Southwestern Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pittsburgh, Pennsylvania.
- Location
- 500 North Lewis Run Road, Pittsburgh, Pennsylvania 15122
- CMS Provider Number
- 395742
- Inspections on file
- 50
- Latest survey
- January 24, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Southwestern Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to maintain proper food safety practices, as the dish machine was not functioning correctly and staff were not trained in chemical sanitation verification. Additionally, a gray fuzzy substance was found on the refrigerator fan blades and ceiling, posing a risk for foodborne illness.
The facility failed to provide the required 12 hours of annual in-service training for four nurse aides, as mandated by regulations. The deficiency was confirmed through a review of staff education records and an interview with the Nursing Home Administrator, revealing that the aides received insufficient training hours within the specified period.
The facility failed to complete accurate MDS assessments for several residents, as required by the Resident Assessment Instrument User's Manual. The BIMS and mood assessments were not conducted for residents who were at least sometimes understood, leading to incomplete documentation of their cognitive and mood status. This was confirmed by staff interviews.
The facility failed to provide mandatory abuse and neglect prevention training for three staff members, including a Nurse Aide, an RN, and an LPN. The deficiency was confirmed by the Nursing Home Administrator, who acknowledged the lapse in training provision.
The facility failed to provide three residents the opportunity to formulate advance directives, as required by policy. Despite having diagnoses such as muscle weakness, high blood pressure, heart failure, dyspnea, epilepsy, and liver transplant status, their clinical records lacked documentation of being offered this opportunity. This was confirmed by the DON and Admissions Director.
A facility failed to complete a significant change MDS assessment for a resident who was admitted to hospice care, despite the requirement to conduct such an assessment within 14 days of a significant change in condition. The oversight was confirmed by both the DON and the Nursing Home Administrator during interviews.
A facility failed to provide adequate care for a resident after hospitalization for dehydration-related conditions. Despite hospital discharge instructions emphasizing the need for increased fluid intake, the resident's care plan and Kardex lacked interventions for hydration monitoring. Clinical records and physician's orders also omitted fluid status directives, which was confirmed by facility leadership.
A resident with multiple sclerosis and dementia was given Seroquel for anxiety without documented behaviors justifying its use. Facility policy requires medications to be clinically indicated, but reviews showed no unwanted behaviors, confirming a deficiency in medication management.
The facility failed to provide mandatory infection control training for a registered nurse hired in 2022, as revealed by a review of training records and staff interviews. The Nursing Home Administrator confirmed the lack of training for eight of nine staff members, indicating a broader compliance issue.
The facility did not ensure a neutral arbitration process as required by regulations. The Admission Agreement packet's 'Indemnification' statement failed to clearly identify itself as an arbitration agreement and did not allow for the selection of a neutral arbitrator agreed upon by both the resident or their representative and the facility. The Nursing Home Administrator confirmed the agreement's language might not ensure a fair arbitration process.
The facility failed to provide compliance and ethics training to nine staff members, including nurse aides, a central supply employee, an activities assistant, a maintenance employee, an RN, and an LPN. The required annual training was not documented for these employees, as confirmed by the Nursing Home Administrator.
The facility failed to provide behavioral health training to eight staff members, including NAs, a Central Supply Employee, an Activities Assistant, an RN, and an LPN. The deficiency was confirmed by the Nursing Home Administrator and identified under 28 Pa Code regulations, highlighting a lack of compliance with required training protocols.
The facility failed to provide mandatory effective communication training for eight staff members, including NAs, a Central Supply Employee, an Activities Assistant, an RN, and an LPN. This deficiency was confirmed by the Nursing Home Administrator and noted under relevant Pennsylvania Code sections.
The facility failed to provide required resident rights training to eight staff members, including NAs, a Central Supply employee, an Activities Assistant, a Maintenance employee, and an LPN. This deficiency was confirmed by the Nursing Home Administrator and noted under federal regulation §483.95(b) and state codes related to licensee responsibility, management, and staff development.
The facility failed to provide mandatory QAPI training to eight staff members, including NAs, a Central Supply Employee, an Activities Assistant, an RN, and an LPN. The deficiency was confirmed by the Nursing Home Administrator and identified through a review of training records and staff interviews.
The facility failed to ensure that four nurse aide employees completed the required annual emergency preparedness education. A review of records and staff interviews revealed that these employees did not have documented training on emergency preparedness within the specified time frames. The Nursing Home Administrator confirmed this deficiency.
The facility failed to meet state-required nurse aide staffing levels over a three-week period, with insufficient nurse aides on nine daylight shifts, four evening shifts, and seven midnight shifts. The Nursing Home Administrator confirmed the shortfalls, which were identified through a review of staffing schedules.
The facility did not meet the required LPN staffing levels on one day shift and three night shifts over a 21-day period. On a specific day shift, the facility provided 23.98 LPN hours instead of the required 25.60 hours for 80 residents. On three night shifts, the actual LPN hours provided were below the required hours, with discrepancies ranging from 0.20 to 0.60 hours. The Nursing Home Administrator confirmed these staffing shortages.
The facility failed to provide appropriate care and treatment, resulting in harm to residents. A resident experienced severe constipation due to the facility's failure to follow bowel regimen protocols, leading to hospitalizations. Additionally, several residents did not receive prescribed wound care, resulting in infections and hospital transfers. Staff interviews confirmed these deficiencies, highlighting inconsistencies in following protocols and physician orders.
A resident with dementia and macular degeneration suffered a skin tear due to neglect when a CNA provided care alone, despite orders requiring two-person assistance. The care plan was not updated to reflect the necessary level of assistance, leading to the resident's injury during an episode of agitation.
The facility failed to provide adequate pressure ulcer care and prevention for four residents, resulting in a new pressure ulcer for a resident with existing conditions like osteomyelitis and diabetes. Despite orders for repositioning and use of a PRAFO boot, the facility did not assess the skin under the boot, leading to a worsening unstageable ulcer. Other residents with heart failure, lymphedema, and dementia also received improper wound care, with discrepancies in treatment frequency and lack of updated orders.
The facility failed to protect two residents from injury, resulting in skin tears during transfers. One resident, with macular degeneration and dementia, required two-person assistance but was cared for by a single nurse aide, leading to a skin tear. Another resident, with heart failure and dementia, was resistant during a transfer and sustained a skin tear. The care plans lacked clear instructions on required assistance levels, contributing to these incidents.
The facility failed to properly label and date food items, maintain refrigerator temperature logs, and ensure cleanliness in nutrition rooms on both floors. Observations showed unlabeled and undated food items, missing temperature assessments, and cleanliness issues, confirmed by the Nursing Home Administrator.
The facility failed to provide sufficient nursing staff, resulting in unmet needs for 22 residents. Observations showed delayed call light responses, inadequate personal care, and missed wound dressing changes. Residents and family members reported concerns about inattentive staff and poor care quality. The Nursing Home Administrator confirmed the staffing deficiency.
The facility failed to maintain an effective training program for staff regarding the care of surgical drains, such as the JP drain. Despite the facility assessment indicating the need for staff competencies, no detailed education was provided, and competency evaluations were not conducted. Errors in documentation and inconsistent staff understanding of JP drain care were noted, affecting three of six staff members sampled.
A facility failed to ensure that licensed nurses had the necessary competencies to manage a JP drain for a resident with complex medical needs. The resident's JP drain was not properly maintained, leading to fluid buildup and a clot in the tubing. Interviews revealed inconsistent understanding among staff regarding the correct procedure for emptying and maintaining the drain, contributing to the deficiency.
A resident with severe dementia and a history of combativeness was not provided with appropriate interventions for behavioral disturbances. The care plan lacked guidance for managing such behaviors, leading to an incident where the resident sustained a skin tear during care. The facility failed to document and address the resident's behavioral issues adequately.
A resident with a history of hemiplegia and Alzheimer's experienced a delay in cancer treatment due to the facility's failure to schedule necessary medical appointments and provide transportation. Despite clear instructions for a PET/CT scan and echocardiogram, these tests were not completed, leading to the cancellation of a crucial port placement surgery. The oncology team confirmed that the facility's inaction resulted in a change from breast conservation to a mastectomy, as they doubted the facility's ability to ensure consistent transportation for radiation therapy.
A resident with osteomyelitis, PVD, and diabetes was found with a soiled bunny boot, contrary to infection control practices. The boot, used for heel elevation as part of wound care, was observed to be extremely soiled with wound drainage. This was confirmed by an RN during a dressing change, highlighting a failure in infection control protocols.
Deficiencies in Kitchen Sanitation and Food Storage
Penalty
Summary
The facility failed to ensure proper food safety practices in the main kitchen, as evidenced by issues with the dishwashing process and food storage. During an observation, it was noted that the dish machine, which was supposed to operate at high temperatures, was not functioning correctly and was being used as a low-temperature machine with chemical sanitation. Dietary Aides operating the machine were not trained to use test strips to verify the level of sanitation, and the District Manager confirmed that the staff had not received the necessary training to prevent cross-contamination. Additionally, during an inspection of the refrigerator leading to the deep freezer, a gray fuzzy substance was observed on the fan blades, cover, and ceiling, with food stored underneath. This condition posed a potential risk for foodborne illness. The District Manager acknowledged that the presence of the substance could lead to contamination of the food stored in the area.
Plan Of Correction
1. No residents were affected. 2. The dish machine is working properly and running at proper temperatures. Fan blades and the cover on the ceiling of the freezer have been cleaned. 3. Kitchen employees were in serviced by the District Manager regarding proper use of strips for measuring the sanitation level in dishwasher. The kitchen employees have been in serviced by the District Manager on the cleaning schedule of the fan blades and the cover on the ceiling of the freezer. 4. The Administrator/kitchen manager or designee will conduct inspections of the dish machine temps and sanitation, fan blades and the cover on the ceiling in the freezer to ensure they are in good working order and clean weekly x 4 weeks. The QAPI committee will determine the need for further audits.
Inadequate In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to meet the required in-service training hours for nurse aides, as mandated by §483.95(g). Specifically, four nurse aides, identified as Employees E6, E7, E8, and E9, did not receive the minimum 12 hours of in-service education within 12 months of their hire date anniversary. Employee E6, hired on 9/16/21, completed only 10.25 hours of training between 9/16/23 and 9/16/24. Employee E7, hired on 10/4/12, completed 9.75 hours between 10/4/23 and 10/4/24. Employee E8, hired on 10/14/13, completed 10.00 hours between 10/14/23 and 10/14/24. Employee E9, hired on 8/15/22, completed only 6.75 hours between 8/15/23 and 8/15/24. During an interview on 1/24/25, the Nursing Home Administrator confirmed the facility's failure to provide the required annual in-service education for these nurse aides. This deficiency was identified through a review of staff education records and interviews, indicating a lapse in the facility's compliance with the regulatory requirements for staff development and training.
Plan Of Correction
1. The facility will ensure certified nursing assistants receive 12 hours of in-service training on a yearly basis. 2. A full house employee file audit will be conducted to identify the training needs of each nursing assistant to ensure ongoing yearly training. 3. The Human Resources Director or designee will ensure that each nursing assistant of the facility receives 12 hours of in-service training on a yearly basis by reviewing their training courses prior to their performance appraisal due date. If the training has been inadvertently missed, the employee will be trained on the missed course prior to the performance appraisal being completed. 4. The Administrator or designee will review 5 employee files due for performance review each month to ensure yearly training is completed weekly x4 weeks. The QAPI committee will determine the need for further audits.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure that comprehensive Minimum Data Set (MDS) assessments were accurate and fully completed for seven out of eight residents. The deficiency was identified through a review of the Resident Assessment Instrument User's Manual, clinical records, and staff interviews. Specifically, the facility did not complete the Brief Interview for Mental Status (BIMS) and Resident Mood Interview for residents who were at least sometimes understood, as indicated in Section B: Hearing, Speech, and Vision of the MDS. This discrepancy was noted for residents R7, R21, R22, R24, R38, R43, and R60, whose assessments inaccurately reflected their cognitive and mood status. During interviews, the Registered Nurse Assessment Coordinator and the Nursing Home Administrator confirmed the inaccuracies in the MDS assessments. The assessments failed to align with the guidelines provided in the Long-Term Care Facility Resident Assessment Instrument User's Manual, which mandates that the BIMS and mood assessments be conducted if a resident is at least sometimes understood. This oversight resulted in incomplete and inaccurate assessments for the affected residents, compromising the accuracy of their documented care needs.
Plan Of Correction
1. MDS cannot be corrected. 2. and 3. Education will be completed with Social Services by the Regional Nurse Consultant on the accuracy of section B0700 and C0100 of the MDS. 4. Five random audits will be completed by RNAC or designee weekly for 4 weeks of residents MDS to ensure accuracy of sections B0700 and C0100. The QAPI committee will determine the need for further audits.
Failure to Provide Abuse and Neglect Prevention Training
Penalty
Summary
The facility failed to provide mandatory training on abuse and neglect prevention for three out of nine staff members, specifically a Nurse Aide, a Registered Nurse, and a Licensed Practical Nurse. The Nurse Aide, hired on August 15, 2022, did not receive the required training between August 15, 2024, and August 15, 2024. Similarly, the Registered Nurse, hired on October 6, 2022, and the Licensed Practical Nurse, hired on September 6, 2022, also did not receive the necessary training within their respective timeframes in 2023 and 2024. This deficiency was confirmed during an interview with the Nursing Home Administrator on January 24, 2025, who acknowledged the lapse in providing the required training to these staff members.
Plan Of Correction
1. The facility will ensure employees receive abuse, neglect and exploitation training on a yearly basis. 2. A full house employee file audit will be conducted to identify the training needs of each employee to ensure ongoing yearly training. 3. The Human Resources Director or designee will ensure that each employee of the facility receives abuse, neglect and exploitation training on a yearly basis by reviewing their training courses prior to their performance appraisal due date. If the training has been inadvertently missed, the employee will be trained on the missed course prior to the performance appraisal being completed. 4. The Administrator or designee will review 5 employee files due for performance review each month to ensure yearly training is completed weekly x4 weeks. The QAPI committee will determine the need for further audits.
Failure to Provide Advance Directive Opportunities
Penalty
Summary
The facility failed to comply with the requirements related to advance directives for three residents. The deficiency was identified during a survey that reviewed facility policies, clinical records, and included staff interviews. The facility's policy on advance directives, last reviewed on November 5, 2024, mandates that all adult residents be informed about their rights to accept or refuse medical treatment and to formulate an advance directive. However, the clinical records for three residents did not contain documentation that they were given the opportunity to formulate an advance directive. Resident R41, who was readmitted to the facility with diagnoses including muscle weakness, high blood pressure, and heart failure, had no documentation of being offered the opportunity to create an advance directive. Similarly, Resident R75, admitted with dyspnea, muscle weakness, and epilepsy, and Resident R77, admitted with high blood pressure, dysphagia, muscle weakness, and liver transplant status, also lacked such documentation. The Director of Nursing and the Admissions Director confirmed the absence of this documentation during interviews conducted on January 24, 2025.
Plan Of Correction
1. R41 has a completed advanced directive, R75 has a completed advanced directive, R77 has a completed advanced directive. 2. A full house audit has been completed to ensure current residents have a current advanced directive. 3. New admissions to the facility will have the opportunity to formulate an advanced directive. Advanced directives will be placed as an order in the medical record. Advanced directives will be reviewed on a quarterly basis with the IDT team and the resident and/or family. 4. The Social Service Director or designee will review new admission medical charts for advanced directives weekly x4 to ensure current advanced directives are in place. The QAPI committee will determine the need for further audits.
Failure to Complete Significant Change MDS Assessment
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment for a resident, identified as R27, who experienced a significant change in condition. The resident, admitted on December 24, 2021, had diagnoses including dementia, Wernicke's encephalopathy, and schizophrenia. A physician order dated November 27, 2024, indicated that the resident was admitted to hospice care, which constitutes a significant change in the resident's condition. However, the facility did not complete a significant change MDS assessment to reflect the inclusion of hospice services. During interviews conducted in January 2025, both the Director of Nursing and the Nursing Home Administrator confirmed that the facility failed to complete the required significant change MDS assessment for the resident. This oversight was identified during a clinical record review and staff interviews, highlighting a deficiency in the facility's compliance with the requirement to conduct a comprehensive assessment within 14 days of determining a significant change in a resident's condition.
Plan Of Correction
1. MDS cannot be corrected. 2. Audit of residents starting hospice in the past 14 days will be completed by the RNAC or designee to ensure a significant change MDS has been completed. 3. Education will be completed with RNAC by the Regional Nurse Consultant on when to schedule a comprehensive assessment after a Significant Change in status. 4. Audits will be completed by RNAC consultant or designee weekly for 4 weeks for all residents starting hospice care for scheduling and completion of a Significant Change MDS. The QAPI committee will determine the need for further audits.
Failure to Monitor Hydration Status Post-Hospitalization
Penalty
Summary
The facility failed to provide adequate care and services for a resident following hospitalization, as evidenced by the lack of interventions related to hydration status in the resident's care plan. The resident, who had a history of dementia, Wernicke's encephalopathy, and schizophrenia, was admitted to the facility with a care plan that did not address hydration needs. After being hospitalized for acute metabolic encephalopathy and hypernatremia, conditions often linked to dehydration, the resident's discharge paperwork emphasized the need for increased oral fluid intake. However, the facility did not update the resident's care plan or Kardex to include instructions for monitoring hydration status. The clinical records and physician's orders post-hospitalization did not contain any notes or directives regarding the resident's fluid status, despite the hospital's recommendations. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed the oversight, acknowledging that the facility did not provide the necessary care and services for the resident after their hospitalization. This deficiency highlights a failure to adhere to professional standards of practice and the comprehensive person-centered care plan required for the resident's well-being.
Plan Of Correction
1. Resident R27 is currently being fed by staff for all meals. Hospice and physician will be notified if R27 has a decrease in fluid intake, for new orders. 2. The last 14 days of all re-admissions and new admission discharge paperwork will be reviewed by the DON or designee to ensure instructions for fluid recommendations are followed. 3. Licensed staff will be in serviced on reviewing all re-admissions and new admission's discharge records to ensure fluid recommendations are reviewed and implemented. 4. The Director of Nursing or designee will review discharge paperwork for all re-admissions and new admissions to ensure fluid recommendations have been reviewed and implemented weekly x4 weeks. The QAPI committee will determine the need for further audits.
Unnecessary Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary psychotropic medications. Specifically, Resident R23, who was diagnosed with multiple sclerosis, dementia without behaviors, and anxiety, was administered Seroquel, an antipsychotic medication, for anxiety. The facility's policy on psychotropic medication use states that residents should not receive medications that are not clinically indicated to treat a specific condition. However, a review of Resident R23's progress notes and behavior monitoring documentation from July 2024 through January 2025 showed no documentation of unwanted behaviors that would justify the use of such medication. The deficiency was confirmed during an interview with the Nursing Home Administrator and the Director of Nursing, who acknowledged that the facility did not ensure that each resident's drug regimen was free from unnecessary drugs without adequate indications for use. This oversight was identified for one of five residents reviewed, highlighting a lapse in adherence to the facility's medication policy and federal regulations regarding the use of psychotropic drugs.
Plan Of Correction
1. Resident R23 has a correct diagnosis for Seroquel and the care plan has been updated and behavior monitoring is in place. 2. Current residents on antipsychotics will be reviewed to ensure the medications have the correct diagnosis, the care plan is updated, and behavior monitoring is in place. 3. The DON or designee will in service the licensed staff on correct diagnoses for antipsychotics, updating the care plans and implementing behavior charting. 4. The DON or designee will review new orders for antipsychotics medications during the clinical meeting to ensure antipsychotic medications have the correct diagnosis, the care plan is updated and behavior monitoring is in place weekly x4 weeks. The QAPI committee will determine the need for further audits.
Infection Control Training Deficiency
Penalty
Summary
The facility failed to provide mandatory infection control training as part of its infection prevention and control program for one of nine staff members, specifically Registered Nurse Employee E13. The review of facility personnel in-service training records and staff interviews revealed that Employee E13, who was hired on October 6, 2022, did not receive documented infection control in-service education between October 6, 2023, and October 6, 2024. During an interview on January 24, 2025, the Nursing Home Administrator confirmed the lack of infection control training for eight of nine staff members, indicating a broader issue with compliance in the facility's training program.
Plan Of Correction
1. The facility will ensure employees receive infection control training on a yearly basis. 2. A full house employee file audit will be conducted to identify the training needs of each employee to ensure ongoing yearly training. 3. The Human Resources Director or designee will ensure that each employee of the facility receives infection control training on a yearly basis by reviewing their training courses prior to their performance appraisal due date. If the training has been inadvertently missed, the employee will be trained on the missed course prior to the performance appraisal being completed. 4. The Administrator or designee will review 5 employee files due for performance review each month to ensure yearly training is completed weekly x4 weeks. The QAPI committee will determine the need for further audits.
Failure to Ensure Neutral Arbitration Process
Penalty
Summary
The facility failed to ensure a neutral and fair arbitration process as required by regulations. The review of the facility's Admission Agreement packet revealed that the 'Indemnification' statement did not clearly identify itself as an arbitration agreement. Furthermore, it did not provide for the selection of a neutral arbitrator agreed upon by both the resident or their representative and the facility. This omission is contrary to the regulatory requirement that mandates the selection of an impartial third-party arbitrator agreed upon by both parties to resolve disputes. During an interview, the Nursing Home Administrator acknowledged that the language in the admission and financial agreement might not clearly identify the indemnification statement as an arbitration agreement. Additionally, it was confirmed that the agreement did not ensure a neutral and fair arbitration process by failing to allow both parties to agree on the selection of a neutral arbitrator. This deficiency highlights the facility's non-compliance with the requirement to avoid any appearance of bias or conflict of interest in the arbitration process.
Plan Of Correction
1. No residents were affected. 2. and 3. The facility will remove the Indemnification clause from all current admission agreements. Current residents or responsible parties will be sent the updated admissions agreement. 4. New admission files will be audited by the Administrator or designee for compliance with the new admissions agreement weekly for 4 weeks. The QAPI committee will determine the need for future audits.
Failure to Provide Compliance and Ethics Training
Penalty
Summary
The facility failed to provide required compliance and ethics training to nine staff members, as evidenced by a review of personnel in-service training records and staff interviews. The staff members, including nurse aides, a central supply employee, an activities assistant, a maintenance employee, a registered nurse, and an LPN, did not have documented training on compliance and ethics as required by the regulations. The training was supposed to occur annually, but records showed that these employees did not receive the necessary training within the specified time frames. During an interview, the Nursing Home Administrator confirmed the lack of compliance and ethics training for these staff members. The deficiency was identified based on the absence of documented in-service education for each employee within the required period, which varied according to their hire dates. This oversight indicates a failure to meet the regulatory requirements for staff development and compliance training, as outlined in the facility's compliance and ethics program.
Plan Of Correction
1. The facility will ensure employees receive Compliance and Ethics training on a yearly basis. 2. A full house employee file audit will be conducted to identify the training needs of each employee to ensure ongoing yearly training. 3. The Human Resources Director or designee will ensure that each employee of the facility receives Compliance and Ethics training on a yearly basis by reviewing their training courses prior to their performance appraisal due date. If the training has been inadvertently missed, the employee will be trained on the missed course prior to the performance appraisal being completed. 4. The Administrator or designee will review 5 employee files due for performance review each month to ensure yearly training is completed weekly x4 weeks. The QAPI committee will determine the need for further audits.
Failure to Provide Behavioral Health Training
Penalty
Summary
The facility failed to provide required behavioral health training to eight out of nine staff members, as evidenced by a review of personnel in-service training records and staff interviews. The staff members who did not receive the training included Nurse Aides, a Central Supply Employee, an Activities Assistant, a Registered Nurse, and a Licensed Practical Nurse. Each of these employees had specific hire dates, and the records showed that they did not receive behavioral health in-service education within the required timeframe after their hire dates. During an interview, the Nursing Home Administrator confirmed the lack of behavioral health training for these staff members. This deficiency was identified under the regulatory requirements of 28 Pa Code, which outlines the responsibility of the licensee, management, and staff development. The absence of documented training indicates a failure to comply with the behavioral health training requirements as stipulated by the facility's assessment and federal regulations.
Plan Of Correction
1. The facility will ensure employees receive behavioral health training on a yearly basis. 2. A full house employee file audit will be conducted to identify the training needs of each employee to ensure ongoing yearly training. 3. The Human Resources Director or designee will ensure that each employee of the facility receives behavioral health training on a yearly basis by reviewing their training courses prior to their performance appraisal due date. If the training has been inadvertently missed, the employee will be trained on the missed course prior to the performance appraisal being completed. 4. The Administrator or designee will review 5 employee files due for performance review each month to ensure yearly training is completed weekly x4 weeks. The QAPI committee will determine the need for further audits.
Failure to Provide Mandatory Communication Training
Penalty
Summary
The facility failed to provide mandatory training on effective communication for eight out of nine staff members, as required by §483.95(a). The deficiency was identified through a review of facility personnel in-service training records and staff interviews. The staff members who did not receive the required training included Nurse Aides, a Central Supply Employee, an Activities Assistant, a Registered Nurse, and a Licensed Practical Nurse. Each of these employees had specific hire dates, and the review showed that they did not have documented training on effective communication within the specified time frames after their hire dates. During an interview, the Nursing Home Administrator confirmed the lack of effective communication training for these staff members. The deficiency was noted under the Pennsylvania Code sections related to the responsibility of the licensee, management, and staff development. The absence of this training indicates a failure to comply with the mandatory training requirements, which are crucial for ensuring effective communication among direct care staff in the facility.
Plan Of Correction
1. The facility will ensure employees receive communication training on a yearly basis. 2. A full house employee file audit will be conducted to identify the training needs of each employee to ensure ongoing yearly training. 3. The Human Resources Director or designee will ensure that each employee of the facility receives communication training on a yearly basis by reviewing their training courses prior to their performance appraisal due date. If the training has been inadvertently missed, the employee will be trained on the missed course prior to the performance appraisal being completed. 4. The Administrator or designee will review 5 employee files due for performance review each month to ensure yearly training is completed weekly x4 weeks. The QAPI committee will determine the need for further audits.
Failure to Provide Resident Rights Training
Penalty
Summary
The facility failed to provide mandatory training on resident rights to eight out of nine staff members, as required by federal regulations. The deficiency was identified through a review of facility personnel in-service training records and staff interviews. The staff members who did not receive the required training included Nurse Aides, a Central Supply employee, an Activities Assistant, a Maintenance employee, and an LPN. Each of these employees had specific hire dates, and the records showed that they did not receive resident rights training within the required timeframe after their hire dates. During an interview, the Nursing Home Administrator confirmed the lack of training for these staff members. The deficiency was noted under the federal regulation §483.95(b), which mandates that facilities ensure staff are educated on resident rights and facility responsibilities. Additionally, the report cites violations of state codes related to the responsibility of the licensee, management, and staff development, further emphasizing the facility's failure to comply with training requirements.
Plan Of Correction
1. The facility will ensure employees receive resident rights on a yearly basis. 2. A full house employee file audit will be conducted to identify the training needs of each employee to ensure ongoing yearly training. 3. The Human Resources Director or designee will ensure that each employee of the facility receives resident rights training on a yearly basis by reviewing their training courses prior to their performance appraisal due date. If the training has been inadvertently missed, the employee will be trained on the missed course prior to the performance appraisal being completed. 4. The Administrator or designee will review 5 employee files due for performance review each month to ensure yearly training is completed weekly x4 weeks. The QAPI committee will determine the need for further audits.
Failure to Provide QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training on Quality Assurance and Performance Improvement (QAPI) to eight out of nine staff members, as required by §483.95(d). The deficiency was identified through a review of facility personnel in-service training records and staff interviews. The staff members who did not receive the required QAPI training included Nurse Aides, a Central Supply Employee, an Activities Assistant, a Registered Nurse, and a Licensed Practical Nurse. Each of these employees had specific hire dates, and the records showed that they did not receive QAPI in-service education within the required timeframe after their hire dates. During an interview, the Nursing Home Administrator confirmed the facility's failure to provide the necessary QAPI training to these staff members. This lack of training was in violation of the regulatory requirements set forth by the facility's QAPI program, as well as state codes related to the responsibility of the licensee, management, and staff development.
Plan Of Correction
1. The facility will ensure employees receive QAPI training on a yearly basis. 2. A full house employee file audit will be conducted to identify the training needs of each employee to ensure ongoing yearly training. 3. The Human Resources Director or designee will ensure that each employee of the facility receives QAPI training on a yearly basis by reviewing their training courses prior to their performance appraisal due date. If the training has been inadvertently missed, the employee will be trained on the missed course prior to the performance appraisal being completed. 4. The Administrator or designee will review 5 employee files due for performance review each month to ensure yearly training is completed weekly x4 weeks. The QAPI committee will determine the need for further audits.
Failure to Complete Annual Emergency Preparedness Training
Penalty
Summary
The facility failed to ensure that employees completed the required annual emergency preparedness education for four nurse aide employees. A review of employee education records and staff interviews revealed that Nurse Aide Employees E6, E7, E8, and E9 did not have documented training on emergency preparedness. Specifically, NA Employee E6, hired on 9/16/21, did not complete the required training between 9/16/23 and 9/16/24. NA Employee E7, hired on 10/4/12, failed to complete the training between 10/4/23 and 10/4/24. NA Employee E8, hired on 10/14/13, did not have the training documented between 10/14/23 and 10/14/24. Lastly, NA Employee E9, hired on 8/15/22, did not complete the training between 8/15/24 and 8/15/24. The Nursing Home Administrator confirmed the facility's failure to ensure the completion of the required annual emergency preparedness education for these employees during an interview on 1/24/25.
Plan Of Correction
1. The facility will ensure employees receive Emergency Preparedness on a yearly basis. 2. A full house employee file audit will be conducted to identify the training needs of each employee to ensure ongoing yearly training. 3. The Maintenance Manager and Human Resources Director or designee will ensure that each employee of the facility receives Emergency Preparedness training on a yearly basis by reviewing their training courses prior to their performance appraisal due date. If the training has been inadvertently missed, the employee will be trained on the missed course prior to the performance appraisal being completed. 4. The Administrator or designee will review 5 employee files due for performance review each month to ensure yearly training is completed weekly x4 weeks. The QAPI committee will determine the need for further audits.
Staffing Deficiency in Nurse Aide Ratios
Penalty
Summary
The facility failed to meet the state-required minimum staffing levels for nurse aides across multiple shifts over a three-week period. Specifically, the facility did not provide the required number of nurse aides per resident on nine daylight shifts, four evening shifts, and seven midnight shifts. The deficiency was identified through a review of nursing schedules and staffing documents, which showed that the number of nurse aides on duty was consistently below the required minimums. For example, on the daylight shift of December 24, 2024, the facility needed 7.90 nurse aides for a census of 79 residents but only had 6.25 nurse aides available. The Nursing Home Administrator confirmed these staffing shortfalls during an interview, acknowledging the facility's failure to meet the state-mandated nurse aide-to-resident ratios. The report does not mention any specific residents affected by this deficiency or any immediate consequences resulting from the staffing shortages. The focus is solely on the facility's inability to comply with the staffing requirements as outlined by state regulations.
Plan Of Correction
1. The facility is unable to retroactively correct the staffing ratio for days: 12/22/24, 12/24/24, 12/28/24, 1/10/25, 1/11/25, 1/12/25, 1/13/25, 1/14/25, 1/15/25, 1/16/25, 1/19/25, 1/29/25, and 1/21/25. 2. The facility will schedule CNA's to state ratio. Call outs will be monitored by NHA/DON and/or designee. Facility staff as well as staffing agencies will be utilized to facilitate replacement/procurement of staff. 3. NHA or designee will educate the scheduling coordinator on the requirements of CAN ratios of 1 to for day shifts, 1 to for afternoon shifts and 1 to for midnight shifts. The staffing ratio will be monitored weekly x4 weeks. 4. NHA or designee will randomly audit the staffing ratio weekly x4 weeks. Findings will be summarized and brought to the quality assurance and performance improvement committee and reviewed for any further monitoring or changes needed.
LPN Staffing Shortages Identified
Penalty
Summary
The facility failed to meet the regulatory requirement for staffing Licensed Practical Nurses (LPNs) as evidenced by a review of nursing time schedules and staff interviews. Specifically, the facility did not provide the minimum required number of LPNs per residents on one day shift and three night shifts within a 21-day period. On the day shift of January 19, 2025, with a census of 80 residents, the facility provided 23.98 actual LPN hours instead of the required 25.60 hours. On the night shifts of January 10, 13, and 21, 2025, the facility also fell short of the required LPN hours, with actual hours ranging from 16.00 to 16.60, while the required hours ranged from 16.20 to 16.80. The Nursing Home Administrator confirmed these staffing shortages during an interview on January 22, 2025.
Plan Of Correction
1. The facility is unable to retroactively correct the staffing ratio for days: 1/10/25, 1/13/25, 1/19/25, and 1/21/25. 2. The facility will schedule LPNs to state ratio of 1 to 25 for day shifts, and 1 to 40 for midnight shifts. Call outs will be monitored by NHA/DON and/or designee. Facility staff as well as staffing agencies will be utilized to facilitate replacement/procurement of staff. 3. NHA or designee will educate the scheduling coordinator on the requirements of LPN ratios of 1 to 25 for day shifts, and 1 to 40 for midnight shifts. The staffing ratio will be monitored weekly x4 weeks. 4. Findings will be summarized and brought to the quality assurance and performance improvement committee and reviewed for any further monitoring or changes needed.
Failure to Provide Appropriate Care and Treatment
Penalty
Summary
The facility failed to provide appropriate treatment and care according to orders, resident preferences, and goals, resulting in actual harm to several residents. One resident, identified as R28, experienced significant issues with constipation management. Despite having a bowel regimen protocol in place, the facility did not administer the prescribed treatments, such as Milk of Magnesia, Dulcolax suppository, and Fleets enema, in a timely manner. This oversight led to the resident being hospitalized twice for fecal impaction and small bowel obstruction. Interviews with staff revealed inconsistencies in following the bowel protocol, and the care plan lacked interventions for preventing constipation. Additionally, the facility failed to provide prescribed wound care treatments for several residents, including R4, R11, R12, and R29. Resident R4 did not receive timely dressing changes for wounds on the right lateral calf and foot, leading to a hospital transfer for a diabetic foot infection. Resident R11 returned from a post-operative appointment with an unchanged surgical dressing, contrary to discharge instructions. Resident R12's treatment administration record lacked documentation of wound care for several days, and there was no explanation for this omission. Resident R29's wound care orders were not updated to reflect hospice provider instructions, leading to discrepancies in treatment frequency. The Director of Nursing and other staff confirmed these deficiencies during interviews, acknowledging the failure to recognize signs of constipation, implement preventive interventions, and adhere to prescribed wound care treatments. The facility's inability to follow established protocols and physician orders resulted in hospital admissions and inadequate care for the affected residents.
Neglect Resulting in Resident Harm Due to Inadequate Assistance
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in actual harm in the form of a skin tear on the resident's lower leg. The resident, who was diagnosed with macular degeneration and dementia, was dependent on staff for transfers and lower body dressing. The care plan for the resident was not updated to reflect the physician's order for transfer assistance, which required the assistance of two staff members. On the day of the incident, a nurse aide provided care alone to the resident, despite being aware that the resident required two-person assistance. During the care, the resident became agitated and combative, leading to a skin tear on the left shin. The nurse aide attempted to manage the situation alone, which was against the prescribed care plan and physician's orders. The incident was documented by the nursing staff, and the resident received wound care. The facility's failure to adhere to the care plan and physician's orders for the resident's transfer and dressing needs resulted in neglect and actual harm to the resident. Interviews with staff confirmed the oversight and the lack of adherence to the required level of assistance for the resident.
Failure in Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide prescribed treatment and services related to the care of pressure ulcers for four residents and failed to prevent avoidable pressure ulcer development, resulting in actual harm for one resident. Resident R1, who had a history of osteomyelitis, peripheral vascular disease, and diabetes, was at risk for pressure ulcer development. Despite having orders for a PRAFO boot and regular repositioning, there were no documented interventions to assess the skin under the PRAFO. A new unstageable pressure ulcer developed on Resident R1's left Achilles, likely due to the PRAFO boot, and the wound worsened over time. Resident R12, with heart failure and lymphedema, was at high risk for pressure ulcer development and had a Stage 4 pressure ulcer. The facility failed to follow the Wound NP's orders for wound care frequency, providing care daily instead of every other day as ordered. Resident R13, with atherosclerotic heart disease and coronary artery disease, was at risk for pressure ulcers and had an unstageable pressure wound to the right heel. The facility did not adjust the wound care frequency according to the Wound NP's updated orders, continuing to provide care twice daily instead of once daily. Resident R14, with hemiplegia and dementia, was at high risk for pressure ulcer development and had four Stage 3 pressure ulcers. The facility failed to maintain treatment orders for a reopened wound on the left medial foot, with no orders in place until after the survey began. Interviews with staff confirmed the discrepancies in wound care orders and practices, highlighting the facility's failure to provide adequate pressure ulcer care and prevention.
Failure to Prevent Resident Injuries During Transfers
Penalty
Summary
The facility failed to protect residents from injury, resulting in actual harm in the form of lower leg skin tears for two residents. The facility's policy on Safety and Supervision of Residents emphasizes the importance of resident safety and supervision to prevent accidents. However, the care plans for the residents involved did not adequately specify the level of staff assistance required for certain activities, such as transferring and dressing/undressing, which contributed to the incidents. Resident R2, who has diagnoses of macular degeneration and dementia, was dependent on staff for transfers and lower body dressing. Despite a physician's order requiring assistance from two staff members for care, the care plan did not clearly outline the necessary interventions for transferring and dressing. During an incident, a nurse aide provided care alone, contrary to the order, and the resident sustained a skin tear while resisting care. The nurse aide admitted to providing care alone because the resident was usually not combative. Resident R10, diagnosed with heart failure and dementia, required substantial assistance for transfers. During a transfer, the resident was resistant and sustained a skin tear. The incident report noted the resident's confusion and inability to provide an accurate account of the event. The Nursing Home Administrator confirmed the facility's failure to protect these residents from injury, which resulted in actual harm.
Deficiencies in Food Labeling, Storage, and Temperature Logging
Penalty
Summary
The facility failed to adhere to its policy on food receiving and storage, resulting in multiple deficiencies in the labeling, dating, and storage of food items in the nutrition rooms on both the first and second floors. Observations revealed that numerous food items, including partially consumed beverages and food containers, were not labeled with names or use-by dates as required. Additionally, grocery bags containing unidentified items were found without proper labeling. This lack of proper labeling and dating of food items was consistent across both nutrition rooms. Furthermore, the facility did not maintain accurate refrigerator temperature logs, with significant gaps in daily temperature assessments for both April and May 2024. The second-floor nutrition room was missing temperature assessments for 11 days in each month, while the first-floor room was missing assessments for five days in May. Cleanliness issues were also noted, such as an ice scoop left on an unclean counter and open food items exposed to air. These findings were confirmed by the Nursing Home Administrator during an interview, indicating a failure to maintain proper food safety and hygiene standards.
Insufficient Nursing Staff and Inadequate Resident Care
Penalty
Summary
The facility was found to have insufficient nursing staff to meet the needs of 22 out of 47 residents, as evidenced by multiple observations and interviews. Observations revealed that call lights were left unanswered for extended periods, with staff members, including a nurse aide, registered nurse, and licensed practical nurse, failing to respond promptly. Residents reported long wait times for assistance, with one resident noting that call light responses could take up to two hours. Additionally, a resident was observed to be unshaven with unclean fingernails, indicating a lack of adequate personal care. Further investigation into the care records of specific residents highlighted deficiencies in wound care management. One resident with osteomyelitis, peripheral vascular disease, and diabetes did not have their wound dressings changed as per the physician's orders, with documentation missing for several shifts. Another resident with diabetes and necrotizing fasciitis also had their wound dressings unchanged, with the dressing noted to be saturated with drainage. Interviews with the residents and staff confirmed these lapses in care, with staff acknowledging that the dressings should have been changed. The facility's Resident Council Minutes and grievance forms from previous months indicated ongoing issues with staff being inattentive, using phones during work, and not responding to call lights promptly. Residents and their family members expressed concerns about the quality of care, with reports of staff rushing through care, not assisting with toileting, and failing to ensure meals were provided. The Nursing Home Administrator confirmed the facility's failure to provide sufficient nursing staff to meet the residents' needs, as required by state regulations.
Deficiency in Staff Training for JP Drain Care
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for its staff, particularly concerning the care of surgical drains such as the Jackson Pratt (JP) drain. The facility assessment indicated that surgical drains were a type of care provided, and staff competencies were required. However, there was no detailed information on the education provided for this care. Two residents had orders for the care of a JP drain, but documentation errors were noted, such as incorrect references to a J-tube instead of a JP drain. Interviews with staff revealed inconsistencies in their understanding of the proper procedure for JP drain care, with some staff members unable to correctly describe the process. The Director of Nursing (DON) admitted that the only educational material provided was a paper placed on the medication cart, and no competency evaluations were conducted to ensure staff understanding. The Nursing Home Administrator confirmed that the care of a JP drain was not common in the facility and acknowledged the lack of staff competency evaluations. This deficiency affected three of the six staff members sampled, highlighting the facility's failure to address training needs based on the resident population and specific care requirements.
Inadequate Competency in JP Drain Management
Penalty
Summary
The facility failed to ensure that licensed nurses demonstrated the appropriate competencies and skills necessary to provide nursing services for Resident R11. The resident, who was admitted with diagnoses including hemiplegia, Alzheimer's disease, and aftercare following surgery for neoplasm, had a physician's order to have a Jackson Pratt (JP) drain emptied every shift. However, there were multiple instances where the JP drain was not properly managed, leading to a lack of output and a buildup of fluid. The clinical records and progress notes revealed that there was confusion among the nursing staff regarding the management of the JP drain. On several occasions, the drain was reported to have no output, and there was a misunderstanding between a J-tube and a JP drain, as noted in the progress notes. Interviews with nursing staff indicated a lack of consistent understanding of the procedure for emptying and maintaining the JP drain, with some staff members failing to compress the bulb before closing the valve, which is a critical step in ensuring the drain functions properly. The deficiency was further highlighted by a surgical provider's note indicating a palpable seroma due to a clot in the drain tubing, which was resolved only after the tubing was stripped. The oncology nurse also noted significant fluid buildup, suggesting improper management of the drain. The Nursing Home Administrator confirmed the facility's failure to ensure that licensed nurses had the necessary competencies to provide appropriate nursing services, as required by state regulations.
Failure to Provide Appropriate Dementia Care
Penalty
Summary
The facility failed to provide necessary services and appropriate treatment for a resident diagnosed with dementia, specifically in managing behavioral disturbances associated with the condition. The resident, identified as having severe cognitive impairment with a BIMS score of 0, was admitted with diagnoses including dementia and macular degeneration. The care plan for this resident did not include interventions for behavioral disturbances, despite the resident's potential for physical behaviors such as combativeness. The incident in question involved a nurse aide providing care to the resident alone, despite the resident being ordered to have two-person assistance due to occasional combativeness. During the care, the resident became agitated and attempted to kick the aide, resulting in a skin tear on the resident's left shin. The care plan and the Kardex used by nurse aides failed to provide guidance on managing such behavioral disturbances, and there was no documentation of behavior charting in the clinical record. Interviews with staff confirmed the lack of appropriate interventions and documentation for the resident's behavioral issues. The Nursing Home Administrator acknowledged the facility's failure to provide necessary services and appropriate treatment for the resident's dementia, as required by the facility's policies and state regulations.
Failure to Schedule Appointments and Provide Transportation Delays Cancer Treatment
Penalty
Summary
The facility failed to schedule necessary medical appointments and provide transportation for a resident, resulting in a delay in cancer treatment. The resident, who was cognitively intact with a BIMS score of 15, had a history of hemiplegia, Alzheimer's disease, and was undergoing aftercare following surgery for a neoplasm. Despite having clear instructions and orders for a PET/CT scan and an echocardiogram, these tests were not scheduled in a timely manner, leading to the cancellation of a port placement surgery that was crucial for the resident's chemotherapy treatment. The resident's medical records indicated multiple missed appointments for essential tests and procedures, including a PET scan and echocardiogram, which were prerequisites for the oncology team to develop a treatment plan. The surgical provider noted significant difficulties in coordinating the resident's care with the facility, highlighting missed appointments and unreliable communication. This lack of coordination led to a change in the treatment plan from breast conservation to a mastectomy, as the medical team doubted the facility's ability to ensure consistent transportation for daily radiation therapy. Interviews with the oncology nurse confirmed that the facility's failure to transport the resident to appointments directly contributed to the delay in cancer treatment. The oncology nurse emphasized that the port placement was canceled solely due to the incomplete tests, which were necessary for determining the chemotherapy plan. The facility's inaction in scheduling and transporting the resident to medical appointments resulted in actual harm by delaying the resident's cancer treatment, as confirmed by the surgical and oncology teams.
Infection Control Deficiency Due to Soiled Wound Care Equipment
Penalty
Summary
The facility failed to maintain proper infection control practices for a resident, identified as Resident R1, who was admitted with diagnoses including osteomyelitis, peripheral vascular disease, and diabetes. A physician's order required wound care every two hours, including turning and repositioning in bed and elevating heels with bunny boots. However, during an observation, it was noted that the bunny boot used for Resident R1 was extremely soiled with wound drainage, indicating a failure to adhere to infection control protocols. The soiled condition of the boot was confirmed by RN Employee E1 during a dressing change, who acknowledged that the boot should have been changed to prevent infection. The Nursing Home Administrator also confirmed the failure to maintain infection control practices, which could potentially lead to infection or reinfection for the resident. This deficiency was identified as a violation of several Pennsylvania Code regulations related to the responsibility of the licensee, management, staff development, resident care policies, and nursing services.
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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