Simpson House Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- 2101 Belmont Avenue, Philadelphia, Pennsylvania 19131
- CMS Provider Number
- 395121
- Inspections on file
- 18
- Latest survey
- April 28, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Simpson House Inc during CMS and state inspections, most recent first.
The facility did not comply with NFPA 10 standards as a fire extinguisher was found unmounted in the medical records room. This was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility did not maintain the fire protection rating for linen chutes, affecting one level. The chute door in the first-floor soiled utility room failed to self-close because it was wedged into the drywall when fully opened. This issue was confirmed by the Administrator and Maintenance Director.
The facility was found in violation of fire-resistance rating requirements due to its four-story, Type II (000), unprotected noncombustible construction, which exceeds the maximum allowed height for this type. The building is fully sprinklered, but the construction type is not permitted to exceed one story when sprinklered, as confirmed by the Administrator and Maintenance Director.
The facility failed to submit required direct care staffing information for a fiscal quarter, as mandated by CMS. This deficiency was identified through a review of the PBJ staffing data report and confirmed by the DON, who could not provide additional documentation. The missing submission could affect the facility's ability to report on staff levels and quality of care.
The facility failed to implement enhanced barrier precautions for residents with indwelling catheters and pressure ulcers, as required by their infection control policy. Observations revealed a lack of signage and PPE outside residents' rooms, and interviews confirmed staff were unaware of the need for these precautions.
A resident with pulmonary hypertension and chronic respiratory failure was found to be receiving 2 liters of oxygen instead of the prescribed 1 liter, and the oxygen tubing was undated. This was confirmed by a licensed nurse, indicating a failure to follow the physician's orders and proper equipment management.
A resident with multiple health conditions, including dementia and heart failure, was admitted to hospice services without a comprehensive care plan being developed by the facility. Despite a physician's order for hospice consultation, the facility did not create a care plan to address the resident's hospice needs, which was confirmed by the DON.
The facility did not provide inservice education for a nurse aide who was rated as 'Needs Improvement' in maintaining confidentiality during an annual performance review. Despite the identified need for improvement, there was no documentation of re-training on confidentiality for the nurse aide in 2023 and 2024. An interview confirmed the lack of documented re-education on this matter.
Uninspected and Unmounted Fire Extinguisher in Medical Records Room
Penalty
Summary
The facility failed to ensure that portable fire extinguishers were properly inspected and mounted, as required by NFPA 10, Standard for Portable Fire Extinguishers. During an observation on April 28, 2025, at 8:55 a.m., it was noted that a fire extinguisher was not mounted in the medical records room. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director on the same day at 10:30 a.m.
Plan Of Correction
1: The fire extinguisher was mounted in medical records with signage. 2: The Director of Facilities/ Designee will perform random monthly audits times 4 then quarterly audits to ensure all fire extinguishers are properly mounted. 3: The Facilities Director/Designee will report audit findings in the quarterly QA meeting and or the Facilities Governing Body meetings.
Failure to Maintain Fire Protection Rating for Linen Chutes
Penalty
Summary
The facility failed to maintain the fire protection rating for linen chutes, specifically affecting one of the four levels. During an observation on April 28, 2025, at 9:35 a.m., it was noted that the chute door in the soiled utility room on the first floor did not self-close as required. This failure was due to the door being wedged into the drywall when fully opened. An interview with the Administrator and Maintenance Director at 10:30 a.m. on the same day confirmed the issue with the chute door not self-closing.
Plan Of Correction
A wall stop was placed to ensure the soiled utility room chute door can self-close. The Director of Facilities/Designee will perform random monthly audits times 4 then quarterly audits to ensure all utility room chute doors self-close. The Facilities Director/Designee will report audit findings in the quarterly QA meeting and or the Facilities Governing Body meetings.
Violation of Fire-Resistance Rating Requirements
Penalty
Summary
The facility was found to be in violation of fire-resistance rating requirements due to its building construction type and height. During an observation and document review, it was noted that the building is a four-story, Type II (000), unprotected noncombustible construction with a basement, which is fully sprinklered. This construction type is not permitted to exceed one story when sprinklered, according to the NFPA 101 standards. The surveyors confirmed with the Administrator and Maintenance Director that the story height exceeds the maximum allowed for this type of construction, indicating a failure to comply with the fire safety regulations, affecting the entire facility.
Plan Of Correction
1: The FSES will be updated by Lenhardt Rodgers Architecture, and a copy will be forwarded to Life Safety as well as DOH Harrisburg and the Local Field office in Norristown. 2: FSES will be updated yearly.
Failure to Submit Staffing Data for Fiscal Quarter
Penalty
Summary
The facility failed to electronically submit direct care staffing information for the first quarter of the fiscal year 2025, covering the period from October 1, 2024, to December 31, 2024. This deficiency was identified through a review of the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) staffing data report and confirmed during an interview with the Director of Nursing. The report indicated that the facility did not meet the mandatory submission requirements as outlined in Section 6106 of the Affordable Care Act (ACA) and the State Operations Manual, which mandates the electronic submission of complete and accurate direct care staffing information, including agency and contract staff, based on payroll and other verifiable data. The failure to submit the required staffing data was further highlighted by the facility's triggering for 'Failed to Submit Data for the Quarter' in the PBJ staffing data report. During the interview, the Director of Nursing, identified as Employee E2, was unable to provide any additional information or documentation to account for the missing submission. This lack of compliance with the CMS requirements for staffing data submission could potentially impact the facility's ability to report on staff levels, turnover, and tenure, which are critical for assessing the quality of care provided to residents.
Plan Of Correction
1. The Director of Nursing and Administrator will be in-serviced on CMS, 483.70 Mandatory submission of staffing based on payroll data in a uniform format that Long Term Care facilities must electronically submit to CMS direct care staffing information according to the CMS submission schedule. 2. The Director of Nursing along with the Administrator will be reviewing the direct care staffing data monthly for electronic submission. 3. The administrator will monitor that the facility submits the direct care staffing data electronically in the uniform format for each quarter as directed by CMS for Payroll Based Journal. Data submission will be reported by the Director of Nursing or the Administrator through the Quality Assurance meeting and/or the Facilities Governing Body meetings for compliance.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions for four residents, leading to a deficiency in infection prevention and control. The facility's policy on enhanced barrier precautions, which was reviewed in July 2024, mandates the use of personal protective equipment (PPE) such as gowns and gloves during high-contact resident care activities for residents with wounds or indwelling medical devices. However, observations and interviews revealed that these precautions were not followed for residents with indwelling catheters and pressure ulcers. Resident R36, who had an indwelling catheter, and Resident R50, who had pressure ulcers, did not have enhanced barrier precautions documented in their care plans. Observations showed no signage indicating the need for such precautions on their doors, and no gowns or waste containers were available outside their rooms. Interviews with the residents and staff confirmed the lack of awareness and implementation of these precautions. Similarly, Residents R24 and R48, both with indwelling catheters, also lacked signage and available gowns outside their rooms. Interviews with the residents and staff further confirmed the absence of enhanced barrier precautions. The Unit Manager acknowledged the lack of signage and gowns, indicating a systemic failure to adhere to the facility's infection control policies.
Plan Of Correction
1- Residents R36, R50, R24, and R48 were all placed on Enhanced Barrier Precautions. This includes PPE immediately available outside of the resident's room and a waste container near the exit of the room with signage posted for each resident's room. All residents will be screened during the admissions process for the need of Enhanced Barrier Precautions prior to admission to the facility. The Director of Nursing/Designee will review the new orders report to determine if Enhanced Barrier Precautions need to be initiated and added to a resident's plan of care. All licensed staff will be educated on the policy and procedures of Enhanced Barrier Precautions and the location of where PPE will be readily available on the nursing units. The Director of Nursing/Designee will perform random weekly audits times 4, then monthly audits times 4, then quarterly audits times 4 to assure the facility has implemented Enhanced Barrier Precautions for the required residents. Audit results will be reported by the Director of Nursing/Designee through the Quality Assurance meeting and/or the Facilities Governing Body meetings for compliance. Date of Corrective action: May 30, 2025.
Failure to Adhere to Prescribed Oxygen Therapy
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident R45, who was receiving oxygen therapy. Resident R45 was admitted with diagnoses including pulmonary hypertension, chronic obstructive pulmonary disease, and chronic respiratory failure. The physician's orders for Resident R45 specified the administration of oxygen at 1 liter per minute via nasal cannula to maintain blood oxygen levels above 92%. However, observations on two separate occasions revealed that the resident was receiving 2 liters of oxygen, contrary to the physician's orders. Additionally, it was noted that the oxygen tubing used for Resident R45 was not dated, which is a deviation from standard practice. This was confirmed during an interview with a licensed nurse, Employee E3, who acknowledged that the oxygen concentrator was set at 2 liters and that the tubing was undated. These findings indicate a failure to adhere to the prescribed oxygen therapy regimen and proper equipment management, as required by professional standards and the resident's care plan.
Plan Of Correction
1. Resident R45's oxygen concentrator setting was placed at 1 Liter as ordered by the physician. The oxygen tubing was changed and dated. 2. All residents' oxygen concentrator settings have been evaluated and are administering the proper liters of oxygen according to the physician orders. All oxygen tubing's were changed and dated. All residents on oxygen will receive physician orders to change and date oxygen tubing weekly. 3. All licensed staff will be re-educated on physician's orders and concentrator settings. The Director of Nursing/Designee will review the new orders report for oxygen orders and accurate concentrator settings. 4. The Director of Nursing/Designee will perform random weekly audits times 4, then monthly audits times 4, then quarterly audits times 4 of physician's orders for oxygen orders and for accurate concentrator settings. Audit results will be reported by the Director of Nursing/Designee through the Quality Assurance meeting and/or the Facilities Governing Body meetings for compliance. 5. Date of Corrective action: May 30, 2025.
Failure to Develop Hospice Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for hospice services for Resident R40, who was admitted to the facility with multiple diagnoses including dementia, chronic kidney disease, anemia, heart failure, hypertension, and polyneuropathy. Despite a physician's order for a hospice consult and the resident's subsequent admission to hospice services, no care plan was created to address her hospice care needs. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged that no care plan had been developed for the resident's hospice care from the time of her hospice admission until her death.
Failure to Provide Confidentiality Training for Nurse Aide
Penalty
Summary
The facility failed to provide inservice education based on the outcome of an annual performance review for one of the three nurse aides reviewed, identified as Employee E10. The performance review, dated December 13, 2023, rated Employee E10 as 'Needs Improvement' in maintaining confidentiality of resident, employee, operations data, and health information. A comment in the review advised Employee E10 to be mindful of discussing nursing concerns in front of residents and family members and to ensure appropriate conversation in common areas. Despite this identified need for improvement, a review of inservice records for 2023 and 2024 revealed no documentation of re-training for Employee E10 regarding confidentiality. An interview conducted on July 3, 2024, confirmed the absence of documented re-education on confidentiality for Employee E10 after the performance evaluation.
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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