University City Rehabilitation And Healthcare Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- 3609 Chestnut Street, Philadelphia, Pennsylvania 19104
- CMS Provider Number
- 395722
- Inspections on file
- 36
- Latest survey
- March 23, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at University City Rehabilitation And Healthcare Ctr during CMS and state inspections, most recent first.
A resident admitted for rehab after knee arthroplasty with multiple comorbidities experienced significant medication errors when admission orders were incorrectly transcribed into the EMR. An RN entered the wrong antibiotic within the cephalosporin class, resulting in Cefaclor being administered instead of the ordered Cefadroxil, and also entered incorrect start dates for Aspirin and Lovenox. As a result, Aspirin 81 mg was given before the ordered start date while the resident was on Lovenox, and Lovenox was administered and discontinued outside the physician-ordered timeframe. The resident was notified of the errors, reported being upset, and experienced mild nausea but remained otherwise stable.
A cognitively intact resident admitted with acute respiratory failure was found with a full bottle of Fluticasone Propionate nasal spray on the bedside table that lacked a resident-specific label and was not stored in a locked compartment, contrary to facility policy requiring proper labeling and secure storage of medications. Review of the medical record showed no physician order for this nasal spray, and interviews with the resident, ADON, nurse, and DON confirmed that the medication had been given by a physician, remained at the bedside, and was not documented or labeled according to professional standards.
Two residents with upper and lower extremity range-of-motion impairments, hemiplegia, and cognitive deficits were care-planned as dependent on staff for grooming and personal hygiene, with specific interventions to check and clean nails on bath days and as needed. Observations showed each resident had a hand contracture with the hand resting in a fist, and in both cases the fingernails were long and unmaintained, including nails folding into the palm and nails that were long, thick, and dirty. A nurse confirmed that nail care was needed, demonstrating that staff did not carry out the planned ADL support and nail hygiene interventions for these dependent residents.
Both passenger elevators were not maintained in working order, leading to residents on the second floor being unable to access the onsite dialysis center for scheduled treatments after the elevators became inoperable. Staff confirmed that some residents missed their dialysis sessions due to the elevator outages.
A resident was provided with prescription medications, including baclofen and oxycodone, in their room without being observed taking them and without an assessment for self-administration. Medications were left unsecured and accessible, and the clinical record lacked documentation of any assessment for the resident's ability to self-administer drugs.
A resident with multiple complex medical conditions did not have grievances regarding delayed care, inadequate staffing, and malfunctioning call systems properly investigated or resolved by facility staff. Despite policy requiring prompt written responses, the facility failed to document any investigation or communicate findings to the complainant.
A resident with multiple medical conditions reported not receiving timely assistance with toileting, resulting in being found soiled. The facility's investigation into the alleged neglect was incomplete, as it failed to document or confirm whether the assigned nurse aide provided necessary care during the shift, leading to a deficiency in compliance with abuse and neglect investigation policies.
Two residents with ESRD missed scheduled hemodialysis treatments due to issues such as inadequate staffing, facility flooding, and an inoperable elevator, and the facility failed to notify their physicians as required by policy and physician orders.
A resident's prescribed medicated lotion was found unsecured and unlabeled in their room, contrary to facility policy requiring medications to be properly labeled and stored in locked compartments. The medication was not assigned to an individual holding area, and the bottle lacked the resident's name.
A resident did not receive moisturizer cream as ordered by the physician after all scheduled showers. Documentation showed the cream was only applied after Friday showers, with no record of application after Tuesday showers. The resident reported inconsistent application, and facility leadership confirmed the omission.
A resident room was found to have a persistent urine odor due to one resident's refusal to use the toilet or allow staff to clean up, resulting in unsanitary conditions for others sharing the room. Additional issues included a broken bed, an inaccessible overbed light, and uncomfortable room temperature, with staff and residents confirming these ongoing problems.
Two residents were found with medications at their bedside without proper assessment or physician's orders for self-administration. One resident had eye drops to maintain her home routine due to inconsistent administration times by staff, while another had hydrocortisone cream for a rash. A nurse confirmed the lack of evaluations or orders, indicating non-compliance with regulations.
A facility failed to accurately document a resident's advance directive preferences. The resident's POLST form indicated a DNR status, while the physician's orders listed a 'Full Code' status. A nurse confirmed the inconsistency and the need for clarification with the resident and physician.
A resident with moderate cognitive impairment was hit by another resident with a cane in the dining room after taking food from the latter's tray. The facility failed to document a care plan for the resident's known behavior of taking food from others, and the incident was not fully documented by staff. The facility's policy on abuse prevention was not adequately followed, leading to resident-to-resident abuse.
A facility failed to provide a resident and their representative with a written notice of the bed-hold policy during a transfer to a hospital. The resident was admitted for chest pain, but there was no documentation of the required notice being given. An interview with the Nursing Home Administrator confirmed the absence of a system to ensure compliance with this requirement.
The facility failed to develop baseline care plans for two residents, leading to deficiencies in their care. One resident, admitted with orthopedic aftercare needs, did not have her bathing preferences and assistance needs documented, while another resident with a surgical wound requiring enhanced barrier precautions lacked appropriate care plan documentation. Staff were unable to provide necessary information or documentation for these residents' care needs.
The facility failed to provide adequate assistance with ADLs for two residents. One resident, admitted with orthopedic aftercare needs, did not receive proper bathing assistance, while another resident, requiring total assistance with eating due to medical conditions, was left without 1:1 feeding help. Staff were unaware of specific care needs, leading to unmet essential daily living activities.
Three residents experienced significant delays in medication administration, with medications scheduled for the morning and evening being administered several hours late. A nurse was observed administering morning medications late, confirming the delay. The facility's policy requires medications to be administered within one hour of their prescribed time, which was not followed.
A facility failed to maintain a PICC line for a resident with osteomyelitis, as the dressing was not changed according to policy and physician orders. The dressing was observed to be soiled and not adhering properly, despite records indicating a recent change. Interviews revealed discrepancies between documented care and actual practice, with an LPN admitting to not having changed the dressing.
The facility failed to maintain accurate records and reconcile controlled drugs as required. Observations revealed missing documentation in narcotic log books for several periods across three medication carts, indicating that shift-to-shift counts were not completed. Interviews with licensed nurses confirmed these findings, highlighting a lapse in adherence to the facility's policy on controlled substances.
The facility failed to properly label and date insulin pens, as observed in two medication carts. Several insulin pens were found opened and undated, and one was not labeled with a resident's name. This was confirmed by two LPNs during observations. The facility's policy requires that the date opened be recorded on multi-dose containers and that insulin pens be labeled with the resident's name.
The facility failed to meet the dietary preferences and needs of two residents. One resident did not receive requested meal items, such as tuna salad and coffee, while another resident following a vegetarian diet did not receive appropriate vegetarian protein options. The facility lacked necessary vegetarian products, and staff were unable to explain the discrepancies in meal provisions.
A facility failed to use enhanced barrier precautions during medication administration for a resident with a feeding tube. The resident, who had oropharyngeal dysphagia and malnutrition, required a gastrostomy tube. Despite the facility's policy requiring gown and gloves during high-contact care activities, an LPN did not use these precautions while caring for the resident's PEG tube.
The facility failed to ensure functional and accessible call devices for two residents. One resident's call bell was non-functional, while another's was repeatedly found on the floor and out of reach. The latter resident, being soft-spoken, had no alternative means to call for assistance. A nurse aide confirmed the call bell's tendency to fall, highlighting the inaccessibility issue.
The facility failed to maintain required nurse aide staffing ratios on multiple occasions, as evidenced by staff schedules and punch reports. On several dates, the facility did not provide the necessary hours of nurse aide care based on the resident census, leading to a deficiency in staffing. The Nursing Home Administrator confirmed the failure to meet these staffing requirements.
The facility failed to meet required LPN staffing ratios on six occasions, affecting day, evening, and overnight shifts. For example, on one occasion, 23.00 hours of LPN care were needed overnight for 115 residents, but only 16.00 hours were provided. The Nursing Home Administrator confirmed the staffing shortfalls.
The facility failed to provide the required 3.20 hours of direct nursing care per resident on multiple occasions, as revealed by a review of nursing schedules and punch reports. The deficiency was confirmed by the Nursing Home Administrator, indicating a systemic issue in maintaining adequate staffing levels.
The facility failed to maintain delayed egress doors as required by NFPA 101, specifically lacking proper signage on a ground floor door leading to the loading dock. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility failed to maintain its sprinkler system, affecting two levels. On the second floor, storage was found within 18 inches of sprinklers in a supply closet, and on the ground floor, several ceiling tiles were missing in a construction area. These issues were confirmed during an exit interview with the Administrator and Maintenance Director.
The facility failed to maintain the fire resistance of smoke barriers due to unsealed penetrations by data wires. Observations revealed these penetrations on the second floor near a resident room and on the first floor near another resident room. This deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director.
The facility was found to be in violation of building construction requirements as it is a three-story, Type II (000), unprotected non-combustible building with a basement and sub-basement, exceeding the maximum allowed stories for this construction type. The building is fully sprinklered, but the story height surpasses the permitted limit. This was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility was found to be non-compliant with NFPA 101 Life Safety Code requirements, as the sub-basement lacked two required emergency fire exits. This deficiency affects one of the six smoke compartments and was confirmed during an interview with the Administrator and Maintenance Director.
The facility failed to serve food at the proper temperature, as two residents reported receiving cold and burnt food. A test tray observation revealed that juice, canned pineapple, and cold pie were served at temperatures above the acceptable range, which was acknowledged by the facility cook.
A facility failed to administer and document a prescribed topical ointment for a resident as per physician orders. The resident reported not receiving the ointment for several days, and a review of records confirmed the lack of documentation for its administration. Interviews with the DON and facility administrator verified these findings.
The facility failed to ensure that employee identification tags were displayed as required. An LPN and two Nurse Aids were observed providing care without visible identification tags. Interviews revealed that one LPN needed to look for her tag, one Nurse Aid did not have a tag, and another Nurse Aid stated she would retrieve it. The Nursing Home Administrator confirmed the requirement for visible identification.
The facility did not notify the State Long-Term Care Ombudsman of emergency transfers and discharges for five residents. These residents experienced medical emergencies requiring hospital evaluations, but the facility failed to document the necessary notifications. The Regional Director confirmed the lack of documentation during an interview.
The facility failed to document the risk and benefits of influenza, pneumococcal, and COVID-19 vaccines in the medical records of several residents. Additionally, two residents' records lacked documentation of tuberculosis tests and various vaccines. The DON confirmed that while the vaccines were administered, the details were not properly recorded.
The facility failed to maintain effective infection control during medication administration for three residents. An LPN used improper techniques, such as handling medications with fingers and pouring excess liquid back into bottles, violating the facility's infection control policy.
A resident with multiple diagnoses and a BIMS score indicating cognitive intactness was found with six pills on the bedside table without a physician order for self-administration. The medication was left by a nurse at the resident's request, contrary to facility policy.
The facility failed to maintain a clean, comfortable, and homelike environment for three residents. One resident's room was very dark due to a broken window blind, and another resident's dresser had a missing front panel. Staff and maintenance confirmed awareness of these issues.
The facility failed to complete comprehensive MDS assessments at discharge for three residents. One resident was transported to the hospital after a fall, and two others were discharged home by the facility's contracted transportation service. These deficiencies were confirmed by the RN Assessment Coordinator.
A resident with multiple medical conditions was found to have a Fentanyl patch that was not properly labeled with the date of application, only the employee's initials. The Director of Nursing confirmed the labeling error, which violated the facility's medication administration policy.
A resident with limited range of motion did not receive appropriate treatment and services to prevent further decrease in ROM. Despite having a care plan and physician's order for a hand splint, the resident was not evaluated for splinting during occupational therapy, and no current orders for a splint were found. Staff confirmed the need for a splint to prevent deterioration of hand function.
The facility failed to label and date enteral feeding formulas for two residents, despite facility policy requiring such labeling. This was confirmed by both a licensed nurse and the Director of Nursing.
The facility failed to implement a complete drug regimen review process for two residents, leading to deficiencies in medication management. For one resident with COPD and another with Parkinson's disease, there was no documentation indicating that the attending physician reviewed or acted upon the pharmacist's recommendations. Additionally, inconsistencies were found in the pharmacy review process for another resident, with delays and missing documentation.
The facility failed to document the dates of TST results for newly hired staff members, making the results inconclusive. The personnel files for four employees were missing the date that the TST was read, and the Regional Nursing Home Administrator confirmed this omission during an interview with surveyors.
The facility failed to ensure that call bells were available and operable for resident use, affecting three residents. One resident's call bell was non-functional for several days, and two residents were observed without call bell connections in their room. Staff and maintenance were either unaware or did not promptly address the issues.
A resident experienced significant unplanned weight loss, and the facility failed to ensure a physician assessment was completed as required by policy. Despite the Registered Dietitian's intervention, there was no documentation of physician involvement until much later, leading to a deficiency in compliance with state regulations.
The facility failed to administer medications according to professional standards for a resident, who received another resident's medication for a couple of months. The facility also did not place refill orders for the resident's medication for three months, as confirmed by the DON and pharmacy documentation.
The facility failed to store medications according to professional standards. An LPN found a resident's Diclofenac Sodium Topical Gel 1% in the resident's unlocked drawer instead of the locked medication cart, contrary to facility policy.
Medication Reconciliation and Administration Errors Leading to Significant Medication Variances
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when medications were not administered in accordance with physician orders. The resident was admitted for rehabilitation following a right total knee arthroplasty with additional diagnoses including hypertension, hyperlipidemia, coronary artery disease, obesity, and osteoarthritis. Hospital discharge medications included Aspirin EC 81 mg, Cefadroxil 500 mg every 12 hours, and Enoxaparin (Lovenox) 30 mg subcutaneously every 12 hours. The facility’s own policies required accurate medication reconciliation on admission, verification of correct medication, dose, time, and route, and administration in accordance with physician orders. Record review showed that Aspirin 81 mg was administered earlier than ordered. The original order entered at the facility directed Aspirin 81 mg chewable twice daily starting on a specific date, but this was later corrected to start two days later due to concurrent Lovenox therapy. Despite the corrected order specifying that Aspirin was to be held until the later start date, the MAR showed that Aspirin 81 mg was administered before that start date. Physician and nursing notes documented that Aspirin 81 mg, which was ordered to be held until a specified date because of concurrent Lovenox therapy, was given early. The review also revealed that the wrong antibiotic within the same drug class was transcribed and administered. Hospital records showed an order for Cefadroxil 500 mg every 12 hours for postoperative prophylaxis, but the MAR documented administration of Cefaclor 500 mg every 12 hours instead. The corrected order clarified that Cefadroxil 500 mg was the intended medication, to be given every 12 hours for 7 doses starting on a later date. Additionally, Lovenox 30 mg subcutaneously every 12 hours was ordered to start on a specific date and continue until another specified date, but the MAR indicated that Lovenox was administered earlier than the ordered start date and discontinued before the ordered end date. The DON reported that these errors resulted from a transcription error during admission medication reconciliation, where the nurse did not accurately enter the physician’s discharge orders into the electronic medical record. The resident was informed of the administration of the wrong medications and expressed upset and dissatisfaction. Physician and nursing progress notes documented that the resident experienced mild nausea but remained stable with no other adverse effects noted at that time. The facility’s incident report identified that the licensed nurse responsible for reconciling the admission orders entered the wrong medication and incorrect start dates, leading to the administration of Aspirin before the ordered start date, substitution of Cefaclor for Cefadroxil, and incorrect timing of Lovenox administration, all of which were not in accordance with physician orders.
Unlabeled, Unordered Nasal Spray Left at Resident Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medications were stored and labeled according to professional standards and facility policy for one resident. Facility policy required that medications and biologicals be stored in locked compartments, that only the issuing pharmacist authorize transfer of medications between containers, that medications be stored in an orderly manner with each resident’s medications assigned to an individual area, and that labels include the medication name, prescribed dose, strength, expiration date when applicable, resident’s name, route of administration, and appropriate instructions and precautions. The policy also specified that only the dispensing pharmacy may label or alter the label on a medication container or package. Resident R1, who was cognitively intact per a BIMS score of 15 and admitted with a diagnosis of acute respiratory failure, was observed to have a full bottle of Fluticasone Propionate nasal spray on the bedside table during a unit tour. The bottle did not have a label with the resident’s name, and review of the physician’s orders showed no order for Fluticasone Propionate nasal spray for this resident. The resident reported that the physician had given the nasal spray the previous day. The ADON and a licensed nurse confirmed that the unlabeled Fluticasone Propionate nasal spray was present at the bedside and that there was no physician’s order for it. A follow-up observation with the DON again found the same unlabeled, full nasal spray bottle at the bedside, confirming that the medication was not stored in a locked compartment and was not labeled in accordance with facility policy and professional standards.
Failure to Provide Nail and Personal Hygiene Care for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain personal care and hygiene, specifically nail care, for dependent residents who required staff assistance with activities of daily living (ADLs). Facility policy stated that appropriate care and services were to be provided for residents unable to carry out ADLs independently, including hygiene such as grooming and personal care. Resident R68’s quarterly MDS dated December 10, 2025, showed impairment in range of motion in both upper and lower extremities, moderate cognitive impairment, and diagnoses including CVA, right-sided hemiplegia, and malnutrition. The comprehensive care plan dated October 25, 2024, identified an ADL self-care performance deficit and dependence on staff for grooming/personal hygiene, with an intervention dated December 4, 2025, directing staff to check nail length and clean on bath day and as necessary. On January 7, 2026, at 10:15 a.m., observation revealed a right-hand contracture with the hand naturally in a fist and fingernails that were long and folding into the palm; the resident confirmed wanting the nails trimmed. Resident R10’s comprehensive MDS indicated impairment in range of motion in upper and lower extremities and dependence on staff for personal hygiene, along with severe cognitive impairment and diagnoses of arthritis, aphasia, CVA, and hemiplegia or hemiparesis. The comprehensive care plan dated May 14, 2021, documented an ADL self-care performance deficit and the need for assistance with grooming/personal hygiene, with an intervention dated November 5, 2021, to check nail length and clean on bath day and as necessary. On January 8, 2026, at 12:15 p.m., observation showed a right-hand contracture with the hand naturally in a fist. With assistance from Licensed Nurse Employee E11, the resident’s right hand was opened, revealing long, thick nails with dirt beneath them; the nurse confirmed that the nails required care. These findings demonstrated that staff did not follow the care-planned interventions and policy requirements to monitor and maintain nail hygiene for these dependent residents.
Failure to Maintain Operational Elevators Resulting in Missed Dialysis Treatments
Penalty
Summary
The facility failed to ensure that both passenger elevators were maintained in safe and working condition, resulting in periods where neither elevator was operational. Documentation shows that the #2 passenger elevator was reported as out of service in December 2024 and remained inoperable for several months, with technicians indicating that additional resources were required for repairs. On a separate occasion, the #1 passenger elevator was also reported as shut down, and although technicians checked the unit, issues persisted. These elevator outages were confirmed through facility records and staff interviews. As a direct result of the inoperable elevators, residents residing on the second floor were unable to access the first-floor onsite dialysis center for their scheduled treatments. Specifically, dialysis treatments that had been rescheduled due to staffing issues could not be provided to some residents because the elevator was not functioning, preventing their transport to the dialysis center. Staff interviews corroborated that residents missed their dialysis sessions due to the elevator failures.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was properly assessed for self-administration of medications. During an observation in the resident's room, a bottle of medicated lotion was found unsecured on the dresser, and a medication cup containing three white pills was left on the bedside table. The resident confirmed that nurses routinely leave medications in his room for him to take on his own. A licensed nurse verified that she provided the resident with his medication in the room but did not observe him taking it. The pills included two 5 mg tablets of baclofen, prescribed for chronic pain, and one 5 mg tablet of oxycodone, prescribed for pain. Review of the clinical record showed no evidence that the resident had been assessed for the ability to self-administer medications.
Failure to Investigate and Resolve Resident Grievances
Penalty
Summary
The facility failed to ensure that grievances submitted by a resident's family regarding the resident's care were properly investigated and resolved in a timely manner, as required by facility policy. The policy states that all grievances must be reviewed, investigated, and responded to in writing within five working days, with findings and corrective actions communicated to the complainant both verbally and in writing. However, documentation revealed that grievances submitted on two separate occasions were not listed in the facility's grievance log, and there was no evidence that these grievances were investigated or that prompt efforts were made to resolve the concerns. The grievances submitted by the resident's daughter included allegations that the resident, who had diagnoses of hypertension, cerebral infarction, cognitive communication deficit, end stage renal disease, and dependence on renal dialysis, was left in soiled clothing for extended periods and was not changed in a timely manner. Additional concerns included inadequate staffing, malfunctioning call systems, and lack of consistent supervision of CNAs. The family reported repeated delays in care and lack of response to call bells, as well as concerns about the resident not being showered for several days. Despite these detailed complaints, the facility did not document any investigation or resolution efforts for these grievances. Interviews with facility leadership confirmed receipt of the grievances, but they were unable to provide evidence that the concerns were investigated or that findings were communicated to the complainant. The resident's daughter also confirmed that she had not received any written response or findings regarding her grievances, despite requesting them. This failure to follow grievance policy and to address the family's concerns constitutes a deficiency in honoring the resident's right to voice grievances without discrimination or reprisal.
Incomplete Investigation of Alleged Resident Neglect
Penalty
Summary
The facility failed to conduct a complete and thorough investigation into an allegation of potential abuse/neglect involving a resident with multiple complex medical conditions, including hypertension, cerebral infarction, cognitive communication deficit, end stage renal disease, and dependence on renal dialysis. The incident in question involved the resident contacting his wife to report that he needed assistance with changing, but staff did not respond in a timely manner, resulting in the resident being found in soiled pajamas soaked in urine and feces. The facility initiated an investigation, interviewing several staff members and the resident, but did not obtain or document critical information from the assigned nurse aide regarding whether and when she assisted the resident with toileting or changing during her shift. The investigation was ultimately deemed unsubstantiated by the facility, but review of the documentation revealed that the process was incomplete. Specifically, there was no evidence that the facility asked the assigned nurse aide about her involvement in the resident's care during the relevant shift, nor was there documentation of her actions related to the resident's toileting needs. During a subsequent interview, facility leadership could not provide evidence that this key aspect of the investigation had been addressed. This failure to conduct a comprehensive investigation was found to be out of compliance with facility policy and state regulations regarding the reporting and investigation of abuse and neglect.
Failure to Notify Physician of Missed Dialysis Treatments
Penalty
Summary
The facility failed to notify physicians when residents did not receive their scheduled hemodialysis treatments at the onsite dialysis center. This deficiency was identified for two residents with end-stage renal disease who were dependent on regular dialysis as ordered by their physicians. The facility's policy required care according to recognized standards, which includes physician notification when ordered treatments are missed. For one resident, multiple missed dialysis sessions occurred due to various reasons, including a flood in the dialysis center, inadequate staffing, and an inoperable elevator preventing access to the treatment area. Nursing notes documented the missed treatments but did not show evidence that the physician was notified on any of these occasions. Interviews with facility staff confirmed the lack of documentation and physician notification for each missed or rescheduled dialysis session. A second resident also missed scheduled dialysis treatments due to inadequate staffing and the inoperable elevator. Again, there was no evidence in the nursing notes or clinical record that the physician was notified of these missed treatments. Staff interviews corroborated that the required notifications were not made, and the deficiency was cited under relevant state codes for medical records, resident care policies, and nursing services.
Failure to Properly Label and Secure Medication
Penalty
Summary
Facility staff failed to ensure that medications were properly labeled and securely stored in accordance with professional standards. During an observation in a resident's room, a bottle of medicated lotion (Amlactin Daily External Lotion 12%) was found sitting unsecured on top of the resident's dresser. The bottle did not have any labeling to indicate to whom the medication was prescribed, as there was no individual's name listed on the medication bottle. Review of the facility's policy on medication labeling and storage indicated that nursing staff are responsible for maintaining medication storage areas in a safe and orderly manner, with each resident's medications assigned to an individual holding area to prevent mixing. The resident in question had physician orders for the medicated lotion to be applied daily for dry skin, but the medication was not stored or labeled as required. Facility leadership, including the NHA and DON, were notified of these findings.
Failure to Administer Moisturizer as Ordered After Showers
Penalty
Summary
A deficiency was identified when a resident did not receive moisturizer cream as ordered by the physician following showers. The physician's order specified that moisturizer should be applied within three minutes after each shower to lock in moisture, with repeat applications as needed for dry areas. Documentation review showed that the moisturizer was only applied after Friday showers, with no evidence of application after Tuesday showers as required. The resident reported that the nurse did not consistently apply the moisturizer, and facility leadership confirmed that the application was missed on Tuesdays.
Failure to Maintain Clean, Comfortable, and Homelike Resident Room
Penalty
Summary
Surveyors observed that a resident room had a persistent and strong urine odor, which was confirmed by both staff and residents. One resident in the room consistently urinated on the floor and in her trash can, refusing to use the toilet or allow staff to place a bedside commode. The resident also did not permit staff to empty the trash can, resulting in urine spilling onto the floor. Additionally, the resident refused to allow staff to bathe her, except for one nurse aide she occasionally accepted. These behaviors led to ongoing unsanitary conditions in the shared room. Other residents in the room reported that the odor was constant and that the room was also uncomfortably cold, as nurse aides would turn down the temperature on the heating unit. One resident stated that her bed was broken and the head of the bed would not go up all the way. She also reported that the cord on her overbed light was too short for her to reach while in bed, making it difficult to turn the light on or off at night. Staff interviews confirmed the overwhelming odor and the ongoing issues with the resident's behaviors, as well as the lack of resolution to the complaints about the room's condition.
Failure to Evaluate Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were evaluated for self-administration of medications, as required by 42 CFR part 483.10(c)(7). Specifically, two residents, identified as R114 and R12, were found to have medications at their bedside without proper assessment or physician's orders. Resident R114 had two containers of eye drops, latanoprost and brimonidine tartrate, which she kept at her bedside to maintain her home routine, citing inconsistent administration times by the nursing staff. However, there was no documentation in her clinical record indicating that she had been assessed for the capacity and ability to safely self-administer these medications. Similarly, Resident R12 had a tube of hydrocortisone cream at her bedside, which she used as needed for a rash on her leg. Like Resident R114, there was no evidence in her clinical record of an assessment for her ability to self-administer the medication safely. Observations and interviews with Employee E6, a licensed nurse, confirmed the presence of these medications at the residents' bedsides and the lack of necessary evaluations or physician's orders for self-administration. This oversight indicates a failure to comply with both federal and state regulations regarding resident rights and pharmacy services.
Plan Of Correction
1. R114 eye drops at bedside have been removed. R12 hydrocortisone cream was removed. No adverse effects were noted. 2. An initial audit was conducted to ensure medication is not at any residents bedside unless self administration evaluation was completed and residents were deemed safe to self administer. Variances were addressed at the time of the audit and placed on the facility audit tool. 3. Licensed nursing staff were educated by DON/designee on policy of medication at bedside and self-administration. 4. DON/Designee will conduct audit on medication at bedside which will be completed 3 times per week for 4 weeks then 1 time a month for 2 months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations as needed.
Discrepancy in Resident's Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that a resident's right to request or refuse medical treatments was accurately reflected in the resident's clinical record. Specifically, for Resident R86, there was a discrepancy between the physician's orders and the resident's POLST form regarding life-saving interventions. The physician's orders indicated a 'Full Code' status, allowing all interventions needed to restore breathing or heart functioning, while the POLST form, signed by the resident, indicated a 'Do Not Resuscitate' (DNR) status, meaning the resident did not want life-saving interventions in the event of no pulse and stopped breathing. This inconsistency was confirmed during an interview with Employee E5, a licensed nurse, who acknowledged that Resident R86's wishes regarding life-saving medical treatments were not accurately reflected in the clinical record. The nurse indicated the need to clarify the resident's wishes with both the resident and the physician. This deficiency highlights a failure in accurately documenting and respecting the resident's advance directives, as required by facility policy and state regulations.
Plan Of Correction
1. R86 POLST form and order were updated and accurately reflect the residents' wishes. 2. An initial audit was conducted to ensure all POLST forms and physicians orders match per residents wishes. Variances were addressed at the time of the audit and placed on the facility audit tool. 3. Social Services and licensed nursing staff were educated by DON/designee to ensure POLST form and orders coincide. 4. DON/Designee will conduct an audit on POLST forms/physicians orders for advanced directives 3 times per week for 4 weeks then 1 time per month for 2 months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations as needed.
Resident-to-Resident Abuse Due to Inadequate Behavior Management
Penalty
Summary
The facility failed to ensure that residents were free from resident-to-resident abuse, as evidenced by an incident involving two residents. Resident R77, who has a history of wandering and taking food that is not his, was involved in an altercation with Resident R37 in the dining room. Resident R77, with a BIMS score indicating moderate cognitive impairment, was eating food from Resident R37's tray when Resident R37 returned and began hitting him with her cane. Resident R37, who is cognitively intact, expressed frustration that Resident R77 frequently attempted to eat her food. The facility's investigation revealed multiple staff members witnessed the incident, including a nurse assistant who saw Resident R37 hitting Resident R77 with her cane. Despite the presence of staff, the facility's documentation was incomplete, as it failed to include a statement from one of the nurse assistants who witnessed the altercation. Additionally, interviews with staff indicated that Resident R77 had a known history of taking food from others, yet there was no documented evidence of interventions or a care plan addressing this behavior prior to the incident. The facility's policy on abuse prevention emphasizes the residents' right to be free from abuse and neglect, particularly for those with behavioral or cognitive issues. However, the lack of a care plan for Resident R77's behavior and the incomplete documentation of the incident suggest a failure to adhere to this policy. The facility administrator confirmed the absence of a care plan addressing Resident R77's behavior of taking food from others, highlighting a gap in the facility's approach to managing resident behaviors and preventing abuse.
Plan Of Correction
This Plan of Correction constitutes this facility's written allegation of compliance for the deficiencies cited. This submission of this plan of correction is not an admission of or agreement with the deficiencies or conclusions contained in the Department's inspection report. 1. R37 and R77 were separated at the time of the incident with no more physical interactions. 2. An initial audit was conducted for past 30 days of resident-to-resident altercations to ensure proper interventions are in place to prevent abuse. Variances were addressed at the time of the audit and placed on the facility audit tool. 3. NHA/Designee will educate all staff on abuse prevention policy and procedures. 4. NHA/Designee will conduct an audit of all resident to resident abuse altercations 3 times per week for 4 weeks then 1 time per month for 2 months to ensure proper interventions/preventions were in place to prevent. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations as needed.
Failure to Provide Bed-Hold Policy Notice Upon Transfer
Penalty
Summary
The facility failed to provide Resident R15 and their representative with a written notice of the facility's bed-hold policy at the time of a facility-initiated transfer to a hospital. This deficiency was identified during a clinical record review and staff interview. The nursing note for Resident R15, dated August 6, 2024, indicated that the resident was admitted to the hospital for chest pain. However, there was no documented evidence in the clinical record that the required written notice, detailing the duration of the bed-hold policy, reserve bed payment policy, and the facility's policies regarding bed-hold periods, was provided to the resident or their representative. An interview with the Nursing Home Administrator, Employee E1, confirmed that neither Resident R15 nor their representative received the necessary bed-hold policy information at the time of transfer. Furthermore, it was acknowledged that there was no system in place to ensure that residents and their representatives receive this written notice during such transfers. This oversight is a violation of the regulatory requirements outlined in §483.15(d)(1)(2) and related state codes, which mandate that residents and their representatives be informed of the bed-hold policy before and upon transfer.
Plan Of Correction
1. Unable to retroactively resolve as R15 is already back into the center. R15 was educated of bed hold policy if for future he does require hospitalization. 2. Center unable to retroactively supply bed hold policies. 3. NHA/Designee will educate nursing supervisors on bed hold policies for facility-initiated transfers to the hospital. 4. NHA/Designee will conduct an audit on all facility-initiated transfers 3 times per week for 4 weeks then 1 time a month for 2 months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations as needed.
Failure to Develop Baseline Care Plans for Residents
Penalty
Summary
The facility failed to develop baseline care plans for two residents, leading to deficiencies in their care. Resident R114, who was admitted with orthopedic aftercare needs, expressed dissatisfaction with her bathing arrangements, as she was only provided with a basin of water and had not had her hair washed since admission. Her care plan did not include interventions related to her preferences and assistance needs for bathing, and a nurse aide was unable to state the level of assistance or preferences required by the resident. Resident R277, admitted with a surgical abdominal wound requiring dressing changes, did not have a care plan indicating the need for enhanced barrier precautions, despite a sign outside her door stating such precautions were necessary. A licensed nurse confirmed the requirement for enhanced barrier precautions due to the resident's surgical wound, but there were no physician orders or care plan documentation to support this need.
Plan Of Correction
1. R114 was given a shower at the time of request. R277 no longer resides in the center. 2. An initial audit was conducted of current residents to validate care plans are updated with bathing preferences and assistance needs. An initial audit was completed of residents that require enhanced barrier precautions to validate orders and care plans. Variances were addressed at the time of the audit and placed on the facility audit tool. 3. DON/Designee educated the nursing staff on residents' bathing preferences and assistance needs and obtaining orders and updating care plans for enhanced barrier precautions. 4. DON/Designee will conduct a random audit to ensure shower preferences are being met and enhanced barrier precautions orders and care plans are updated. This audit will be conducted 3 times per week for 4 weeks then 1 time a month for 2 months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations as needed.
Failure to Provide Adequate ADL Assistance for Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for two residents, specifically in the areas of bathing and eating. Resident R114, who was admitted with orthopedic aftercare needs, expressed dissatisfaction with the bathing assistance provided, stating she only received a basin of water for bed washing and had not had her hair washed since admission. The resident's care plan lacked specific interventions for her bathing preferences and needs, and documentation showed no record of showers or bathing until over a month after her admission. A nurse aide was unaware of the resident's specific assistance needs and did not provide hair washing, assuming the family handled hair care. Resident R78, admitted with conditions including cerebrovascular accident and dysphagia, required total assistance with eating due to shoulder and hand fractures. Despite a physician's order for 1:1 feeding assistance, observations revealed that the resident's meal tray was left untouched, and he was unable to feed himself. Staff failed to provide the necessary assistance, leaving the resident to struggle with eating, resulting in him consuming only a few bites of his meal. The resident reported that the food was cold and unappealing due to the delay in assistance. Interviews with staff indicated a lack of awareness regarding the specific assistance needs of Resident R78, with a nurse aide only recently learning of the requirement for 1:1 feeding assistance. The facility's failure to adhere to care plans and physician orders for these residents resulted in unmet needs for essential daily living activities, highlighting deficiencies in the provision of care and services as required by regulations.
Plan Of Correction
1. R114 was given a shower at the time of request. Unable to retroactively resolve R78 not eating his full meal and no adverse effects were noted. 2. An initial audit was conducted to validate assistance is provided with bathing and 1:1 feeding assistance. Variances were addressed at the time of the audit and placed on the facility audit tool. 3. DON/designee will re-educate the nursing staff on providing bathing and 1:1 feeding assistance. 4. DON/Designee will conduct random audits to ensure bathing and 1:1 feeding assistance is being provided. This audit will be conducted 3 times per week for 4 weeks, then 1 time a month for 2 months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations as needed.
Medication Administration Delays
Penalty
Summary
The facility failed to administer medications in a timely manner for three residents, as evidenced by observations, policy reviews, clinical record reviews, and interviews. Resident R107 reported not receiving her 9:00 p.m. medications until after midnight and her 9:00 a.m. medications until nearly 2:00 p.m. on the following day. Her scheduled medications included treatments for depression, seizures, and blood clots. Similarly, Resident R277's medications, which included treatments for depression, allergies, pain, high blood pressure, and blood clots, were also administered late, with a delay of nearly five hours past the scheduled time. Resident R278 experienced a similar delay, with her morning medications, including treatments for fluid retention, glaucoma, high blood pressure, and steroid medication, not administered until nearly 2:00 p.m. An observation of Employee E5, a licensed nurse, revealed that she was still administering morning medications late into the morning, confirming the delay. The facility's policy requires medications to be administered within one hour of their prescribed time, which was not adhered to in these instances.
Plan Of Correction
1. Unable to retroactively correct R107, R277, R278 being administered medication late. 2. An initial was conducted of past 7 days to validate timely medication administration. Variances were addressed at the time of the audit and placed on the facility audit tool. 3. DON/Designee will re-educate licensed nursing staff on timeliness of medication administration. 4. DON/Designee will conduct random audits to validate medications were administered timely. This audit will be conducted 3 times per week for 4 weeks then 1 time a month for 2 months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations as needed.
Failure to Maintain PICC Line as per Standards
Penalty
Summary
The facility failed to maintain a peripheral inserted central catheter (PICC) for a resident diagnosed with osteomyelitis of the vertebra, who was receiving intravenous antibiotics through the PICC line. The facility's policy required that the PICC dressing be changed immediately if compromised and at least every seven days. However, during an observation, the dressing was found to be soiled and not adhering properly, with a date indicating it had not been changed since January 11, 2024, despite the resident's treatment administration record indicating a change had been documented the previous day. Interviews with the Assistant Director of Nursing (ADON) and a Licensed Practical Nurse (LPN) revealed discrepancies in the documentation and actual care provided. The ADON acknowledged the dressing should have been changed, and the LPN admitted to never having changed the resident's PICC line, despite records suggesting otherwise. This discrepancy indicates a failure to adhere to professional standards of practice and physician orders, as well as a lack of compliance with the comprehensive person-centered care plan for the resident.
Plan Of Correction
1. R110's PICC dressing was changed immediately. No adverse effects were noted. 2. An initial audit was conducted of residents to validate that their PICC dressings were changed per order. Variances were addressed at the time of the audit and placed on the facility audit tool. 3. DON/Designee will re-educate the licensed nursing staff on changing PICC line dressings per order. 4. DON/Designee will conduct random audits of residents with PICC lines to ensure dressing changes are completed per order. This audit will be conducted 3 times per week for 4 weeks, then 1 time a month for 2 months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations as needed.
Failure to Maintain Accurate Controlled Drug Records
Penalty
Summary
The facility failed to ensure that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled. This deficiency was identified during observations and interviews with staff, as well as a review of facility policies. The facility's policy on 'Controlled Substances' requires that controlled substance inventory be monitored and reconciled to identify loss or potential diversion, with nursing staff counting controlled medication inventory at the end of each shift. However, it was found that there was no documentation in the narcotic log books for several periods across three medication carts on the first floor, indicating that shift-to-shift counts were not completed as required. During observations on January 21, 2025, it was noted that the narcotic log books for the first floor front, back, and middle medication carts lacked documentation of shift-to-shift counts for various dates spanning from October 2024 to January 2025. Interviews with the licensed nurses responsible for these carts confirmed the absence of required documentation. In one instance, a nurse attempted to sign the log book without a corresponding signature from the previous shift, further indicating a lapse in the reconciliation process. These findings demonstrate a failure to adhere to the facility's policy and regulatory requirements for maintaining accurate drug records.
Plan Of Correction
1. Unable to retroactively correct. No adverse effects were noted. 2. An initial audit was conducted to validate shift to shift counts in narcotic log books are completed. Variances were addressed at the time of the audit and placed on the facility audit tool. 3. DON/Designee will re-educate the licensed nursing staff on proper documentation of shift to shift counts in the narcotic log books. 4. DON/Designee will conduct random audits of narcotic log books to ensure documentation of shift to shift counts are completed. This audit will be conducted 3 times per week for 4 weeks then 1 time a month for 2 months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations as needed.
Failure to Properly Label and Date Insulin Pens
Penalty
Summary
The facility failed to ensure that insulin pens were labeled in accordance with currently accepted professional principles. During an observation of the first floor back medication cart, it was found that several insulin pens were opened and undated. Specifically, an aspart insulin pen for a resident, a glargine insulin pen for another resident, a lispro insulin pen that was not labeled with a resident's name, a degludec insulin pen for a different resident, and another aspart insulin pen for yet another resident were all found to be opened and undated. These findings were confirmed by Employee E11, a licensed nurse, during the observation. Further observation of the first floor middle medication cart revealed a glargine insulin pen for a resident that was also opened and undated. This was confirmed by Employee E5, another licensed nurse. The facility's policy on administering medications, dated April 2019, states that when opening a multi-dose container, the date opened should be recorded on the container, and insulin pens should be clearly labeled with the resident's name or other identifying information. The failure to adhere to this policy led to the deficiency noted in the report.
Plan Of Correction
1. R122, R25, R5, R380 open and undated medication were disposed of and replaced. 2. An initial audit was conducted of insulin pens to ensure they are properly labeled and dated. Variances were addressed at the time of the audit and placed on the facility audit tool. 3. DON/Designee will re-educate licensed nurses on proper labeling and dating insulin pens. 4. DON/Designee will conduct random audits on insulin pens being labeled and dated correctly. This audit will be conducted 3 times per week for 4 weeks then 1 time a month for 2 months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations as needed.
Failure to Accommodate Dietary Preferences and Needs
Penalty
Summary
The facility failed to provide meals in accordance with the preferences and dietary needs of two residents, R40 and R278. Resident R40, who is alert and oriented, reported not receiving the correct food at meal times on multiple occasions. Specifically, R40 requested tuna salad but received chicken, asked for coffee but was given a tea bag without hot water or cream, and requested kielbasa but again received chicken. These discrepancies indicate a failure to accommodate the resident's meal preferences as outlined in their care plan. Resident R278, who follows a vegetarian diet, reported not receiving appropriate vegetarian protein options with meals. During an interview, R278's lunch tray was observed to lack a requested veggie burger, and the resident stated that soy milk, which was supposed to be provided, was not available. The resident's meal slip confirmed a vegetarian diet, yet the facility did not provide the necessary vegetarian products. The Food Service Director admitted to a lack of vegetarian options and the dietician acknowledged the failure to order necessary vegetarian food products, highlighting a systemic issue in meeting the dietary needs of vegetarian residents.
Plan Of Correction
1. R40 preferences were updated, R278 no longer resides in the center. 2. An initial audit was conducted to validate residents' meal preferences are provided. Variances were addressed at the time of the audit and placed on the facility audit tool. 3. NHA/Designee to re-educate food service director and dietician on providing food preferences. 4. NHA/Designee will conduct random audits on food preference and tray accuracy 3 times per week for 4 weeks, then 1 time a month for 2 months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations as needed.
Failure to Use Enhanced Barrier Precautions During Medication Administration
Penalty
Summary
The facility failed to utilize enhanced barrier precautions during medication administration for a resident with a feeding tube. The facility's policy for Enhanced Barrier Precautions, revised in March 2024, requires the use of gown and gloves during high-contact resident care activities, such as device care or use, to reduce the transmission of multi-drug-resistant organisms. However, during an observation of medication administration, a Licensed Practical Nurse (LPN) did not don a gown and gloves while providing care to the resident's percutaneous endoscopic gastrostomy (PEG) tube. The resident involved was admitted to the facility with oropharyngeal dysphagia and malnutrition, requiring a gastrostomy tube for nutrition, fluids, and medications. The resident's care plan specifically required the use of gloves and gown during high-contact care activities involving the feeding tube. Despite these requirements, the LPN failed to adhere to the facility's infection prevention and control program, as evidenced by the lack of appropriate protective equipment during the observed medication administration.
Plan Of Correction
1. R105 no longer resides in the center. No adverse effects were noted. 2. An initial audit was conducted to validate EBP's are utilized during medication administration via feeding tube. Variances were addressed at the time of the audit and placed on the facility audit tool. 3. DON/Designee will re-educate all licensed nurses on utilizing EBP's during medication administration via feeding tube. 4. DON/Designee will conduct random audits to validate EBP's are utilized during medication administration via feeding tube 3 times per week for 4 weeks then 1 time a month for 2 months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations as needed.
Deficiency in Resident Call System Accessibility
Penalty
Summary
The facility failed to ensure that call devices were functional and accessible to residents, affecting two of the 30 residents reviewed. Resident R55 reported that his call bell was non-functional, which was confirmed through observation and an interview with the Nursing Home Administrator. Additionally, Resident R78's call bell was observed on the floor and out of reach on multiple occasions. Resident R78, who was soft-spoken and unable to call out loudly, stated he had no other way to call for assistance. A nurse aide acknowledged that Resident R78's call bell sometimes falls on the floor, further indicating the inaccessibility of the call system for this resident.
Plan Of Correction
1. R55 and R78 call bell has been replaced, is currently working properly and accessible. No adverse effects were noted. 2. An initial audit was conducted to validate call bells were in proper working condition and accessible. Variances were addressed at the time of the audit and placed on the facility audit tool. 3. NHA/Designee will re-educate all dept managers on validating call bells are properly working and accessible. 4. NHA/Designee will conduct random audits on call bell functionality and accessibility 3 times per week for 4 weeks then 1 time a month for 2 months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations as needed.
Facility Fails to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to maintain the required staffing ratios for nurse aides on 15 out of 21 days reviewed. The regulation mandates a minimum of one nurse aide per 10 residents during the day, one per 11 residents during the evening, and one per 15 residents overnight. However, the facility did not meet these requirements on multiple occasions, as evidenced by the review of nursing staff schedules, punch reports, and interviews with staff. On specific dates, such as July 14, 2024, the facility census was 114, necessitating 77.73 hours of nurse aides during the evening shift, but only 66.00 hours were provided. Similarly, on July 20, 2024, with a census of 123, the overnight shift required 61.50 hours of nurse aide care, yet only 37.50 hours were provided. These discrepancies were consistent across several other dates, indicating a pattern of insufficient staffing. The Nursing Home Administrator confirmed the failure to meet the required staffing ratios during a review of staffing calculations, nursing staff schedules, and staff punch reports. This acknowledgment highlights the facility's awareness of the deficiency in maintaining adequate nurse aide coverage as per the regulatory requirements.
Plan Of Correction
No specific residents were identified. No residents were negatively impacted by the CNA ratios. An audit was completed of staffing ratios for the past 30 days. Variances were reviewed with the staffing coordinator and recorded on the facility audit tool. The Administrator re-educated the staffing coordinator on the staffing ratios. The Administrator has reviewed staff recruitment and retention initiatives and has communicated those initiatives to the facility recruitment manager. The Administrator / Designee will audit CNA ratios 3 times per week for 4 weeks, then weekly for 2 months. Audit findings will be submitted to the Quality Assurance Performance Improvement Committee monthly for further review and recommendations as needed. Further audit frequency will be determined based on the outcome of the previously completed audit findings.
Failure to Meet LPN Staffing Ratios
Penalty
Summary
The facility failed to maintain the required staffing ratios for LPNs on six occasions across different dates. Specifically, the facility did not meet the mandated LPN-to-resident ratios during various shifts, including the day, evening, and overnight shifts. For instance, on July 16, 2024, the facility had a census of 115 residents, necessitating 23.00 hours of LPN care during the overnight shift, but only 16.00 hours were provided. Similar deficiencies were noted on other dates, such as July 17, 2024, when 23.80 hours were required, but only 16.00 hours were provided, and on July 20, 2024, when the day shift required 39.36 hours, but only 32.00 hours were provided. The deficiency was confirmed through a review of nursing staff schedules, punch reports, and interviews with staff. The Nursing Home Administrator acknowledged that the required staffing ratios were not met on the specified dates. The report highlights that the facility's failure to provide the mandated LPN hours affected multiple shifts and dates, indicating a pattern of non-compliance with staffing regulations.
Plan Of Correction
No specific residents were identified. No residents were negatively impacted by the LPN ratios. An audit was completed of staffing ratios for the past 30 days. Variances were reviewed with the staffing coordinator and recorded on the facility audit tool. The Administrator re-educated the staffing coordinator on the staffing ratios. The Administrator has reviewed staff recruitment and retention initiatives and have communicated those initiatives to the facility recruitment manager. The Administrator / Designee will audit LPN ratios 3 times per week for 4 weeks then weekly for 2 months. Audit findings will be submitted to the Quality Assurance Performance Improvement Committee monthly for further review and recommendations as needed. Further audit frequency will be determined based on the outcome of the previously completed audit findings.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.20 hours of direct nursing care per resident per day on 16 out of 21 days reviewed. This deficiency was identified through a review of nursing time schedules, punch reports, and staff interviews. Specific dates where the facility did not meet the required staffing levels include July 14, 15, 16, 17, 18, and 20, 2024; September 3, 4, and 7, 2024; and January 17, 18, 19, 20, 21, 22, and 23, 2025. On these dates, the facility's census ranged from 112 to 123 residents, and the direct nursing care hours provided per resident varied from 2.67 to 3.19 hours, falling short of the mandated 3.20 hours. The Nursing Home Administrator confirmed the shortfall in staffing during a review of the staffing calculations, nursing staff schedules, and staff punch reports on January 24, 2025. The deficiency was consistently observed across multiple months, indicating a systemic issue in maintaining adequate staffing levels to meet the regulatory requirements. The report does not provide any information on corrective actions or plans to address this deficiency.
Plan Of Correction
No residents were negatively impacted by not meeting 3.20 PPD. The facility completed an audit of HPPD for the past 30 days. Variances were reviewed with the staffing coordinator and recorded on the facility audit tool. The Administrator re-educated the staffing coordinator on the required HPPD. The Administrator has reviewed staff recruitment and retention initiatives and have communicated those initiatives to the facility recruitment manager. The Administrator / Designee will audit centers HPPD 3 times per week for 4 weeks then weekly for 2 months. Audit findings will be submitted to the Quality Assurance Performance Improvement Committee monthly for further review and recommendations as needed. Further audit frequency will be determined based on the outcome of the previously completed audit findings.
Deficiency in Delayed Egress Door Signage
Penalty
Summary
The facility failed to maintain compliance with the requirements for delayed egress doors, as observed on January 22, 2025. Specifically, the delayed egress door on the ground floor leading to the loading dock was missing the required signage. The signage should have stated: 'PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS.' This deficiency was identified during an observation conducted at 10:29 a.m. The lack of proper signage was confirmed during an exit interview with the Administrator and the Maintenance Director at 10:30 a.m. on the same day. This oversight affects one of the four levels in the facility, indicating a failure to adhere to the National Fire Protection Association (NFPA) 101 Life Safety Code requirements for egress doors, which are critical for ensuring safe and efficient evacuation in case of an emergency.
Plan Of Correction
Maintenance Director was in serviced on proper signage for egress doors. Area identified has been resolved by the maintenance director by posting signage stating "PUSH UNTIL ALARM SOUNDS DOOR WILL OPEN IN 15 SECONDS." All egress doors will be reviewed by the maintenance director to assure that all egress doors have proper signage. Maintenance Director/Designee will monitor egress doors 3 times per week for 4 weeks and 1 time a month for 2 months. Results will be brought to QAPI and variances will be addressed.
Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its sprinkler system, affecting two of the four levels within the building. During observations conducted on January 22, 2025, deficiencies were noted. On the second floor, a supply closet across from resident room 270 was found to have storage items placed within 18 inches of the sprinklers, which is a violation of the required clearance for sprinkler systems. Additionally, on the ground floor, in a construction area across from the reception, several ceiling tiles were missing, potentially compromising the effectiveness of the sprinkler system. These deficiencies were confirmed during an exit interview with the Administrator and the Maintenance Director.
Plan Of Correction
Maintenance director was in serviced on having storage within 18 inches of sprinklers and on checking facility for missing ceiling tiles. Areas identified have been resolved by maintenance director by removing all storage that is within 18 inches of sprinklers and replacing missing ceiling tiles. All supply closets will be reviewed by maintenance director to assure that no storage is within 18 inches from sprinklers. All areas will be reviewed by maintenance director to assure that there are no missing ceiling tiles. Maintenance Director/ Designee will monitor all supply rooms that no storage is within 18 inches of sprinklers and that no area has missing ceiling tiles 3 times per week for 4 weeks and 1 time per month for 2 months. Results will be brought to QAPI and variances will be addressed.
Unsealed Penetrations in Smoke Barriers
Penalty
Summary
The facility failed to maintain the fire resistance of smoke barriers, which is a requirement for ensuring safety in the event of a fire. During an observation on January 22, 2025, unsealed penetrations by data wires were found in the smoke barriers at two locations within the facility. The first unsealed penetration was observed on the second floor near resident room 257 at 10:02 a.m., and the second was on the first floor near resident room 172 at 10:19 a.m. This deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director on the same day at 10:30 a.m.
Plan Of Correction
Maintenance director was in serviced on checking that all penetrations are properly sealed. Areas identified have been resolved by maintenance director by sealing penetrations around data wires with 3M Fire Barrier Sealant (CP 25WB+). All areas will be reviewed by maintenance director to assure that there are no open penetrations around data wires. Maintenance Director/Designee will monitor all areas to ensure that there are no open penetrations around data wires 3 times per week for 4 weeks and 1 time per month for 2 months. Results will be brought to QAPI and variances will be addressed.
Building Construction Type Exceeds Allowed Story Height
Penalty
Summary
The facility failed to maintain building construction requirements, as evidenced by a document review and interview conducted on January 22, 2025. The facility was identified as a three-story, Type II (000), unprotected non-combustible building, which is fully sprinklered and includes a basement and sub-basement. However, the story height of the building exceeds the maximum number of stories allowed for this construction type, which is not permitted for non-sprinklered buildings and is limited to one story for sprinklered buildings. This deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director.
Deficiency in Emergency Fire Exits in Sub-Basement
Penalty
Summary
The facility failed to maintain compliance with the National Fire Protection Association (NFPA) 101 Life Safety Code, specifically regarding the requirement for two acceptable exits from each story. During a document review and interview conducted on January 22, 2025, it was discovered that the sub-basement of the facility lacked the necessary two emergency fire exits. This deficiency affects one of the six smoke compartments within the facility. The issue was confirmed during an exit interview with the Administrator and the Maintenance Director.
Failure to Serve Food at Proper Temperature
Penalty
Summary
The facility failed to provide food that was palatable and served at the proper temperature for two residents. The facility's policy on food preparation, revised in November 2022, specifies that food temperatures should be maintained at or below 41 degrees Fahrenheit or at or above 135 degrees Fahrenheit to prevent the growth of pathogenic microorganisms. However, interviews with two residents revealed complaints about cold and burnt food. During a test tray observation with the facility cook, it was found that the juice, canned pineapple, and cold pie were served at temperatures above the acceptable range, specifically at 58, 55, and 62 degrees Fahrenheit, respectively. The cook acknowledged that these temperatures were above the acceptable range and not palatable.
Plan Of Correction
1. Unable to correct retroactively. R1 and R2 had no adverse effects. 2. Initial audit was conducted to validate food is served at the proper temperature. Variances were addressed at the time of the audit and placed on the facility audit tool. 3. Dietary staff will be re-educated on serving food at the proper temperature. 4. FSD/designee will complete random audits to validate food is served at the proper temperature five times a week for four weeks and monthly for two months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations as needed.
Failure to Administer and Document Topical Medication as Prescribed
Penalty
Summary
The facility failed to follow physician orders for a resident, identified as Resident R2, regarding the administration of a prescribed topical ointment. The facility's policy requires that medications be documented in the Medication Administration Record (MAR) and Treatment Administration Record (TAR) after each administration. However, a review of Resident R2's records revealed that the prescribed Clobetasol Propionate ointment was not documented as administered according to the physician's orders. The orders specified that the ointment should be applied to various parts of the body twice daily for skin care and every 12 hours as needed for open areas. Interviews with Resident R2 indicated that the ointment had not been applied for several days, including the day of the interview. The Director of Nursing and the facility administrator confirmed the lack of documentation and administration of the ointment as per the physician's orders. The deficiency was identified through a review of the resident's clinical records, facility policies, and interviews with staff and residents.
Plan Of Correction
This Plan of Correction constitutes this facility's written allegation of compliance for the deficiencies cited. This submission of this plan of correction is not an admission of or agreement with the deficiencies or conclusions contained in the Department's inspection report. 1. R2's ointment was being administered and documented according to physician order. R2 had no adverse effects. 2. Initial audit of residents with ointments was completed to validate they are being administered and documented according to physician orders. Variances were addressed at the time of the audit and placed on the facility audit tool. 3. Licensed nursing staff will be re educated on administering ointments and documenting according to physician orders. 4. DON/designee will complete random audits to validate administration and documentation of ointments according to physician orders for five times a week for four weeks and monthly for two months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations as needed.
Failure to Display Employee Identification Tags
Penalty
Summary
The facility failed to ensure that employee identification tags were displayed as required, as observed during a survey. On December 9, 2024, at 10:36 a.m., a Licensed Practical Nurse, identified as Employee E9, was observed providing care to residents without displaying an identification tag. Upon interview, Employee E9 mentioned that she needed to look for it in her bag. Similarly, at 10:39 a.m. on the same day, a Nurse Aid, Employee E10, was also observed without an identification tag while providing care, and she stated that she did not have one. On December 10, 2024, at 10:40 a.m., another Nurse Aid, Employee E11, was observed with her identification tag not visible, and she stated she would go get it. An interview with the Nursing Home Administrator confirmed that employee identification information was supposed to be displayed visibly.
Plan Of Correction
1. E9, E10, and E11 applied temporary identification badges and were issued new identification badges. 2. Initial audit was conducted to validate employees have identification badges and are being displayed as required. 3. Employees will be re-educated on displaying identification badges as required. 4. NHA/designee will complete random audits to validate employees are displaying identification badges as required five times a week for four weeks and monthly for two months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations as needed.
Failure to Notify Ombudsman of Emergency Transfers
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers and discharges for five residents. Clinical record reviews and staff interviews revealed that the facility did not document the required notifications for emergency transfers and discharges of these residents. The residents involved experienced various medical emergencies, such as pain around a gastric tube, chest pain, difficulty breathing, and unresponsiveness, which necessitated their transfer to local hospitals for evaluation. The deficiency was confirmed during an interview with the Regional Director, who acknowledged the lack of documentation indicating that the Ombudsman was notified of these transfers and discharges. The specific residents affected by this oversight were transferred multiple times for medical evaluations, yet there was no evidence that the required notifications were made to the Ombudsman, as mandated by regulations.
Failure to Document Vaccine Information in Resident Records
Penalty
Summary
The facility failed to maintain clinical records on each resident in accordance with accepted professional standards. Specifically, the documentation of the risk and benefits of the influenza vaccine, pneumococcal vaccine, and COVID-19 vaccine was missing for seven of eight resident records reviewed. The facility's policies require that residents or their legal representatives be provided with information and education regarding the benefits and potential side effects of these vaccines, and that this education be documented in the resident's medical record. However, the review revealed that this documentation was not present in the clinical records of the residents in question. Additionally, the medical records of two residents lacked documentation of acquiring tuberculosis tests, as well as COVID-19, pneumococcal, and influenza vaccines. An interview with the Director of Nursing confirmed that while the residents had received the vaccines, the administration details were not properly recorded in the medical records. Instead, handwritten individual papers of vaccinations were provided, which does not meet the required standards for medical record-keeping.
Infection Control Deficiency During Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection control program during medication administration for three residents. During the medication administration for Resident R75, the licensed nurse, Employee E9, poured excess liquid medication back into the bottle and used her fingers to handle multiple medications before administering them via G-Tube. Resident R75 had a history of cerebral infarction, hemiplegia/hemiparesis, seizure disorder, anemia, hypertension, hyperlipidemia, major depressive disorder, and atrial fibrillation. The nurse's actions were not in compliance with the facility's infection control procedures, which require the use of antiseptic techniques and gloves during medication administration. Similarly, during the medication administration for Resident R23, Employee E9 used her fingers to remove tablets from blister packs and placed them into a medication cup. When a tablet fell into the medication drawer, the nurse picked it up with her fingers and placed it back into the cup before administering the crushed medications. Resident R23 had a history of hemiplegia/hemiparesis following a cerebrovascular accident, hyperlipidemia, hypertension, and atherosclerotic heart disease. For Resident R15, Employee E9 also used her fingers to handle and place medications into a cup before administration. Resident R15 had a diagnosis of hypertensive heart disease. These actions were observed to be in violation of the facility's infection control policy, which mandates the use of proper techniques to prevent contamination during medication administration.
Failure to Evaluate Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was evaluated for self-administration of medications. Resident R9, who had a BIMS score of 12 indicating cognitive intactness, was observed with a small cup containing six pills on the bedside table. The resident, who had multiple diagnoses including atherosclerotic heart disease, chronic hepatitis C, end-stage renal disease, depression, and hypertension, did not have a physician order for self-administration of medication. During an interview, Resident R9 was unsure of what each pill was for, although he mentioned that some were for his heart. Licensed nurse Employee E21 confirmed that the medication was left on the table and believed that the resident did not have an order to self-administer. Another licensed nurse, Employee E11, admitted to leaving the medication on the table at the resident's request. This action was against the facility's policy, which requires that residents may self-administer their medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely.
Failure to Maintain Clean and Comfortable Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for three residents. Observations revealed that Resident R11's room was very dark due to a broken window blind that had not been repaired since her admission. Interviews with Resident R11 and staff confirmed the issue, and the Maintenance Director acknowledged that parts were being obtained to fix the blind. Additionally, Resident R2's room had a dresser with a missing front panel on the third drawer, which was observed leaning against the wall. These deficiencies indicate a failure to provide a safe and comfortable living environment for the residents.
Failure to Complete Comprehensive MDS Assessments at Discharge
Penalty
Summary
The facility failed to ensure that comprehensive resident assessments were completed in a timely manner for three discharged residents. Resident R67 experienced a fall and was transported to the hospital, but no comprehensive Minimum Data Set (MDS) assessment was completed at discharge. Resident R110 was discharged home by the facility's contracted transportation service, and similarly, no comprehensive MDS assessment was completed. Resident R111 was also discharged home with all his belongings in a wheelchair, and again, no comprehensive MDS assessment was done. These deficiencies were confirmed during an interview with the RN Assessment Coordinator, Employee E16.
Improper Labeling of Pain Medication Patch
Penalty
Summary
The facility failed to ensure that a pain medication patch was properly labeled for one of the residents reviewed. The resident, who has a diagnosis of central nervous system vasculitis, multiple strokes, right hemiparesis, encephalopathy, hypertension, and anxiety, was ordered to have a Fentanyl patch applied every seventy-two hours for pain management. During an observation, it was noted that the Fentanyl patch on the resident's left upper arm did not have the date it was applied, only the employee's initials were present. The facility's policy on administering medications, revised in April 2019, requires that medications be properly labeled, especially when administered at times other than the scheduled time. The Director of Nursing confirmed during an interview that the Fentanyl patch was not labeled correctly, which is a violation of the facility's policy and state regulations. This deficiency was identified during a clinical record review, staff interview, and observation.
Failure to Provide Appropriate ROM Treatment
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. The resident, who had diagnoses including cerebral infarction, muscle weakness, and hemiplegia/hemiparesis, had a physician's order for a left upper extremity resting hand splint to be worn for 6-8 hours during nighttime with every 2-hour skin checks. However, this order was discontinued, and no current physician's orders for a hand splint were found in the resident's clinical record. Observations revealed that the resident's left hand was in a clenched position, and no splint was present in the vicinity. Interviews with staff confirmed that the resident was not evaluated for splinting during the last episode of restorative occupational therapy and that splinting was not part of the recommendation, despite the resident's need for it to prevent deterioration of hand function. The resident's care plan included goals for the use of a hand splint and skin checks, but these interventions were not implemented. The occupational therapy evaluations did not address the limitation in hand range of motion, and there were no discharge recommendations for splinting. Staff interviews confirmed that the resident should have had a splint to prevent further deterioration of the left-hand limitation. The Director of Rehab acknowledged the oversight and indicated that the resident would be re-evaluated and recommended for a hand splint. The facility's failure to provide the necessary treatment and services for the resident's limited range of motion resulted in a deficiency under the relevant state codes.
Failure to Label and Date Enteral Feeding Formulas
Penalty
Summary
The facility failed to ensure appropriate enteral feeding practices relating to labeling for two residents observed for tube feeding. Resident R332, who had multiple diagnoses including absence of larynx, diabetes type 2, dysphagia, and malignant neoplasm of the epiglottis, was observed with an unlabeled and undated feeding tube formula at his bedside. This observation was confirmed by a licensed nurse, Employee E21, who acknowledged that the enteral feed formula should have been dated but was not. Similarly, Resident R80, who had diagnoses including CNS vasculitis, multiple strokes, right hemiparesis, encephalopathy, hypertension, and anxiety, was also observed with an unlabeled and undated feeding tube formula at the bedside. This observation was confirmed by the Director of Nursing, Employee E2. The facility's policy on enteral nutrition, revised in 2018, mandates that enteral feeding should be properly labeled and dated, which was not adhered to in these instances.
Failure to Implement Complete Drug Regimen Review Process
Penalty
Summary
The facility failed to implement a complete drug regimen review process for two residents, leading to deficiencies in medication management. For Resident R63, who was admitted with chronic obstructive pulmonary disease (COPD), the medical record showed multiple instances where the medication regimen was reviewed by the pharmacist. However, there was no documentation indicating that the attending physician reviewed or acted upon the pharmacist's recommendations. Similarly, for Resident R101, who was admitted with Parkinson's disease, the medical record contained only one pharmacy progress note with no further documentation of physician review or action on the pharmacist's recommendations. Additionally, the facility's documentation for Resident R105 revealed inconsistencies in the pharmacy review process. The March 2024 pharmacy review was signed by the Director of Nursing (DON) on April 24, 2024, indicating a delay. Furthermore, there was no pharmacy review for February 2024, and the DON confirmed that the pharmacy consultant did not send the review to the facility. The physician was only made aware of the recommendations on April 24, 2024, via telephone, with no documented evidence of the physician's review for February and March 2024. These deficiencies indicate a failure to follow the facility's Medication Regimen Review Policy and ensure proper medication management for the residents.
Failure to Document TST Results for New Hires
Penalty
Summary
The facility failed to properly document the dates of tuberculin skin test (TST) results for newly hired staff members on four of five personnel records reviewed. Specifically, the personnel files for Employees E17, E18, E19, and E20 were missing the date that the TST was read for both steps of the test. This omission made the results inconclusive, as it was unclear if the test was read within the 48 to 72-hour window required for accurate results. The Regional Nursing Home Administrator confirmed that the dates were not documented on the PPD Information Forms for these employees during an interview with surveyors.
Failure to Ensure Operable Call Bells for Residents
Penalty
Summary
The facility failed to ensure that call bells were available and operable for resident use, affecting three residents. Resident R184 reported that her call bell had not worked since April 19, 2024, and despite informing the staff, no alternative call bell was provided. The maintenance staff was aware of the issue but did not fix it until April 22, 2024. Interviews with the nurse aide and unit clerk confirmed the lack of awareness and follow-up on the broken call bell, indicating a communication breakdown among the staff and maintenance team. On the 2nd floor nursing unit, Resident R22 and her roommate, Resident R8, were observed without call bell connections on their respective sides of the room. This was confirmed by the unit manager during an observation. The absence of call bells in these rooms indicates a failure to provide essential communication tools for residents to request assistance, compromising their safety and well-being.
Failure to Document Physician Assessment for Unplanned Weight Loss
Penalty
Summary
The facility failed to ensure a physician assessment was completed for a resident experiencing unplanned weight loss. The facility's policy requires that any significant weight change, defined as a gain or loss of 5% or more in one month, be reported to the Registered Dietitian and the physician. Resident R4, who was admitted with multiple diagnoses including abnormal weight loss and severe protein-calorie malnutrition, experienced a weight loss of 7.70% over three months. Despite the Registered Dietitian evaluating the resident and implementing weight gain interventions, there was no documented evidence of a physician assessment related to this unplanned weight loss. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed the absence of physician documentation regarding the weight loss assessment. It was only on March 5, 2024, that the physician was contacted and new orders were prescribed for further evaluations to rule out potential causes of the weight loss. This lack of timely physician involvement and documentation constitutes a deficiency in the facility's compliance with state regulations regarding nursing and physician services, as well as clinical records management.
Failure to Administer Medications According to Professional Standards
Penalty
Summary
The facility failed to ensure that medications were administered in accordance with professional standards for one of seven residents reviewed. Resident R7 had a physician's order for Diclofenac Sodium 1% Gel to be applied to both knees for knee pain. However, it was discovered that staff had been applying another resident's medication to Resident R7's legs for a couple of months. This was confirmed by an interview with Resident R7 and Licensed Practical Nurse (LPN) Employee E3, who found the mislabeled medication in Resident R7's drawer and replaced it with the correct one. Further investigation revealed that the facility had not placed refill orders for Resident R7's medication for the months of October, November, and December 2023. The Director of Nursing (DON) confirmed this oversight and speculated that Resident R7 might have been using another resident's prescription. Pharmacy documentation showed that the Diclofenac 1% Gel was dispensed on four different dates, but no refills were ordered during the specified months, leading to the deficiency.
Improper Storage of Medications
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in accordance with professional standards. During an observation of the second-floor medication cart with an LPN, it was found that a resident's gel medication, Diclofenac Sodium Topical Gel 1%, was missing from the cart. The LPN then retrieved two tubes of the medication from the resident's unlocked side drawer. The facility's policy requires that compartments containing medications be locked when not in use, and the Director of Nursing confirmed that the medication should have been stored in the locked medication cart, not in the resident's drawer.
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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