Rolling Fields, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Conneautville, Pennsylvania.
- Location
- 9108 State Highway 198, Conneautville, Pennsylvania 16406
- CMS Provider Number
- 395619
- Inspections on file
- 28
- Latest survey
- November 18, 2025
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Rolling Fields, Inc during CMS and state inspections, most recent first.
The facility did not maintain its fire alarm system as required, with the fire alarm panel displaying fault and trouble indicators over multiple survey visits. The deficiencies were confirmed by the maintenance supervisor and remained uncorrected due to delays in vendor payment and scheduling.
The facility did not provide documentation for required sprinkler system inspections and allowed sprinkler heads to become covered in dust and corrosion. Staff confirmed missing inspection records and overdue maintenance, and the facility was unable to complete necessary repairs due to a payment hold with the vendor. The deficiencies remained uncorrected during follow-up surveys, resulting in a continuous fire watch.
A dry sprinkler system was found out of service because of a malfunctioning air compressor, with the backup unit also inoperable and not connected to power. No documentation was available regarding the duration or extent of the outage, and the deficiency remained uncorrected as repairs had not been completed. The facility maintained a continuous fire watch during this period.
A resident with Diabetes, Hypertension, and Hemiplegia refused Insulin Lispro 111 times in September and 118 times in October. The facility's policy required notifying the physician after three refusals, but this was not done, as confirmed by the DON.
A facility failed to protect resident privacy when a medication cart was left unattended in a hallway with an open computer displaying health information. The LPN responsible confirmed the oversight, which violated the facility's policy on safeguarding resident records.
The facility inaccurately coded the MDS for two residents, leading to discrepancies in their clinical records. One resident was incorrectly marked as having an indwelling catheter, while another was wrongly recorded as receiving insulin. These errors were confirmed by the RNAC and Corporate RNAC, highlighting a failure in the facility's assessment processes.
A facility failed to update a resident's care plan after a physician ordered a Texas catheter for the resident, who had multiple sclerosis and other conditions. The care plan did not reflect this new order, as confirmed by the RN Assessment Coordinator.
A resident with diabetes did not receive Insulin Lispro as ordered by the physician, according to a sliding scale based on blood glucose levels. The MAR for September and October showed multiple instances where insulin was not administered or documented despite elevated blood glucose readings. The DON confirmed the failure to follow the physician's orders.
A resident with lung cancer and atrial fibrillation did not receive routine oxygen as ordered by a physician. The MAR showed the resident missed prescribed oxygen on every shift over two months. An LPN confirmed the oversight.
The facility did not ensure the Medical Director's attendance at a QAPI Committee meeting in September 2024, as required by their policy. A review of attendance records from April to October 2024 confirmed the absence, which was acknowledged by the Nursing Home Administrator.
The facility inaccurately submitted PBJ staffing data for the first quarter of 2024, failing to report RN hours and 24-hour Licensed Nursing Coverage on specific dates. Despite documentation showing adequate staffing, the report was confirmed inaccurate by the Scheduler.
Failure to Maintain Fire Alarm System in Accordance with NFPA Standards
Penalty
Summary
The facility failed to maintain its fire alarm system in accordance with NFPA 70 and NFPA 72 requirements. During an observation and interview, the fire alarm panel was found to display a "FAULT RSTRD" message, with both supervisory and system trouble indicator lights illuminated, indicating a malfunction of the system. The maintenance supervisor confirmed these deficiencies at the time of the survey. Subsequent document reviews and interviews during onsite revisit surveys revealed that the deficiencies with the fire alarm panel remained uncorrected over multiple visits. The facility had not completed the necessary inspection or repairs, as a vendor required payment in advance and funding had not been secured. Throughout this period, the facility continued to experience a malfunctioning fire alarm system.
Plan Of Correction
1. Absolute Fire Protection will be contacted to correct the system malfunction and restore the fire alarm panel to "normal" status by 1/30/2026. 2. The Environmental Services Director/designee will perform an audit to ensure that the fire alarm panel reads "normal" status; the audit will be conducted daily for four weeks, weekly for four weeks, and bi-weekly for five weeks. 3. The results of this audit will be reviewed at the facility's next two quarterly Quality Assurance Performance Improvement meetings to ensure compliance.
Failure to Maintain and Document Sprinkler System Inspections and Maintenance
Penalty
Summary
The facility failed to meet sprinkler system requirements for two of three systems, as evidenced by missing documentation for required quarterly inspections and overdue trip tests. Specifically, there was no documentation for the second and third quarter sprinkler inspections, the last full-flow trip test was completed over three years prior, and the last annual partial trip test was completed more than a year ago. Additionally, a quarterly inspection noted that the system compressor had parts on order, and the facility was unable to provide further documentation due to a payment hold with the sprinkler vendor. Interviews with facility staff confirmed the lack of required documentation at the time of the survey. Further deficiencies were observed, including multiple sprinkler heads covered in dust and corrosion in the corridor outside the maintenance office and in the mechanical room inside the laboratory. These conditions were confirmed by staff interviews. During subsequent revisit surveys, it was found that the deficiencies had not been corrected, as the facility was still awaiting vendor approval and funding to schedule the necessary inspections and repairs. As a result, the facility was maintaining a continuous fire watch.
Plan Of Correction
1. Absolute Fire Protection will be contacted to ensure that: a. The fourth quarter sprinkler inspection is completed. b. The three-year, full-flow trip test is completed by April 30th, once the partial trip test verifies that the dry valves are working correctly. c. The annual partial trip test is completed by the designated "substantial compliance" date of 1/30/2026. d. Any needed parts for the system compressor are ordered, received, and installed to ensure the system compressor is operational. 2. The Administrator will assist the Environmental Services Director in ensuring that Absolute Fire Protection is contacted for service and that payment will be secured for any and all necessary parts to ensure the system compressor is operational. 3. The results of these corrective actions will be reviewed at the facility's next two quarterly Quality Assurance Performance Improvement meetings to ensure compliance. K 0353
Sprinkler System Out of Service Due to Equipment Failure
Penalty
Summary
A deficiency was identified when the facility failed to maintain compliance with sprinkler system regulations for one of its two dry sprinkler systems. On observation, system #1 was found to be out of service due to a malfunctioning air compressor, and the backup air compressor was not operational or connected to a power source. There was no documentation provided regarding the extent or duration of the system being out of operation. The maintenance technician confirmed that the dry system was out of service at the time of the survey. Subsequent surveys revealed that the deficiency remained uncorrected, as the facility had not completed the necessary repairs or inspections to restore the sprinkler system to service. The facility had received a bid from a vendor but had not secured funding or payment to proceed with the repairs. During this period, the facility maintained a continuous fire watch as the sprinkler system remained nonfunctional.
Plan Of Correction
1. Absolute Fire Protection has been contacted to ensure that any and all necessary parts needed to fix the malfunctioning air compressor will be ordered and installed, so that the dry sprinkler system can be turned back on prior to the "substantial compliance" date of 1/30/2026. Documentation WAS provided to the extent and duration of the dry system being out of operation in the form of "fire walk" documentation, from the day the system went down through present day. 2. The Administrator will assist the Environmental Services Director in ensuring that Absolute Fire Protection is contacted for service and that payment will be secured for any and all necessary parts to ensure the malfunctioning air compressor is operational, which will then allow for the dry sprinkler system to be turned back on. 3. The results of these corrective actions will be reviewed at the facility's next two quarterly Quality Assurance Performance Improvement meetings to ensure compliance.
Failure to Notify Physician of Medication Refusal
Penalty
Summary
The facility failed to notify the physician regarding a resident's refusal of medication, as required by their policy. The policy stated that the provider should be notified after a medication is refused three times. Resident R1, who was admitted with diagnoses including Diabetes, Hypertension, and Hemiplegia, had a physician's order for Insulin Lispro to be administered four times a day. However, the resident refused this medication 111 times in September 2024 and 118 times in October 2024. The Director of Nursing confirmed that the physician was not notified of these refusals, which was a deviation from the facility's policy.
Resident Privacy Breach on Medication Cart
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical records as required by their policy. During an observation on Dogwood Hall, a medication cart was found unattended in the hallway with an open computer displaying resident health information. This information was visible to several visitors, residents, and staff who passed by until the nurse returned to the cart. The facility's policy mandates that access to medical records is limited to staff and consultants providing direct care, and all records must be safeguarded to ensure confidentiality. The Licensed Practical Nurse (LPN) responsible for the cart confirmed leaving the computer open and acknowledged that resident information should be covered when not in view.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two residents, leading to discrepancies in their clinical records. Resident R29, who was admitted with multiple diagnoses including multiple sclerosis and spastic hemiplegia, had a physician's order for a Texas catheter to be used at night. However, the MDS inaccurately indicated that the resident had both an external catheter and an indwelling catheter. This error was confirmed by the Registered Nurse Assessment Coordinator (RNAC) during an interview, who acknowledged that the MDS was incorrectly coded regarding the indwelling catheter. Similarly, Resident R16, who was admitted with conditions such as Type II diabetes and dysphagia, had a physician's order for an Ozempic injection, which is not classified as insulin. Despite this, the Quarterly MDS inaccurately recorded that the resident received insulin during the seven-day look-back period. This mistake was confirmed by the Corporate RNAC, who stated that the MDS should have indicated zero days of insulin administration. These inaccuracies in the MDS coding reflect a failure in the facility's assessment processes.
Failure to Update Care Plan for Resident with New Physician's Order
Penalty
Summary
The facility failed to update the care plan for one of the residents, identified as Resident R29, following a physician's order for a Texas catheter. The resident, who was admitted with diagnoses including multiple sclerosis, benign prostatic hyperplasia, spastic hemiplegia, and weakness, had a physician's order dated 7/12/24 for a Texas catheter to be used at bedtime and removed in the morning. However, a review of the clinical records showed no evidence that the care plan was updated to include this new order. This deficiency was confirmed during an interview with the Registered Nurse Assessment Coordinator, who acknowledged that the care plan had not been revised to reflect the use of the Texas catheter.
Failure to Administer Insulin as Ordered
Penalty
Summary
The facility failed to administer medications as ordered by the physician for a resident diagnosed with diabetes, hypertension, and hemiplegia. The resident had a physician's order for Insulin Lispro to be administered four times a day based on a sliding scale determined by blood glucose results. However, a review of the Medication Administration Records (MAR) for September and October 2024 revealed multiple instances where the resident's blood glucose levels indicated the need for insulin, but the MAR lacked documentation of the insulin being administered according to the physician's order. Specifically, on several occasions, the resident's blood glucose levels were recorded at levels that required insulin administration, yet the MAR showed either no insulin was given or the amount was not documented. An interview with the Director of Nursing confirmed that the insulin was not administered in accordance with the physician's orders, acknowledging the failure to follow the prescribed treatment plan. This deficiency was identified during a review of clinical records, facility policies, and staff interviews.
Failure to Administer Routine Oxygen as Ordered
Penalty
Summary
The facility failed to administer routine oxygen as ordered for a resident, identified as Resident R31, who was admitted with diagnoses including lung cancer, atrial fibrillation, and low back pain. A physician's order dated July 31, 2024, specified that Resident R31 was to receive routine oxygen at 2 liters per minute via nasal cannula. However, a review of the Medication Administration Record (MAR) for September and October 2024 revealed that the resident did not receive the prescribed oxygen on every shift from September 1 to October 29, 2024. This deficiency was confirmed during an interview with Licensed Practical Nurse Employee E3 on October 30, 2024, who acknowledged that the routine oxygen order was not being followed as prescribed.
Medical Director's Absence from QAPI Meeting
Penalty
Summary
The facility failed to ensure the required attendance of the Medical Director at the Quality Assurance and Performance Improvement (QAPI) Committee meetings for one of the four quarterly meetings in September 2024. According to the facility's policy dated July 5, 2024, the QAPI committee is mandated to meet at least quarterly and include feedback from the Medical Director. However, a review of the QAPI Committee Attendance Records from April 2024 through October 2024 showed no evidence of the Medical Director's attendance at the September 2024 meeting. This was confirmed during an interview with the Nursing Home Administrator on October 31, 2024, who acknowledged the lack of evidence for the Medical Director's attendance at the required meeting.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to electronically submit accurate direct care staffing information for the first quarter of 2024, as required by Section 6106 of the Affordable Care Act (ACA). The Payroll Based Journal (PBJ) staffing data reports indicated that there were no Registered Nurse (RN) hours on specific dates in December 2023, and there was a lack of Licensed Nursing Coverage for 24 hours on several dates in December 2023. However, upon review of the staffing documentation, it was found that the facility did have RN hours and Licensed Nursing Coverage on those dates. This discrepancy indicates that the facility submitted inaccurate PBJ information. The Scheduler, identified as Employee E2, confirmed during an interview that the PBJ report for Quarter One of 2024 was submitted inaccurately.
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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