Sapphire Care And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in East Stroudsburg, Pennsylvania.
- Location
- 221 East Brown Street, East Stroudsburg, Pennsylvania 18301
- CMS Provider Number
- 395288
- Inspections on file
- 35
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Sapphire Care And Rehab Center during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease and dementia, identified as high risk for elopement, had a PRN quetiapine order for agitation in addition to other psychotropic and dementia-related medications. The care plan included interventions such as reorientation, frequent monitoring, diversionary activities, and redirection, and documentation showed that redirection and contacting the resident’s husband were sometimes effective in calming exit-seeking and agitation. However, PRN quetiapine was administered multiple times without consistent documentation of the specific behaviors present, without evidence that non-pharmacological interventions were attempted and found ineffective before administration for half of the doses reviewed, and without clearly defined, measurable behavioral parameters to guide staff on when PRN antipsychotic use was clinically indicated, resulting in the use of a chemical restraint contrary to facility policy.
A resident with COPD and acute bronchitis experienced a significant change in condition, leading to new treatment orders including supplemental oxygen and medications. The facility did not document notification of the resident's designated representative or POA about these changes, despite policy requiring prompt notification within 24 hours.
A resident with diabetes and moderately impaired cognition did not receive insulin aspart as ordered on multiple occasions, with doses withheld despite the absence of physician-approved parameters for holding the medication. There was also no documentation that the physician was notified when insulin was not administered, contrary to facility policy.
The facility did not ensure proper inspection and maintenance of bed frames with extenders, resulting in gaps between mattresses and footboards in several rooms. Two residents were found with bed extenders creating entrapment zones, and staff reported using repositioning wedges to fill these gaps instead of appropriate equipment, leading to unaddressed safety hazards.
A deficiency was cited when a resident did not receive sufficient food and fluids to maintain their health, as required. The report indicates that the facility did not meet the necessary standards for nutrition and hydration, but does not provide further details about the circumstances or the resident's condition.
Surveyors found that several licensed resident rooms were missing required beds and mattresses, with no evidence that the missing beds were stored elsewhere in the facility. This resulted in the facility not maintaining the full complement of licensed and certified beds as required.
A resident with hemiplegia and contractures in both hands was unable to use the standard push-button call bell due to physical limitations. Despite facility policy requiring evaluation and accommodation of unique needs, the resident was not provided with a touch-sensitive call system until after surveyor inquiry. An LPN and the administrator confirmed the lack of appropriate accommodation prior to the survey.
Two residents did not have their clinical status accurately reflected in their MDS assessments, with one resident's significant weight loss not documented and another resident's ongoing dialysis treatments omitted, as confirmed by facility staff and clinical records.
A resident did not receive appropriate care for existing pressure ulcers, and preventive measures to avoid new ulcers were not consistently implemented. The facility did not follow established protocols for assessment, monitoring, and treatment of pressure ulcers.
A resident with hemiplegia and hemiparesis following a stroke did not receive restorative nursing services or a prescribed therapeutic device as ordered by the physician and recommended by therapy staff. The resident's care plan did not include the required interventions, and there was no documentation or evidence that staff provided the ordered exercises or consistently applied the palm guard.
Nursing staff did not consistently follow facility policy for documenting controlled medication counts, with multiple instances where required signatures from oncoming and off-going nurses were missing on narcotic count sheets for a medication cart. This failure was confirmed by staff interviews and review of records, indicating the facility did not consistently implement its procedures for controlled substance documentation.
Surveyors found that an LPN had left expired multi-dose insulin medications, including Humalog and Basaglar pens and vials, on a medication cart past their manufacturer-recommended 28-day discard dates. The medications remained available for resident use, contrary to facility policy and manufacturer instructions, a fact confirmed by both the LPN and the DON.
A resident with acute kidney failure and a history of inability to care for herself was discharged home without documented evidence that her needs for food and support services would be met. Social service notes lacked details on how the family would assist, and upon return home, the resident had no food available, indicating the facility did not ensure a safe and appropriate discharge.
A resident with moderate cognitive impairment tested positive for COVID-19 and, while both the resident and physician were informed, the facility did not promptly notify the resident's emergency contact as required by policy. The emergency contact only learned of the diagnosis through the resident, and staff confirmed there was no timely documentation of notification.
The facility did not meet the required nurse aide to resident ratios on five shifts. On specific dates, the evening and night shifts were understaffed, with no additional higher-level staff available to compensate. The Nursing Home Administrator confirmed these deficiencies.
The facility did not meet the required LPN to resident ratios on two night shifts, providing only 2.00 LPNs for 103 residents instead of the required 2.58. No additional higher-level staff were available to compensate for this deficiency, as confirmed by the Nursing Home Administrator.
The facility did not meet the required minimum of 3.2 hours of direct resident care per resident on two occasions, providing only 3.06 and 2.91 hours respectively. This was confirmed by the Nursing Home Administrator.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with chronic wounds or indwelling medical devices, as required by new CMS and CDC guidance. Observations revealed no EBP measures in place, confirmed by the DON, despite six residents meeting the criteria for EBP due to conditions like tube feeding and indwelling catheters.
The facility failed to comply with CMS regulation S483.80(b)(3) by not having a designated Infection Preventionist (IP) responsible for the Infection Prevention and Control Program. The previous IP left in April 2024, and as of the survey's end, no new IP had started. The DON confirmed the absence of credentialed infection preventionists.
The facility did not implement proper screening procedures for five employees, as required by their abuse prohibition policy. The policy lacked procedures for obtaining references from previous employers, and personnel files showed no evidence of such checks. This was confirmed by the NHA.
A resident's medications were left unattended on an overbed table, creating a potential accident hazard. The resident was scheduled to receive medications via a feeding tube, but there was no authorization for self-administration. An LPN confirmed the medications were left unattended, and the DON verified the resident was not to self-administer medications.
A facility failed to maintain sanitary conditions for a resident's catheter supplies, leading to potential urinary tract infection risks. The resident required an indwelling catheter due to urine retention, and a physician's order for Acetic Acid irrigation lacked clarity. Observations found unsanitary storage of irrigation supplies, with opened and undated bottles of Acetic Acid improperly stored, contrary to manufacturer instructions. An LPN and the DON confirmed the unsanitary conditions.
The facility did not follow physician orders for oxygen therapy and failed to maintain oxygen equipment properly for three residents. A resident with COPD had undated oxygen tubing and a dusty concentrator filter, while another resident received oxygen at a higher flow rate than prescribed. An LPN confirmed these issues, and the Nursing Home Administrator acknowledged the facility's non-compliance with policy.
The facility failed to implement procedures for accounting for controlled drugs on a medication cart. The narcotic logbook was not with the cart, and shift-to-shift sign-offs were incomplete on several occasions. The DON confirmed the failure to accurately account for controlled drugs at shift changes.
The facility failed to ensure that the attending physician acted upon the pharmacist's reports of irregularities in the drug regimens of four residents. For one resident, the pharmacist recommended identifying the duration of Lovenox therapy and considering therapy modification due to potential interactions with NSAIDs. However, there was no documentation of the physician's response. Similar issues were found for three other residents, where the facility could not provide evidence of the physician's acknowledgment or response to the pharmacist's recommendations.
The facility failed to document clinical rationale for the continued use of as-needed psychotropic medication for two residents. One resident with Bipolar Disorder received lorazepam without a documented rationale for its continued use. Another resident with anxiety and depression had lorazepam administered without an end date, despite pharmacy recommendations for a stop date. The DON confirmed the lack of documentation for the use of the medication beyond 14 days.
The facility failed to properly label and store insulin pens on two medication carts. Insulin pens were found opened without being dated or marked with expiration dates, and one pen was not labeled with resident identification. The DON confirmed these deficiencies.
The facility failed to offer routine annual dental services to a resident with Medicaid and did not promptly refer another resident with mouth pain for a dental consult, despite a physician's order. These deficiencies were confirmed through clinical record reviews and staff interviews, indicating non-compliance with nursing services regulations.
The facility did not implement an antibiotic stewardship program for six months, as required by their infection control policies. Despite the policy mandating antibiotic monitoring, there was no documentation of such monitoring from April to September 2024. The DON confirmed the absence of a surveillance system and could not provide tracking records for this period.
A resident with dementia was not assisted with her lunch meal for approximately 25 minutes after it was placed in front of her, despite requiring assistance with feeding. The NHA confirmed that the meal service did not promote the resident's dignity, as required by regulations.
A facility failed to ensure accurate MDS Assessments, as a resident's discharge was incorrectly recorded as to an acute care hospital instead of home. Clinical records and staff confirmed the resident was discharged home, highlighting a discrepancy in the MDS Assessment.
The facility failed to create comprehensive care plans for three residents, neglecting to include critical medical devices and behaviors in their plans. A resident with a pacemaker and another requiring a SmartVest for respiratory issues did not have these needs documented in their care plans. Additionally, a resident with dementia who hoarded food had no interventions for this behavior in their care plan. The DON confirmed these deficiencies.
A facility failed to update a resident's care plan to reflect current needs, despite the resident being assessed as a low wander risk and cognitively intact. The care plan, which included interventions for potential elopement, had not been revised since the previous year, even after a physician's order allowed the resident to go out on pass alone. The DON confirmed the oversight.
A resident with conditions including congestive heart failure and anxiety was prescribed Midodrine HCL with instructions to hold the medication if systolic blood pressure (SBP) exceeded 120 mm/Hg. However, the medication was administered multiple times despite the resident's SBP being above this threshold. The DON confirmed the nursing staff's failure to follow the physician's order, indicating a deficiency in nursing services and documentation.
A resident with dementia experienced significant weight loss, and the facility failed to adhere to its policy of reweighing after a 5-pound loss. The dietician's recommendations for nutritional support and weekly weights were not implemented, and the facility did not timely address the resident's weight loss, as confirmed by the DON.
A resident with end-stage renal disease and dependent on hemodialysis did not have necessary emergency supplies available in their room or on their wheelchair. The care plan included monitoring the dialysis catheter site but lacked interventions for emergency supplies. Observations and interviews confirmed the absence of supplies, and the deficiency was noted under nursing services regulations.
A resident with schizoaffective disorder exhibited ongoing behavioral issues such as agitation and restlessness, yet the facility failed to update the care plan or provide necessary psychological services. Despite recommendations for continued behavioral health services, the resident's care plan did not address these needs, and no interventions were observed during a survey.
Failure to Document and Use Non-Pharmacological Interventions Before PRN Antipsychotic Use
Penalty
Summary
The deficiency involves the facility’s failure to prevent the use of a chemical restraint and to ensure that non-pharmacological interventions were attempted and documented prior to administering a PRN psychotropic medication. Facility policy on psychotropic medication required that residents not receive such medications unless clinically indicated and necessary, with behavioral and other non-pharmacological approaches used first and documented as ineffective. The policy also required that psychotropic medications be used at the lowest possible dose and only after non-pharmacological interventions had been tried and found ineffective in relieving distressing or unsafe symptoms. The resident involved was admitted with Alzheimer’s disease and dementia and was assessed as moderately cognitively impaired, with a care plan identifying a high risk for elopement and interventions such as reorientation, frequent monitoring, structured and diversionary activities, and redirection away from exits. On admission, the resident had orders for divalproex, donepezil, and memantine, and shortly thereafter a PRN order for quetiapine every 12 hours for agitation was added. The clinical record showed multiple episodes of exit-seeking and agitation, including attempts to open the front door and a dining room window, searching for the resident’s husband, and attempts to pull a fire alarm. In some instances, documentation indicated that redirection or contacting the husband was effective in calming the resident. However, review of the MAR and progress notes showed that PRN quetiapine was administered on several occasions without adequate documentation of the behaviors requiring medication or of non-pharmacological interventions attempted beforehand. For one administration, there was no documentation of symptoms of agitation or any non-pharmacological measures prior to giving the medication. For two of four PRN administrations, the record lacked evidence that non-pharmacological interventions were attempted and found ineffective before quetiapine was given. The record also did not define the resident’s behavioral symptoms in observable, measurable terms to guide staff in determining when PRN quetiapine was clinically indicated, leaving staff without objective criteria for consistent and appropriate use of the antipsychotic. During interview, the DON was unable to provide documentation to show consistent use of non-pharmacological interventions or clearly defined behavioral parameters for PRN psychotropic use.
Failure to Notify Resident's Representative of Change in Condition and Treatment
Penalty
Summary
The facility failed to promptly notify a resident's designated representative and power of attorney of a significant change in the resident's condition and new treatment orders. According to the facility's policy, the resident, their attending physician, and representative must be notified within 24 hours of a significant change in the resident's medical or mental condition, unless otherwise instructed by the resident. A review of the clinical record for a resident with chronic obstructive pulmonary disease (COPD) and acute bronchitis showed that after the resident experienced increased coughing and hypoxia, new treatment orders were initiated, including supplemental oxygen, medication, and additional monitoring. Despite these changes, there was no documentation that the resident's responsible party or power of attorney was notified of the change in condition or the new treatment orders, as required by facility policy. Interviews confirmed that the resident wished for his daughter, who was his responsible party and POA, to be informed of changes to his care. The Nursing Home Administrator acknowledged that the facility could not provide evidence of such notification.
Failure to Administer Insulin per Physician Orders and Notify Physician When Withheld
Penalty
Summary
The facility failed to follow professional standards of practice for diabetes management for one resident. According to the clinical record, the resident had diagnoses including cerebral infarction and diabetes, and was assessed as having moderately impaired cognition. Physician orders specified that the resident was to receive insulin aspart 5 units subcutaneously four times daily. However, the Medication Administration Record (MAR) showed that multiple doses of insulin aspart were withheld on several occasions, with documented blood glucose levels ranging from 94 mg/dL to 118 mg/dL, and in one instance, no blood glucose was documented at all. There were no physician orders providing parameters for when insulin aspart could be held, and there was no documented evidence that the physician was notified when the insulin doses were withheld. Facility policy required that medications be administered according to physician orders and that the physician be contacted if there were concerns about the appropriateness of a medication or if it was withheld. The failure to administer insulin as ordered and to notify the physician of withheld doses constituted a deficiency in following professional standards and facility policy.
Failure to Maintain Bed Systems and Prevent Entrapment Hazards
Penalty
Summary
The facility failed to maintain an effective inspection and maintenance program for bed frames with bed extenders, resulting in unaddressed entrapment hazards in multiple resident rooms. Specifically, observations revealed that two residents were using bed frames with extenders that created significant gaps—ranging from approximately 4 to 6 inches—between the mattress and the footboard. In one instance, the gap was filled with wedges typically used for repositioning, rather than equipment designed to eliminate entrapment zones. Additional rooms were also found to have similar gaps when bed extenders were in use. Interviews with facility staff, including the physical therapy director, confirmed that the practice was to use repositioning wedges to fill these gaps when bed extenders were applied. This practice was acknowledged during the survey, and the information was reviewed with the Nursing Home Administrator. The deficiency was identified for two residents out of a sample of 29, as well as in three observed resident rooms, indicating a lack of consistent and appropriate maintenance procedures to minimize or eliminate entrapment hazards as required.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide adequate food and fluids necessary to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is essential for the well-being of residents. Specific details about the actions or inactions leading to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Missing Licensed Resident Beds on Two Care Units
Penalty
Summary
The facility failed to ensure the availability of a functioning bed for all current licensed and certified resident beds on two of three resident care units. During an environmental tour, surveyors observed that multiple resident rooms, which were licensed as double or triple occupancy, were missing beds for specific bed spaces (such as 104B, 106B, 113B, 116B, and 217B). These beds were not present in the rooms nor stored elsewhere in the facility, making them unavailable for immediate use. The facility is required to provide bedrooms that are appropriately furnished with a bed, mattress, and related equipment for each licensed bed in accordance with its license and certification. The absence of these beds demonstrated that the facility did not maintain the full complement of licensed and certified beds, as required. The findings were reviewed and confirmed with the Nursing Home Administrator.
Failure to Provide Call Bell Accommodation for Resident with Physical Limitations
Penalty
Summary
The facility failed to reasonably accommodate the needs of a resident with significant physical limitations by not providing an appropriate call bell system. The facility's policy requires that each resident be evaluated for unique needs and that any necessary special accommodations for the call system be identified and provided. In this case, a resident with hemiplegia, muscle wasting, and contractures in both hands was unable to use the standard push-button call bell due to these physical limitations. The resident expressed during an interview that he was unable to use the call bell and requested a touch-sensitive system. A Licensed Practical Nurse confirmed that the resident could not utilize the standard call light because of his hand contractures. It was only after the surveyor's inquiry that the facility provided a touch-sensitive call light device, which the resident was able to operate. The Nursing Home Administrator confirmed that the resident had not been provided with a compatible call system prior to the surveyor's involvement. This failure to provide a necessary accommodation was in direct violation of the facility's own policy and relevant regulatory requirements.
Inaccurate MDS Assessments for Weight Loss and Dialysis
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the clinical status of two residents. For one resident, the MDS assessment did not document a significant weight loss, despite clinical records showing a decrease from 123 pounds to 107 pounds within a month, which constitutes a 13% weight loss. The Registered Dietitian confirmed that this weight loss was not accurately recorded in Section K0300 of the MDS, resulting in an inaccurate assessment of the resident's nutritional status. For another resident with end-stage renal disease receiving maintenance hemodialysis, the MDS assessment failed to indicate that the resident was receiving dialysis treatments, even though clinical records showed dialysis was administered on multiple occasions. The Registered Nurse Assessment Coordinator confirmed that the omission in Section O0110 of the MDS was an error. These inaccuracies were identified through clinical record reviews and staff interviews, and they represent a failure to ensure that assessments accurately reflected the residents' conditions as required by regulatory standards.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through observations and record reviews that indicated lapses in the assessment, monitoring, and treatment of pressure ulcers for residents at risk. The report notes that necessary interventions to prevent skin breakdown were not consistently applied, and existing pressure ulcers were not managed according to established protocols.
Failure to Provide Ordered Restorative Nursing Services and Therapeutic Device
Penalty
Summary
The facility failed to provide restorative nursing services and a prescribed therapeutic device as ordered by the physician and recommended by rehabilitative therapy staff for one resident. The resident, who had a history of hemiplegia and hemiparesis following a stroke, was recommended to receive a restorative nursing program including bilateral lower extremity assisted active range of motion (AAROM) exercises and active range of motion (AROM) exercises for the left upper extremity. Additionally, the use of a left modified palm guard and specific positioning of the left upper extremity were ordered. These interventions were confirmed by physician orders and therapy discharge summaries. Despite these orders, the resident's plan of care did not incorporate the required restorative nursing needs. The resident reported not receiving restorative exercises since discharge from therapy and noted inconsistent application of the palm guard. Review of the clinical record revealed no documentation that the restorative nursing program or the application of the palm guard was provided as ordered. The Nursing Home Administrator was unable to provide evidence that these services were being delivered according to physician orders.
Failure to Document Controlled Medication Counts per Policy
Penalty
Summary
The facility failed to implement its procedures for accurate documentation of controlled medications on one of three medication carts reviewed. According to the facility's policy, nursing staff are required to count controlled medications at the end of each shift, with both the oncoming and off-going nurses completing the count together and signing the record to verify accuracy. The policy also requires that any discrepancies be reported to the Director of Nursing Services immediately. However, a review of controlled drug records for the first-floor, back medication cart revealed multiple instances where the required signatures were missing. Specifically, on several dates, either the oncoming or off-going nurses, or both, failed to sign the narcotic count sheets as required. These findings were confirmed through staff interviews and review with the Director of Nursing. The lapses in documentation were directly observed in the narcotic sheets, and staff acknowledged that the required signatures were not present on the specified dates. The facility did not consistently follow its established procedures to ensure accurate documentation of controlled substances, as required by its own policy and state regulations.
Expired Insulin Medications Found on Medication Cart
Penalty
Summary
Surveyors observed that the facility failed to follow its own policy and manufacturer guidelines regarding the storage and use-by dates for multi-dose insulin medications. During an inspection of a medication cart on the first floor, surveyors found a Humalog KwikPen, a Humalog Insulin vial, and a Basaglar KwikPen that had been opened beyond the manufacturer's recommended 28-day discard date. These medications were still available for resident use, despite being expired according to both facility policy and manufacturer instructions. A review of the facility's policy confirmed that discontinued, outdated, or deteriorated drugs should not be used and must be returned to the pharmacy or destroyed. Staff interviews, including with an LPN present during the observation, acknowledged that the insulin medications were past their use-by dates and should have been removed from the cart. The Director of Nursing also confirmed that the facility had not adhered to the required procedures for medication storage and use-by dates.
Failure to Ensure Safe and Appropriate Discharge Planning
Penalty
Summary
The facility failed to ensure that a resident's discharge was appropriate and necessary, as required by regulations. Clinical record review showed that a resident with acute kidney failure and unsteadiness, who had previously been hospitalized due to an inability to care for herself, was discharged home. The Minimum Data Set Assessment indicated the resident was cognitively intact, but there was documented evidence from the Area Agency on Aging that upon returning home, the resident had no food available except for ice cubes in the refrigerator/freezer. Social service notes indicated that discharge planning was discussed with the resident's family, but there was no documentation detailing how the family would assist the resident in obtaining food or other necessary services to support her transition home. Interviews with the Director of Social Services confirmed the lack of documented evidence that the resident would receive the required care and services to ensure a safe discharge. The facility did not demonstrate that the discharge was safe and appropriate, as required by state regulations.
Failure to Timely Notify Resident's Representative of Change in Condition
Penalty
Summary
The facility failed to promptly notify a resident's designated representative of a significant change in condition, specifically a positive COVID-19 test result. According to facility policy, the resident, their attending physician, and their representative must be notified of changes in the resident's medical or mental condition. The resident in question, who had Alzheimer's disease and hypertension and was assessed as having moderate cognitive impairment, reported feeling unwell and subsequently tested positive for COVID-19. Documentation confirmed that the resident and physician were informed of the positive result, but there was no evidence that the emergency contact was notified within the required timeframe. Further review of the clinical record and staff interviews revealed that the family was not updated about the resident's condition and positive COVID-19 test until two days after the diagnosis, and the emergency contact reported learning of the situation only through a conversation with the resident, not from facility staff. Both the President of Operations and the Infection Preventionist confirmed the lack of timely notification and documentation. This failure to notify the emergency contact as required by policy constituted a deficiency under the applicable nursing services regulations.
Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios on five out of 21 reviewed shifts. Specifically, on December 17, 2024, the evening shift had 9.00 nurse aides instead of the required 9.36 for a census of 103, and the night shift had 6.00 nurse aides instead of the required 6.87. On December 21, 2024, the night shift had 5.00 nurse aides instead of the required 6.80 for a census of 102. On December 22, 2024, the day shift had 9.00 nurse aides instead of the required 10.20, and the night shift again had 5.00 nurse aides instead of the required 6.80. No additional higher-level staff were available to compensate for these deficiencies. The Nursing Home Administrator confirmed the facility's failure to meet the required staffing ratios during an interview on December 30, 2024.
Plan Of Correction
The facility cannot retroactively correct the deficiency. The Nursing Staffing Coordinator will be re-educated regarding the ratios for nurse aides. The facility will focus on retention of existing nurse aides and recruitment of new nurse aides through efforts of the facility Recruitment & Retention Committee. Calculation of the daily nurse aide ratios will be completed and reviewed for accuracy by the scheduler/designee. Daily ratios will be audited weekly x4 then monthly x2. The audits will be taken to QAPI for further action planning as needed. Facility will be in compliance 02/15/2025.
LPN Staffing Deficiency on Night Shifts
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios on two specific night shifts. On December 19 and December 20, 2024, the facility provided only 2.00 LPNs for a census of 103 residents, whereas the regulation required 2.58 LPNs. This deficiency was identified through a review of the facility's weekly staffing records, which showed that the minimum staffing levels were not met. Additionally, there were no higher-level staff available to compensate for this shortfall. The Nursing Home Administrator confirmed the failure to meet the required LPN to resident ratios during an interview on December 30, 2024.
Plan Of Correction
The facility cannot retroactively correct the deficiency. The Nursing Staffing Coordinator will be re-educated regarding the ratios for LPNs. The facility will focus on retention of existing LPNs and recruitment of new LPNs through efforts of the facility Recruitment & Retention Committee. Calculation of the daily LPN ratios will be completed and reviewed for accuracy by the scheduler/designee. Daily ratios will be audited weekly x4 then monthly x2. The audits will be taken to QAPI for further action planning as needed. Facility will be in compliance 02/15/2025.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the state regulation requiring a minimum of 3.2 hours of direct resident care per resident in each 24-hour period. On December 21, 2024, the facility provided only 3.06 hours of direct care nursing per resident, and on December 22, 2024, the facility provided 2.91 hours per resident. This deficiency was confirmed during an interview with the Nursing Home Administrator on December 30, 2024, who acknowledged the facility's failure to consistently provide the required minimum general nursing care hours to each resident daily.
Plan Of Correction
The facility cannot retroactively correct the deficiency. The Nursing Staffing Coordinator will be re-educated regarding the new staffing hours of 3.2. The facility will focus on retention of existing staff and recruitment of new staff through efforts of the facility Recruitment & Retention Committee. Calculation of the daily staffing hours will be completed and reviewed for accuracy by the Nursing Staffing Coordinator/designee. Daily hours will be audited weekly x4 then monthly x2. The audits will be taken to QAPI for further action planning as needed. Facility will be in compliance by 02/15/2025.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain and implement a comprehensive infection prevention and control program, specifically regarding Enhanced Barrier Precautions (EBP) for residents with chronic wounds or indwelling medical devices. The deficiency was identified through a review of the facility's infection control tracking log, observations, and staff interviews. The facility did not adhere to the new guidance issued by CMS and the CDC, which requires the use of EBP during high-contact resident care activities to prevent the spread of multidrug-resistant organisms. Six residents were identified as requiring EBP due to their medical conditions, which included tube feeding, neurogenic bladder, stage 4 pressure ulcers, and indwelling urinary catheters. Despite these requirements, observations during the initial environmental tour revealed no evidence of EBP being implemented for these residents. The Director of Nursing confirmed that no EBP measures were in place for any resident at the time of the survey, despite the residents meeting the criteria for such precautions.
Lack of Designated Infection Preventionist
Penalty
Summary
The facility was found to be non-compliant with the Centers for Medicare and Medicaid Services regulation S483.80(b)(3), which requires the designation of one or more individuals as the Infection Preventionist (IP) responsible for the facility's Infection Prevention and Control Program. The regulation mandates that the IP must work at least part-time at the facility, be physically present onsite, and cannot be an off-site consultant or perform the IP work at a separate location. During interviews with the Nursing Home Administrator (NHA) and Director of Nursing (DON), it was revealed that the previous IP left the role in early April 2024, and as of the survey's conclusion on October 25, 2024, no new IP had started in the position. The DON confirmed that the facility currently had no staff credentialed as infection preventionists.
Failure to Implement Employee Screening Procedures
Penalty
Summary
The facility failed to fully develop and implement established abuse prohibition procedures for screening prospective employees, as required by regulatory standards. Specifically, the facility's Resident Abuse policy, last reviewed on January 24, 2024, did not include procedures for obtaining references from current or previous employers. This omission was identified during a review of the facility's abuse prohibition policy, employee personnel files, and staff interviews. The review revealed that five employees (a Nurse Aide, an LPN, an Activities staff member, another Nurse Aide, and an RN) were hired without the facility contacting their previous employers for references. The employees' applications indicated prior employment, yet there was no evidence in their personnel files that the facility had obtained information from former employers. This deficiency was confirmed during an interview with the Nursing Home Administrator, who verified the lack of evidence for contacting previous employers.
Medication Administration Hazard
Penalty
Summary
The facility failed to maintain an environment free of potential accident hazards during medication administration on the first floor nursing unit. An observation revealed that medications were left unattended on an overbed table in a resident's room. The medications included a clear plastic cup with crushed medications in a liquid, a second cup with a red liquid, and a large cup filled with a pink liquid. The resident, identified as Resident 83, confirmed that the nurse left the medications on the table and stated that she would eventually administer them herself. Further investigation revealed that Resident 83 was scheduled to receive multiple medications via a feeding tube at 8:30 AM. However, there was no evidence in the resident's physician orders that she was to self-administer her medications. An interview with an LPN confirmed that the medications were left unattended at the bedside, and the Director of Nursing verified that Resident 83 was not authorized to administer her own medications. This oversight created a potential accident hazard, as the medications could have been accidentally consumed by another resident.
Failure to Maintain Sanitary Catheter Supplies
Penalty
Summary
The facility failed to provide necessary care and services to prevent potential urinary tract infections for a resident with an indwelling urinary catheter. The resident, who was admitted with a diagnosis of urine retention, required the use of an indwelling catheter. A physician's order dated October 4, 2024, prescribed Acetic Acid irrigation solution to be used daily, but the order did not specify what was to be flushed or the amount to be administered. This lack of clarity in the physician's order contributed to improper catheter care. Observations on October 22, 2024, revealed unsanitary storage and handling of catheter irrigation supplies in the resident's room. Two opened irrigation kits with piston syringes and two opened, undated bottles of Acetic Acid were found behind the resident's television. The containers, which are single-dose, had significant amounts remaining, indicating improper use and storage. Manufacturer instructions specify that opened containers should be used promptly to prevent bacterial growth, and any unused portion should be discarded. An LPN confirmed the unsanitary condition of the supplies, and the DON, along with the NHA, acknowledged the facility's failure to maintain sanitary conditions for the resident's catheter supplies.
Failure to Follow Oxygen Therapy Orders and Equipment Maintenance
Penalty
Summary
The facility failed to adhere to physician orders for oxygen therapy and did not maintain oxygen equipment in a functional and sanitary manner for three residents. Resident 28, who has chronic obstructive pulmonary disease (COPD) and chronic respiratory failure, was observed with undated oxygen tubing and a dusty oxygen concentrator filter. Additionally, the resident's nebulizer equipment was improperly stored, uncovered, and undated. Resident 61, also diagnosed with COPD and chronic respiratory failure, was found with undated oxygen tubing and a dusty concentrator filter. An LPN confirmed these observations, indicating non-compliance with the facility's policy. Resident 52, dependent on supplemental oxygen, was receiving oxygen at a higher flow rate than prescribed, with undated tubing and a dusty concentrator filter. An LPN confirmed the discrepancy in oxygen administration and the condition of the equipment. The Nursing Home Administrator acknowledged the facility's failure to follow physician orders and maintain the oxygen delivery equipment according to policy, as required by state regulations.
Failure to Implement Controlled Drug Accounting Procedures
Penalty
Summary
The facility failed to implement pharmacy procedures for accounting for controlled drugs on one of its medication carts, specifically the First Floor Back cart. According to the facility's policy on Controlled Substances, nursing staff are required to count controlled medications at the end of each shift, with both the incoming and outgoing nurses conducting the count together. They must document and report any discrepancies to the Director of Nursing Services. However, a review of the Change of Shift Controlled Substances Count Sheet revealed that the required signatures of the nurses arriving and departing were missing on several occasions, indicating that the controlled drugs were not properly counted and reconciled. Observations on October 24, 2024, showed that the narcotic logbook was not with the medication cart as required, but instead was found on the desk at the nurse's station while the assigned nurse was passing morning medications. Further investigation revealed that on specific dates, the shift-to-shift sign-off was not completed, including on October 9, 17, and 23, 2024. The Director of Nursing confirmed these findings and acknowledged that the facility failed to implement procedures for accurately accounting for controlled drugs at the beginning and end of each shift.
Failure to Act on Pharmacist's Recommendations
Penalty
Summary
The facility failed to ensure that the attending physician acted upon the pharmacist's reports of irregularities in the drug regimens of four residents. For Resident 28, the consultant pharmacist recommended that the physician identify the duration of Lovenox therapy and consider therapy modification due to potential interactions with NSAIDs. However, there was no documentation of the physician's response to these recommendations, nor acknowledgment of the pharmacy report. Similarly, for Resident 10, the facility documentation indicated that a medication regimen review was conducted, but the facility was unable to provide the Clinical Pharmacy Report or documentation of the physician's response to the pharmacist's recommendations. This lack of documentation was also observed for Residents 73 and 36, where the facility failed to provide evidence of the physician's acknowledgment or response to the pharmacist's recommendations following medication regimen reviews. An interview with the Director of Nursing confirmed the facility's inability to provide documented evidence that the attending physician acted upon the pharmacy recommendations. This deficiency was identified under the regulations 28 Pa. Code 211.2 (d)(3)(9) Medical director, 28 Pa Code 211.5 (f)(vii) Medical records, and 28 Pa. Code 211.9 (k) Pharmacy services.
Failure to Document Clinical Rationale for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychoactive drugs by not providing clinical rationale for the continued use of as-needed psychotropic medication for two residents. Resident 44, diagnosed with Bipolar Disorder, had a physician's order for lorazepam to be administered as needed for anxiety, starting in September 2023, with no specified end date. The medication was administered four times in October 2024, but the physician did not document the clinical rationale for its continued use or the need for an extended duration without re-evaluation. Similarly, Resident 20, with diagnoses of anxiety and depression, had a physician's order for lorazepam as needed, also without an end date. The medication was last administered in December 2023, and despite pharmacy recommendations in January 2024 for a stop date or gradual dose reduction, the physician did not document the clinical rationale for its continued use. The Director of Nursing confirmed the lack of physician documentation for the use of the prn medication beyond 14 days.
Improper Labeling and Storage of Insulin Pens
Penalty
Summary
The facility failed to adhere to proper labeling and storage protocols for multi-dose medications, specifically insulin pens, on two of the six medication carts observed. During an inspection of the first-floor medication cart, it was found that several insulin pens, including Basaglar, Lispro, and Humulin 70/30, were opened and available for use without being dated when opened or marked with an expiration/beyond use date. Additionally, a Fiasp insulin pen was observed to be labeled as opened on September 19, 2024, but had not been discarded after the recommended 28 days as per manufacturer instructions. Employee 9, an LPN, confirmed these deficiencies during the observation. On the second-floor medication cart, two Lispro insulin pens were also found to be opened and available for use without being dated when opened or marked with an expiration/beyond use date. Furthermore, one of these pens was not properly labeled with resident identification. The Director of Nursing confirmed that the facility failed to correctly label and date multi-dose medications when opened, which is necessary to ensure acceptable storage times and adherence to expiration dates.
Failure to Provide Dental Services to Residents with Medicaid
Penalty
Summary
The facility failed to provide necessary dental services to two residents with Medicaid as their payor source. Resident 52, who was admitted to the facility, was not offered routine annual dental services within the past year, as confirmed by the Director of Nursing. Additionally, Resident 86, who was experiencing mouth pain, had a physician's order dated August 1, 2024, for a dental consult. However, the facility did not provide timely assistance to obtain the required dental services for this resident, as there was no documented evidence of a dental consult being conducted by the time of the survey ending October 25, 2024. These deficiencies were identified through a review of clinical records, payor source data, and staff interviews, highlighting the facility's failure to comply with the necessary nursing services regulations as per 28 Pa. Code 211.12 (c)(d)(3)(5).
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for six months, from April 2024 to September 2024, as required by their infection control policies. The facility's policy, last reviewed in January 2024, mandates that antibiotics be prescribed and administered under the guidance of an antibiotic stewardship program to monitor their use among residents. However, a review of the facility's infection control surveillance records from September 2023 to September 2024 revealed a lack of documentation indicating that antibiotic monitoring was conducted during the specified six-month period. During an interview on October 25, 2024, the Director of Nursing confirmed the absence of a system for surveillance to monitor antibiotic use and laboratory correlation for infections during this time. The Director was unable to provide tracking records for the months in question, further confirming the facility's failure to adhere to its antibiotic stewardship program.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for Resident 42, who was admitted with a diagnosis of unspecified dementia. On October 22, 2024, at approximately 12:20 p.m., Resident 42 was observed in the dining room on the third floor nursing unit. Her lunch tray was placed in front of her at approximately 12:22 p.m., but she was not assisted with her meal until approximately 12:47 p.m., a delay of about 25 minutes. Resident 42 required assistance with feeding and was unable to feed herself, which was not provided in a timely manner. An interview with the Nursing Home Administrator confirmed that Resident 42 should have been served and assisted with her lunch meal within the same time frame as other residents on the third floor unit. The administrator acknowledged that the facility failed to conduct the lunch meal service in a manner that promotes each resident's dignity, as required by resident rights regulations.
Inaccurate MDS Assessment for Resident Discharge
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) Assessments accurately reflected the status of a resident. Specifically, for one resident, the MDS Assessment incorrectly indicated that the resident was discharged to an acute care hospital, while the clinical records and staff interviews confirmed that the resident was discharged home. The resident's clinical record included a physician's order for discharge to home, and a nurse's note documented the resident's discharge home via facility transport, noting the resident's ability to walk independently and that all discharge procedures were completed. The Nursing Home Administrator confirmed the discrepancy in the MDS Assessment regarding the discharge location.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement person-centered comprehensive care plans for three residents, leading to deficiencies in meeting their medical and treatment needs. Resident 86, who had a pacemaker implanted, did not have this critical medical device included in their care plan, despite having a remote monitoring device in their room and a physician's order for a cardiologist check. Similarly, Resident 28, who required the use of a SmartVest for cough assistance due to chronic respiratory conditions, did not have the use and care of this device reflected in their care plan, even though there was a physician's order for its application. Resident 13, diagnosed with dementia and known to hoard food, had a room with a strong odor and visible food items hidden, yet their care plan only addressed hoarding of personal belongings and did not include interventions for food hoarding. The Director of Nursing confirmed the facility's failure to ensure comprehensive care plans were developed to meet the residents' needs, as required by regulations.
Failure to Update Resident Care Plan for Elopement Risk
Penalty
Summary
The facility failed to ensure that a resident's comprehensive care plan was reviewed and revised to accurately reflect the resident's current needs and services. Resident 22, who was admitted with diagnoses including congestive heart failure, stroke, and anxiety, was assessed as a low wander risk with a score of 1 on the Elopement/Wander Risk Evaluation. Despite being cognitively intact with a BIMS score of 15 and having no presence of wandering during the 7-day lookback period, the resident's care plan still included interventions for potential elopement and associated injury related to exit-seeking behavior, which had not been updated since November 1, 2023. The care plan for Resident 22 included interventions such as door alarms, encouraging group activities, and notifying social services for persistent exit-seeking behavior. However, there was no documented evidence that the care plan had been reviewed or revised to reflect the resident's current status, particularly after a physician's order allowed the resident to go out on pass by himself via the bus. The Director of Nursing confirmed that the facility did not update the care plan to reflect the resident's current needs, leading to the deficiency noted in the report.
Failure to Administer Medication as Prescribed
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of quality by not administering medications as prescribed to a resident. The resident, who was admitted with diagnoses including congestive heart failure, stroke, and anxiety, had a physician's order for Midodrine HCL 10mg to be administered three times a day for essential hypotension, with instructions to hold the medication if the systolic blood pressure (SBP) exceeded 120 mm/Hg. However, a review of the resident's Medication Administration Record for September 2024 revealed multiple instances where the medication was administered despite the resident's SBP being greater than 120 mm/Hg. The Director of Nursing confirmed that the nursing staff failed to adhere to the physician's order by not holding the medication when the resident's SBP was above the specified threshold. This oversight was identified through a review of clinical records and staff interviews, highlighting a deficiency in the facility's nursing services and documentation practices as per the Pennsylvania Code and the American Nurses Association Principles for Nursing Documentation.
Failure to Monitor and Address Resident's Nutritional Needs
Penalty
Summary
The facility failed to adequately monitor and address the nutritional needs of a resident who experienced significant weight loss. The facility's policy required that any weight change of 5 pounds or more be retaken for confirmation, and if verified, the physician and dietician should be notified. However, the facility did not adhere to this policy for a resident diagnosed with dementia, who showed a weight loss from 125.0 lbs on July 1, 2024, to 114.0 lbs by September 10, 2024, indicating a 6.6% weight loss in 30 days. The dietician requested a reweight after a 5-pound loss was noted between August 2 and September 4, 2024, but the facility delayed the reweighing by six days. Additionally, the dietician recommended adding nutritious shakes twice a day and requested weekly weights to prevent further weight loss. Despite these recommendations, the facility failed to complete the weekly weights as requested. There was no evidence that the facility had timely acted upon the resident's weight loss or developed and implemented nutritional support measures to maintain acceptable nutritional parameters and deter further weight loss. The Director of Nursing confirmed the facility's failure to timely identify, address, and implement weight loss interventions.
Failure to Provide Emergency Supplies for Dialysis Resident
Penalty
Summary
The facility failed to ensure the ready availability of necessary emergency supplies for a resident receiving hemodialysis. Resident 85, who was admitted with end-stage renal disease and dependent on renal hemodialysis, did not have emergency care supplies available in their room or on their wheelchair. The resident's care plan, last revised in August 2024, included monitoring the dialysis catheter site for signs of infection, swelling, bleeding, and pain but did not include planned interventions for emergency supplies related to the dialysis access site. Observations conducted in October 2024 confirmed the absence of emergency supplies in the resident's room and on their wheelchair. Interviews with the resident, an LPN, and the Director of Nursing corroborated the lack of emergency supplies at the bedside, as well as the omission of necessary interventions in the care plan for the dialysis access site in case of an emergency. This deficiency was noted under the 28 Pa. Code 211.12 (d)(3)(5) Nursing Services.
Failure to Provide Behavioral Health Care
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident diagnosed with schizoaffective disorder. The resident, admitted with symptoms such as agitation, restlessness, crying, and yelling, was observed to be restless and agitated without any behavioral interventions being implemented. Despite these ongoing behaviors, the resident's care plan, initiated in January 2024, did not address these specific behavioral problems or symptoms, as noted in the nursing documentation. The last psychological evaluation for the resident was conducted in August 2024, which recommended continued behavioral health services due to intermittent behaviors that were not easily redirectable. However, nursing progress notes from August to October 2024 indicated continued and increased behaviors, yet the facility did not update the care plan to address the resident's mental health needs. Furthermore, the facility failed to provide evidence of continued psychological services to maintain the resident's highest practicable mental and psychosocial well-being, as confirmed by the Nursing Home Administrator during an interview.
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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