Stroudsburg Post Acute Nursing & Rehabilitationllc
Inspection history, citations, penalties and survey trends for this long-term care facility in Stroudsburg, Pennsylvania.
- Location
- 4227 Manor Drive, Stroudsburg, Pennsylvania 18360
- CMS Provider Number
- 395491
- Inspections on file
- 28
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Stroudsburg Post Acute Nursing & Rehabilitationllc during CMS and state inspections, most recent first.
A resident was discharged after their responsible party had paid the facility in advance for the month of discharge, but the facility did not complete and clearly convey a final accounting of the resident’s personal funds within the required 30-day timeframe. An email from the NHA months after discharge stated the account was still pending due to awaited payments, and a later account statement showed a credit balance without confirming it as a final reconciliation. Billing records spanning several months did not document a final, reconciled statement, and the responsible party reported multiple unsuccessful attempts to obtain clear information needed to settle the resident’s estate. During surveyor interviews, the NHA could not provide evidence that a complete final accounting of all charges, credits, and remaining balance had ever been provided, resulting in a violation of resident rights and management regulations.
The facility failed to create and implement individualized discharge plans for two residents who expressed a desire to return to the community or home. For one cognitively intact resident with schizophrenia, the MDS Section Q showed no active discharge planning, and the care plan lacked goals, interventions, or documentation of barriers, despite the resident’s stated wish to live with a family member and the DON’s knowledge of family refusal and complex history. For another resident with dementia and moderate cognitive impairment, the MDS also showed no active discharge planning, and the care plan did not address discharge goals or options, even though the resident had a prior unsuccessful discharge, continued to express a desire to go home, and the SSD was aware of safety concerns and an uninhabitable home environment. The NHA and DON could not provide documentation of individualized discharge care plans for these residents.
A resident with a PICC line for long-term IV vancomycin therapy and an active MSSA infection did not receive safe, person-centered PICC care as ordered. The care plan noted the PICC but lacked specific goals, interventions, and monitoring for PICC care and IV antibiotics. After a prior PICC malfunction and replacement, staff did not document arm circumference or external catheter length. On observation, the PICC dressing was peeling, saturated with yellow drainage, and dated well beyond the facility’s 7‑day change policy and the physician’s weekly order, despite the TAR showing a recent dressing change. IV tubing from an empty antibiotic bag was unlabeled, uncapped, and hanging freely, and no emergency PICC kit was present or ordered at the bedside. The RN Unit Manager and DON confirmed failures in dressing maintenance, tubing management, catheter monitoring, availability of emergency supplies, and accurate documentation.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
Surveyors found that food items, including nutritional shakes, salad dressing, BBQ sauce, and liquid eggs, were stored in the facility's walk-in refrigerator without proper labeling or adherence to manufacturer-recommended use periods. The Food Service Director confirmed that food and beverages should be labeled and dated, but the absence of this information prevented staff from determining product safety, resulting in a deficiency in food storage and labeling practices.
Several residents experienced extended delays in meal delivery at shared tables, with some waiting up to 20 minutes after others at their table had been served. Staff reported insufficient staffing and disorganized meal tray distribution, leading to undignified meal service. Facility leadership confirmed the lack of timely and coordinated meal delivery.
A resident with severe cognitive impairment and cardiac conditions did not have blood pressure or heart rate monitored prior to receiving Metoprolol, as required by physician orders. Additionally, the medication was inappropriately withheld on two occasions despite the resident's vital signs being above the hold parameters. These failures were confirmed by facility leadership.
Two residents admitted with complex care needs did not have baseline care plans developed within 48 hours that addressed all immediate health and safety concerns. One resident's plan omitted interventions for incontinence, skin integrity, and fall prevention, while another's plan failed to include fall risk interventions and therapy recommendations for safe handling, despite documented needs and staff awareness.
A resident did not receive appropriate care for existing pressure ulcers, and preventive measures to avoid new ulcers were not consistently implemented. The facility did not follow established protocols for assessment, monitoring, and treatment of pressure ulcers.
A resident admitted with an indwelling Foley catheter did not have a physician order, documented medical justification, or an individualized care plan for catheter use and management. The catheter's presence, size, and care instructions were not recorded in the treatment administration record, and appropriate documentation was only initiated after surveyor inquiry.
The facility did not set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action, resulting in a lack of systematic review and response to quality issues.
A resident with rheumatoid arthritis and mononeuropathy, assessed as cognitively intact and independent in smoking, was observed using a plastic cup as an ashtray and keeping a lighter in her room, contrary to facility policy requiring lighters to be secured at the nurse's station and use of approved ashtrays. Facility leadership could not provide documentation that these protocols were followed or that staff had identified burn holes in the resident's clothing prior to the survey.
The facility did not ensure that Department of Health survey results were posted and accessible on two nursing units. During interviews, several alert and oriented residents stated they were unaware of where the survey results were posted, and a facility tour confirmed the results were not visible. The DON and NHA acknowledged the survey results were not posted on the units.
A resident with severe cognitive impairment and multiple risk factors developed new unstageable pressure injuries due to the facility's failure to investigate the cause and consistently implement preventive interventions, such as regular skin checks and repositioning, as outlined in the care plan. Documentation did not confirm that required preventive measures were performed prior to the wounds' development, and no investigation was conducted after the injuries were identified.
A resident with severe cognitive impairment and chronic pain received a narcotic pain medication without documented attempts at non-pharmacological interventions, contrary to facility policy and physician orders. Additionally, the physician's order for the opioid lacked clear parameters to guide staff on when to administer it, and pain assessments were inconsistently documented.
The facility failed to properly label medications and biologicals, as observed with undated Lantus insulin pens and a normal saline solution bottle. Insulin pens lacked opening and expiration dates, and one was stored incorrectly. A resident's saline solution was undated and used beyond the recommended timeframe. These issues were confirmed by staff and the DON.
The facility's QAPI committee failed to correct deficiencies related to the storage and labeling of multi-use medications and the accountability of controlled substances. Despite a corrective plan, a revisit survey revealed ongoing issues, confirming the ineffectiveness of the quality assurance plan.
The facility failed to ensure accurate MDS assessments for three residents. One resident's assessment incorrectly documented the use of a trunk restraint, while another's inaccurately indicated anticoagulant medication administration. A third resident's assessment wrongly reported both antipsychotic and anticoagulant medication use. These discrepancies were confirmed by the RNAC.
A resident with Alzheimer's and glaucoma, who was not to self-administer medications, mistakenly used ear drops as eye drops after an LPN left medications unattended. The LPN confirmed that medications should not be left at the bedside, and the DON acknowledged the failure to maintain a hazard-free environment.
The facility failed to monitor the nutritional parameters of two residents who experienced significant weight fluctuations. One resident with dementia and severe protein calorie malnutrition lost 23.4 pounds without immediate reweighing or notifying the physician. Another resident with severe protein calorie malnutrition gained 13.2 pounds, also without reweighing or notification. The dietitian's requests for reweights were ignored, and further weight changes were not addressed, impeding accurate nutritional assessment.
A facility failed to follow its pain management policy by not attempting non-pharmacological interventions before administering Oxycodone to a resident with rheumatoid arthritis, COPD, and hypertension. Despite having a policy that requires such interventions, the resident's records showed multiple instances of medication administration without prior non-drug interventions. The DON confirmed this inconsistency, resulting in a deficiency.
A facility failed to create an individualized care plan for a resident with PTSD, neglecting to identify symptoms, triggers, and specific interventions to prevent re-traumatization. This oversight was confirmed by the Nursing Home Administrator, highlighting a lack of culturally competent, trauma-informed care.
The facility did not follow procedures for reconciling controlled drugs on a medication cart, as evidenced by missing nurse signatures on the Shift Change Checks sheet. Interviews with staff confirmed the expectation for nurses to count and sign off on controlled medications at each shift change, which was not done on multiple occasions.
A resident with severe cognitive impairment was administered morphine sulfate twice in November without documented clinical rationale, despite reporting a pain level of zero. This action violated the facility's pain management policy, which requires specific pain level parameters for administering pain medication.
Two residents in an LTC facility suffered neglect due to staff failures. One resident, with quadriplegia, was left on a bedpan for hours, resulting in a pressure wound, and did not receive proper wound care due to a lack of supplies. Another resident with dementia fell because staff did not follow the care plan, leading to a head injury. The DON confirmed the neglect in both cases.
A resident with incomplete quadriplegia and neurogenic bowel did not receive prescribed medications and wound treatment due to the facility's failure to implement pharmacy procedures. Medications were unavailable from the pharmacy, and despite the availability of some in the emergency supply, they were not administered. Additionally, the facility ran out of Mesalt for wound treatment over a holiday weekend, and staff did not consult the pharmacy or physician for alternatives.
A resident with quadriplegia and neurogenic bowel was left on a bedpan for an extended period, resulting in a pressure sore. The facility ran out of Mesalt for wound treatment, and LPNs failed to document the unavailability and attempts to contact the physician. Additionally, false documentation regarding the resident's care was identified.
Failure to Provide Timely Final Accounting of Discharged Resident’s Personal Funds
Penalty
Summary
The deficiency involves the facility’s failure to complete and convey a final accounting of a discharged resident’s personal funds within 30 days of discharge, as required by regulation. The resident, identified as CR1, was admitted on an unspecified date and discharged on September 12, 2025. Financial documentation showed that the responsible party had paid the facility in advance for the month of September 2025. An email dated November 12, 2025, from the Nursing Home Administrator to the responsible party indicated that the resident’s account had not yet been reconciled because the facility was awaiting payments from other sources and that the account remained pending. The facility’s records included an account statement dated December 31, 2025, reflecting a credit balance, but the facility could not demonstrate that this statement represented a final accounting of all charges, credits, and the remaining balance. Review of billing documentation from April 2025 through February 2026 did not show evidence that a final, reconciled accounting of the resident’s personal funds was provided or clearly explained to the responsible party within 30 days of discharge. During an interview, the responsible party reported contacting the facility multiple times to inquire about the status of the account and stated that she did not receive clear information regarding the final status of the account after discharge, noting that the last communication received was the December 31, 2025 statement. She indicated that this information was needed to complete financial matters related to the resident’s estate. In a separate interview, the Nursing Home Administrator was unable to provide documentation that a final accounting of the resident’s personal funds, including all charges, credits, and remaining balance, had been completed and conveyed within the required timeframe. The surveyors determined that, as of March 2026, the facility had not provided evidence that the final accounting and status of the resident’s personal funds had been completed and communicated within 30 days of discharge, in violation of 28 Pa. Code 201.18(b)(2)(e)(1) and 201.29(a).
Failure to Develop Individualized Discharge Plans Reflecting Resident Goals
Penalty
Summary
The facility failed to develop and implement individualized discharge planning that addressed residents' discharge goals and incorporated those goals into their comprehensive care plans for two residents. One resident with schizophrenia, who was cognitively intact with a BIMS score of 15, had an MDS Section Q assessment indicating that the overall discharge plan was unknown and that no active discharge planning process was occurring for a potential return to the community. The resident’s comprehensive care plan, initiated months earlier and recently reviewed, contained no interventions, goals, or planning related to discharge preferences, discharge planning activities, or barriers to discharge, despite documentation that the resident expressed a desire to return to the community and live with his sister. The DON reported that the sister did not want the resident to live with her and that the resident’s complex history made community discharge difficult, but these considerations and barriers were not documented in the care plan. Another resident with dementia and moderate cognitive impairment, reflected by a BIMS score of 12, also had an MDS Section Q assessment documenting that the overall discharge plan was unknown and that no active discharge planning process was occurring for a return to the community. This resident’s comprehensive care plan, initiated after readmission following an unsuccessful discharge, did not include discharge planning goals, interventions, or evaluation of discharge options, even though the record showed the resident continued to express a desire to return home. The Social Services Director stated that the resident occasionally expressed a desire to go home but that discharge was considered unsafe due to the resident’s inability to care for herself and the home being described as uninhabitable; however, no discharge care plan addressing the resident’s stated preference, barriers to discharge, or alternative options had been developed. The NHA and DON were unable to provide documentation showing individualized discharge care plans for either resident.
Failure to Maintain Safe PICC Line Care and IV Antibiotic Management
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, person-centered PICC line care and IV antibiotic administration for a resident receiving long-term IV therapy. The resident was admitted with a left leg fracture and active MSSA infection and had a PICC line inserted in the hospital for long-term IV antibiotics. The comprehensive care plan identified the presence of a PICC line for antibiotic therapy but did not include measurable goals, specific interventions, or monitoring related to PICC line care and IV antibiotic administration. Physician orders directed weekly PICC dressing changes on Tuesdays and as needed, and ordered IV vancomycin 1000 mg twice daily through a specified end date. Clinical documentation showed that on one occasion the PICC line was not patent, would not allow infusion of vancomycin, and had been pulled out 5 cm from the insertion site, resulting in the resident being sent to the emergency room, where the PICC was replaced. After replacement, there was no documented evidence that staff monitored arm circumference or measured and documented the external catheter length, despite the known prior complications with the PICC line. This lack of monitoring occurred even though the hospital documentation specified the new catheter length and external measurement at the skin. During an observation, the resident’s PICC dressing was found peeling at the bottom, with yellow drainage throughout most of the surface, and was dated from a prior month, indicating it had not been changed in accordance with the facility’s seven-day dressing change policy or the physician’s weekly order. The resident reported it had been a long time since the dressing was changed, and the RN Unit Manager confirmed the dressing should have been changed. At the same time, an empty antibiotic bag was observed on the IV pole connected to unlabeled IV tubing that lacked a sterile end cap and was hanging freely. No emergency PICC kit or supplies were present in the room, and there were no physician orders or documentation requiring or monitoring an emergency kit at the bedside. The Treatment Administration Record showed a dressing change documented as completed the day before, which was inconsistent with the observed condition and date on the dressing. The DON confirmed the failures related to PICC dressing maintenance, tubing management, catheter monitoring, absence of emergency supplies, and inaccurate documentation.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Label and Store Food Items According to Safety Standards
Penalty
Summary
Surveyors observed that the facility failed to maintain proper food storage and labeling practices in the food and nutrition services department. During an initial tour, a tray of seven thawed 4-ounce nutritional shakes was found in the walk-in refrigerator with a defrost date of June 5, 2025, despite the manufacturer's label specifying the product must be used within 14 days of thawing. As of the observation date, the shakes had been thawed for over six weeks, exceeding the recommended use period. Additional observations included a one-gallon container of salad dressing and a one-gallon container of BBQ sauce, both opened but lacking dates of opening, making it impossible to determine their viability. A 32-ounce carton of liquid eggs was also found opened and undated, despite manufacturer instructions requiring use within three days after opening. During interviews, the Food Service Director confirmed that all food and beverages are expected to be labeled, dated, stored, and thawed according to food safety standards. The absence of opening and thawing dates on multiple food items prevented staff from determining whether products were still safe to use, representing a failure to follow federal food safety standards and manufacturer guidelines. No information about specific residents or their conditions was provided in the report.
Delayed Meal Service Compromises Resident Dignity
Penalty
Summary
The facility failed to provide meal service in a manner that maintained residents' dignity by allowing extended delays in meal delivery at shared tables. Observations revealed that at Dining Table #5, one resident received her meal and began eating while the other three residents at the same table waited between 15 to 20 minutes before being served. Similarly, at Dining Table #4, one resident was served first, while the other two residents at the table waited 10 to 13 minutes before receiving their meals. These delays occurred while staff continued to serve other residents in the dining room. Staff interviews indicated that there were not enough staff members assigned to the dining room to ensure timely meal delivery and assistance. Additionally, meal trays were not organized by table but were randomly placed on the meal cart, further delaying service to some residents at shared tables. The Nursing Home Administrator and DON confirmed that the lunch meal service was not conducted in a timely or coordinated manner, resulting in a failure to ensure that residents were provided meals in a dignified manner.
Failure to Follow Physician Orders for Medication Administration Parameters
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of quality by not ensuring that licensed nurses evaluated and provided nursing care according to physician orders for a resident with hypertension and atrial fibrillation. The resident, who was severely cognitively impaired, had a physician's order for Metoprolol to be administered twice daily with specific parameters to hold the medication if the systolic blood pressure was less than 100 mm Hg or the heart rate was less than 60 beats per minute. However, a review of the Medication Administration Records (MAR) for May and June revealed no evidence that the resident's blood pressure or heart rate was monitored prior to administering the antihypertensive medication as required by the order. Additionally, in July, the MAR showed that Metoprolol was held on two occasions due to 'parameters,' even though the resident's blood pressure and heart rate were above the hold thresholds specified in the physician's order. These findings were confirmed by facility leadership, who acknowledged that the physician's orders were not followed as written. The deficiency was identified through clinical record review, facility policy review, and staff interviews.
Failure to Develop and Implement Timely Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for two residents, as required. For one resident with end-stage renal disease and diabetes mellitus, the baseline care plan addressed dialysis needs but did not include interventions for incontinence, skin integrity concerns, mobility limitations, or fall prevention, despite documentation of these issues in the clinical record. Staff interviews confirmed that the baseline care plan lacked the minimum healthcare information necessary to address the resident's immediate health and safety needs upon admission. For another resident with paraplegia, assessments identified a high risk for falls and a need for two staff to assist with bed mobility and hygiene. However, the baseline care plan did not document interventions to mitigate fall risk or include therapy recommendations for safe resident handling. Interviews with therapy and nursing leadership confirmed that the care plan was not updated to reflect these critical needs, and no evidence was provided to show that the required information was incorporated into the resident's baseline plan of care.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through observations and record reviews that indicated lapses in the assessment, monitoring, and treatment of pressure ulcers for residents at risk. The report notes that necessary interventions to prevent skin breakdown were not consistently applied, and existing pressure ulcers were not managed according to established protocols.
Failure to Document and Plan Care for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to ensure that appropriate physician's orders, documented medical justification, and an individualized plan of care were in place for the use and management of an indwelling urinary catheter for a resident admitted with a Foley catheter. Upon review, there was no documentation in the resident's care plan reflecting the presence of the catheter or the need for catheter-related care, despite the resident being admitted with the device. Additionally, the treatment administration record did not include entries documenting the catheter's presence, size, balloon volume, or instructions for nursing care, and there were no physician orders or medical justification for the catheter's use at the time of the surveyor's observation. Observation of the resident confirmed the presence of the Foley catheter, and interviews with the resident and facility staff verified that the catheter had been in place since admission. The Director of Nursing and Registered Nurse Assessment Coordinator acknowledged the absence of a physician order and a care plan for the catheter. Documentation and appropriate care planning were not initiated until several days after admission and only after the issue was identified by surveyors.
Failure to Establish Ongoing Quality Assessment and Assurance Group
Penalty
Summary
The facility failed to establish an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. This inaction resulted in the absence of a systematic process for identifying, reviewing, and addressing quality issues within the facility. As a result, there was no documented evidence that quality deficiencies were being regularly reviewed or that corrective plans were being developed and implemented to address identified concerns.
Failure to Implement Smoking Safety Procedures and Use of Approved Ashtrays
Penalty
Summary
The facility failed to implement its established procedures for smoking safety and the safety of smoking areas, as evidenced by the case of one resident who smokes. According to the facility's Smoking/Vaping Policy, residents who smoke are to have an initial smoking assessment upon admission, with safety considerations such as the need for assistance, supervision, and the use of special equipment. Matches and lighters are required to be kept at the nurse's station, and only approved, noncombustible ash containers are to be used in designated smoking areas. However, observations revealed that the resident was using a plastic cup as an ashtray while smoking in the designated area, and had a blue lighter stored in her cigarette pack in her room, contrary to facility policy. The resident reported difficulty using the facility-provided ash receptacles and therefore used a plastic cup instead. Further review of the resident's clinical record showed she had a history of rheumatoid arthritis and mononeuropathy, was assessed as cognitively intact, and was considered safe to smoke independently. Despite this, the resident's shirt was observed to have multiple small holes, which she identified as old burn marks. Facility leadership, including the DON and NHA, were unable to provide documentation that the required protocols for securing lighters and matches were followed, nor could they confirm that the plastic cup used as an ashtray was an approved receptacle. Additionally, there was no evidence that staff had previously identified or addressed the burn holes in the resident's clothing until prompted by surveyors.
Survey Results Not Accessible to Residents and Visitors
Penalty
Summary
The facility failed to ensure that the most recent Department of Health survey results were readily accessible to residents and visitors on both Nursing Units 1 and 2. During a group interview, four alert and oriented residents reported they did not know where the survey results were posted. Subsequent observation and a facility tour confirmed that the survey results could not be located on either unit. In an interview, the DON and NHA acknowledged that the Department of Health survey results were not posted on Nursing Units 1 or 2, resulting in a lack of accessibility for residents and visitors.
Failure to Investigate and Prevent Pressure Ulcers
Penalty
Summary
The facility failed to investigate the cause of newly developed pressure injuries and did not consistently implement preventive interventions for one resident. The resident, who was severely cognitively impaired and at high risk for pressure ulcer development due to multiple comorbidities including diabetes, incontinence, neuropathy, and peripheral vascular disease, had a care plan in place with interventions such as regular skin checks, repositioning, and use of pressure-relieving devices. Despite these interventions being documented in the care plan, there was no evidence that they were consistently carried out prior to the identification of new pressure injuries. A review of the resident's records showed that two unstageable pressure injuries developed on the left and right ischium, with wound assessments documenting progression in size and severity over several weeks. Physician orders for wound care were implemented after the wounds were identified, and the family requested offloading every two hours. However, there was no documentation to confirm that offloading or other preventive measures were consistently performed before the wounds appeared. Additionally, there was a lack of documentation of skin assessments between the last recorded shower and the discovery of the wounds. Interviews with the Nursing Home Administrator and Director of Nursing confirmed that no investigation was conducted to determine the cause of the pressure injuries, nor was there a review to ensure that preventive interventions had been implemented as required. The facility's failure to investigate the cause and ensure consistent implementation of preventive measures led to the deficiency cited under the relevant nursing services regulation.
Failure to Implement Non-Pharmacological Interventions and Lacking Clear PRN Opioid Parameters
Penalty
Summary
The facility failed to implement non-pharmacological interventions prior to administering a narcotic pain medication and did not ensure that physician orders for the narcotic included clear parameters for use. According to the facility's pain management policy, non-drug interventions such as repositioning, therapy modalities, and relaxation techniques were required before administering PRN pain medications, and pain assessments were to be documented using a numerical scale or the PAINAD tool. For one resident with severe cognitive impairment, diabetes, neuropathy, and peripheral vascular disease, the clinical record showed that Tylenol was administered on several occasions with documentation of attempted non-pharmacological interventions, but without recording pain scale ratings or clinical rationale for medication selection. On a specific occasion, the resident received Oxycodone for a pain rating of 9 out of 10, but there was no documentation that non-pharmacological interventions were attempted prior to administration, as required by both facility policy and physician orders. Additionally, the physician's order for Oxycodone lacked defined parameters, such as pain scale thresholds, to guide staff in determining when to administer the opioid. The Nursing Home Administrator confirmed these findings during an interview, acknowledging the absence of required documentation and specific criteria in the physician's order.
Medication and Biological Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to medication expiration and use-by dates on one of its medication carts and did not properly date biologicals when opened for use. During an observation of a medication cart, two opened Lantus insulin pens were found without dates indicating when they were opened or their expiration/use by dates. Additionally, one of the insulin pens was incorrectly stored in another resident's pharmacy-labeled packaging. This was confirmed by an LPN present during the observation and later by the Director of Nursing (DON), who acknowledged that the insulin pens should have been dated when opened to ensure they did not exceed their expiration dates. Furthermore, the facility did not ensure that biologicals, such as normal saline solution, were labeled with the date they were opened and the timeframe for discarding after opening. In Resident 14's room, an opened and undated bottle of normal saline solution was observed on two separate occasions, with the volume decreasing over time, indicating continued use. The RN Unit Manager confirmed that the saline solution should have been dated when opened and discarded after 24 hours. The DON also confirmed the facility's failure to label biologicals according to professional standards.
Failure in Medication Management and Controlled Substance Accountability
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address quality deficiencies related to the storage and use by dates of multi-use medications and the accountability of controlled substances. During a survey conducted on September 13, 2024, deficiencies were identified in the procedures for storing and labeling multi-dose medications and maintaining accurate records for controlled substances. The facility developed a plan of correction, which included specific procedures such as replacing insulin pens for a resident, auditing medication carts, and educating nursing staff on handling controlled substances. However, during a revisit survey on November 27, 2024, it was found that the facility's QAPI committee did not successfully implement the corrective plan. The ongoing deficient practices were observed in the same areas of concern, indicating that the quality assurance plan was ineffective. Interviews with the Nursing Home Administrator and Director of Nursing confirmed that the facility's plan failed to prevent the recurrence of these deficiencies, specifically in the labeling and storage of multi-use medications and the accountability of controlled substances.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the status of three residents. For Resident 59, the quarterly MDS assessment inaccurately documented the use of a trunk restraint, which was not supported by any physician's orders or the resident's clinical record. The Director of Nursing confirmed that the resident had never been subjected to any physical restraint while residing in the facility. Resident 66's quarterly MDS assessment incorrectly indicated the administration of anticoagulant medication during the 7-day look-back period, despite the clinical record showing no prescription for such therapy in August 2024. Similarly, Resident 24's MDS assessment inaccurately reported the administration of both antipsychotic and anticoagulant medications. The clinical record confirmed the resident received antipsychotic medication daily during the look-back period but did not receive any anticoagulant therapy. These inaccuracies were confirmed by the RNAC during an interview.
Medication Administration Error Due to Inadequate Supervision
Penalty
Summary
The facility failed to maintain an environment free of potential accident hazards during medication administration for a resident diagnosed with Alzheimer's disease and glaucoma. The resident, who was cognitively intact with a BIMS score of 15, was not to self-administer medications according to a physician's order. However, during a medication administration, a licensed practical nurse (LPN) left the resident's medications, including eye drops, on the bedside table while attending to another task. During the nurse's absence, the resident mistakenly self-administered ear drops into her eyes, which were not prescribed for her. The incident was documented in a Medication Error Report, and interviews with the resident and the LPN confirmed the sequence of events. The LPN acknowledged that medications should not be left at the bedside and that the resident did not have an order for ear drops or self-administration of medications. The Director of Nursing confirmed that the facility's policy required staff to check medication labels before entering a resident's room and that medications should not be left unattended. This oversight resulted in a failure to ensure the resident's environment was free of accident hazards.
Failure to Monitor Nutritional Parameters and Notify Physician
Penalty
Summary
The facility failed to monitor the nutritional parameters of two residents, Resident 25 and Resident 64, who experienced significant weight fluctuations. Resident 25, diagnosed with dementia and severe protein calorie malnutrition, experienced a 23.4-pound weight loss, which was not immediately reweighed as per facility policy. Additionally, there was no documented evidence that the physician and resident representative were notified of this significant weight loss. The dietitian noted the weight loss and questioned its accuracy, requesting reweights multiple times, but the facility staff did not comply. Subsequent weight measurements showed further weight loss, yet the facility again failed to reweigh the resident or notify the physician and resident representative. Similarly, Resident 64, with diagnoses including a nontraumatic intracranial hemorrhage, dysphagia, and severe protein calorie malnutrition, experienced a 13.2-pound weight gain, which was not immediately reweighed. The facility did not document notifying the physician and resident representative of this significant weight gain. The dietitian noted the weight gain and requested reweights to confirm the change, but no new weight was recorded. Further weight measurements indicated an additional 27.3-pound gain, yet the facility again failed to reweigh the resident or notify the physician and resident representative in a timely manner. The Registered Dietitian confirmed these failures, highlighting the lack of timely notification and reweighting, which impeded accurate assessment of the residents' nutritional status and needs.
Failure to Attempt Non-Pharmacological Pain Management
Penalty
Summary
The facility failed to adhere to its pain management policy by not attempting non-pharmacological interventions before administering pain medication to a resident. The policy, last revised in July 2023, mandates that non-drug interventions such as positioning, physical therapy, occupational therapy, relaxation techniques, and diversional activities should be tried prior to medication administration. However, a review of the clinical records for a resident with rheumatoid arthritis, chronic obstructive pulmonary disease, and hypertension revealed that Oxycodone was administered multiple times in September 2024 without evidence of prior non-pharmacological interventions. The resident had a physician's order for Oxycodone HCL 5mg every 6 hours as needed for moderate to severe pain. Despite this, the Medication Administration Record showed several instances of Oxycodone administration without documented attempts of non-drug interventions. The Director of Nursing confirmed during an interview that the facility did not consistently attempt these interventions, leading to a deficiency under 28 Pa. Code 211.12 (d)(3)(5) Nursing Services.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to develop and implement an individualized person-centered care plan for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). Upon review, it was found that the care plan did not identify the resident's PTSD symptoms or triggers, nor did it include specific interventions to minimize these triggers and prevent re-traumatization. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the facility's inability to provide culturally competent, trauma-informed care in accordance with professional standards of practice. The lack of a tailored care plan compromised the resident's emotional well-being and safety.
Failure to Reconcile Controlled Drugs on Medication Cart
Penalty
Summary
The facility failed to implement proper pharmacy procedures for the reconciliation of controlled drugs on one of its medication carts, specifically the A2 Cart E even. A review of the Shift Change Checks sheet for September 2024 revealed that the required signatures from both the on-coming and off-going nurses were missing on several occasions. These dates included September 1, 2, 9, 10, and 12, 2024, indicating that the task of counting controlled drugs was not verified as completed during these shift changes. Interviews with staff members, including an LPN, an RN Unit Manager, and the Director of Nursing, confirmed the expectation that nursing staff must count controlled medications at the end of each shift and sign the logs to confirm the inventory is correct. The absence of these signatures suggests a failure to adhere to the facility's procedures for controlled drug reconciliation, as outlined in the facility's policy and state regulations.
Inadequate Justification for Opioid Administration
Penalty
Summary
The facility failed to adequately justify the administration of an opioid pain medication, morphine sulfate, to a resident with severe cognitive impairment. The resident, who was admitted with diagnoses of unspecified psychosis and major depressive disorder, was prescribed morphine sulfate to be administered as needed for pain. However, the medication was given on two occasions in November 2024, despite the resident reporting a pain level of zero out of ten. This action was not in accordance with the facility's pain management policy, which requires pain management orders to have parameters using a numerical scale for pain levels. During an interview, the Director of Nursing confirmed the lack of documented clinical rationale for administering the opioid medication to the resident on the specified dates. The facility's policy, last revised in July 2023, mandates that pain management should be evaluated and managed for all residents, with specific guidelines for administering pain medication based on reported pain levels. The failure to adhere to these guidelines resulted in the administration of unnecessary medication, highlighting a deficiency in the facility's adherence to its own pain management policies.
Neglect in Resident Care Leads to Physical Harm
Penalty
Summary
The facility failed to provide necessary care and services to prevent physical harm and maintain the health of two residents, leading to neglect. Resident 1, who was admitted with incomplete quadriplegia and neurogenic bowel, was dependent on staff for bed mobility and toilet use. Despite a care plan requiring staff to remove the resident from the bedpan at the beginning of the 11:00 PM to 7:00 AM shift and to reposition the resident every two hours, the resident was left on a bedpan from 9:27 PM on February 3, 2024, until 4:30 AM the next day. This resulted in a stage 2 pressure wound on the resident's buttocks. The investigation revealed that Employee 1, an LPN, falsely documented the removal of the bedpan and failed to notify the oncoming shift. Employee 2, a nurse aide, neglected to perform the scheduled turning and repositioning, which would have identified the resident's prolonged time on the bedpan. Additionally, the facility neglected to provide Resident 1 with the necessary wound treatment due to a lack of Mesalt, a dressing used for the resident's wound care. Despite a physician's order for daily treatment, the facility ran out of Mesalt over a holiday weekend, and staff failed to consult with the physician for alternative treatment. Employee 4, an LPN, used the last of the Mesalt on May 26, 2024, and did not attempt to obtain more from the pharmacy, resulting in incomplete wound care for the resident. Resident 2, who was admitted with dementia and required moderate assistance for activities of daily living, fell while being walked back from the dining room. The staff member, Employee 7, neglected to follow the resident's care plan, which required the use of a gait belt and a wheelchair to follow the resident. The employee was too far from the resident to provide proper assistance, leading to the resident's fall and resulting in a large hematoma and swelling. The Director of Nursing confirmed that the staff neglected to provide the necessary care and services for both residents.
Failure to Administer Medications and Wound Treatment Timely
Penalty
Summary
The facility failed to implement pharmacy procedures to ensure the timely acquisition and administration of medications for a resident with incomplete quadriplegia and neurogenic bowel. The resident was admitted with specific physician orders for medications including Bactrim, Prednisone, Plavix, Vancomycin, and Carvedilol. However, the resident did not receive these medications on specified dates because they were not available from the pharmacy. The Director of Nursing (DON) confirmed that the facility's procedure when medications are unavailable is to check the emergency supply and consult the physician for further instructions. Despite the availability of some medications in the emergency supply, there was no documented evidence that the physician was consulted. Additionally, the facility ran out of Mesalt, a dressing used for the resident's wound treatment, over a holiday weekend. The resident did not receive the prescribed wound treatment due to the unavailability of Mesalt. Interviews with staff revealed that the Central Supply employee was informed of the shortage but could not order more until after the holiday. The LPN did not contact the pharmacy for an alternative supply, assuming it was closed. The DON acknowledged that the staff should have used the emergency supply to prevent missed doses and confirmed the lack of documentation regarding physician consultation for the unavailability of medications and treatments.
Failure to Maintain Accurate Clinical Records
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for a resident with incomplete quadriplegia and neurogenic bowel. The resident reported being left on a bedpan for an extended period, resulting in a pressure sore. Additionally, the facility ran out of Mesalt, a dressing used for the resident's wound treatment, and the prescribed treatment was not administered as ordered. Employee 4, an LPN, did not document the unavailability of Mesalt or her attempts to contact the physician regarding this issue. Furthermore, she failed to record a dressing change performed later in the day due to the dressing becoming soiled. Another LPN, Employee 6, signed the treatment administration record indicating the treatment was performed as prescribed, despite the lack of Mesalt. There was no documentation of any consultation with the physician for an interim treatment plan. Additionally, an investigation revealed that Employee 1 falsely documented the removal of the resident from the bedpan, which was confirmed by the Nursing Home Administrator. These documentation failures were in violation of professional standards and state regulations.
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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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