Spiritrust Lutheran The Village At Gettysburg
Inspection history, citations, penalties and survey trends for this long-term care facility in Gettysburg, Pennsylvania.
- Location
- 1075 Old Harrisburg Road, Gettysburg, Pennsylvania 17325
- CMS Provider Number
- 395647
- Inspections on file
- 17
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Spiritrust Lutheran The Village At Gettysburg during CMS and state inspections, most recent first.
A resident with orthopedic aftercare and muscle weakness had expressed a wish to be DNR, which was documented in a social worker note but not entered as a physician order or care plan, and no POLST was present in the paper chart. Facility policy requires resident treatment choices to be incorporated into the medical record and orders, but staff could not locate any code status in the electronic or paper record. In interviews, an RN and an LPN stated they would treat the resident as a full code and start CPR if code status could not be found, while the DON acknowledged the DNR order was missed in batch orders and not transcribed into the electronic chart.
A resident with an artificial knee joint and muscle weakness, receiving IV Ampicillin for cellulitis, did not receive IV antibiotic doses at the times ordered by the physician. Facility policy required medications to be administered according to the 5 rights, including correct timing, and the resident’s care plan called for IV therapy as ordered. Surveyors observed that a scheduled midday IV dose had not been given more than an hour after the scheduled time, and documentation showed that multiple midnight doses were also administered late. The DON acknowledged that nurses may delay or late-document medications due to competing care priorities, despite an expectation for timely administration.
A resident with an unstageable sacral pressure ulcer and hospice status had ordered daily wound care, including cleansing with normal saline, packing with calcium alginate silver, and covering with a border foam dressing. During an observed dressing change, an LPN, while wearing clean gloves, handled a pen marker from under PPE, adjusted a scrub jacket cuff to check the time, and labeled the dressing, then used the same contaminated gloved hand to pick up the calcium alginate silver and place it into the wound bed. These actions did not follow the facility’s clean dressing change policy or infection control standards for wound care.
Surveyors found that two residents receiving respiratory treatments did not receive care consistent with professional standards. One resident with asthma and obstructive sleep apnea was observed twice receiving oxygen at 3 L/min via nasal cannula with undated oxygen tubing, despite an active order for oxygen therapy and a related care plan. Another resident with CHF and muscle weakness was observed twice with a nebulizer mask left uncovered on a table after use, despite an order for nightly albuterol nebulizer treatments and a care plan addressing breathing difficulty. The DON stated that oxygen tubing should be dated, nebulizer masks should be cleaned and put away after use, and acknowledged there were no facility policies for supplemental oxygen or nebulizer use.
The facility failed to follow its own menu extension sheets, production sheets, and recipes when serving a main meal, resulting in several residents receiving only one manicotti instead of the two portions specified on their tray tickets and the planned menu. Policies required that recipes be followed exactly and that production sheets list correct portion sizes and quantities, and the recipe defined one manicotti portion as 6 oz. During tray line service, a dietary employee chose to serve only one manicotti based on personal judgment that the items were “pretty big,” and subsequent review and weighing by the dining services director confirmed that the served portion did not meet the specified recipe portion size.
Surveyors found that staff were not disinfecting glucometers according to the manufacturer’s instructions and facility policy. The policy required cleaning before and after use and at storage using an EPA-registered disinfectant wipe, such as bleach wipes, with sufficient contact time on all external surfaces. Instead, two LPNs reported and demonstrated using alcohol wipes to clean glucometers after use, allowing them to air dry, and then storing them on the med cart, despite bleach wipes being available. The NHA stated that staff were expected to follow the policy, confirming that these practices did not comply with the required infection control procedures.
Surveyors found that the facility did not follow its own TB screening policy for new employees. The written policy required a baseline TB status using a 2-step TST for all team members, with specific allowances for recent prior testing. However, one newly hired employee had only a single TST documented and no additional testing, and another newly hired employee had only an older QuantiFERON Gold result with no new TB testing at hire. The HR manager reported she was accepting outside TB test results from within the past year for new hires without further testing, while the NHA and DON stated they expected adherence to the facility’s TB testing policy and CDC recommendations.
Surveyors identified that hazardous area doors, including the Sprinkler Tank Room and 1st floor Dietary Storage Room, were not maintained within required gap margins and were held open with unauthorized devices, as confirmed by the Director of Facilities.
The 1st floor Dining Room had its doors removed, leaving the room open to the corridor without any smoke detector protection. This was confirmed by the Director of Facilities, resulting in a failure to provide required fire alarm protection in that smoke compartment.
Surveyors found that several corridor doors, including those to the Kitchen, Linen Closet, and PC Unit Office, failed to positively latch due to obstructions or misalignment. The Director of Facilities confirmed these deficiencies during the inspection.
Surveyors observed that the double smoke barrier door between two compartments did not latch as required, with the hardware failing to function per manufacturer specifications. This issue was confirmed by the Director of Facilities and affected two smoke compartments.
Surveyors found that food and equipment were not stored or maintained according to professional standards, with multiple open and expired food items lacking proper labeling and dating in the kitchen and pantries. Additionally, there were significant cleanliness and maintenance issues, including stained ovens, water damage, and unsanitary shelving in the walk-in freezer, with no cleaning schedule in place. Facility leadership confirmed these practices did not meet their stated expectations.
The facility did not ensure prompt responses to resident call bells, with multiple instances of response times exceeding 20 minutes and some calls going unanswered for over an hour. Several residents reported long wait times for assistance, especially at night and on weekends, leading to discomfort and unmet needs. Staff interviews revealed a lack of clear expectations and consistent monitoring of call bell response times.
A resident with a urostomy and neurogenic bladder independently performed her own urostomy care and requested supplies as needed. However, there was no physician order specifying urostomy care, and documentation of care was missing from the clinical record after a certain date. The DON confirmed that both an order and documentation should have been present, as required by facility policy.
Two residents with complex medical needs did not receive their ordered nutritional supplement, Magic Cup, due to it being on back order. Staff did not notify the physician or dietician about the unavailability, and in one case, provided Ensure as a substitute without an order. This failure to communicate and follow proper procedures was confirmed by staff interviews.
Surveyors found that controlled substances, such as lorazepam, were not double locked in the medication storage room, and multiple open bottles of medications on two medication carts were missing required open dates. Staff confirmed that facility policy requires double locking of controlled substances and dating of opened medications, but these procedures were not followed.
Two residents did not receive care in accordance with professional standards: a nurse left medications at the bedside for a resident without an order for self-administration, and another resident receiving hospice care did not have a physician's order for hospice services documented, despite hospice interventions being in place.
A resident with multiple medical conditions developed a stage 1 pressure ulcer and was evaluated by a wound care provider, who recommended specific daily wound care. The recommended treatment was not entered as a physician order, resulting in the resident not receiving the necessary wound care as required.
Two residents did not receive meals according to their preferences or selected menu items: one was served chicken that was not prepared as requested and found unpalatable, while another was given mashed potatoes instead of the penne pasta with red sauce marked on her meal ticket, despite the correct item being available.
The facility failed to update care plans for three residents, resulting in discrepancies between physician orders and care plans. This included missing updates for supplemental oxygen use, heel protector boots, and a left-hand splint.
The facility failed to change a resident's enteral feeding tubing and water bag as required by policy and physician orders. The tubing and bag were observed to be dated from the previous day, and the DON confirmed they were not replaced on the night shift as expected. The resident had diagnoses including surgical aftercare, dysphagia, and dementia.
The facility failed to ensure that the physician reviewed and responded to pharmacy review recommendations for a resident with myasthenia gravis, anxiety disorder, and major depressive disorder. The clinical record did not reveal a medication regimen review by a licensed pharmacist for November 2023, which was confirmed by the DON.
Failure to Document and Communicate Resident DNR Code Status
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to formulate and have an advance directive and code status accurately reflected and readily available in the medical record. Facility policy on advance care planning states that residents’ choices about treatment, including decisions to decline treatment, are to be incorporated into the medical record and related orders. Resident 39’s record showed diagnoses including a right artificial knee joint, encounter for orthopedic aftercare, and muscle weakness. However, review of the resident’s clinical record did not show any physician order or care plan documenting her code status. Review of the resident’s paper chart also failed to reveal a POLST form. During interviews, an RN and an LPN both stated that if they could not locate a resident’s code status in the electronic or paper record, they would treat the resident as a full code and initiate CPR. The resident reported that advance directive information had been reviewed with her at admission and that her wish was to be DNR. The clinical record contained a social worker note documenting that the resident declined to complete a POLST but requested DNR code status. The DON later explained that the DNR code status order for this resident had been missed from the batch physician orders and was not transcribed into the electronic chart, resulting in the absence of an electronic order that nursing staff could locate in an emergency.
Plan Of Correction
1. Order for resident #39 transcribed and placed in electronic medical record. 2. Advanced Directive orders audited for current residents to ensure electronic records reflect POLST/Advanced Directive. 3. Educate licensed nursing staff on the process of transcribing POLST/Advance Directive's at time of admission. 4. Audit all new admission X1 month for transcription of POLST/Advance Directive orders correctly listed on electronic chart, then 5 random admissions X2 months. All audits will be brought to QAPI for further recommendations for quality assurance and performance improvement.
Failure to Administer IV Antibiotic as Ordered and on Time
Penalty
Summary
The facility failed to ensure that medication services met professional standards of quality for a resident receiving IV antibiotic therapy. Facility policy on medication administration required medications to be given as prescribed and in accordance with the 5 rights of medication administration, including administration within the time frame specified by the physician’s order. The resident had diagnoses including a right artificial knee joint and muscle weakness and had a physician’s order for IV Ampicillin 2 grams every 6 hours for cellulitis, scheduled at 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM daily. The resident’s care plan identified a risk of complications related to IV therapy for infection, with an intervention for IV therapy as ordered. On one surveyor observation and resident interview, the resident reported not having received the scheduled 12:00 PM IV dose, and the IV antibiotic had still not been administered by 1:13 PM. A nursing progress note later documented that the 12:00 PM dose on that date was given past the administration time at 1:20 PM and marked late on the MAR. Review of the MAR also showed two additional late administrations of the 12:00 AM IV Ampicillin dose on other dates, documented as given at 2:20 AM and 1:56 AM instead of at the scheduled time. The DON stated that nurses may start medication administration but be diverted by other priorities or emergent situations and then sign completion later, and that a progress note should be entered if a medication is administered late or signed late, while also stating the expectation that medications are administered timely and as ordered.
Plan Of Correction
1. Facility cannot correct late administration of IV medication administration for resident identifier #39 during survey. Dr. was notified with no new orders for resident #39. 2. Audit completed, no other residents currently ordered IV medication 3. Education to licensed staff on IV medication administration to include timely administration and proper documentation. 4. Audit of all residents ordered an IV medication will be audited 3 times a week on random administration times for 1 month and then 2 times a week on all residents ordered IV medications for 1 month and then move audit to 1X a week on all residents ordered IV medication for 1 month. Audits will be brought to QAPI for further recommendations for quality assurance and performance improvement.
Improper Infection Control During Pressure Ulcer Dressing Change
Penalty
Summary
The deficiency involves the facility’s failure to provide wound care consistent with professional standards of practice and its own policy for dressing changes for a resident with an unstageable sacral pressure ulcer. The facility’s “Dressing Change, Clean” policy required creating a clean field, using disposable gloves appropriately, and applying prescribed medication and dressings in a manner that maintains cleanliness and infection control. Resident 7’s clinical record showed an unstageable sacral pressure ulcer and hospice status, with physician orders directing daily sacral wound care that included cleansing with normal saline, packing with calcium alginate silver, and covering with a border foam dressing. During an observed dressing change for this resident, an LPN wearing clean gloves removed a pen marker from under her PPE gown, lifted the cuff of her scrub jacket to check the time, and labeled the border foam dressing, then used the same gloved hand to pick up the calcium alginate silver and place it into the wound bed. This sequence of actions showed that the same gloves used to handle personal items and clothing were then used to handle and place the wound packing material into the resident’s wound, contrary to the facility’s clean dressing change procedure and infection control standards. In an interview, the Nursing Home Administrator acknowledged that the facility’s policy should be followed for dressing changes.
Plan Of Correction
1. Resident no longer resides in facility. 2. Staff member performing dressing change educated on performing wound care/clean dressing change following surveyor identifying the concern. 3. Education provided to licensed nursing staff on wound care/clean dressing change. 4. Audit of wound care involving dressing changes by licensed nursing staff will be completed on random shifts weekly for 2 residents X1 month, then 1 resident per week X 1 month and then biweekly of 1 resident X 1month. Audits will be brought to QAPI for further recommendations for quality assurance and performance improvement.
Failure to Follow Professional Standards for Oxygen and Nebulizer Respiratory Care
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care and services consistent with professional standards of practice for two residents who required such care. For one resident with asthma and obstructive sleep apnea, surveyors observed the resident in bed on two separate occasions receiving supplemental oxygen at 3 liters per minute via nasal cannula, with the oxygen tubing not dated either time. The resident’s care plan included a focus on potential complications related to asthma and restrictive lung disease with an intervention to provide oxygen therapy as ordered, and the physician’s order specified oxygen via nasal cannula at 2–4 liters per minute. The DON stated that oxygen tubing should have been dated when applied or changed and acknowledged that the facility did not have a policy regarding supplemental oxygen use. For another resident with diagnoses including heart failure and muscle weakness, surveyors twice observed the resident sitting in a recliner with her nebulizer mask left out on the table beside her, not covered or stored in a bag after use. The resident’s care plan addressed difficulty breathing due to CHF, and there was a physician’s order for albuterol sulfate solution via nebulizer daily at bedtime. The DON reported that she would expect the resident’s nebulizer mask to be cleaned and put away after use and confirmed that the facility did not have a policy regarding nebulizer use. The lack of specific policies and the observed handling of oxygen tubing and nebulizer equipment formed the basis of the cited deficiency under respiratory care requirements and related state nursing services regulations.
Plan Of Correction
1. Removed, replaced and dated oxygen tubing for resident identifier # 5. Nebulizer mask for resident identifier # 37replaced and placed in bag with date for storage when not in use. 2. Audit done to ensure that the oxygen tubing was dated properly and residents oxygen and nebulizer equipment was being stored correctly when not in use. Audit included order was in place on mar/tar for nursing staff to document completion of dating and changing. 3. Education provided to licensed staff on process for changing oxygen tubing and dating tubing correctly. Education on cleaning nebulizer equipment and storing oxygen and nebulizer equipment when not being used provider. 4. Audit of oxygen tubing dates and storage of equipment involving oxygen tubing and nebulizer will be done weekly X 1 month on 5 residents, biweekly for 1 month on 5 residents and then 5 audits X1 month. Audits will be brought to QAPI for further recommendations for quality assurance and performance improvement.
Failure to Follow Menu and Recipe Portion Sizes for Entrée Service
Penalty
Summary
The deficiency involves the facility’s failure to follow its own menus, production sheets, and recipes to provide correct portion sizes for the planned meal. Facility policies titled “Recipes” and “Production Sheet,” last reviewed March 23, 2026, require that recipes be used for all menu items, adjusted for facility yield, and followed exactly, and that production sheets list all items, recipe numbers, portion sizes, and quantities to be produced based on the resident diet census. The menu extension sheet for a specified Wednesday main meal indicated that residents were to receive two baked manicotti with tomato sauce (6 ounces per portion), 4 ounces of vegetable blend, a 2‑ounce warm dinner roll with butter, and one slice of pound cake with fruit topping. During observation of the tray line meal service, five residents with similar diet needs were each served only one manicotti instead of the two specified on their tray tickets and the menu extension sheet. When the surveyor raised this concern, a dietary employee stated that the manicotti were “pretty big” and estimated each at least three ounces, so he only served one. Review of the facility recipe showed that one portion of manicotti was defined as 6 ounces. The Director of Dining Services weighed one manicotti from the steam table and found it to be approximately 5 ounces, and agreed this was not the correct portion size. The Nursing Home Administrator stated she would expect recipes to be followed and appropriate portions to be served during meal service.
Plan Of Correction
1. Facility cannot correct the inaccurate portion size served to the 5 residents observed during meal service during survey. Residents able to request additional serving of meal following original meal provided. 2. Appropriate portion sizes were provided to remaining residents moving forward following observation of the 5 residents during survey. 3. Education provided to cooks on following recipes and serving appropriate portion sizes. 4. Audit of random meal service will be completed daily for 2 weeks, then 3 times a week for 2 months. Audits will be brought to QAPI for further recommendations for quality assurance and performance improvement.
Improper Glucometer Disinfection Practices Contrary to Manufacturer Instructions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to improper cleaning and disinfection of glucometers on two of three nursing units reviewed. The facility’s policy, last reviewed March 23, 2026, required that glucometers be cleaned per the manufacturer’s instructions before use, after use, and when stored. The manufacturer’s instructions for the specific glucometer brand in use directed staff to use an EPA-registered disinfectant wipe, such as bleach wipes, on all external surfaces of the device, including the front, back, and sides, and to ensure the surface remained wet for the required contact time of about four minutes. These requirements were in place to support the facility’s infection prevention and control program under the cited regulatory standards. During interviews and observations, surveyors found that nursing staff were not following these established procedures. One LPN demonstrated her usual process by cleaning the glucometer after use with alcohol wipes, placing it on the medication cart to air dry, and then storing it back in the cart. When presented with a container of bleach wipes from the medication cart, this LPN acknowledged their availability and stated she “probably should use these” but preferred alcohol wipes. Another LPN reported that after using the glucometer, she wiped it down with alcohol wipes, allowed it to air dry, and then stored it in the medication cart. In a subsequent interview, the Nursing Home Administrator stated that she expected staff to follow the facility’s policy, confirming that the observed and reported practices were inconsistent with the manufacturer’s instructions and the facility’s written standards for glucometer disinfection.
Plan Of Correction
1. Glucometers were cleaned per manufacturer's instructions following observation during state survey 2. Ensured proper disinfectant wipes used for cleaning glucometers were available in nursing carts. 3. Education provided to licensed nursing staff on cleaning and disinfecting the glucometers after use. 4. Audit to be completed of proper glucometer cleaning during medication pass 3 times a week on random shifts x 1 month, 2 times a week for 1 month and then 1 time a week X 1 month. Audits will be taken to QAPI for further recommendations for quality assurance and performance improvement.
Failure to Follow TB Screening Policy for New Employees
Penalty
Summary
Surveyors identified a deficiency in the facility’s implementation of its tuberculosis (TB) screening policy for employees. The facility’s written policy, titled “Respiratory Protection Program Standard” and last reviewed on March 23, 2026, required that a baseline TB status be obtained on all residents, team members, and volunteers, using a 2-step intradermal tuberculin skin test (TST) for initial testing. The policy allowed prior documented 2-step TSTs within the past 12 months to stand as the initial TST, and if more than 12 months had passed since a prior 2-step TST but a 1-step TST had been given in the last 12 months, a one-step test would be given to fulfill the 2-step requirement. Despite this, personnel file reviews showed that the facility did not obtain the required TB testing at the time of hire for certain employees. Employee 9, hired on April 20, 2026, had documentation of only a single 1-step TST dated December 17, 2025, with no additional TB testing in the personnel file at the time of hire to meet the 2-step requirement. Employee 10, hired on January 27, 2026, had documentation of a QuantiFERON Gold TB blood test dated January 27, 2025, which was negative, but there was no record of any additional TB testing at the time of hire. During an interview, the Human Resources Manager (Employee 11) confirmed she was accepting TB test results from outside the facility within the last year for new hires without further testing, in line with what she believed to be facility protocol. In a separate interview, the Nursing Home Administrator and Director of Nursing stated they would expect the facility to follow its current TB testing policy at the time of employment and to follow current CDC recommendations.
Plan Of Correction
1. Employee screenings were corrected to follow current policy for TB testing at time of employment for staff identifier # 9 and #10. 2. Audit of employee files that were hired in the past 3 months completed to ensure current policy for TB testing/screening and CDC guidelines was followed, at time of employment. 3. Education provided to Human Resource Manager on current TB policy and current CDC guidelines for testing/screening of staff at time of employment. 4. Audit of all new hires TB records will be completed X3 months. Audits will be brought to QAPI for further recommendations for quality assurance and performance improvement.
Hazardous Area Door Deficiencies and Improper Hold-Open Devices
Penalty
Summary
The facility failed to maintain hazardous area doors in accordance with required safety standards in two of ten smoke zones. Specifically, during an observation, the Sprinkler Tank Room door (1A29D) was found to have gaps greater than 3/16 inch, which exceeds the allowed gap margins for such doors. This was confirmed by the Director of Facilities at the time of observation. Additionally, the 1st floor Dietary Storage Room rated doors (1B20) were observed being held open with manual hold-open drop downs, which are unauthorized devices. The Director of Facilities confirmed that these doors were being held open in this manner. These findings indicate that the facility did not ensure hazardous area doors were properly maintained to meet fire safety requirements.
Plan Of Correction
1. A rated door system will be installed on door 1A29D to maintain proper gap margins to less than 3/16". A recurring work order will be created to inspect the door for proper gap margins quarterly for one year. Completed work order documentation will be presented to QAPI for evaluation. 2. Manual hold open devices will be removed from doors 1B20. A recurring work order will be created to inspect doors for proper operation and positive latching quarterly for one year. Completed work order documentation will be presented to QAPI for evaluation.
Lack of Smoke Detector Protection in Open Dining Room
Penalty
Summary
Surveyors observed that the 1st floor Dining Room had its doors (1C10 and 1C11) removed, resulting in the room being open to the corridor. Despite this change, there was no smoke detector protection installed in the area. This deficiency was confirmed during an interview with the Director of Facilities, who acknowledged the absence of smoke detection in the room. The lack of smoke detector protection in a room open to the corridor constitutes a failure to provide required fire alarm protection in one of ten smoke compartments within the facility.
Plan Of Correction
Two battery-operated, ten-year smoke detectors will be installed in the Personal Care Dining Room to alert team members of a possible fire event. A procedure will be developed to explain the steps to follow in the event that detectors sound during a fire event. Current team members associated with Personal Care will be educated initially upon installation and then annually on the procedures. New hired team members will be educated and trained during their orientation. A recurring work order will be created to test these detectors monthly for proper operation and audible levels to the end of the Personal Care corridors. Completed documentation will be presented to QAPI for evaluation.
Failure to Maintain Corridor Doors with Positive Latching
Penalty
Summary
Surveyors observed that the facility failed to maintain corridor doors in a manner that ensured they positively latched, as required by NFPA 101 and CMS regulations. Specifically, during an inspection, it was found that the door to the Kitchen near the 2nd floor Dining Room was impeded from closing properly due to a fatigue mat. Additionally, the double doors to the Linen Closet (2E66) had an inactive door that was not latched, and the PC Unit Office (1C06) door was hitting the frame, preventing it from latching. These issues were identified in three out of ten smoke compartments within the facility. The Director of Facilities confirmed during an interview that the corridor doors in these locations failed to positively latch. The report does not mention any specific residents or their medical conditions in relation to these deficiencies. The findings are based solely on direct observation and staff interview, with no mention of corrective actions or follow-up steps taken at the time of the survey.
Plan Of Correction
1. The fatigue mat located at the ice machine in the main kitchen will be reduced in size to prevent interference with the door. A recurring work order will be created to inspect this area for an impediment to the door quarterly for one year. Documentation will be presented to QAPI for evaluation. 2. An automatic bolt assembly and spring-loaded hinges will be installed to the Ellison linen closet right side door 2E66. A recurring work order will be created to inspect the door for automatic positive latching quarterly for one year. Completed work order documentation will be presented to QAPI for evaluation. 3. Shims will be removed from door 1C06 to prevent the door from hitting the frame. A recurring work order will be created to inspect the door for positive latching and gap margins quarterly for one year. Completed work order documentation will be presented to QAPI for evaluation.
Smoke Barrier Door Hardware Failed to Latch Properly
Penalty
Summary
During an observation, surveyors found that the double smoke barrier door located between compartments AA and AE did not latch properly when closed. The latching hardware on this smoke barrier door failed to function according to manufacturer specifications. This issue was confirmed in an interview with the Director of Facilities, who acknowledged that the smoke barrier door hardware was not operating as required. The deficiency affected two out of ten smoke compartments within the component. No information regarding residents' medical history or condition at the time of the deficiency was provided in the report.
Plan Of Correction
Hardware will be repaired and adjusted on smoke barrier doors between compartments AA and AE. A recurring work order will be created to inspect doors for proper operation and positive latching quarterly for one year. Completed work order documentation will be presented to QAPI for evaluation.
Deficient Food Storage, Labeling, and Equipment Maintenance
Penalty
Summary
The facility failed to store food and equipment in accordance with professional standards for food service safety in multiple areas, including the main kitchen, walk-in freezer, and two pantries. Observations revealed several open food items such as chips, bread, rolls, and a bowl with a green flaky substance in the main kitchen that were not labeled or dated as required by facility policy. Additional findings included open containers in refrigerators without open dates, and some items with open dates far exceeding the facility's three-day 'use by' policy. There was also evidence of expired food items, such as Thick It with an expiration date that had passed, and thicken coffee packets with expired dates in the pantries. Staff interviews confirmed that all open and prepared foods should be dated and discarded according to policy, but this was not consistently followed. Further deficiencies were noted in the cleanliness and maintenance of equipment and storage areas. The main kitchen had multi-use ovens with heavy white staining and water damage behind the ice machine due to a leaking water line. The walk-in freezer contained a metal shelving unit with brownish-red discoloration and a significant amount of greenish/brown substance on the shelves and floor, with no cleaning schedule in place. The facility's leadership confirmed the expectation for proper dating, discarding of expired foods, and maintenance of clean equipment, but these standards were not met as observed during the survey.
Failure to Ensure Prompt Call Bell Response Times
Penalty
Summary
The facility failed to ensure prompt response times to resident call bells for four residents over a three-month period, as evidenced by call bell monitoring system reports and resident and staff interviews. The facility's policy requires all staff to be aware of and respond promptly to call lights, regardless of assignment, and to only turn off the call light once the resident's needs are met. However, multiple instances were documented where response times exceeded 20 minutes, with some calls going unanswered for over an hour. Residents reported variable and often lengthy wait times, particularly at night and on weekends, and described situations where they remained on a bedpan for extended periods or avoided drinking fluids due to anticipated delays in assistance. Staff interviews revealed that the Nursing Home Administrator reviews call bell reports only when a grievance is filed or a concern is voiced, focusing on average response times rather than individual incidents. The NHA could not confirm whether staff had responded to the residents in a timely manner and was unable to specify expectations for response times. The Director of Nursing also could not provide clear expectations for call bell response. The facility was cited for failing to reasonably accommodate the needs and preferences of residents, as required by state regulations.
Failure to Document and Order Urostomy Care for Resident
Penalty
Summary
The facility failed to provide proper urostomy care for a resident with a diagnosis of neurogenic bladder and a urostomy. Review of the facility's policy indicated that documentation of ostomy care should include the date and time care was provided, the name and title of the caregiver, any skin issues or signs of infection, the resident's tolerance of the procedure, refusals and interventions, and the signature of the person recording the data. However, the resident's clinical record did not contain documentation of urostomy care after March 23, 2025, and there was no physician order specifying the details of urostomy care. The care plan referenced care as ordered by the physician, skin nurse, or charge nurse, but lacked current, specific interventions or documentation. Interviews with the resident revealed that she independently performed her own urostomy care and was comfortable doing so. Staff interviews confirmed that the resident managed her own care and requested supplies as needed to maintain independence. Despite this, the DON acknowledged that there should have been a physician order detailing urostomy care and that the provision of care should have been documented in the clinical record, in accordance with facility policy and regulatory requirements.
Failure to Notify Physician/Dietician of Unavailable Nutritional Supplement
Penalty
Summary
The facility failed to notify the dietician or physician regarding the unavailability of an ordered nutritional supplement, Magic Cup, for two residents with significant medical needs. One resident, with diagnoses including diabetes mellitus and dementia, experienced a weight loss over three months and had a physician's order for Magic Cup twice daily. Progress notes indicated that the supplement was not available on multiple occasions due to a back order, and there was no documentation that the physician or dietician was informed of this issue. Another resident, admitted with dementia and a stage 4 pressure injury, also had an order for Magic Cup twice daily for a low BMI. Documentation showed repeated instances where the supplement was unavailable, and in some cases, Ensure was provided as a substitute without a physician's order. Staff interviews confirmed that the supplement was on back order and that appropriate notifications to the dietician or physician were not made, as required.
Failure to Secure Controlled Substances and Appropriately Label Opened Medications
Penalty
Summary
Surveyors observed that controlled substances, specifically lorazepam, were not properly secured in the medication storage room refrigerator in Arlington Hall. One bottle of lorazepam was found lying on top of the non-removable lock box, and the lock box itself was not locked, containing seven additional vials of lorazepam. Facility policy requires that controlled substances be double locked, and staff confirmed that the lorazepam should have been stored inside the locked box. Additionally, during inspection of two medication carts (2-AE and 2-A hall), multiple open bottles of medications, including acetaminophen, cranberry tablets, calcium with vitamin D, multivitamins, and prosource powder, were found without open dates. Facility policy mandates that all multi-dose vials be dated when opened. Staff interviews confirmed that the expectation is for medications to be dated upon opening, but this was not followed in the observed instances.
Failure to Ensure Professional Standards in Medication Administration and Hospice Orders
Penalty
Summary
The facility failed to ensure that care and services were provided in accordance with professional standards for two residents. For one resident with myasthenia gravis and muscle weakness, a nurse left medications (acetaminophen and ferrous sulfate) on the bedside table and exited the room to retrieve additional medication. The resident partially took the medications left at the bedside, despite not having a physician's order for self-administration of these medications. The resident's record only approved self-administration of saline nasal spray, and facility policy required an order and evaluation for self-administration of any medication. For another resident with Huntington disease who was admitted for respite hospice care, the clinical record did not contain a physician's order for hospice services, even though the care plan included interventions and contact details for hospice care. The facility's expectation, as stated by the NHA, was that physician orders for care and services should be entered, but this was not done at the time of review.
Failure to Implement Wound Care Orders for Pressure Ulcer
Penalty
Summary
A deficiency was identified when a resident with diagnoses including cervicalgia and acute diastolic congestive heart failure developed a stage 1 pressure ulcer on the right buttock. The resident was evaluated by a contracted wound care provider, who recommended daily treatment with a superabsorbent gelling fiber with silicone border. However, a review of the clinical record and physician orders revealed that the recommended wound care orders were not entered for the resident's pressure ulcer. This omission resulted in the resident not receiving the necessary treatment and services consistent with professional standards of practice to promote healing and prevent infection, as required by facility policy and regulation.
Failure to Provide Palatable Food and Correct Menu Items
Penalty
Summary
The facility failed to provide food that was palatable and prepared according to resident preference for one resident, and failed to serve the correct menu item for another. One resident did not eat her chicken at lunch because it was not prepared as she requested; she had marked her meal ticket for plain, well-done chicken, but the chicken served lacked grill marks, appeared undercooked, and did not meet her texture and appearance preferences. The Director of Dining Services confirmed that the chicken was not prepared as requested and acknowledged the deviation from the resident's preference. Another resident, who was unable to select her own food, was served mashed potatoes with chicken and yellow gravy instead of the chicken and penne pasta with red sauce that was marked on her meal ticket. Staff interviews revealed that the dietary staff served mashed potatoes because the resident generally eats them well, but the selected pasta dish was available and should have been served. Continued observation confirmed that the resident was not provided with the selected pasta dish during the meal service.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure the care plan was reviewed and revised for three residents. Resident 17 had a care plan that did not reflect the current physician's orders for supplemental oxygen use and the updated order for the hinged elbow brace to be worn only at night. The care plan still indicated that the brace should be worn at all times, and there was no mention of the supplemental oxygen use, despite the physician's orders being updated in March 2024. The Director of Nursing (DON) confirmed that the care plan should have been updated to reflect these changes. Resident 19's care plan did not include the use of heel protector boots, which were observed on the resident and confirmed by the DON to be necessary for preventing skin breakdown. The care plan was only updated to include this intervention on April 30, 2024, despite the resident's need for the boots being evident earlier. Similarly, Resident 29's care plan failed to include the use of a left-hand splint, which was ordered by the physician in January 2024. The DON acknowledged that the care plan should have been updated in a timely manner to include this intervention. These deficiencies indicate a failure to maintain accurate and current care plans for the residents, as required by the facility's policy and regulatory standards.
Failure to Change Enteral Feeding Tubing and Bags
Penalty
Summary
The facility failed to provide appropriate care and services for a resident receiving a tube feeding. The facility's policy required that feeding solution bags and tubing be replaced daily, and irrigation syringes be labeled with the resident's name and date, and changed daily on the night shift. However, an observation revealed that Resident 19's enteral feed tubing and the hanging bag of water for flushing were not changed as required. The tubing and water bag were dated from the previous day, indicating they were not replaced on the night shift as per the physician's order and facility policy. The Director of Nursing confirmed that the tubing was not changed on the specified night shift and acknowledged that it should have been done according to the policy and physician's order. Resident 19 had diagnoses including surgical aftercare following digestive system surgery, dysphagia, and dementia.
Failure to Ensure Physician Review of Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that the physician reviewed and responded to pharmacy review recommendations for one of five residents reviewed for unnecessary medications. Specifically, for Resident 24, who has diagnoses including myasthenia gravis, anxiety disorder, and major depressive disorder, the clinical record did not reveal a medication regimen review completed by a licensed pharmacist for the month of November 2023. This was confirmed during an email correspondence and follow-up interview with the Director of Nursing (DON), who was unable to locate the pharmacy recommendation for that month and acknowledged that such recommendations should be available and reviewed by the physician. The facility's policy titled Drug Regimen Review, last revised in February 2023, mandates that a record of the consultant pharmacist's observations and recommendations be made available to nurses, physicians, and the care planning team. The policy also requires documentation of the date each medication regimen review is completed and notation of the findings in the medical record or other designated site. The failure to adhere to this policy for Resident 24 was identified during a clinical record review on April 30, 2024, and confirmed by the DON on May 1, 2023.
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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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