Uniontown Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Uniontown, Pennsylvania.
- Location
- 129 Franklin Avenue, Uniontown, Pennsylvania 15401
- CMS Provider Number
- 395674
- Inspections on file
- 23
- Latest survey
- July 24, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Uniontown Nursing And Rehab during CMS and state inspections, most recent first.
Facility administrative staff did not consistently meet required minimum nurse aide staffing ratios on the night shift, as shown by a review of nursing schedules and census data over a multi-week period. On multiple nights, the total nurse aide hours provided were below the calculated hours needed to maintain at least one nurse aide per 15 residents, resulting in several shifts where required coverage was not achieved. The Nursing Home Administrator acknowledged that the facility failed to provide the mandated minimum nurse aide staffing on these night shifts.
The facility did not ensure that staff providing services under contractual arrangements completed all required annual trainings, as evidenced by incomplete training records and confirmation from the Nursing Home Administrator.
Five nurse aides did not receive the required 12 hours of annual in-service education, instead receiving only one to four hours each during their respective annual periods. This deficiency was confirmed through review of facility policy, staff education records, and staff interviews.
The facility did not provide required infection control training to seven staff members, including nurse aides, a registered nurse, an occupational therapist, a housekeeping employee, and a dietary employee, as confirmed by review of training records and staff interviews.
The facility did not provide required in-service education on effective communication to several staff members, including a nurse aide, an occupational therapist, a registered nurse, a housekeeping employee, and a dietary employee, as confirmed by review of training records and staff interviews.
The facility did not provide required resident rights training to five staff members, including a nurse aide, an occupational therapist, a registered nurse, and a housekeeping employee, as confirmed by review of training records and interviews with the NHA and DON.
The facility did not provide required annual in-service education on abuse and neglect prevention to two staff members, including an occupational therapist and a housekeeping employee, as confirmed by review of training records and staff interviews. This failure was not in accordance with facility policy and state regulations regarding staff development.
Nine out of ten staff members, including nurse aides, therapy, nursing, laundry, housekeeping, and dietary staff, did not receive mandatory annual training on the facility's QAPI program as required by policy and state regulations. This deficiency was confirmed through review of training records and staff interviews.
The facility did not provide required Compliance and Ethics training to seven staff members, including nurse aides, a registered nurse, an occupational therapist, a housekeeping employee, and a dietary employee, as evidenced by missing documentation of annual in-service education. This was confirmed by the administrator during staff interviews and review of training records.
The facility did not provide required Behavioral Health training to five staff members, including a nurse aide, an occupational therapist, a registered nurse, a housekeeping employee, and a dietary employee, as evidenced by missing documentation in their in-service training records. This deficiency was confirmed by the Nursing Home Administrator and cited under state regulations for staff development and management.
The facility did not comply with its policy on employee hygiene, as a dietary aide was observed in the kitchen without a hair restraint, risking cross-contamination. The Nursing Home Administrator confirmed that kitchen staff should wear hair restraints to prevent foodborne illness.
A resident with vascular dementia and other health issues eloped from the facility due to a failure in the Wanderguard system, which was supposed to alert staff of her departure. Despite regular checks, the device was not functioning, leading to the resident being found outside by an RN. Staff interviews revealed confusion about the maintenance process, and the NHA confirmed the system's failure.
Failure to Maintain Minimum Night Shift Nurse Aide Staffing Ratios
Penalty
Summary
Facility administrative staff failed to meet state-required minimum nurse aide staffing ratios on the night shift on five of 21 reviewed days. Review of nursing schedules and census data from 4/5/26 through 4/25/26 showed that on 4/14/26, the night shift required 52.00 hours of nurse aide care but only 48.50 hours were provided; on 4/18/26, 52.00 hours were required but 43.00 hours were provided; on 4/23/26, 50.00 hours were required but 41.25 hours were provided; on 4/24/26, 50.50 hours were required but 36.50 hours were provided; and on 4/25/26, 51.00 hours were required but only 47.00 hours were provided. These shortfalls meant the facility did not maintain the mandated minimum of one nurse aide per 15 residents during the overnight shift on those dates. During an interview on 5/1/26 at approximately 12:00 p.m., the Nursing Home Administrator confirmed that the facility failed to provide the required minimum nurse aide staffing on the night shift on these five days. No specific residents, medical histories, or clinical conditions were identified in the report; the deficiency is based on staffing hours and ratios compared to the required standard for nurse aide coverage on the night shift.
Plan Of Correction
1. The Facility will continue to take measures to adequately provide staff to ensure the needs of residents are met. 2. The Facility will continue to take measures to adequately provide staff to meet the required certified nursing assistant to resident ratios on dayshift, evening shift, and night shift. 3. The Director of Nursing/designee will provide re-education on minimum staffing ratios to RN Supervisors, HR, and Scheduling who are responsible to monitor staffing and staffing ratios. 4. The Director of Nursing/designee will audit the daily schedules to monitor the minimum number of staff to resident ratios are being met. If ratios are not met the Director of Nursing/designee will make attempts to meet the number of staff to resident ratios. These audits will be conducted daily for 14 days and then weekly X 3 weeks. Audit results will be reviewed in Quality Assurance Performance Improvement Committee x 2 months.
Failure to Ensure Completion of Required Staff Training
Penalty
Summary
The facility failed to implement and maintain an effective training program for individuals providing services under contractual arrangements, as required by their roles. Review of the facility assessment and personnel files revealed that all employees were required to complete both general orientation and annual trainings on topics such as resident rights, abuse prevention, compliance, infection control, dementia care, emergency preparedness, and more. However, a review of ten training records showed that staff providing services had incomplete annual trainings. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the failure to ensure completion of required trainings for these individuals.
Failure to Provide Required Annual In-Service Education to Nurse Aides
Penalty
Summary
The facility failed to provide at least 12 hours of annual in-service education to nurse aides within 12 months of their hire date anniversary, as required by policy and regulation. A review of staff education records and facility policy revealed that five nurse aides received significantly fewer hours of in-service training than mandated, with individual totals ranging from one to four hours during their respective annual periods. The deficiency was confirmed by the Nursing Home Administrator during an interview, who acknowledged that the required training had not been completed for these staff members. This finding was based on a review of facility policy, staff education records, and staff interviews, and it specifically involved five nurse aides who did not meet the annual in-service education requirement.
Failure to Provide Required Infection Control Training to Staff
Penalty
Summary
The facility failed to provide mandatory infection control training to seven out of ten reviewed staff members, as required by its own policy and state regulations. The policy, last reviewed on 10/29/24, mandates that all new and existing staff receive training on infection prevention and control, including written standards, policies, and procedures. Documentation revealed that several staff members, including nurse aides, an occupational therapist, a registered nurse, a housekeeping employee, and a dietary employee, did not have evidence of receiving infection control in-service education within the required timeframes based on their hire dates. During an interview, the Nursing Home Administrator confirmed the lack of infection control training for these staff members. The deficiency was identified through a review of facility policies, training records, and staff interviews, and it was cited under multiple Pennsylvania state codes related to staff development and management responsibilities. No information about residents' medical history or conditions was included in the report.
Failure to Provide Effective Communication Training to Staff
Penalty
Summary
The facility failed to provide required training on effective communication to five out of ten reviewed staff members, as evidenced by a review of facility policy, personnel in-service training records, and staff interviews. The facility's policy mandates that all new and existing staff receive training on effective communication, among other topics, as part of its training program. However, documentation showed that a nurse aide, an occupational therapist, a registered nurse, a housekeeping employee, and a dietary employee did not have records of completing effective communication in-service education within the required timeframes based on their hire dates. During an interview, the Nursing Home Administrator confirmed the lack of effective communication training for these staff members. The deficiency was cited under state regulations regarding the responsibility of the licensee, management, and staff development. No information was provided regarding any residents directly affected or any immediate consequences resulting from this deficiency.
Failure to Provide Resident Rights Training to Staff
Penalty
Summary
The facility failed to provide required training on resident rights to five out of ten reviewed staff members, as evidenced by a review of facility assessment, documents, in-service training records, and staff interviews. The facility's policy mandates an effective training program for all new and existing staff, including education on resident rights and facility responsibilities. However, documentation showed that a nurse aide, an occupational therapist, a registered nurse, and a housekeeping employee did not receive in-service education on resident rights within the required timeframes. The absence of this training was confirmed by the Nursing Home Administrator and the Director of Nursing during an interview. The deficiency was identified through a review of training records, which revealed gaps in compliance with the facility's own training requirements. The affected staff members had varying hire dates, but all lacked documented resident rights training for the most recent annual period. This failure to provide mandated education was found to be in violation of state regulations regarding the responsibility of the licensee to ensure staff are properly trained.
Failure to Provide Required Abuse and Neglect Prevention Training to Staff
Penalty
Summary
The facility failed to provide required training on abuse and neglect prevention for two of ten staff members reviewed. Specifically, an occupational therapist and a housekeeping employee did not have documented in-service education on abuse and neglect prevention within the required annual period following their respective hire dates. Review of facility policy indicated that all new and existing staff must receive training on topics including abuse, neglect, and exploitation prevention, but training records did not show completion for these two employees during the specified timeframes. During staff interviews, the Nursing Home Administrator confirmed that the facility did not provide abuse and neglect prevention training for six of nine staff members reviewed. The deficiency was identified through review of facility policy, personnel in-service training records, and staff interviews. The lack of documented training was found to be out of compliance with state regulations regarding staff development and management responsibilities.
Failure to Provide Required QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training on its Quality Assurance and Performance Improvement (QAPI) program to nine out of ten reviewed staff members. Review of the facility's policy indicated that all new and existing staff are required to receive training on several topics, including the elements and goals of the QAPI program. Examination of training records and personnel files revealed that staff members from various departments, including nurse aides, an occupational therapist, a registered nurse, laundry, housekeeping, and dietary, did not have documented QAPI in-service education within the required annual period. This lack of documentation was confirmed through review of training records and staff interviews. The deficiency was further substantiated during an interview with the Nursing Home Administrator, who acknowledged that the required QAPI training had not been provided to the majority of staff reviewed. The absence of this training was found to be in violation of the facility's own policy and state regulations regarding staff development and management responsibilities. No information was provided regarding any residents directly affected or their medical conditions at the time of the deficiency.
Failure to Provide Compliance and Ethics Training to Staff
Penalty
Summary
The facility failed to provide required training on Compliance and Ethics to seven out of ten reviewed staff members, as determined through a review of facility policy, personnel in-service training records, and staff interviews. The facility's policy mandates an effective training program for all new and existing staff, including content on compliance and ethics, among other topics. Documentation revealed that several staff members, including nurse aides, an occupational therapist, a registered nurse, a housekeeping employee, and a dietary employee, did not have records of completing the required Compliance and Ethics in-service education within the specified annual timeframes. The deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the lack of documented training for the identified staff members. The absence of this training was found despite the facility's policy and the availability of annual education sessions, indicating a lapse in adherence to established staff development requirements.
Failure to Provide Behavioral Health Training to Staff
Penalty
Summary
The facility failed to provide required Behavioral Health training to five out of ten reviewed staff members, as evidenced by a review of in-service training records and staff interviews. The facility's policy mandates that all new and existing staff receive training on several topics, including Behavioral Health, as part of an effective training program. However, documentation showed that a nurse aide, an occupational therapist, a registered nurse, a housekeeping employee, and a dietary employee did not have evidence of completing Behavioral Health in-service education within the required annual period following their respective hire dates. During an interview, the Nursing Home Administrator confirmed the lack of Behavioral Health training for these five staff members. The deficiency was cited under state regulations related to the responsibility of the licensee, management, and staff development. No information was provided regarding the involvement or condition of residents, and the deficiency was based solely on staff training records and facility policy requirements.
Failure to Enforce Hair Restraints in Kitchen
Penalty
Summary
The facility failed to adhere to its policy on preventing foodborne illness through proper employee hygiene and sanitary practices. During an observation, a dietary aide was seen working in the kitchen without a hair restraint, which is a violation of the facility's policy that requires hair nets or caps and/or beard restraints to be worn to prevent hair from contacting exposed food, clean equipment, utensils, and linens. This observation was confirmed by the Nursing Home Administrator during an interview, acknowledging that kitchen staff should wear hair restraints as per the policy. The deficiency was identified during a survey, where it was noted that the facility's failure to enforce the use of hair restraints in the kitchen could potentially lead to cross-contamination, thus compromising food safety standards. The facility's policy, last reviewed on September 13, 2023, clearly outlines the necessity of hair restraints to maintain hygiene and prevent foodborne illnesses.
Elopement Incident Due to Wanderguard System Failure
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for Resident R76, resulting in an elopement incident. Resident R76, who has vascular dementia, diabetes, and high blood pressure, was identified as being at risk for elopement through evaluations conducted on admission, quarterly, and annually. Despite these assessments, Resident R76 was found outside the facility by a registered nurse, indicating a failure in the Wanderguard system, which is supposed to alert staff when a resident at risk for elopement leaves a safe area. Interviews with staff revealed that the Wanderguard system was not functioning correctly for Resident R76, as her device was not working at the time of the incident. Staff members confirmed that the Wanderguard devices are checked every shift for placement and a blinking light, and maintenance conducts weekly checks. However, there was a lack of clarity among staff about the maintenance process, and it was confirmed by the Nursing Home Administrator that the facility did not ensure the Wanderguard system was working properly for Resident R76.
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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