Saunders Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wynnewood, Pennsylvania.
- Location
- 100 Lancaster Avenue, Wynnewood, Pennsylvania 19096
- CMS Provider Number
- 395380
- Inspections on file
- 37
- Latest survey
- April 24, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Saunders Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions, including HTN, PVD, CHF, and Alzheimer’s disease, was seated in a wheelchair inside a room doorway with feet extended into the hallway when a dietary aide pushed a meal cart past the room. The aide, who reported looking forward and to the side rather than down and did not announce his presence, maneuvered around med carts, hampers, and other residents and failed to see the resident’s feet. The cart rolled over the resident’s foot, and an LPN who heard the resident scream found the resident’s foot under the cart; assessment and x‑ray confirmed a laceration and a nondisplaced fracture of the right distal 3rd metatarsal, demonstrating unsafe meal cart handling and inadequate accident prevention.
The facility did not obtain direct verification from the Pennsylvania Nurse Aide Registry before allowing an agency nurse aide to work, despite a policy requiring verification of active licenses and certifications. Instead, the facility relied on a staffing agency that accepted an uploaded, falsified nurse aide license without independently verifying it. This led to an unlicensed nurse aide working multiple shifts in the facility before the issue was identified by the state Attorney General's Office and the aide was removed from the schedule.
A resident with multiple chronic conditions and intact cognition was discharged home, via a scheduled dialysis appointment, without receiving discharge instructions, prescriptions, or personal belongings, despite facility policy requiring a discharge transition packet for residents going to a private residence. Documentation showed that the RN signed the discharge summary and medication instructions later that evening, after the resident had already left, and there was no record that instructions or prescriptions were offered or refused. The administrator confirmed the resident should have received discharge instructions and prescription information, and the resident’s representative did not obtain the discharge paperwork until later that night, demonstrating a breakdown in the discharge process.
Surveyors found that several residents did not have accessible call bells to request staff assistance. During an observation with the DON, one resident’s call bell was behind a nightstand and covered by a pillow, another’s was on a dresser out of reach, and another’s was behind the bed. Two residents had call bells hanging down and out of reach, and a family member reported that one resident’s call bell was often on the floor. Another resident’s call bell was wrapped behind the bed and not accessible.
Two residents reported receiving cold meals, and a test tray conducted with the Dietary Director confirmed that several food items, including hot entrees and vegetables, were served below the required temperature for hot foods. The Food Service Director acknowledged that these items were not within the acceptable temperature range for palatability.
A resident who was fully dependent for bed mobility and transfers was left unattended by a single aide during care, despite the care plan requiring two staff and use of a Hoyer lift. The aide was distracted by a cellphone and earbuds, resulting in the resident sliding from the bed to the floor and experiencing minor knee pain. The incident was substantiated as neglect due to failure to follow the care plan and use of personal electronic devices during care.
A resident who was dependent on staff for bed mobility and required two-person assistance experienced a fall from bed while being cared for by a single CNA who was distracted by cellphone use. The incident was not reported to nursing staff during the shift, and the resident was not assessed until the following day when she reported pain. The facility failed to immediately report the allegation of neglect to the state health department as required.
A resident developed a blister on the left shoulder after receiving heat therapy when staff failed to follow facility protocols, including daily hydrocollator temperature checks and routine skin assessments during treatment. Documentation showed that required temperature monitoring was missed on multiple dates, and the resident's skin was not checked as per policy, leading to unrecognized injury.
Two residents experienced abuse and neglect when one was verbally threatened and physically mistreated by a nurse aide, while another was left in a soiled brief overnight and intimidated by their assigned aide. Both residents were cognitively intact and reported feeling unsafe or afraid to seek help due to staff behavior, with staff and documentation confirming the incidents.
A resident with severe cognitive impairment and multiple diagnoses, including dementia and Parkinson's disease, was not provided with care-planned safety interventions during bed mobility by hospice staff. The required use of bilateral 1/4 side rail enablers was not followed, and the hospice aide was unaware of this intervention, resulting in the resident falling from bed and sustaining head lacerations that required hospital treatment.
A resident receiving hospice care did not have a physician order or a comprehensive care plan for hospice services, including the use of enablers to support independence during morning care. Staff interviews and record reviews revealed confusion about responsibilities for entering orders and care plans, and hospice aides lacked access to the facility's electronic care plan. The facility's policies requiring coordination with the hospice provider and inclusion of hospice care details in the resident's plan were not followed.
Three residents experienced a lack of dignity and respect from staff, including rough handling of a hearing-impaired resident and dismissive or rude remarks made to two other cognitively intact residents. Staff actions did not align with facility policies on resident rights and effective communication.
The facility did not conduct complete or thorough investigations into multiple allegations of abuse and neglect, including delayed incontinence care, rough handling, and verbal abuse. In several cases, required interviews and documentation were missing, and some incidents were not reported to the Department of Health as required.
A deficiency was found when a resident with a new diagnosis of delusional disorder did not have their PASRR Level I form updated as required by facility policy. Staff confirmed that the necessary update was not completed after the new mental health diagnosis was identified.
Three residents did not receive care in accordance with physician orders and facility policy. One resident's family member applied a medicated cream without proper authorization or nurse supervision. Another resident's medications were left at the bedside without staff observing ingestion. A third resident continued to receive oxygen therapy after the order was discontinued in error, with documentation showing ongoing administration and a low oxygen saturation event.
A resident with significant immobility and multiple health conditions was identified as being at risk for pressure ulcers and had a wound consult recommending heel protection. However, surveyors found that staff did not implement the recommended intervention to float the resident's heels, and this was confirmed by the DON. The facility failed to have preventative measures in place to protect the resident's heels.
A resident with multiple medical conditions, including metabolic encephalopathy and type 2 diabetes, experienced a significant weight loss over a one-month period. Facility staff did not perform a timely reweigh or nutritional assessment as required by policy, and no interventions were documented until several days after the weight change was identified.
A resident with a fractured tibia and multiple surgical staples experienced moderate to severe pain that was not effectively managed, as only acetaminophen for mild pain was administered despite reports of higher pain levels. It took nearly two weeks before the physician was notified and a stronger pain medication was ordered, resulting in a failure to follow professional standards and facility policy for pain management.
Two residents with significant medical needs and intact cognition experienced prolonged wait times for call bell responses, with one waiting up to an hour for assistance and another observed waiting at least 30 minutes for a request to be answered.
The facility failed to serve food and drinks at safe temperatures on the third-floor unit. Residents reported ongoing issues with cold meals, which were discussed in meetings with the NHA but remained unresolved. A test tray confirmed the food was not at acceptable temperatures, and the issue was attributed to a broken heating device that had not been replaced.
The facility failed to investigate and resolve grievances for three residents, including issues with cold meals, unclean rooms, and missing food items. There was no documentation of investigations or resolutions, indicating a systemic issue in handling grievances.
The facility failed to address ongoing resident grievances about cold food, as reported during resident council meetings over three months. Despite residents arranging a meeting with the NHA to discuss these issues, no actions were taken to resolve the problem, and the NHA acknowledged the need for equipment replacement. The facility did not demonstrate any response to the residents' concerns.
A facility failed to create a person-centered care plan for a resident with COPD, neglecting to address sensitivities to irritants like perfumes and sprays. An incident occurred where a nurse aide's perfume affected the resident's breathing, highlighting the lack of specific interventions in the care plan. The DON was aware of the incident and provided staff education, but the care plan still did not include measures to prevent exposure to irritants.
A resident with cognitive impairment and multiple health conditions was left with medications unattended by a nurse, despite lacking authorization to self-administer. The DON confirmed the medications and identified the responsible nurse, revealing a failure in supervision and adherence to medication protocols.
The facility did not meet the required nurse aide staffing ratios for several shifts, failing to provide the mandated hours of care based on resident census. This deficiency was identified through a review of nursing schedules and census data, revealing shortfalls in care hours provided on specific dates. Discussions with the Nursing Home Administrator and DON confirmed the failure to meet state staffing requirements.
The facility did not meet the required LPN staffing ratios during an overnight shift, providing only 33.74 hours of care instead of the required 35.20 hours for 176 residents. This deficiency was identified through a review of nursing schedules and staff interviews.
The facility failed to provide the required minimum of 3.2 hours of direct resident care per resident in a 24-hour period for 13 out of 21 days reviewed. Staffing documentation revealed multiple days where care hours fell short, with the lowest being 2.94 hours. This issue was discussed with the Nursing Home Administrator and DON.
A resident with cognitive and physical impairments sustained a second-degree burn after being served a hot beverage without proper temperature checks or supervision. The facility's failure to adhere to its hot liquid safety policy and inaccurate temperature logs contributed to the incident.
The facility failed to follow diabetes management protocols for three residents, resulting in unreported elevated blood sugar levels and missed insulin doses. The DON confirmed the lack of adherence to facility policies and physician orders.
The facility failed to conduct thorough investigations into incidents involving residents, including unexplained injuries, elopement, and burns. A resident's shoulder fracture was not investigated for potential abuse, another resident's elopement lacked proper documentation, and a resident's ankle injury was not fully assessed. Additionally, a resident suffered a burn from hot water, with the investigation revealing lapses in checking water temperature.
A facility failed to create a comprehensive care plan for a resident's chronic constipation. Despite medical interventions ordered by a CRNP, including Milk of Magnesia and Docusate, the facility did not develop a care plan as required by its policy. This was confirmed by the DON.
A facility failed to provide restorative nursing services for a resident with hemiplegia post-neurosurgery. Despite the resident's care plan including a Restorative Nursing Program for ambulation, there was no evidence of nursing staff providing the necessary therapy. The resident expressed a desire to walk again, but after physical therapy ended, no assistance was given. The DON confirmed the oversight in coordinating care.
A resident with Parkinson's disease and cognitive impairment was inadequately supervised and assessed, leading to a burn injury from a hot beverage. The facility's NHA and DON failed to implement necessary safety measures, such as serving beverages at safe temperatures and providing appropriate supervision, as outlined in their Hot Liquid Safety policy.
Injury Caused by Unsafe Meal Cart Handling in Hallway
Penalty
Summary
The facility failed to ensure the safe handling of a meal cart, resulting in a cart rolling over a resident’s foot and causing a fracture of the right distal 3rd metatarsal. The resident involved had physician orders reflecting diagnoses including hypertension, peripheral vascular disease, congestive heart failure, and Alzheimer’s disease. During meal service, a dietary staff member was pushing a food cart down a hallway when the incident occurred at the doorway of the resident’s room. According to documentation and staff interviews, the resident was seated in a wheelchair inside the room’s doorway with legs extended so that the feet were in the hallway, while the resident’s body remained inside the doorframe and was not visible in the hall. The dietary aide reported he did not see the resident’s feet as he passed the room and acknowledged that he was not looking down at the floor, as he had been instructed to look forward and to the side when pushing the cart. He stated there was nothing obstructing his line of sight, but he had to maneuver the cart around medication carts, hampers, and residents in the hallway, and he did not announce his presence as he moved through the area. The aide reported that when the cart contacted the resident’s foot, the resident said that the cart had hit them. A licensed nurse at the nurses’ station heard the resident screaming about their foot and observed the resident sitting in the doorway with one foot under the food cart the dietary aide was pushing. Subsequent assessment documented the resident’s complaint of right foot pain and a laceration on the bottom of the right foot, and an x-ray confirmed a nondisplaced fracture of the distal 3rd metatarsal. The surveyors determined that the facility failed to ensure that the meal cart was handled in a safe manner, resulting in actual harm to the resident.
Failure to Verify Nurse Aide Certification Prior to Allowing Work
Penalty
Summary
The facility failed to ensure that a Pennsylvania Nurse Aide Registry check was obtained prior to allowing an agency nurse aide to work in the building. Facility policy, last revised July 7, 2023, required that all offers of employment be contingent upon a thorough criminal background check and verification that any required license or certification was active and in good standing. Despite this policy, one agency nurse aide (Employee E3) worked multiple shifts at the facility without the facility obtaining direct verification of her nurse aide certification status from the Pennsylvania Nurse Aide Registry. The deficiency was identified after the Pennsylvania Attorney General's Office notified the facility that the agency nurse aide did not possess a valid nurse aide certification during the time she provided services. The facility had relied on the staffing agency to obtain and verify the nurse aide’s credentials. The facility’s investigation file included an email from the staffing agency stating that the nurse aide had submitted a falsified license document that appeared legitimate, and that the agency’s onboarding team had been accepting uploaded licenses from clinicians rather than independently running verification checks. As a result, the unlicensed agency nurse aide worked several dates at the facility before being removed from the schedule.
Failure to Provide Discharge Instructions and Prescriptions at Time of Discharge
Penalty
Summary
The facility failed to provide a resident with discharge instructions and prescription medication at the time of discharge. The resident was admitted with multiple diagnoses, including cervical disc degeneration, lumbar radiculopathy, hemiplegia, end stage renal disease, muscle wasting/atrophy, difficulty in walking, need for assistance with personal care, chronic diastolic condition, and thrombocytopenia. The admission MDS showed a BIMS score of 15, indicating the resident was cognitively intact. Facility policy required completion of discharge transition instructions for residents anticipating discharge to a private residence or similar setting to assist with a safe adjustment to their living environment. Clinical record review showed that on the day before discharge, the social worker communicated with the resident’s family about referrals for potential facility-to-facility transfers and, when no transfer was secured and Medicare benefits were exhausted, the facility planned discharge home with skilled home care referrals and a post-discharge primary care appointment. Transportation was arranged for the morning of the discharge date. A progress note documented that the resident was discharged to home, first going to dialysis and then home, and that all personal belongings remained at the facility awaiting family pickup and receipt of discharge instructions and prescriptions. The discharge summary, signed later that day by an RN, listed several medications with specific dosing schedules and times for the next doses, but there was no indication that these instructions or prescriptions were provided to the resident at the time of discharge. In an interview, the RN who signed the discharge summary confirmed that the resident had already left the facility when she signed the discharge packet around 9:00 p.m., and therefore she could not provide the packet to the resident. She stated that the usual practice is to complete the discharge before any scheduled appointment and to ensure the resident leaves with discharge instructions, prescriptions, and belongings, which did not occur in this case. The RN also confirmed she was not the nurse who discharged the resident and that discharge instructions were not provided at the time of discharge. The administrator confirmed that the resident was alert and oriented and should have received discharge instructions and prescription medication upon discharge, and that there was no documentation that the discharge summary and prescription information were offered or refused. The resident’s representative did not pick up the discharge instructions and prescription documentation until later that evening, confirming that the resident had been discharged without these materials, in violation of state regulatory requirements cited in the report.
Inaccessible Call Bells for Multiple Residents
Penalty
Summary
The facility failed to ensure that all residents had access to a functioning call system in their rooms and bathrooms, as required by policy and state regulations. During an observation conducted with the Director of Nursing, multiple residents were found without accessible call bells. One resident’s call bell was located behind a nightstand dresser, covered with a pillow, and not accessible. Another resident’s call bell was observed on top of a dresser and not within reach. A third resident’s call bell was behind the bed and not accessible. Two additional residents had call bells hanging down and out of reach, and a family member sitting with one of these residents reported that this resident’s call bell was often found on the floor and not accessible. Another resident’s call bell was wrapped behind the bed and not accessible. These observations showed that several residents did not have call bells within reach to request staff assistance. The deficiency was cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(b)(1) regarding management responsibilities.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to serve food at the proper temperature as required by its Food Temperatures Policy, which mandates that hot foods be held and served at or above 135°F and cold foods at or below 41°F. During interviews, one resident reported receiving cold sausages and pancakes for breakfast, while another resident expressed grievances about receiving cold dinners on two separate occasions. A test tray conducted with the Dietary Director revealed that the temperatures of steamed broccoli, sweet potatoes, and honey garlic chicken were all below the required 135°F, and the juice was above the acceptable cold temperature. The Food Service Director confirmed that these foods were outside the acceptable temperature range for palatability.
Neglect Due to Failure to Follow Care Plan and Use of Personal Devices During Resident Care
Penalty
Summary
A deficiency occurred when a resident, who was cognitively intact and dependent on staff for all bed mobility and transfers due to multiple sclerosis and other conditions, was not provided care according to her established care plan. The care plan specified that two staff members were required for bed mobility and transfers, and the use of a Hoyer lift was indicated for transfers in and out of bed. Despite these requirements, a certified nurse aide performed bed mobility alone, without a second staff member present, and was using her personal cellphone and wearing earbuds during the provision of care. During the incident, the resident was being turned to her side by the aide when she slid from the bed onto her knees and then to the floor. The resident reported experiencing minor knee pain following the fall, and an x-ray was ordered to rule out fractures, which later returned negative. The resident also stated that no nursing staff came to assess her immediately after the fall, and that the aide was alone, distracted by her phone, and wearing earbuds at the time of the incident. The facility's internal investigation confirmed that the aide failed to follow the resident's care plan by not having a second staff member present and by being distracted with personal electronic devices during care. The incident was substantiated as neglect, as the resident's safety and care needs were not met according to established protocols and policies.
Failure to Immediately Report and Investigate Alleged Neglect Following Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to ensure that all allegations of neglect were reported immediately to the Pennsylvania Department of Health for one resident. The facility's policy requires that all incidents involving mistreatment, neglect, abuse, or injuries of unknown origin be reported immediately to the Director of Nursing (DON) and Administrator for further review and reporting as per state and federal regulations. However, in this case, a resident who was dependent on staff for bed mobility and transfers, and required the assistance of two staff members, experienced a fall from bed while being cared for by a single certified nurse aide who was also using a personal cellphone and wearing earbuds during the incident. The resident, who was cognitively intact and bedbound due to multiple medical conditions including muscle weakness and multiple sclerosis, reported that the aide was alone and distracted at the time of the fall. The aide did not report the incident to nursing staff during the shift, and the resident was not assessed by nursing staff until the following day, after she reported knee pain. Documentation shows that the facility only became aware of the fall when the resident informed a licensed nurse the next day, at which point an assessment and investigation were initiated. Interviews and internal investigation confirmed that the certified nurse aide failed to follow the resident's care plan, which required two-person assistance for bed mobility, and did not report the fall to nursing staff as required. The Director of Nursing confirmed that staff failed to notify nursing staff on both the evening and overnight shifts, resulting in a delay in reporting the incident and initiating appropriate follow-up.
Failure to Follow Heat Therapy Protocols Resulting in Resident Injury
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice related to heat therapy. According to facility policy, hydrocollator temperatures should be checked daily, and specific procedures must be followed when applying heat packs, including wrapping the pack in layers of toweling, checking the resident's skin after application, and documenting the patient's response. Review of records revealed that a male resident developed a blister on his left shoulder after receiving heat therapy. The hydrocollator temperature was not checked daily as required, and the physical therapy associate did not routinely check the resident's skin during the application, only after the treatment was completed, which was not in accordance with facility protocol. Interviews and documentation indicated that redness was noted on the resident's shoulder after the heat therapy session, but no pain or discomfort was reported immediately post-treatment. The resident later experienced pain and was found to have a blister. There was no evidence that skin concerns were noted during the resident's scheduled bath/shower following the therapy. Additionally, facility records showed multiple dates where the hydrocollator temperature was not checked as per policy. The facility did not ensure daily temperature checks of the hydrocollator and did not accurately assess and report skin changes as required by their own procedures.
Failure to Prevent Resident Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by two separate incidents involving two cognitively intact residents. In the first incident, a resident with anxiety and depression reported that a nurse aide intentionally struck their foot with a linen cart and then verbally abused and threatened them. The nurse aide was overheard yelling at the resident, making threatening statements, and using profane language. This behavior was witnessed by a registered nurse, who confirmed the verbal abuse and threats directed at the resident. In the second incident, another resident with depression, muscle weakness, and a need for assistance with personal care reported being afraid to use the call bell for help during a night shift due to intimidating comments made by their assigned nurse aide. The resident stated they were not changed throughout the shift and remained in a soiled brief until the following morning. The resident's bed was found soaked and required cleaning due to a strong urine odor. Documentation and interviews revealed that the nurse aide made disparaging remarks to the resident and other residents under their care, contributing to an environment of intimidation and neglect. Both incidents were substantiated through staff witness statements, resident interviews, and facility documentation. The facility's failure to prevent and address these actions resulted in residents being subjected to verbal abuse, threats, and neglect, contrary to facility policy and regulatory requirements for resident rights and safety.
Failure to Implement Care-Plan Interventions for Fall Risk Resident
Penalty
Summary
A deficiency occurred when hospice staff failed to implement care-planned interventions for a resident identified as a fall risk. The resident, who had diagnoses of dementia, Parkinson's disease, and anxiety, was assessed as having severe cognitive impairment and required extensive assistance with bed mobility. The resident's care plan and physician orders specified the use of bilateral 1/4 side rail enablers while in bed to assist with mobility and increase safety. During personal care, a hospice nurse aide turned the resident in bed to assist with dressing and, while moving to the other side of the bed, did not realize the resident was holding onto the aide's pocket. The resident subsequently fell from the bed to the floor, sustaining lacerations to the left eyebrow and the back of the head, which required sutures and staples at a hospital. Documentation and investigation revealed that the side rail enablers were not utilized at the time of the incident, and the hospice aide was unaware of the care plan interventions and physician's orders regarding the use of side rails. Facility records and staff interviews confirmed that the required safety interventions were not communicated or implemented by the hospice staff, resulting in actual harm to the resident. The incident report also indicated that proper tools or equipment were not being used during the event, and the hospice aide did not have knowledge of the resident's specific care plan requirements for fall prevention.
Failure to Obtain Physician Order and Develop Comprehensive Hospice Care Plan
Penalty
Summary
The facility failed to obtain a physician order and develop a comprehensive care plan for hospice services for one resident who was receiving hospice care. Review of the resident's clinical record showed that there was no physician order for hospice care and no comprehensive care plan addressing hospice services or the use of enablers to support the resident's independence during morning care. Staff interviews confirmed that the resident had been receiving hospice services, but there was confusion among staff regarding who was responsible for entering the necessary physician order and care plan. Additionally, the hospice contractor's care plan did not include instructions regarding the use of enablers, and hospice aides did not have access to the facility's electronic care plan. Documentation in the hospice communication binder indicated that the resident had been on hospice since the end of May, and the last documented hospice service was provided in early June. Interviews with facility staff and hospice aides revealed a lack of clarity about the resident's care needs, particularly regarding the use of enablers during morning care. The facility's policies required coordination with the hospice provider and inclusion of the hospice plan of care and physician orders in the resident's written care plan, but these requirements were not met for the resident in question.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
Surveyors identified that the facility failed to maintain resident dignity and respect for three residents. One resident with hearing impairment and cognitive intactness was observed being approached from behind by a nursing aide, who pulled the resident's shoulders back roughly into a wheelchair and spoke in a loud tone, instructing the resident to sit back and pick up their feet. The resident's care plan specified the need for direct communication, including facing the resident and establishing eye contact, which was not followed during this interaction. Two other cognitively intact residents reported staff making disrespectful and dismissive remarks. One resident stated that when they required frequent assistance to the bathroom due to illness, staff questioned them with, "What's your problem," and responded, "That's not my job," when asked to change bedding. Another resident reported that staff were rude and rough during care, making comments such as, "What do you want, stop complaining." These actions and statements were inconsistent with the facility's policies on resident rights and communication, as well as the residents' care plans.
Failure to Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to conduct complete and thorough investigations into allegations of abuse and neglect for six residents. Facility policy required staff to prevent, report, and investigate suspected or alleged abuse, neglect, or mistreatment, with specific steps for interviewing involved parties and documenting findings. However, in multiple cases, the facility did not follow these procedures, resulting in incomplete investigations and lack of proper documentation. For one resident with hemiplegia and incontinence, a family member reported neglect due to delayed incontinence care. The facility's documentation confirmed the delay but did not provide a complete investigation or documentation of the incident. Another resident, who was severely cognitively impaired and on hospice care, was found saturated in urine by a hospice nurse, but the facility did not document a thorough investigation or report the incident to the Department of Health as required. In another case, a cognitively intact resident was observed being handled roughly by a nurse aide, but the facility's report omitted key details of the incident. Additional deficiencies included a resident reporting rough handling, being hit, denied a snack, and experiencing verbal abuse from a nursing assistant. The facility did not investigate or document these allegations. Another resident reported being grabbed and thrown by a nurse, but there was no evidence that the facility interviewed other staff or residents as part of the investigation. These failures to investigate and document allegations of abuse and neglect were confirmed through interviews with facility leadership and staff, as well as review of facility records.
Failure to Update PASRR Documentation After New Mental Health Diagnosis
Penalty
Summary
A deficiency was identified when the facility failed to update the PASRR (Pre-admission Screening and Resident Review) Level I form for a resident who had a new diagnosis of delusional disorder during their stay. The facility's policy requires that any new diagnosis identified during a resident's stay be added to the Level I PASRR form. However, review of the clinical record showed that the resident was admitted with schizoaffective disorder and later diagnosed with delusional disorder, but the PASRR Level I form, initially completed at admission, was not updated to reflect the new diagnosis. Staff interviews confirmed that there was no evidence of the PASRR Level I form being updated after the new diagnosis was made. This failure to update the PASRR documentation was found during clinical record review and staff interviews, and it was determined that the facility did not coordinate assessments with the PASRR program as required by policy and regulation.
Failure to Follow Physician Orders for Medication and Treatment Administration
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice by not following physician orders for medication administration for three residents. For one resident with a history of stroke, aphasia, dysphagia, diabetes, and hemiplegia, the resident's grandson was observed applying hemorrhoidal cream without a physician's order or nurse supervision, contrary to facility policy and physician instructions. Documentation showed that the grandson applied the cream before an order was obtained, and after the order was in place, there was no evidence that a nurse was present during application as required. Another resident, who was cognitively intact but had functional impairments and required set-up assistance with eating, was found with her prescribed 9:00 a.m. medications left at her bedside. The resident reported difficulty taking all pills at once and preferred to take them throughout the day with pudding or applesauce. The nurse responsible for administering the medications confirmed that the medications were left at the bedside and that the resident was not observed ingesting them, which is against facility policy requiring staff to observe medication ingestion and document administration immediately. A third resident with a history of congestive heart failure and pulmonary hypertension continued to receive oxygen therapy after the physician's order for oxygen was discontinued. Nursing progress notes indicated ongoing oxygen administration, and hospice notes documented the resident being found with low oxygen saturation and the oxygen device disconnected. The discontinuation of the oxygen order was later confirmed to have been done in error during a review of physician orders by the Assistant Director of Nursing.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
A deficiency was identified when the facility failed to implement appropriate interventions to prevent pressure ulcers for one resident. The facility's policy requires early identification of at-risk residents and the use of preventative strategies. The resident in question had a history of stroke with resulting hemiplegia, aphasia, dysphagia, and diabetes, and was completely dependent on staff for all activities of daily living, including bed mobility and toileting. The resident was assessed as being at risk for developing pressure ulcers, and a wound consult specifically recommended floating the resident's heels with pillows while in bed to prevent skin breakdown. Despite these recommendations, both clinical record review and direct observation during the survey revealed that the resident's heels were not protected or off-loaded as directed by the wound healing specialist. This lack of preventative measures was confirmed by the DON during the survey. The facility did not have the required interventions in place to protect the resident's heels, resulting in noncompliance with resident care policies and nursing service regulations.
Failure to Monitor and Respond to Significant Weight Loss
Penalty
Summary
The facility failed to ensure proper monitoring and follow-up of a significant weight loss for one resident. According to the facility's policy, any weight change greater than or less than 5 pounds within 30 days requires a reweigh the next day, confirmed by a licensed nurse. A resident with diagnoses including metabolic encephalopathy, type 2 diabetes, and muscle wasting experienced a weight loss of 20.9 pounds (13.59%) between two monthly weigh-ins. There was no documented evidence that a reweigh or nutritional assessment was performed in response to this significant weight change, and no interventions were documented until several days after the weight loss was identified. Staff interviews confirmed the lack of timely assessment and intervention.
Failure to Provide Timely and Appropriate Pain Management
Penalty
Summary
A deficiency was identified when a resident with a fractured right tibia and multiple surgical staples reported ongoing moderate to severe pain that was not effectively managed according to professional standards. Upon admission, the resident was alert, oriented, and able to communicate needs, but was only provided acetaminophen for pain, which was ordered for mild pain. Despite the resident reporting pain levels of 7/10 and 8/10, which indicate moderate to severe pain, acetaminophen continued to be administered, and there was no evidence of further action to address the resident's discomfort. The resident communicated to staff that the prescribed pain medication was not effective, but it took 13 days from admission before the physician was contacted and an order for Tramadol, appropriate for moderate to severe pain, was obtained. The DON confirmed that the pain management provided was not consistent with the resident's needs and that the physician should have been notified sooner. The facility failed to follow its own pain management policy and did not ensure timely and appropriate pain relief for the resident.
Failure to Timely Respond to Resident Call Bells
Penalty
Summary
The facility failed to ensure that call bells were answered in a timely manner for two residents. One resident, admitted with hemiplegia and hemiparesis following a stroke and assessed as cognitively intact, reported waiting up to an hour for assistance to get off the toilet, with call bell wait times sometimes reaching 30 minutes. Another resident, also cognitively intact and admitted with muscle wasting, atrophy, arthritis, and multiple rib fractures, stated that the call bell was never answered timely. Direct observation confirmed that this resident's call bell light remained on for at least 23 minutes, and the resident reported waiting at least 30 minutes for a cup of coffee. These findings were based on resident interviews, clinical record reviews, and direct observation.
Failure to Serve Food at Safe Temperatures
Penalty
Summary
The facility failed to provide food and drinks at safe and appetizing temperatures on the third-floor nursing unit. Multiple residents reported ongoing issues with cold food, which had been discussed in resident council meetings and a separate meeting with the Nursing Home Administrator (NHA). Despite these discussions, the problem persisted, and residents continued to receive cold meals. The NHA acknowledged the issue, attributing it to a broken heating device used to keep food warm during transport, which had not been replaced. Interviews with several residents revealed dissatisfaction with the temperature of their meals, including cold coffee, French fries, hamburgers, and eggs. These concerns were repeatedly raised in meetings, but residents reported no follow-up or resolution. The Food Service Director (FSD) confirmed that the heating device was broken and needed replacement, but no interim measures were implemented to ensure meals were served at appropriate temperatures. A test tray conducted on the third floor confirmed that food and beverages were not served at acceptable temperatures. The Food Service Director and the NHA were aware of the broken heating device but had not taken steps to address the issue. The facility's failure to maintain food at safe temperatures violated regulatory requirements, as evidenced by the test tray results and resident complaints.
Plan Of Correction
The facility cannot go back retroactively to correct this issue. Dietary staff members were educated on appropriate food temperatures. The Dietary Director/designee will conduct test tray audits on each floor weekly x 4 weeks then monthly x 2 months. Results of these audits will be submitted to the Quality Assurance Committee to determine if further action is needed.
Failure to Investigate and Resolve Resident Grievances
Penalty
Summary
The facility failed to ensure that resident grievances were investigated and resolved for three residents. Resident R12 reported a grievance about receiving cold breakfast meals, but there was no documentation of any investigation or resolution provided by the facility. This indicates a lack of follow-through on the part of the grievance official or the designated department responsible for addressing such concerns. Resident R15 filed a grievance upon admission, reporting that her room was not clean and contained someone else's belongings. Additionally, she did not receive requested food items such as soup and tea. The facility did not document any investigation or resolution for these grievances, showing a failure to address the resident's immediate concerns and uphold the grievance policy. Resident R14's daughter submitted a grievance regarding multiple issues, including cold meals and missing food items. She detailed specific instances where her father received cold food and incomplete meals, which were not addressed by the facility. The lack of investigation and resolution for these grievances highlights a systemic issue in the facility's grievance handling process, as evidenced by the absence of documented actions or solutions for the residents' reported concerns.
Plan Of Correction
The facility cannot go back retroactively to correct this issue. The NHA/designee conducted an audit of the last 2 weeks of grievances to ensure grievances are investigated and resolved. The Interdisciplinary Team was educated on the grievance policy by the Regional Nurse. The NHA/designee will audit grievances to ensure grievances are investigated and resolved. Audits will be done weekly x 4 weeks then monthly x 2 months. Results of these audits will be submitted to the Quality Assurance Committee to determine if further action is needed.
Failure to Address Resident Grievances on Cold Food
Penalty
Summary
The facility failed to act promptly upon resident grievances and recommendations during monthly resident group meetings, specifically concerning the dietary department. Over a period of three months, residents consistently reported issues with cold food during resident council meetings. Despite these repeated complaints, there was no evidence that the facility took action to address these concerns. The facility's policy on resident council meetings emphasizes the importance of addressing resident concerns, but the facility did not demonstrate any response or rationale for the lack of action. Interviews with residents revealed ongoing dissatisfaction with the food temperature, with multiple residents reporting that their meals were often served cold. Residents expressed their grievances during meetings and even arranged a separate meeting with the Nursing Home Administrator (NHA) to discuss these issues. However, the residents reported that they were not updated on any actions taken to resolve the problem, and the issue of cold food persisted. The NHA acknowledged awareness of the problem, specifically noting that a heating device used to keep food warm needed replacement but had not been addressed. Despite the residents' efforts to communicate their concerns through formal channels, the facility did not provide evidence of any steps taken to resolve the issues raised, leading to a deficiency in addressing resident grievances effectively.
Plan Of Correction
The facility cannot go back retroactively to correct this issue. A Resident Council meeting was held on 12/20/2024 and concerns voiced were documented and acted upon promptly with a resolution. Resolutions will be reported to the individuals voicing concerns. The Interdisciplinary Team was educated by the Regional Nurse on the Resident Council process and acting upon any concerns in a timely manner as well as communicating actions taken to resolve those concerns. The NHA/designee will audit Resident Council Meeting minutes monthly to ensure any concerns voiced are acted upon promptly. Audits will be done monthly x 3 months. Results of the audits will be submitted to the quality assurance committee to determine if further action is needed.
Failure to Develop Person-Centered Care Plan for Resident with COPD
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident with chronic obstructive pulmonary disease (COPD) and other health conditions, such as pulmonary hypertension, heart failure, and chronic kidney disease. The deficiency was identified when it was found that the resident's care plan did not address sensitivities to irritants like aerosol sprays and perfumes, which could adversely affect the resident's health. This oversight was discovered during a review of the resident's clinical records and facility policies. An incident was reported where a nurse aide wore perfume that had a suffocating effect on the resident, exacerbating her respiratory condition. The Director of Nursing (DON) acknowledged awareness of the incident and provided education to the staff member involved. However, the care plan still lacked specific interventions to prevent exposure to such irritants, despite the resident's known sensitivities and previous complaints about similar issues. The facility's policy on care planning requires that each resident's needs be addressed with specific goals and interventions, but this was not adhered to in the case of the resident with COPD. The absence of a comprehensive plan to manage the resident's exposure to irritants indicates a failure to ensure all staff were informed of the potential health impacts, as confirmed by the DON during an interview.
Plan Of Correction
R1 care plan was updated to include the resident's sensitivities to aerosol sprays and perfumes and the effects that the use of them could have on the residents health related to the diagnosis of COPD. The DON/designee audited residents with a diagnosis of COPD to ensure appropriate care plans are in place. The facility educated licensed staff on the development of person-centered plan of care for residents with COPD that addresses sensitivities to aerosol sprays, perfumes, and the effects that the use of them could have on a resident. The DON/designee will audit new admissions with a diagnosis of COPD to ensure care plans are developed that address sensitivities to aerosol sprays and perfumes. Audits will be done weekly x 4 weeks then monthly x 2 months. Results of these audits will be submitted to the Quality Assurance Committee to determine if further action is needed.
Inadequate Supervision During Medication Administration
Penalty
Summary
The facility failed to ensure adequate supervision during medication administration for a resident, identified as Resident R2. The resident, who has a medical history of kidney failure, hypertension, diabetes, cerebral infarction, and senile degeneration of the brain, was observed with a plastic cup containing approximately four pills on her bedside table. The resident, who was assessed with moderate cognitive impairment and lacked the capacity to make general healthcare decisions, reported that the nurse left the pills for her to take. The Director of Nursing (DON) confirmed that the medications included nifedipine, Allegra, Farxiga, and aspirin, and identified the licensed nurse responsible for leaving the medications unattended. The review of the resident's physician orders indicated that there was no authorization for the resident to self-administer medication. The facility's policy on medication administration requires that medications be administered under the orders of the attending physician or their designees. The incident was discussed with the DON, who acknowledged that the resident's clinical record did not show evidence of authorization for self-administration of medication, highlighting a failure in supervision and adherence to medication administration protocols.
Plan Of Correction
E4 was educated by the DON on the medication administration policy. The DON/designee did an audit of the unit to ensure there were no other residents with medications left at the bedside. Licensed staff were inserviced on the Medication Administration/Disposition policy by the Facility Educator. The DON/designee will conduct random room audits of 10 rooms on each unit to ensure medications are not left at the bedside. Audits will be done weekly x 4 weeks then monthly x 2 months. Results of these audits will be submitted to the Quality Assurance Committee to determine if further action is needed.
Failure to Maintain Required Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to maintain the required staffing ratios for nurse aides across several shifts, as mandated by the regulation effective July 1, 2024. Specifically, the facility did not meet the minimum staffing requirements of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight for 6 out of the 63 shifts reviewed. This deficiency was identified through a review of nursing staff schedules and facility census data, which revealed discrepancies in the hours of care provided by nurse aides compared to the hours required based on the resident census. On multiple occasions, the facility's staffing levels fell short of the required hours of care. For instance, on October 20, 2024, the facility provided only 116.4 hours of care instead of the required 140 hours during the day shift. Similarly, on November 28, 2024, only 75.93 hours of care were provided overnight, falling short of the required 89.60 hours. These findings were discussed with the Nursing Home Administrator and the Director of Nursing, highlighting the facility's failure to meet state staffing requirements on specific dates.
Plan Of Correction
The Provider submits the following plan of correction in good faith and to comply with federal regulations. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. The facility cannot go back retroactively to correct this issue. The NHA, DON, and Staffing Coordinator were educated by the Regional Nurse on the CNA staffing ratios for dayshift, evening shift, and nightshift. The NHA/designee will audit staffing ratios daily as well as projected ratios for the upcoming shifts using the PA DOH staffing grid to ensure the required CNA ratios are met. Results of these audits will be submitted to the Quality Assurance Committee to determine if further action is needed.
Failure to Meet LPN Staffing Ratios Overnight
Penalty
Summary
The facility failed to maintain the required staffing ratios for Licensed Practical Nurses (LPNs) during the overnight shift on one of the 63 shifts reviewed. Specifically, on October 20, 2024, the facility had a census of 176 residents, necessitating 35.20 hours of care by LPNs for the 11:00 p.m. to 7:00 a.m. shift. However, the review of nursing time schedules revealed that only 33.74 hours of care were provided by LPNs, falling short of the required staffing ratio. This deficiency was identified during a review of nursing staff schedules and interviews with staff, and it was discussed with the Nursing Home Administrator and the Director of Nursing on December 3, 2024.
Plan Of Correction
The Provider submits the following plan of correction in good faith and to comply with federal regulations. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. The facility cannot go back retroactively to correct this issue. The NHA, DON, and staffing coordinator were educated by the regional nurse on the LPN staffing ratios on the nightshift. The NHA/designee will audit staffing ratios daily as well as projected ratios for the upcoming shifts using the PA DOH staffing grid to ensure the required LPN ratios are met. Results of these audits will be submitted to the Quality Assurance Committee to determine if further action is needed.
Deficiency in Meeting Minimum Direct Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident in a 24-hour period for 13 out of 21 days reviewed. This deficiency was identified through a review of the facility's nursing staffing documentation for the periods between October 14, 2024, and December 1, 2024. Specific days were noted where the hours of direct care fell below the required threshold, with the lowest being 2.94 hours on October 20, 2024. The deficiency was discussed with the Nursing Home Administrator and the Director of Nursing on December 3, 2024. The review highlighted multiple instances where the facility's staffing levels did not meet the state-mandated requirement, indicating a pattern of insufficient staffing to provide the necessary level of care to residents. No corrective actions or follow-up measures were mentioned in the report.
Plan Of Correction
The Provider submits the following plan of correction in good faith and to comply with federal regulations. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. The facility cannot go back retroactively to correct this issue. The NHA, DON, and Staffing Coordinator were educated by the Regional Nurse on the state required direct resident care hours of 3.2 per patient day (PPD). The NHA/designee will audit the daily PPD as well as the projected PPD for the upcoming day using the PA DOH grid to ensure the required PPD is being met. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.
Failure to Monitor Hot Beverage Temperatures Leads to Resident Burn
Penalty
Summary
The facility failed to monitor and serve hot beverages at a safe temperature, resulting in an Immediate Jeopardy situation for a resident who sustained a second-degree burn. The resident, identified as R371, was cognitively impaired with a BIMS score of 4, indicating significant cognitive impairment. The resident also had impairments in the range of motion in the upper extremity, Parkinson's disease, arthritis, and malnutrition, requiring substantial assistance with eating and drinking. Despite these conditions, the resident was served a hot beverage without adequate supervision or temperature checks. On the day of the incident, the resident was dining in the common room when a licensed nurse, Employee E10, provided a cup of hot water for tea, which was not temperature-checked. The resident spilled the hot beverage on their right thigh, resulting in a burn. The facility's policy on hot liquid safety, which required serving temperatures not to exceed 140 degrees Fahrenheit and the use of protective measures, was not followed. The beverage temperature logs revealed inconsistencies and inaccuracies, with some temperatures exceeding the safe limit. Interviews and documentation indicated that the dietary staff had not been accurately recording beverage temperatures, and the coffee machine had been malfunctioning, leading to incorrect temperature readings. The facility's failure to adhere to its hot liquid safety policy and provide appropriate supervision during meal service directly contributed to the resident's injury.
Removal Plan
- Licensed staff conducted a hot liquid safety evaluation for all residents in the facility. Any resident that triggers at risk will be evaluated further by occupational therapy to determine if the resident requires assistance during meals or adaptive equipment.
- All staff will be educated on the results of hot liquid safety assessment and intervention will be included in the resident care plan.
- To ensure that temperature of hot liquids is accurate, the facility developed a protocol and educated all staff.
- Prior to hot liquids leaving dietary, a temperature will be taken by two staff members in Dietary. One staff member will take the temperature and the supervisor/designee will verify the accuracy of the temperature.
- The temperature will be documented on the hot beverage form along with both staff members signing off on this form.
- Temperature on the unit should not exceed 140 degrees Fahrenheit.
- Any hot beverage temps over 140 degrees will be sent back to the dietary department for a replacement.
- The hot beverage monitoring form will be submitted daily to the NHA/designee for review to assure compliance. The Hot Liquid tools will be submitted to the Quality Assurance Committee for review.
Failure to Follow Diabetes Management Protocols
Penalty
Summary
The facility failed to ensure residents received treatment and care in accordance with professional standards of practice, specifically in managing diabetes care. For Resident R57, the facility did not inform the physician of a missed insulin dose due to the medication not arriving from the pharmacy, as documented in the nursing note dated May 29, 2024. The Director of Nursing confirmed that the nursing staff did not follow the facility policy by failing to notify the physician about the missed medication. Resident R135's clinical records showed multiple instances of elevated blood sugar levels that were not reported to the physician as required by the physician's orders. Similarly, Resident R149 experienced both hypoglycemic and hyperglycemic episodes, with no documented evidence that the facility followed the prescribed protocols for managing these conditions. The Director of Nursing confirmed the lack of documentation and adherence to protocols for both residents.
Inadequate Investigations into Resident Incidents
Penalty
Summary
The facility failed to conduct thorough investigations into several incidents involving residents, leading to deficiencies in addressing potential abuse, neglect, and injuries of unknown origin. For Resident R120, the facility did not investigate the new onset of shoulder pain, which was later diagnosed as a fracture, to rule out potential abuse. The Director of Nursing confirmed that no investigation was conducted, attributing the injury to an old fracture without further inquiry. In another case, Resident R51 eloped from the facility, and the investigation was incomplete. There was no documentation of interviews with the resident's roommate or the person who reported the incident. Additionally, the facility did not determine how the resident removed the alarm bracelet or the duration of time spent outside. The Director of Nursing acknowledged the lack of a thorough investigation into the elopement. Further deficiencies were noted with Resident R102, who complained of ankle pain after being left unattended. The investigation did not include a comprehensive assessment or interviews to determine the source of the injury. Similarly, Resident R371 suffered a burn from hot water, and the investigation revealed that the water temperature was not checked. The facility's documentation and interviews with staff confirmed these lapses in investigation and documentation.
Failure to Develop Comprehensive Care Plan for Constipation
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident's chronic condition of constipation. The facility's policy, revised in July 2023, mandates the creation of a comprehensive care plan for each resident, addressing their specific needs with goals and interventions. However, for one resident, identified as R57, the facility did not adhere to this policy. The resident had a history of constipation, with a progress note from a Certified Registered Nurse Practitioner (CRNP) on April 15, 2024, indicating no bowel movement for 96 hours. The CRNP ordered Milk of Magnesia (MOM) and, if ineffective, a suppository. On May 6, 2024, the CRNP noted another instance of no bowel movement for 48 hours and ordered the initiation of a bowel protocol and daily Docusate. Despite these medical interventions, the facility did not develop a care plan for the resident's constipation, as confirmed by the Director of Nursing on July 19, 2024.
Failure to Provide Restorative Nursing Services
Penalty
Summary
The facility failed to provide restorative nursing services for a resident who was admitted following neurosurgery for a brain tumor and was diagnosed with seizures and hemiplegia. The resident, who was alert and oriented, expressed a desire to walk again and reported that after physical therapy ended, no one assisted her with walking. Her care plan included a Restorative Nursing Program to maintain skills learned in physical therapy, specifically ambulating 200 feet using a quad cane with contact guard assistance. However, there was no documented evidence that nursing staff provided the restorative therapy as outlined in her care plan. The deficiency was confirmed by the Director of Nursing, who acknowledged that the resident should have been on the restorative program, but the facility failed to coordinate this care with therapy. The resident's progress notes and care conference records indicated she was on a physical therapy maintenance program, yet the necessary restorative nursing services were not implemented, leading to a lapse in the resident's care as per her needs and care plan.
Failure to Manage Hot Beverage Safety for Resident with Parkinson's
Penalty
Summary
The Nursing Home Administrator (NHA) and Director of Nursing (DON) failed to effectively manage the facility, leading to an immediate jeopardy situation involving a resident, identified as R371. This resident, who had Parkinson's disease with associated tremors, was not adequately assessed and supervised. Despite being cognitively impaired with a BIMS score of 4 and requiring substantial, maximal assistance for eating, the resident was provided a hot beverage, which resulted in a serious burn injury when it spilled. The facility's documentation and policies indicated that the resident had multiple risk factors, including visual impairment, weakened upper extremity strength, and balance issues, which should have triggered additional precautions. The facility's Hot Liquid Safety policy, last revised in February 2023, was not adhered to, as evidenced by the incident where a licensed nurse provided the resident with a hot beverage without ensuring the temperature was safe. Observations revealed that hot beverages were served at temperatures exceeding the policy's maximum of 140 degrees Fahrenheit, with one instance recorded at 152 degrees Fahrenheit. The failure to implement necessary interventions, such as serving beverages at safe temperatures and providing appropriate supervision, contributed to the deficiency. The NHA and DON did not fulfill their responsibilities to ensure the safety and well-being of the residents, as required by federal, state, and local guidelines.
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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