Spruce Manor Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in West Reading, Pennsylvania.
- Location
- 220 S. Fourth Avenue, West Reading, Pennsylvania 19611
- CMS Provider Number
- 395226
- Inspections on file
- 17
- Latest survey
- April 24, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Spruce Manor Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found multiple environmental and equipment issues across all nursing units, including rusty Hoyer lifts in several shower rooms, a dirty exterior ice machine, and a handrail with a missing edge piece exposing a nail. Resident rooms had stained privacy curtains, peeling paint, exposed wallboard, brown-stained ceiling tiles, and missing top covers on air conditioning units. One room had non-adjustable blinds that left part of the window open, making the toilet visible from the street, along with worn toilet caulking. Additional findings included a broken window screen on the floor, duct tape over a floor drain near a bathtub, and a dirty slipper left in a shower area, demonstrating a failure to maintain a safe, clean, and comfortable environment.
A resident with anxiety and dementia had a PRN lorazepam order written without a specified stop date, allowing administration every two hours as needed for anxiety. Staff administered the medication multiple times over two months, and there was no documented evidence that a physician re-evaluated the PRN psychotropic order after 14 days. The DON confirmed that the order lacked an end date, resulting in a failure to prevent potential chemical restraint related to psychotropic medication use.
The facility failed to complete accurate MDS assessments for two residents. One resident with documented PTSD and night terrors in the care plan was incorrectly coded on the MDS as not having PTSD in the active diagnoses section. Another resident with depression, schizophrenia, and obsessive-compulsive disorder had a standing order for the antidepressant fluvoxamine and received it during the MDS review period per the MAR, yet the MDS medication section was coded to show no antidepressant use. These inaccuracies were confirmed by the Administrator and the DON.
A resident with diabetes mellitus and end-stage kidney disease receiving ongoing hemodialysis did not receive care consistent with the facility’s hemodialysis policy and physician orders. The policy required staff to assess and document pre- and post-dialysis information, including vital signs, pre- and post-treatment weights, medications, meals, fluids, lab work, and any alerts, and to communicate this information with the dialysis provider before and after each treatment. Record review showed repeated failures to obtain and document this required information, including ordered pre- and post-dialysis weights, over multiple months. The Administrator confirmed that required communication and documentation between the facility and the dialysis provider did not occur as required.
A resident with senile degeneration of the brain and a stage 4 sacral pressure ulcer required daily wound treatment under an order and care plan that called for enhanced barrier precautions. During an observed dressing change, an LPN removed and reapplied gloves multiple times without performing hand hygiene and repeatedly took clean gloves from a uniform pocket. The LPN also failed to wear a gown during this high-contact wound care, contrary to facility policies requiring EBP and appropriate PPE use. The DON confirmed that proper PPE and hand hygiene were not used during the procedure.
The facility failed to develop or implement comprehensive care plans for two residents with specific needs identified in their assessments. A resident with depression, dementia, anxiety, and hallucinations did not have interventions for psychotropic medication included in their care plan. Another resident with dementia, depression, and partial blindness lacked interventions for psychotropic medication and vision in their care plan. The DON confirmed the absence of documented evidence addressing these care areas.
The facility failed to provide appropriate continence management for a resident with urinary incontinence. The facility did not review underlying conditions or complete a continence evaluation and 72-hour tracking form upon admission, as required by policy. The resident, who was alert and required substantial assistance with toileting, was frequently incontinent and not placed on a toileting program.
The facility failed to develop and implement an individualized plan for a resident with PTSD, despite a psychiatric consultation noting a history of trauma. The DON confirmed the absence of an assessment or care plan addressing the resident's PTSD symptoms or triggers.
Environmental and Equipment Cleanliness and Safety Deficiencies Across All Units
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment across all four nursing units. Surveyor observations over two days identified multiple pieces of resident care equipment, including several Hoyer lifts in different shower rooms, with rust along the length of their legs and above the front wheels. In the East 2 shower room, duct tape was found covering a floor drain next to the bathtub, and a dirty pink slipper was left on the floor in the third shower section. The ice machine in the second-floor dining room was dirty on the outside. A handrail next to one resident room had a missing edge piece that exposed a nail. Several air conditioning units in resident rooms were missing their top covers. Additional observations showed environmental disrepair and cleanliness issues in multiple resident rooms and bathrooms. Ceiling tiles above a bed had brown spots, and several privacy curtains had brown or dark brown stains. There was peeling paint and exposed wallboard in various locations, including behind a bed, in a bathroom, and behind a dresser, as well as scrapes on walls with peeling wallboard. One room had blinds that were not adjustable, leaving an approximately three-inch open window space that made the toilet visible from the street, and the toilet in that room had worn caulking. A broken window screen was found on the floor under a window in another room. These conditions were identified on West 1, East 1, [NAME] 2, and East 2 units and formed the basis for the cited deficiency under 28 Pa. Code 201.14(a) and 201.18(b)(1)(e)(2.1).
Lack of Timely Re-Evaluation and Stop Date for PRN Lorazepam Order
Penalty
Summary
The facility failed to ensure a resident was free from potential chemical restraint related to the use of a psychotropic medication. Clinical record review showed that a resident with anxiety and dementia had a physician order dated March 17, 2026, for lorazepam, an anti-anxiety medication, to be administered every two hours as needed for anxiety, without any stop date specified in the order. Review of the Medication Administration Record indicated that staff administered lorazepam once in March 2026 and five times in April 2026 under this PRN order. There was no documented evidence that the physician re-evaluated the continued use of this PRN anti-anxiety medication beyond 14 days. In an interview on April 24, 2026, at 11:00 a.m., the Director of Nursing confirmed that the order did not include a date indicating when staff were to stop administering the PRN lorazepam. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Inaccurate MDS Coding for Diagnoses and Antidepressant Use
Penalty
Summary
The facility failed to ensure that MDS assessments accurately reflected the current clinical status of two residents. For one resident with diagnoses including dementia, post-traumatic stress disorder (PTSD), and parasomnia, the care plan documented known PTSD and night terrors, yet the MDS assessment for the specified review period indicated in Section I (Active Diagnoses) that the resident did not have a diagnosis of PTSD. The Administrator confirmed this MDS assessment was inaccurate. For another resident with diagnoses including depression, schizophrenia, and obsessive-compulsive disorder, physician orders showed the resident had been receiving the antidepressant fluvoxamine since May 2025, and the February 2026 MAR documented administration of fluvoxamine during the MDS review period. However, the MDS assessment for that review period indicated in Section N (Medications) that the resident did not receive an antidepressant, and the DON confirmed this MDS assessment was inaccurate.
Failure to Monitor and Communicate Dialysis Treatment Information
Penalty
Summary
The facility failed to provide dialysis services consistent with its own policy, physician orders, and professional standards for one resident receiving hemodialysis. The facility’s Hemodialysis Care Policy required communication between the dialysis provider and facility staff before and after each treatment, including assessment and documentation of vital signs, pre-treatment weight, medications given before treatment, time of last meal, fluid intake, and any alerts. After treatment, staff were to obtain and document post-treatment weight, lab draws and results, medications administered during or after dialysis, food or fluids consumed at dialysis, and any new orders or alerts. A physician’s order also directed staff to record the resident’s pre- and post-dialysis weights. Resident 150 had diabetes mellitus with chronic end-stage kidney disease, no cognitive impairment per the MDS, and a care plan requiring ongoing hemodialysis with monitoring and communication with the dialysis provider to avoid complications. Clinical record review showed no evidence that the facility obtained or documented the required pre- and post-dialysis information, including ordered pre- and post-dialysis weights, on multiple occasions: eight times in one month, on any date in the following two months, and nine times in a subsequent month. In an interview, the Administrator confirmed that the facility failed to document the required communication between the facility and the dialysis provider, resulting in noncompliance with resident care and nursing services regulations.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control policies, specifically enhanced barrier precautions (EBP), appropriate use of personal protective equipment (PPE), and hand hygiene during wound care for one resident. Facility policy required EBP, including the use of gowns and gloves, for high-risk residents with wounds or indwelling devices during high-contact care activities such as wound care, dressing, bathing, transferring, hygiene, toileting, device care, and changing briefs and linens. The Clean Dressing Change Policy required use of clean technique, avoidance of direct contamination of materials and supplies, and performance of hand hygiene each time gloves were removed and new gloves applied. Clinical records showed that Resident 14 had senile degeneration of the brain and a stage 4 pressure ulcer on the sacrum, with care plan directives that EBP be implemented while the wound was present. A physician’s order directed daily application of medicated treatment and foam dressing to the pressure ulcer. During an observed dressing change for Resident 14’s sacral pressure ulcer, an LPN removed soiled gloves and applied clean gloves three times without performing hand hygiene at any point. The LPN obtained the clean gloves from her uniform pocket each time rather than from a clean supply source, and she did not wear a gown during the procedure, despite facility policy requiring EBP and PPE use for this type of high-contact wound care. After the dressing change, the LPN acknowledged that she had performed the dressing change without wearing a gown. The DON later confirmed that staff did not use appropriate PPE and that hand hygiene should have been performed prior to donning new gloves during the dressing change, indicating noncompliance with the facility’s infection prevention and control policies and state regulatory requirements.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop or implement comprehensive care plans for two residents, as identified in their comprehensive assessments. Resident 36, who has diagnoses including depression, dementia, anxiety, and hallucinations, had a Minimum Data Set (MDS) Care Area Assessment (CAA) summary indicating that psychotropic medication should be addressed in the care plan. However, there was no evidence that interventions for the psychotropic medication were included in the current care plan. Similarly, Resident 82, who has dementia, depression, and partial blindness, had an MDS CAA summary noting that psychotropic medication and vision should be addressed in the care plan, but there was no evidence of interventions for these areas in the current care plan. The Director of Nursing confirmed in an interview that there was no documented evidence that these care areas were addressed or implemented in accordance with the care plans, leading to the deficiency.
Failure to Provide Continence Management for Resident
Penalty
Summary
The facility failed to provide treatment and services to restore bladder continence for a resident with urinary incontinence. Upon admission, the facility did not review underlying conditions that could affect the resident's ability to participate in a continence management program. Additionally, the facility did not complete a continence evaluation or a 72-hour bowel and bladder tracking form until 17 days after the resident's admission, contrary to the facility's policy. The resident, who was alert, oriented, and able to make her needs known, was frequently incontinent of bladder and required substantial assistance with toileting. Despite this, the resident was not placed on a toileting program as indicated by the Minimum Data Set assessment. The care plan initiated on February 5, 2024, also noted the resident's bladder incontinence but did not include a continence management plan. The Director of Nursing confirmed that the continence evaluation and 72-hour tracking form were not initiated upon admission as required by the facility's policy. Furthermore, once the tracking form was initiated, there was incomplete documentation during the 72-hour period regarding the resident's continence status on certain shifts. The resident was documented as being incontinent of urine at least 50 times between March 10, 2024, and April 9, 2024. This lack of adherence to the facility's continence management policy resulted in a failure to provide appropriate care for the resident's urinary incontinence.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to develop and implement an individualized person-centered plan to provide trauma-informed care for a resident diagnosed with post-traumatic stress disorder (PTSD). Clinical record review revealed that the resident had diagnoses including PTSD, anxiety, and major depressive disorder. A psychiatric consultation noted a history of trauma related to emotional abuse. However, there was no assessment or care plan in the resident's clinical record addressing the PTSD diagnosis, symptoms, or triggers, nor were there resident-specific interventions to minimize triggers and/or re-traumatization. The Director of Nursing confirmed the absence of such an assessment or care plan.
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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