Sunset Ridge Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bloomsburg, Pennsylvania.
- Location
- 3298 Ridge Road, Bloomsburg, Pennsylvania 17815
- CMS Provider Number
- 395953
- Inspections on file
- 18
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Sunset Ridge Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
The facility's fire alarm system failed to automatically transmit alarms to notify emergency forces during an annual test. This deficiency was confirmed during a survey and remains unresolved.
The facility failed to maintain proper enclosures for three hazardous areas, affecting two smoke compartments. Observations revealed that doors to the Clean Laundry and Medical Records areas needed adjustments to latch properly, and the Oxygen Storage room door was not smoke-tight. These issues were confirmed during an exit conference with the Facility Administrator and Facilities Director.
The facility failed to maintain the automatic sprinkler system, with unsealed penetrations in the West Wing and painted-over sprinkler escutcheons in the Medical Records and East Wing Med room. These deficiencies were confirmed during an exit conference with the Facility Administrator and Facilities Director.
The facility failed to review and update its menu to provide variety, resulting in repetitive meal patterns that did not meet resident satisfaction. Residents reported concerns about the lack of variety, with similar meats served consecutively. The facility's contracted dietary representative and NHA confirmed the menu's repetitiveness, leading to menu fatigue.
The facility's dietary department was found to have unsanitary conditions, including a greasy metal wire rack, a cluttered and dusty windowsill, improperly handled butter, and unclean food preparation equipment. These issues were confirmed with the NHA, indicating a failure to maintain sanitary standards and prevent potential food contamination.
The facility failed to implement a comprehensive infection prevention and control program. A review of policies and infection control logs revealed deficiencies, including the absence of a tracking log for June 2024 and incomplete documentation of critical infection-related details. The ADON confirmed these issues, indicating a lack of support for a comprehensive program.
A facility failed to maintain an effective antibiotic stewardship program, leading to the inappropriate prescription of antibiotics for a resident with a history of cancer and dementia. Despite an elevated WBC, the resident showed no other symptoms justifying antibiotic use. A physician prescribed Bactrim DS before culture results were available, which later confirmed resistance to the antibiotic. The resident received five doses of the ineffective medication, indicating a failure in the facility's monitoring and prescribing practices.
A resident at Sunset Ridge Rehabilitation and Nursing Center experienced multiple falls due to inadequate supervision and ineffective fall prevention measures. Despite being at high risk for falls, the resident suffered injuries from unwitnessed falls in various locations. The facility failed to consistently implement planned interventions, such as frequent visual checks, contributing to the resident's recurrent falls and injuries.
The facility failed to provide adequate pain management for two residents. One resident with rib fractures received narcotic pain medication without documented non-pharmacological interventions in most instances. Another resident with COPD and arthritis had no documented evidence of alternative pain-relief interventions despite continued pain and a new diagnosis of lumbar vertebrae compression fractures. The DON confirmed the facility's failure to implement appropriate pain management interventions.
A facility failed to create an individualized care plan for a resident with dementia, who exhibited agitation, aggression, and delusional behaviors. The care plan lacked specific interventions and did not consider the resident's history or preferences, as confirmed by the Nursing Home Administrator.
A facility failed to maintain a system of records for controlled drugs, as required by policy, leading to a deficiency. A resident discharged against medical advice had no documented accountability record for controlled medications like Oxycodone and Tramadol. The DON confirmed the absence of required documentation, which is necessary to prevent unauthorized use and ensure accurate tracking.
A resident with a history of cancer and dementia received unnecessary antibiotics due to an elevated white blood count but no other infection signs. The physician prescribed Bactrim DS before culture results were available, which later showed resistance to the medication. The resident received five doses of ineffective antibiotics, confirmed by the DON as unjustified.
A facility failed to maintain accurate clinical records for two residents after an incident where one resident kissed another. The records lacked documentation of the interaction, staff intervention, and follow-up assessments, resulting in incomplete and inaccurate records. The Nursing Home Administrator and DON confirmed the documentation failure.
A resident with a history of cancer and dementia was admitted to hospice services, but the facility failed to coordinate care with the hospice agency. The care plan lacked evidence of collaboration to address the resident's daily care needs and terminal diagnosis. The Nursing Home Administrator confirmed the care plan was not coordinated with hospice services.
A facility failed to ensure a physician completed a discharge summary for a resident who was admitted and later expired. The resident's clinical record lacked documentation of a discharge summary upon their death and discharge, as confirmed by the DON during an interview.
The facility did not meet the required nurse aide to resident ratios on two shifts. On one night shift, there were 3.67 nurse aides instead of the required 4.27 for 64 residents. On a day shift, there were 6.17 nurse aides instead of the required 6.40. No additional staff were available to cover these shortages, leading to non-compliance with staffing regulations.
The facility did not meet the required LPN to resident ratio during an evening shift, with only 2.03 LPNs available instead of the required 2.10 for 63 residents. This deficiency was confirmed by interviews with the Nursing Home Administrator and the DON.
The facility failed to protect two residents from sexual abuse by another resident with a known history of inappropriate behavior. Despite staff awareness and documentation of the incidents, the facility did not investigate, report, or implement necessary interventions to prevent further abuse.
The facility failed to report incidents of sexual abuse involving two residents to the State Survey Agency and local law enforcement, despite staff witnessing and documenting the inappropriate behavior by another resident. The facility did not adhere to its own policy or state regulations regarding timely reporting of abuse.
The facility failed to investigate timely and thoroughly the sexual abuse of two residents by another resident. Staff witnessed inappropriate behavior but did not follow the facility's policy, including arranging medical attention, documenting evidence, or obtaining witness statements. The Director of Nursing and the Nursing Home Administrator confirmed the lack of investigation.
The facility failed to develop and implement person-centered comprehensive care plans for five residents, leading to deficiencies in addressing their specific medical needs, including constipation, incontinence, sexually inappropriate behaviors, and management of medical devices and respiratory therapy.
The facility failed to promptly assess two residents after instances of sexual abuse and did not follow physician's orders for bowel protocols for two other residents. Staff witnessed and reported the abuse, but no nursing assessments were documented. Additionally, prescribed bowel regimens were not administered, and physicians were not notified of the lack of bowel movements.
The facility failed to provide routine evening snacks to residents, resulting in more than 14 hours between supper and breakfast. Observations and interviews revealed that snacks and beverages were not consistently available or offered, and there was no documented evidence to support the routine offering of evening snacks.
The facility failed to maintain accurate and complete clinical records for three residents, leading to deficiencies in documentation and care. A resident exhibited inappropriate behaviors towards other residents, but the clinical records lacked detailed documentation. Two residents were victims of sexual abuse by the same resident, but their clinical records did not document the incidents or include nursing assessments for injuries. Staff interviews confirmed the failure to document complete and accurate information.
The facility failed to implement Enhanced Barrier Precautions (EBP) for three residents with conditions requiring such measures, including a resident with a stage 3 pressure ulcer and Foley catheter, another with venous and diabetic foot ulcers, and a third with a tracheal stoma. Observations confirmed the lack of EBP, despite facility policy and CDC guidelines.
The facility failed to notify the physician and the resident's representative of an incident where a resident with dementia was inappropriately touched by another resident. Despite the incident being witnessed by a nurse aide, there was no documented evidence of notification, which was confirmed by the Director of Nursing and the Nursing Home Administrator.
The facility failed to timely train an agency nurse aide on the abuse prohibition policy and procedures. The employee started working without receiving the necessary orientation or training, and there was no documented evidence of such training in her file. The Nursing Home Administrator confirmed the lack of documentation.
The facility failed to provide written notices for hospital transfers to residents and their representatives, affecting five residents. Clinical records and staff interviews confirmed the absence of required notifications, including transfer reasons, effective dates, and contact information for relevant advocacy agencies.
The facility failed to provide residents or their representatives with written information about the bed hold policy upon hospital transfer. This deficiency was identified in five residents, including one who expired at the hospital. The DON confirmed the lack of documented evidence.
Fire Alarm System Deficiency
Penalty
Summary
The facility failed to maintain the fire alarm system for the entire building, as evidenced by the annual fire alarm system testing documentation from January 13, 2025. The documentation revealed that the fire alarm system did not automatically transmit the alarm to notify emergency forces in the event of a fire. This deficiency was observed during a survey on March 17, 2025, at 9:30 a.m., and it was confirmed during an exit conference with the Facility Administrator and Facilities Director at 11:30 a.m. on the same day that the issue still persisted.
Plan Of Correction
1. The fire alarm system will transmit the alarm automatically to notify emergency forces in the event of a fire. 2. The facility has an agreement in place for the work to be completed. 3. The fire alarm system will be audited to ensure ongoing compliance. Audits will be completed by the Maintenance Director/Designee. 4. Audits will be reviewed at the facility's Q.A.P.I. meeting for review and recommendation.
Deficiencies in Hazardous Area Enclosures
Penalty
Summary
The facility failed to maintain proper enclosures for three hazardous areas, affecting two of three smoke compartments. During an observation on March 17, 2025, it was noted that the door to the Clean Laundry area required adjustment to ensure it positively latched into the frame. Similarly, the door to the Medical Records area also needed adjustment for proper latching. Additionally, the door to the Oxygen Storage room in the East Wing was found not to be smoke-tight when latched into the frame, located at the nurses' station. These deficiencies were confirmed during an exit conference with the Facility Administrator and Facilities Director.
Plan Of Correction
1. The Clean Laundry, Medical Records, and East Wing Oxygen Storage room doors have been adjusted to be smoke tight and latch into the frame. 2. The Maintenance Director/Designee will check doors in the facility to ensure they are smoke tight and latch into the frame. 3. Facility doors will be randomly audited to ensure ongoing compliance. Audits will be completed by the Maintenance Director/Designee. 4. Audits will be reviewed at the facilities Q.A.P.I. meeting for review and recommendation.
Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain the automatic sprinkler system, as evidenced by observations and interviews conducted during a survey. On March 17, 2025, between 10:12 a.m. and 10:20 a.m., it was observed that the West Wing had an unsealed penetration of a corridor ceiling tile near Resident Room 109, and the Med room at the Nurses' station had an unsealed penetration of the wall around two blue IT cables. Further observations between 10:39 a.m. and 10:55 a.m. revealed that the Medical Records area had two sprinkler escutcheons that had been painted over, and the East Wing Med room at the Nurses' station also had a painted-over sprinkler escutcheon. These deficiencies were confirmed during an exit conference with the Facility Administrator and Facilities Director.
Plan Of Correction
1. The ceiling tile on West Wing has been replaced. The Medication rooms IT cables have been sealed. The paint has been removed from the escutcheons in the Medical Records room. 2. The Maintenance Director/Designee will check area of the facility to ensure smoke compartments are sealed. 3. Audits of smoke compartments will be audited to ensure ongoing compliance of the automatic sprinkler system. 4. Audits will be reviewed at the facilities Q.A.P.I. meeting for review and recommendation.
Repetitive Meal Patterns in Facility Menu
Penalty
Summary
The facility failed to ensure that the planned menu was sufficiently reviewed and updated to provide variety and avoid repetitive meal selections, as required by §483.60(c). During a Resident Council meeting, multiple residents expressed concerns about the lack of variety in the menu, noting that the same meats were served for consecutive meals. The Resident Council President mentioned that these concerns had been raised in food committee meetings with the Certified Dietary Manager but were not addressed, as the facility's menu was provided by a contracted vendor and reportedly could not be modified. A review of the Fall/Winter 2024-2025 menu revealed multiple instances of repetitive meal patterns over the 4-week cycle, with similar meats being served for consecutive meals. Interviews with the facility's contracted dietary food/menu representative and the Nursing Home Administrator confirmed that the facility's menu was repetitive and did not offer variety, leading to menu fatigue and reduced meal satisfaction among residents. The facility's failure to review and modify the planned menus resulted in repetitive meal patterns that did not meet the satisfaction of the residents.
Plan Of Correction
The facility cannot retroactively correct the menu schedule as observed during survey. Current menu will be reviewed, altered, and updated to reflect variety to assist in deterring menu fatigue and increasing menu satisfaction. Certified dietary manager, Registered Dietician and kitchen staff will be re-educated on meal rotation/variety. Audits will be completed on resident satisfaction of meal variety weekly x 4 weeks, then monthly x 2 months. Audit findings will be reviewed at monthly QAPI meeting, resident council and food committee.
Unsanitary Conditions in Dietary Department
Penalty
Summary
The facility failed to maintain sanitary conditions in the dietary department, as observed during an inspection. In the cook's area, a metal wire rack used for storing clean cooking equipment was found to be greasy with a significant buildup of debris, indicating inadequate cleaning practices. Additionally, the windowsill above the microwave and open bread loaves was cluttered and covered in dust and debris, posing a potential source of contamination. A storage container of butter was improperly handled, with a dirty, uncovered butter spreader resting on it, and the butter itself was discolored, had crumbs adhered to its surface, and appeared soft and melting. Further observations revealed that the interior of the microwave contained food splatter and peeling surfaces, which could lead to cross-contamination. A food prep station had an industrial can opener with a sticky blade, which had been used earlier to open cans of tuna fish and had not been cleaned afterward, failing to meet sanitary standards for food preparation equipment. These findings were confirmed with the facility's Nursing Home Administrator, highlighting the need for maintaining the dietary department in a sanitary manner to prevent potential food contamination and foodborne illness.
Plan Of Correction
Areas of concern noted during tour on 3/11/25 were cleaned/corrected that same day, 3/11/25. New microwave has been purchased to replace the current microwave noted as a concern during survey. Food prep, storage and hard surface areas will be placed on a routine cleaning schedule to prevent food contamination and food-borne illness. CDM and kitchen staff will be re-educated on new routine cleaning schedules. Audits of food prep, storage and hard surface areas will be completed by NHA/designee weekly x 4 weeks, then monthly x 2 months. Results will be reviewed at monthly QAPI meeting.
Inadequate Infection Control Program Implementation
Penalty
Summary
The facility failed to maintain and implement a comprehensive infection prevention and control program as required by regulations. A review of the facility's policies and infection control logs revealed significant deficiencies in the program's execution. The facility's policy on 'Infection Prevention and Control Program' outlined the need to identify, investigate, control, and prevent infections, but the actual practice did not align with these objectives. Specifically, the facility lacked an effective system to analyze infection clusters, track changes in prevalent organisms, or identify increases in infection rates in a timely manner. Further investigation into the facility's infection control logs from May 2024 through March 2025 showed that there was no tracking of infections for June 2024. Additionally, the logs were incomplete, missing critical infection-related details such as the location of infections, whether they were community-acquired or facility-acquired, symptoms experienced by residents, and the onset date of infections. An interview with the Assistant Director of Nursing, who also serves as the facility's Infection Preventionist, confirmed the absence of a tracking log for June 2024 and acknowledged the incompleteness of the logs, indicating a failure to support a comprehensive infection prevention and control program.
Plan Of Correction
Facility logs for June 2024 were located and are present in the facility. Current system utilized for infection prevention and control will be reviewed. Processes not meeting policy guidelines will be updated and implemented. Nursing staff will be re-educated on facility infection prevention and control program and policies. Audits will be completed on new infections to determine that criteria in facility policies have been followed weekly x 4 weeks, then monthly x 2 months. Results will be reviewed in monthly QAPI meeting.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an effective system for monitoring antibiotic usage as part of its antibiotic stewardship program. This deficiency was identified during a survey, which revealed that the facility did not adhere to its own policies regarding antibiotic prescribing and monitoring. Specifically, the facility's policy required that antibiotics be prescribed based on clinical indications of active infection or suspected sepsis, and that antibiotic usage and outcomes be documented and reviewed by the infection preventionist. However, the facility did not provide evidence that prescribing practitioners were informed of their prescribing practices, nor did it demonstrate actions to optimize infection treatment through improved antibiotic prescribing and management. The deficiency involved a resident who was admitted with a history of malignant neoplasm of the bladder and dementia. Despite having an elevated white blood cell count, the resident showed no other symptoms justifying antibiotic use. Nevertheless, a physician ordered a urinalysis with culture and sensitivity, and subsequently prescribed Bactrim DS before the culture results were available. The culture later confirmed the presence of an antibiotic-resistant strain of E. coli, rendering the prescribed antibiotic ineffective. The resident received five doses of the unnecessary antibiotic, highlighting a failure in the facility's antibiotic stewardship program. This was confirmed by the Director of Nursing during an interview.
Plan Of Correction
The facility cannot retroactively correct the administration of antibiotic to resident 1. Current residents on antibiotic therapy for a UTI will be reviewed to determine antibiotic necessity and verification of MD notification. Nursing staff and in-house physicians will be re-educated on antibiotic stewardship policy. Audits will be completed on residents who are ordered a UA C&S to determine the necessity of antibiotic and verification of MD notification weekly x 4 weeks, then monthly x 2 months. Findings will be reviewed in monthly QAPI meeting.
Inadequate Supervision Leads to Recurrent Falls
Penalty
Summary
Sunset Ridge Rehabilitation and Nursing Center was found to be non-compliant with federal and state regulations due to inadequate safety measures and supervision for a resident identified as high risk for falls. The facility failed to implement effective fall prevention interventions, resulting in multiple recurrent falls for a resident with severe cognitive impairment and a history of impulsiveness and poor safety awareness. Despite being identified as high risk for falls, the resident experienced 14 falls over a period of several months, many of which were unwitnessed. The resident, admitted with diagnoses including dysphagia, abnormalities of gait and mobility, repeated falls, hypertensive heart disease, and urinary tract infection, continued to fall in various locations such as their room, bathrooms, and common areas. The facility's documentation revealed a lack of consistent implementation of planned interventions, such as frequent visual checks, which were added to the resident's care plan but not consistently conducted. The resident's falls resulted in injuries, including abrasions, hematomas, and a head wound, and were often associated with attempts to self-transfer or use the bathroom. Interviews with facility staff, including the Director of Nursing, confirmed the failure to provide adequate supervision and follow through with planned interventions. The facility's inaction and lack of effective supervision contributed to the resident's recurrent falls and injuries, highlighting a significant deficiency in meeting the required standards for resident safety and care.
Plan Of Correction
Resident 50 frequent visual checks evaluated and removed from tasks and care plan. Fall interventions reviewed and verified as effective. Facility will continue to implement interventions to assist with prevention of recurrence of falls/injury. Current residents care plans will be reviewed to verify presence of safety interventions to assist in the prevention of falls. Nursing staff will be re-educated on the implementation of effective fall prevention interventions. Audits will be completed on fall incident reports weekly x 4 weeks, then monthly x 2 months to ensure the implementation of fall prevention interventions. Results will be reviewed at monthly QAPI meeting.
Failure in Pain Management for Two Residents
Penalty
Summary
The facility failed to provide adequate pain management for two residents, as evidenced by the lack of non-pharmacological interventions prior to administering narcotic pain medication for one resident and the failure to implement appropriate interventions for another resident's continued pain. Resident 60, admitted with multiple rib fractures, had physician orders for as-needed Oxycodone. However, in January 2025, staff administered the medication 30 times, with 23 instances lacking documented evidence of non-pharmacological interventions. Similar patterns were observed in February and March 2025. Interviews with the Nursing Home Administrator and Director of Nursing confirmed the inconsistency in attempting non-pharmacological interventions before administering narcotic pain medication. Resident 15, admitted with chronic obstructive pulmonary disease and emphysema, had a care plan for pain related to arthritis, which included non-pharmacological interventions such as repositioning and therapy evaluation. Despite complaints of pain and a new diagnosis of lumbar vertebrae compression fractures, there was no documented evidence that the resident was offered as-needed acetaminophen or other alternative pain-relief interventions. The Director of Nursing confirmed the facility's failure to develop and implement appropriate pain management interventions for Resident 15's continued pain.
Plan Of Correction
The facility cannot retroactively correct the nonpharmacological intervention documentation presence prior to as needed oxycodone administration for resident 60 for 1/13/25-1/26/25 and 2/13/25. All other administrations have nonpharmacological interventions documented in the Medication Administration Record. Resident 15 has remained free of verbal/nonverbal complaints of pain since 1/13/25, with dates of pain documented only on 1/12-1/13/25. Facility will assess current residents with as needed pain medications to verify presence of nonpharmacological intervention(s) documentation prompt prior to medication administration in the medical record and administer as needed/indicated. Nursing staff will be re-educated on documentation and implementation of nonpharmacological intervention(s) prior to medication administration. Audits will be done on new admissions with as needed pain medication to ensure presence of nonpharmacological intervention(s) documentation prior to medication administration in the MAR weekly x 4 weeks, then monthly x 2 months. Results will be reviewed at monthly QAPI meeting.
Failure to Implement Individualized Care Plan for Dementia-Related Behaviors
Penalty
Summary
The facility failed to develop and implement an effective individualized person-centered care plan for a resident diagnosed with dementia, who exhibited behavioral symptoms such as agitation, aggression, and delusional ideation. The resident, admitted with dementia and agitation, displayed recurrent episodes of increased agitation, aggressive and argumentative behaviors, verbal threats, and delusional beliefs, including thinking another resident was her daughter and that staff had taken her daughter. These behaviors were documented in multiple progress notes over several months, indicating a pattern of distress and confusion. Despite these documented behaviors, the resident's care plan did not identify specific behavioral symptoms or include individualized interventions tailored to address each behavior. The care plan also failed to incorporate the resident's preferences, social and past life history, customary routines, and interests to support behavior management. An interview with the Nursing Home Administrator confirmed the absence of an individualized, person-centered care plan to manage the resident's dementia-related behaviors, leading to the deficiency finding.
Plan Of Correction
Resident 10 care plan has been updated to reflect specific behavioral symptoms, interventions, resident preferences and interests. Residents with dementia diagnosis will be audited to ensure the presence of personalized interventions related to resident specific behaviors. Nursing staff will be re-educated on resident specific care plans and behaviors related to dementia. Audits will be completed on new admissions with diagnosis of dementia to ensure the presence of resident specific behaviors and interventions in the care plan weekly x 4 weeks, then monthly x 2 months. Results will be reviewed at monthly QAPI meeting.
Failure to Maintain Controlled Medication Records
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not maintaining a system of records for the receipt and disposition of controlled drugs, which is necessary for accurate accounting and to prevent possible diversion. This deficiency was identified during a review of clinical records, facility policy, and staff interviews. Specifically, the facility's policy on Discharge Medications requires that controlled substances not be released upon discharge unless permitted by state law and authorized by the resident's attending physician. Additionally, the policy mandates that a nurse reconcile pre-discharge medications with post-discharge medications and document the reconciliation, including a detailed medication disposition record. In the case of Resident 62, who was admitted with acute cystitis and weakness, there was a failure to document the accountability record for controlled medications, including Oxycodone and Tramadol, upon the resident's discharge against medical advice. The nursing note indicated that the resident signed out against medical advice, and while the attending physician and Nursing Home Administrator were notified, there was no documented evidence of a controlled medication accountability record. The Director of Nursing confirmed the absence of this documentation, which is required by facility policy to prevent unauthorized use and ensure accurate tracking and disposition of controlled medications.
Plan Of Correction
The facility cannot retroactively correct the absence of the medication disposition on resident 62. Residents discharged home in the last 30 days will be reviewed to determine the presence of medication disposition form. Nursing staff will be re-educated on completion of the medication disposition form upon discharge home. Audits will be completed on residents discharging home from the facility to ensure the presence of the medication disposition form weekly x 4 weeks, then monthly x 2 months. Results will be reviewed in monthly QAPI meeting.
Unnecessary Antibiotic Administration
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary antibiotics. A resident, admitted with a history of malignant neoplasm of the bladder and dementia, had an elevated white blood count but no other signs of infection. Despite this, the physician ordered a urinalysis with culture and sensitivity to assess for possible infection. The resident was catheterized to obtain a urine sample, and the results were pending. However, before the culture and sensitivity results were available, the physician prescribed Bactrim DS, an antibiotic, to be administered every 12 hours for five days. The laboratory report later revealed that the urine culture identified Escherichia coli ESBL, which was resistant to the prescribed antibiotic, rendering the treatment ineffective. The resident received five doses of Bactrim DS before the culture and sensitivity results confirmed the medication's ineffectiveness. During an interview, the Director of Nursing confirmed that the administration of Bactrim DS was not clinically justified, as it was ineffective against the identified organism, resulting in the resident receiving an unnecessary medication.
Plan Of Correction
The facility cannot retroactively correct the ordered administration of the antibiotic to resident 1. Lab culture results will be reviewed on all current residents receiving antibiotic therapy for a UTI to ensure that the ordered antibiotic is clinically justified. Nursing staff will be re-educated on medication necessity related to evidence-based infection control and antimicrobial stewardship practices. Audits will be completed on new antibiotics for UTIs to determine the necessity weekly x 4 weeks, then monthly x 2 months. Results will be reviewed at the monthly QAPI meeting.
Failure to Document Resident Interactions and Behaviors
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for two residents, Resident 8 and Resident 44, as required by professional standards of practice. Resident 8, who was admitted with hypertensive heart disease, was cognitively intact according to a recent assessment. Resident 44, admitted with multiple sclerosis, was severely cognitively impaired. An incident occurred where Resident 44 kissed Resident 8 in the hallway, which was observed by staff. Despite the incident, there was no documentation in Resident 8's clinical record regarding the interaction, staff intervention, or any follow-up assessments to determine potential emotional or psychological effects. Similarly, Resident 44's clinical record lacked documentation of the behavior, assessments following the event, or any interventions to prevent recurrence. This lack of documentation resulted in incomplete and inaccurate clinical records for both residents. The Nursing Home Administrator and Director of Nursing confirmed that the nursing staff failed to consistently and accurately document residents' interactions and behaviors in the clinical records. This failure to document significant events and follow-up actions is a deficiency in maintaining accurate and complete clinical records, as required by the regulations.
Plan Of Correction
Medical records were updated on resident 8 and resident 44 to include investigation summary and outcome. Last 3 PB22's will be reviewed to ensure the presence of documentation in the medical record. Nursing staff will be re-educated on maintaining accurate and complete clinical records related to PB 22's. Audits will be completed on new PB22's to verify accurate and complete documentation weekly x 4 weeks, then monthly x 2 months. Findings will be reviewed at monthly QAPI meeting.
Failure to Coordinate Hospice Services
Penalty
Summary
The facility failed to ensure proper coordination of care and services between the long-term care facility and the hospice agency for one resident. This deficiency was identified during a review of clinical records and staff interviews. The resident in question was admitted to the facility with a history of malignant neoplasm of the bladder and dementia, and later admitted into hospice services. However, the care plan for this resident did not reflect the necessary collaboration between the facility and the hospice agency. The resident's care plan, initially dated shortly after admission, lacked documented evidence of collaboration in addressing the resident's daily care needs and specific care and services related to the resident's terminal diagnosis. This indicates a failure to integrate hospice care into the resident's overall care plan, which is essential for ensuring that the resident's needs are met comprehensively. An interview with the Nursing Home Administrator confirmed that the resident's care plan was not coordinated with hospice services. This lack of coordination could potentially impact the quality of care provided to the resident, as the care plan did not adequately address the resident's terminal diagnosis and the necessary hospice services.
Plan Of Correction
Resident 1 care plan has been reviewed and updated to reflect the coordination of care and services between the facility and hospice agency. Current residents on hospice will have care plans reviewed to verify the presence of coordination of care and services between the facility and hospice agency. Nursing staff will be re-educated on the need of care plan coordination of care and services between facility and hospice. Audits will be completed on new hospice admissions to ensure the presence of coordination of care and services between facility and hospice in the care plan weekly x 4 weeks, then monthly x 2 months. Results will be reviewed at monthly QAPI meeting.
Failure to Complete Physician Discharge Summary
Penalty
Summary
The facility failed to ensure that a discharge summary was completed by the physician for one resident. The clinical record review of a resident revealed that the resident was admitted to the facility and later expired and was discharged. However, there was no documented evidence in the resident's clinical record that a discharge summary was completed by the physician upon the resident's death and discharge. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the absence of the required documentation.
Plan Of Correction
The facility cannot retroactively correct the presence of a physician discharge summary on resident 63. Residents who discharged in the last 30 days will be reviewed to determine the presence of a physician discharge summary. Nursing staff and physicians will be re-educated on completion of a discharge summary. Audits will be completed on residents who discharge to ensure completion of a discharge summary by the physician weekly x 4 weeks, then monthly x 2 months. Findings will be reviewed at monthly QAPI meeting.
Staffing Ratio Deficiency
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios on two specific shifts out of 63 reviewed. On September 4, 2024, during the night shift, the facility had 3.67 nurse aides instead of the required 4.27 for a census of 64 residents. Similarly, on December 29, 2024, during the day shift, the facility had 6.17 nurse aides instead of the required 6.40 for the same census. No additional higher-level staff were available to compensate for these deficiencies, resulting in non-compliance with the staffing regulations effective July 1, 2024, which mandate a minimum of 1 nurse aide per 10 residents during the day, 1 per 11 residents in the evening, and 1 per 15 residents overnight.
Plan Of Correction
The facility cannot retroactively correct past Nursing Aide ratios. The facility will continue to take measures to adequately provide nurse-aide staff to ensure the needs of the residents are met. Measures will be put in place to adequately provide staff with the required nurse aide to resident ratios. These measures include continuing our retention committee, increased advertising efforts, utilization of agency staff, and sign-on bonuses. The Director of Nursing/designee will continue to educate minimum staffing ratios to RN Supervisors, HR, and the nursing scheduler who are responsible to maintain adequate staffing ratios. The Director of Nursing/designee will audit the daily schedules to ensure that the minimum number of nurse aide staff to resident ratios have been scheduled. The results of the audits will be reviewed at the facility's QAPI meeting for recommendations.
LPN Staffing Deficiency on Evening Shift
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratio on one occasion during the evening shift. Specifically, on December 25, 2024, the facility's staffing records showed that there were only 2.03 LPNs available, whereas the required number was 2.10 for a census of 63 residents. This deficiency was confirmed through interviews with both the Nursing Home Administrator and the Director of Nursing on March 13, 2025. No additional higher-level staff were available to compensate for this shortfall, leading to a failure in meeting the regulatory staffing requirements.
Plan Of Correction
The facility cannot retroactively correct past LPN ratios. The facility will continue to take measures to adequately provide LPN staff to ensure the needs of the residents are met. Measures will be put in place to adequately provide staff with the required LPN to resident ratios. These measures include continuing our retention committee, increased advertising efforts, utilization of agency staff, and sign-on bonuses. The Director of Nursing/designee will continue to educate minimum staffing ratios to RN Supervisors, HR, and the nursing scheduler who are responsible to maintain adequate staffing ratios. The Director of Nursing/designee will audit the daily schedules to ensure that the minimum number of nurse aide staff to resident ratios have been scheduled. The results of the audits will be reviewed at the facilities QAPI meeting for recommendations.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to ensure that two residents, Resident 45 and Resident 42, were free from sexual abuse perpetrated by Resident 6. Resident 45, who was moderately cognitively impaired due to dementia, was touched inappropriately by Resident 6 in the dining room. Despite being aware of Resident 6's history of sexually inappropriate behavior, the facility did not document the incident in Resident 45's clinical record, nor did they fully investigate or report the incident. Staff interviews confirmed that Resident 6's behaviors were a known issue, yet necessary interventions were not implemented to prevent further incidents. Resident 42, who was also moderately cognitively impaired and diagnosed with multiple sclerosis, was another victim of Resident 6's inappropriate behavior. Staff members witnessed Resident 6 groping Resident 42's breasts, but the facility failed to document this incident in Resident 42's clinical record. Similar to the case with Resident 45, the facility did not investigate or report the incident, nor did they take adequate measures to prevent further abuse. Interviews with various staff members, including nurse aides and an LPN, revealed that Resident 6's sexually inappropriate behavior was a recurring issue that was frequently discussed in staff reports. Despite this, the facility did not take sufficient action to protect the residents from abuse. The Nursing Home Administrator and Director of Nursing confirmed the facility's failure to ensure the safety of Residents 45 and 42 from sexual abuse by Resident 6.
Failure to Report Sexual Abuse Incidents
Penalty
Summary
The facility failed to timely report incidents of sexual abuse involving two residents, Resident 45 and Resident 42, to the State Survey Agency and local law enforcement. According to the facility's policy, all incidents of abuse must be reported electronically to the Pennsylvania Department of Health within 24 hours and a completed investigation must be submitted within five working days. Additionally, the police should be contacted immediately in cases of sexual abuse. However, the facility did not adhere to these protocols in the cases of Resident 45 and Resident 42, who were both moderately cognitively impaired and subjected to inappropriate sexual behavior by Resident 6, who has a history of such behaviors known to the staff and administration. Resident 45, diagnosed with dementia, was inappropriately touched by Resident 6 in the dining room, as witnessed by multiple staff members including nurse aides and an LPN. Despite the staff's awareness and documentation of the incident, the facility did not report the abuse to the State Survey Agency or the local police. Similarly, Resident 42, diagnosed with multiple sclerosis, was also subjected to inappropriate sexual behavior by Resident 6, which was witnessed and documented by staff. Again, the facility failed to report this incident to the appropriate authorities. Interviews with various staff members, including nurse aides, an LPN, and an RN Supervisor, confirmed that the incidents were known and reported internally to the Director of Nursing. However, the facility did not follow through with the required external reporting. The Nursing Home Administrator and Director of Nursing confirmed the failure to report these incidents to the State Survey Agency and local law enforcement, violating multiple Pennsylvania Code regulations regarding the responsibility of the licensee, management, resident rights, and nursing services.
Failure to Investigate Sexual Abuse Allegations
Penalty
Summary
The facility failed to conduct a timely and thorough investigation into the sexual abuse of two residents, Resident 45 and Resident 42, by Resident 6. The facility's policy on investigating allegations of abuse, neglect, or misappropriation of resident property was not followed. Specifically, the Registered Nurse Supervisor or Department Head did not immediately initiate an investigation, remove the alleged perpetrator, or notify the administrator/designee as required. Additionally, the facility did not arrange for medical attention for the victims, document and preserve evidence, or obtain written statements from all appropriate individuals on duty at the time of the incidents. Resident 45, who was moderately cognitively impaired and diagnosed with dementia, was touched inappropriately by Resident 6 in the dining room. Multiple staff members, including nurse aides and an LPN, witnessed the incident but did not follow the facility's policy for handling such situations. Similarly, Resident 42, who was also moderately cognitively impaired and diagnosed with multiple sclerosis, was groped by Resident 6. Staff members were aware of this behavior but failed to document it properly or initiate an investigation. Interviews with various staff members, including nurse aides and an RN, revealed that they were aware of the inappropriate behavior but did not take the necessary steps to address it. The Director of Nursing and the Nursing Home Administrator confirmed that the facility did not complete investigations into the sexual abuse of Resident 45 and Resident 42 by Resident 6. The facility's failure to follow its own policies and procedures resulted in a lack of proper investigation and response to the allegations of sexual abuse.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered comprehensive care plans for five residents, leading to deficiencies in addressing their specific medical needs. Resident 2, who was admitted with a diagnosis of constipation, had multiple physician orders for managing constipation, including medications and interventions. However, the resident's care plan did not include these prescribed bowel regimens, failing to address the resident's diagnosed condition and necessary interventions. Similarly, Resident 60, who had functional incontinence and was placed on a prompted voiding program, did not have this condition or the required interventions included in their care plan, leading to inadequate management of their incontinence needs. Resident 6, admitted with hypertensive heart disease, exhibited sexually inappropriate behaviors towards female residents. Despite multiple incidents and new orders to monitor and document these behaviors, the resident's care plan did not address these behaviors or include specific interventions to manage them and protect other residents from potential abuse. This oversight resulted in continued inappropriate interactions, including an incident where Resident 6 touched another resident inappropriately in the dining room. Resident 61, with complex medical conditions including pancreatic cancer, ischemic cardiomyopathy, and an AICD device, had care needs related to potential complications and emergency care of the Mediport and AICD device that were not addressed in their care plan. The facility failed to document necessary interventions for monitoring and managing these devices. Similarly, Resident 14, diagnosed with obstructive sleep apnea and congestive heart failure, had physician orders for BiPAP and oxygen therapy, but these were not included in the care plan, leading to inadequate documentation and management of their respiratory needs. The Nursing Home Administrator and Director of Nursing confirmed these deficiencies during the survey.
Failure to Assess Residents After Sexual Abuse and Follow Bowel Protocols
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of quality by not ensuring that licensed and professional nurses promptly assessed residents following instances of sexual abuse. Specifically, two residents, one with dementia and another with multiple sclerosis, were victims of sexual abuse by another resident. Despite staff witnessing and reporting these incidents, there was no documented nursing assessment to identify potential trauma, skin injuries, bruising, or pain in the affected areas of the victims' bodies. Additionally, the facility did not follow physician's orders for administering a bowel protocol to promote bowel activity for two residents. One resident with a diagnosis of constipation did not receive the prescribed bowel regimen over a period of three days without a bowel movement. Similarly, another resident with pancreatic cancer and muscle weakness did not receive the ordered bowel regimen over four consecutive days without a bowel movement. There was no documented evidence that the staff notified the physician about the lack of bowel movements. Interviews with staff and a review of clinical records confirmed these deficiencies. The Director of Nursing acknowledged that the physician's orders were not followed to promote normal bowel activity. The failure to promptly assess residents after instances of sexual abuse and to follow physician's orders for bowel protocols were confirmed by the Nursing Home Administrator and Director of Nursing.
Failure to Provide Routine Evening Snacks
Penalty
Summary
The facility failed to ensure the provision of a nourishing evening snack when more than 14 hours elapsed between the supper meal and breakfast the next day for several residents. The facility's Snacks Policy, last reviewed in January 2024, indicated that bulk snacks and beverages should be available upon request, and bedtime snacks should be provided to all residents. However, observations and interviews revealed that snacks and beverages were not consistently available or offered to residents in the evenings. Specifically, Resident 56 mentioned that evening snacks were not always offered, and a group of six alert and oriented residents confirmed that snacks were not routinely provided in the evenings unless specifically requested. Resident 27 noted that while a snack was provided upon request, it was not offered otherwise. An observation of the resident pantry on the [NAME] Unit showed that snacks and beverages such as milk and juice were not available as per the facility policy. The foodservice director confirmed that snacks are sent each evening for nursing staff to offer to residents, but there was no documented evidence to show that residents were routinely offered and provided with a bedtime snack. The administrator also failed to provide documentation supporting the routine offering of evening snacks. This deficiency was identified under 28 Pa. Code 211.12 (d)(3)(5) Nursing Services.
Failure to Maintain Accurate and Complete Clinical Records
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for three residents, leading to deficiencies in documentation and care. Resident 6, who was admitted with hypertensive heart disease, exhibited inappropriate and sexually inappropriate behaviors towards other residents. However, the clinical records lacked detailed documentation of these incidents, including the identities of the affected residents, the nature of the behaviors, and the dates of the interactions. This lack of documentation hindered the ability to monitor and address Resident 6's behaviors effectively. Resident 45, diagnosed with dementia, was a victim of sexual abuse by Resident 6. Despite staff witnessing and reporting the incident, Resident 45's clinical record did not document the abuse or include a nursing assessment for physical signs of injury. Similarly, Resident 42, diagnosed with multiple sclerosis, was also a victim of sexual abuse by Resident 6. Staff reported witnessing the abuse, but Resident 42's clinical record did not document the incidents or include a nursing assessment for injuries. Interviews with staff confirmed that the facility's licensed and professional nursing staff failed to document complete and accurate information in the residents' clinical records. The records did not accurately represent the residents' experiences, leading to a failure in providing appropriate care and monitoring. The facility's failure to maintain accurate and complete clinical records is a violation of professional standards and state regulations.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain infection control practices to prevent the spread of infection for three residents. Resident 1, who had a stage 3 pressure ulcer and a Foley catheter, did not have Enhanced Barrier Precautions (EBP) implemented as required. Observations on two separate dates revealed no evidence of EBP for this resident. Similarly, Resident 56, who had venous ulcers and diabetic foot ulcers, also did not have EBP implemented, as observed on two different occasions. Resident 59, with a tracheal stoma, was also found without the necessary EBP during two separate observations. The facility's infection preventionist confirmed that EBP were not implemented for these residents, despite the facility's policy and CDC guidelines requiring such measures for residents at higher risk of infection. The facility's policy, last reviewed in March 2024, mandates the use of gowns and gloves for residents with conditions like MDRO colonization, indwelling medical devices, and chronic wounds. However, the observations and clinical records indicate that these precautions were not followed for the three residents mentioned.
Failure to Notify Physician and Representative of Sexual Abuse Incident
Penalty
Summary
The facility failed to timely notify the physician and the resident's representative of an incident involving potential sexual abuse. Resident 45, who has dementia, was touched inappropriately by Resident 6, who has hypertensive heart disease, in the dining room. This incident was witnessed by a nurse aide, Employee 3, who observed Resident 6 touching Resident 45 under her nightgown in the upper thigh area near her private area. Despite this observation, there was no documented evidence that the facility notified Resident 45's representative or attending physician about the incident of sexual abuse. An interview with the Director of Nursing and the Nursing Home Administrator confirmed that the facility did not notify the resident's representative and attending physician of the incident. This failure to communicate a significant change in the resident's condition and potential harm is a violation of the facility's policy on Notification of Changes, which mandates that any change in a resident's condition must be reported to the attending physician and the resident's representative.
Failure to Train Agency Employee on Abuse Policy
Penalty
Summary
The facility failed to timely train one agency employee on the facility's abuse prohibition policy and procedures. An interview with the agency nurse aide revealed that it was her first day working in the facility, and she had not received an orientation or training on the facility's abuse policy before working with residents. A review of the employee's file showed no documented evidence of abuse training prior to her working on the nursing units. The Nursing Home Administrator confirmed that there was no documentation of the required training for the employee before she assumed her job duties.
Failure to Provide Written Notices for Hospital Transfers
Penalty
Summary
The facility failed to ensure that written notices regarding facility-initiated transfers to the hospital were provided to the residents and their representatives. This deficiency was identified for five residents (Resident 27, 7, 59, 66, and 29) based on clinical record reviews and staff interviews. The clinical records revealed that these residents were transferred to the hospital on various dates and, in some cases, returned to the facility. However, there was no documented evidence that written notifications, including the reason for the transfer, effective date, location, contact information for the Office of the State Long-Term Care Ombudsman, and information for the agency responsible for the protection and advocacy of individuals with developmental disabilities, were provided to the residents and their representatives upon each transfer. An interview with the Nursing Home Administrator confirmed that there was no evidence of written notifications being provided for these facility-initiated transfers. This failure to provide the required written notices is a violation of resident rights as stipulated by 28 Pa. Code 201.29 (c.3)(2). The deficiency was identified through a combination of clinical record reviews and staff interviews, highlighting a systemic issue in the facility's process for handling hospital transfers.
Failure to Provide Written Bed Hold Policy Information
Penalty
Summary
The facility failed to provide residents or their representatives with written information about the facility's bed hold policy upon transfer to the hospital. This deficiency was identified in the cases of five residents out of 19 sampled. Specifically, Resident 27, Resident 7, Resident 59, Resident 66, and Resident 29 were transferred to the hospital on various dates and returned to the facility without documented evidence that they or their representatives received written notice of the bed hold policy. Resident 66, who was transferred to the hospital on February 24, 2024, expired at the hospital on February 28, 2024, and there was still no documented evidence of the bed hold policy being provided in writing. An interview with the Director of Nursing (DON) confirmed that the facility was unable to provide documented evidence of the provision of written notice of the facility's bed hold policy upon hospital transfer. This failure to provide the required written information is a violation of 28 Pa Code 201.18 (e)(1) Management and 28 Pa Code 201.29 (b) Resident rights.
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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