduled. This deficiency was confirmed with the Unit Manager on June 3, 2024, at approximately 2:15 p.m.
Failure to Maintain Clean Oxygen Concentrator Filters
Penalty
Summary
The facility failed to provide respiratory care services consistent with professional standards of practice for three residents. The facility's policy for oxygen administration, revised in January 2024, requires nursing staff to administer oxygen correctly and clean the oxygen concentrator filters weekly. Resident R40 had a physician's order to administer oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath, with instructions to clean the O2 concentrator filters on Thursdays during the 11-7 shift and as needed. Resident R62 had a similar order for continuous oxygen administration, and Resident R65 had an order for continuous oxygen administration with the same filter cleaning instructions. On May 29, 2024, it was observed and confirmed by a registered nurse that the O2 concentrator filters for these residents were covered with thick dust and had not been cleaned, indicating non-compliance with the facility's policy and physician orders.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure the accurate acquiring, receiving, and administration of medications for residents, as evidenced by the case of Resident R56. The facility's policy requires that medications be administered as ordered, and if unavailable, the physician should be notified, and an alternative should be provided. However, Resident R56 did not receive the prescribed Betamethasone Dipropionate Augmented cream for eczema over several days because the medication was on back order, and there were no corresponding nurse notes for several days to document this issue. Additionally, Resident R31, who was admitted for aftercare following a fracture and malignant neoplasm, did not receive the prescribed Oxycodone and Methocarbamol for pain management on a specific date because the medications were not available. This lack of medication availability and administration indicates a failure to meet the residents' needs as per the facility's policies and procedures.
Failure to Monitor Digoxin Levels
Penalty
Summary
The facility failed to obtain laboratory services to meet the needs of a resident's digoxin levels as per physician orders. Resident R55, who was admitted with a diagnosis of Atrial Fibrillation, was prescribed Digoxin to manage this condition. The resident's care plan included monitoring serum digoxin levels monthly or as ordered by the physician, with specific instructions to check these levels every six months as of October 2020. However, the last documented digoxin serum levels were completed in April 2023, indicating a failure to adhere to the physician's orders. This deficiency was confirmed by the Unit Manager, Employee E29, on June 3, 2024.
Latest citations in Pennsylvania
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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