Watsontown Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Watsontown, Pennsylvania.
- Location
- 245 East Eighth Street, Watsontown, Pennsylvania 17777
- CMS Provider Number
- 395825
- Inspections on file
- 35
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Watsontown Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
The facility failed to develop person-centered care plans that included safe meal positioning for 19 of 32 residents identified as needing to be out of bed during meals for swallowing safety. Residents with dysphagia, nutritional risk, altered texture diets, chewing difficulties, and CVA-related problems had care plans that mentioned monitoring for dysphagia or referenced Speech Therapy but did not specify interventions such as being seated upright or out of bed for meals. Kardexes and a paper census sheet used by NAs to guide care did not contain meal positioning requirements, and staff reported relying on these tools to determine positioning needs. The NHA and DON confirmed that care plans and Kardexes lacked consistent documentation of meal positioning requirements, leaving NAs without accurate information to provide safe care.
Two residents experienced changes in condition related to medication issues that were not appropriately recognized or addressed. One resident with dementia and prior stroke was mistakenly given duloxetine instead of an increased dose of fluoxetine and subsequently developed recurrent nosebleeds with large clots and associated symptoms, while multiple LPNs lacked awareness that duloxetine can cause abnormal bleeding. Another resident with anemia and a pressure ulcer was found with multiple mixed pill bottles in the room, showed slurred speech, leaning, and pinpoint pupils, and may have independently taken Tylenol 3; however, staff still administered tramadol and gabapentin and did not promptly notify the provider about possible narcotic ingestion until family reported worsening altered mental status and requested ED evaluation.
A resident with dementia, hypertension, and a history of stroke, who had been maintained on fluoxetine (Prozac) for MDD, was supposed to have the fluoxetine dose increased from 30 mg to 40 mg daily per psychiatry recommendations. Instead, a physician order was entered for duloxetine 40 mg daily, and the resident received duloxetine for three consecutive days. Facility records and interviews with the DON and NHA confirmed that duloxetine was inadvertently ordered and administered in place of fluoxetine, constituting a significant medication error in violation of the facility’s medication error reporting policy.
A bed rail was used without first attempting alternative interventions, assessing the resident for safety risk, reviewing risks and benefits with the resident or representative, or obtaining informed consent. The facility also failed to ensure the bed rail was correctly installed and maintained.
The facility did not provide or obtain necessary dental services for a resident, resulting in a deficiency related to unmet dental care needs.
Surveyors observed that the main kitchen had blackened flooring, dirt and debris buildup in grout and under equipment, significant black buildup under the dish machine area, and broken or cracked floor tiles. The dietary manager reported ongoing issues with cleaning the flooring and cove base, and these conditions were confirmed during staff interviews.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
The facility did not develop or implement required policies and procedures for flu and pneumonia vaccinations, resulting in a deficiency related to immunization practices.
The facility did not develop or implement complete, person-centered care plans for two residents with complex medical needs. One resident with a cardiac pacemaker lacked a care plan addressing device management and precautions, while another with a tracheostomy had a care plan missing interventions for potential complications and did not ensure an emergency trach tube was available at the bedside as required by policy.
A resident did not receive treatment and care in accordance with physician orders and their stated preferences and goals, resulting in a deficiency related to the delivery of individualized care.
A resident with multiple diagnoses increasing the risk for eye health concerns did not receive routine vision services, as two scheduled appointments with an eye care professional were cancelled and no further attempts to obtain services were documented. The resident reported needing stronger glasses and could not recall her last eye care visit.
A resident with diabetes and neuropathy developed a painful, calloused area on her foot, with no podiatry services provided for over three months despite ongoing symptoms and daily foot checks by nursing staff. Staff failed to identify the change or notify a physician in a timely manner, resulting in delayed professional foot care.
A resident who was continent upon admission experienced multiple episodes of urinary incontinence after admission, primarily during evening and night shifts, due to delays in staff response to call bells and lack of timely assistance with toileting. Despite documented incidents, staff did not assess the incontinence episodes or develop a toileting plan to maintain the resident's continence.
A resident with a tracheostomy did not have a replacement tracheostomy tube or emergency kit available at the bedside as required by facility policy and physician orders. During observations and staff interviews, LPNs were unable to locate the necessary equipment either in the resident's room or at the nurse's station, despite the resident's care plan and orders specifying the need for immediate access to these items.
A resident admitted after incarceration did not receive timely assistance from facility staff to reinstate Social Security and Medicare benefits, resulting in delayed access to over $1,700 in entitled funds and lack of monthly personal fund statements. The facility failed to provide necessary social services to help the resident manage financial matters.
A resident's EHR contained documents that belonged to two other residents, including a POLST form and a medication clarification notice, due to erroneous uploads. This failure to maintain accurate and resident-specific clinical records was identified during a clinical record review and confirmed by staff.
A facility failed to notify a physician in a timely manner regarding a resident's change in condition, which required interventions. The resident was documented as unable to swallow and unresponsive, with a high blood sugar level. Despite these changes, the physician was not notified until hours later, after the resident's daughter requested updates and the resident was sent to the emergency room. The physician's response to send the resident to the ER was received after the resident had already been sent.
A resident admitted for a respite stay had physician orders for blood sugar monitoring four to five times daily. However, these orders were not transcribed into the resident's physician orders upon admission, leading to a failure in monitoring the resident's blood sugars. This deficiency was confirmed by the Nursing Home Administrator.
The facility failed to provide adequate care for three residents by not following physician orders for weight monitoring and medication administration. One resident did not receive necessary weight monitoring and Bumex due to unavailable orders, while two others did not receive prescribed Lidocaine patches for pain management due to supply issues. The facility lacked documentation and communication regarding these deficiencies.
The facility failed to administer physician-ordered supplemental oxygen properly for two residents. One resident was observed without the required trach collar and supplemental oxygen, despite having an SPO2 below the prescribed level. Another resident's care plan lacked focus on respiratory failure, and there were no documented SPO2 assessments or oxygen administration, despite an order for as-needed oxygen. Staff interviews confirmed these deficiencies.
The facility failed to ensure nursing staff had the necessary competencies for tracheostomy, peg tube, and catheter care. Despite having residents with these needs, the facility could not provide documentation verifying that four staff members, including RNs and LPNs, were competent in these areas.
The facility failed to implement Enhanced Barrier Precautions (EBP) and proper infection control measures for residents with multidrug-resistant organisms and those requiring high-contact care. Observations revealed inadequate use of PPE, lack of proper signage, and failure to perform hand hygiene during wound care. These deficiencies affected multiple residents, including those with ESBL infections and indwelling medical devices.
The facility did not ensure that nurse aides received the required 12 hours of annual in-service training. A review of records and interviews revealed that three nurse aides lacked documentation of this training. The Nursing Home Administrator confirmed the absence of evidence for the required training.
The facility failed to maintain a clean and homelike environment in two nursing units, with issues such as a dirty shower gurney, loose handrails, and moldy ceiling tiles. Additionally, the facility did not protect residents' property, as evidenced by missing documentation for personal belongings of two residents. These deficiencies were confirmed by interviews with the Nursing Home Administrator and the Director of Nursing.
The facility failed to provide written bed-hold notices to residents or their responsible parties during hospital transfers. This deficiency was identified for five residents who were transferred due to medical conditions, but there was no documentation of the required notices. The Nursing Home Administrator and DON confirmed the lack of documentation, indicating a systemic issue in the notification process.
A facility failed to secure and account for medications, as evidenced by an unknown pill found in a resident's room and an LPN not verifying controlled medication counts during administration. The LPN was unaware of the facility's policy for controlled medication counts, and the DON confirmed the requirement for staff to verify counts.
The facility failed to assist two residents in obtaining routine dental services. One resident with broken teeth had not been offered routine dental care as required, and another resident with natural teeth had not received professional dental services despite a referral. The lack of documentation and follow-up was confirmed by facility staff.
A facility failed to administer the pneumococcal vaccine to a resident due to incomplete documentation and lack of follow-up on immunization status. The resident's immunization consent form was not properly filled out, and there was no record of previous vaccinations or offers for the pneumococcal vaccine. The facility's staff, including the Infection Preventionist and DON, could not provide additional documentation or consent, highlighting a lapse in adherence to the facility's vaccination procedures.
A facility failed to offer or provide education on COVID-19 vaccination to a resident, as required by their policy. The resident's records lacked evidence of vaccination, history, or documentation of offers or refusals. The Infection Preventionist could not provide further documentation, and the DON noted an upcoming immunization clinic but lacked written consent or vaccine history for the resident.
The facility's main laundry area was found to be unsafe and unclean, with debris in a laundry bin, dust-covered vents, and a leaking ceiling causing water stains and exposed pipes. A commode without a lid had debris, and cobwebs were present. An electric heater had a stained ceiling tile above it, and a blood spill compliance center was dusty. The NHA acknowledged the issues and mentioned efforts to obtain repair quotes.
A facility failed to respect a resident's advance directive preferences for no artificial nutrition or hydration, as indicated in their POLST and living will. Despite these directives, a physician's order for enteral feeding was issued, leading to a discrepancy identified during a survey. Attempts to confirm the resident's wishes with their responsible party were unsuccessful, and no updated POLST was provided by the survey's conclusion.
A facility failed to provide timely notification to a resident regarding changes in Medicare coverage, as required by regulations. The facility did not deliver the Notice of Medicare Non-Coverage (NOMNC) or the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) with the necessary signatures, indicating a lapse in notifying the resident of their financial liability for non-covered services.
The facility failed to implement comprehensive care plans for two residents, leading to deficiencies in their well-being. One resident's care plan lacked specific interventions for foley catheter care, while another's care plan inaccurately reflected their advance directive, showing a full code status instead of DNR with comfort measures only.
The facility failed to provide necessary shaving assistance to two residents who were assessed as needing help with personal hygiene. One resident was dependent on staff due to cognitive status, while the other required partial assistance but did not receive the necessary support. The Nursing Home Administrator confirmed these deficiencies.
A resident with cerebral palsy and impaired mobility did not have a physician-ordered left grip splint applied as required. Observations showed the splint was not used, despite documentation indicating otherwise. An LPN assumed therapy staff were responsible, but records assigned the task to nursing staff. The issue was discussed with the Nursing Home Administrator and DON.
The facility did not assess the need for bed rails, evaluate entrapment risks, or obtain informed consent for two residents. One resident had a bed rail without a physician's order or consent, while another had incomplete entrapment risk assessments despite a physician's order for bed rail use.
The facility failed to develop and implement individualized person-centered care plans for two residents diagnosed with dementia. One resident with Alzheimer's dementia and another with dementia with behavioral disturbance did not have care plans addressing their cognitive loss, as confirmed by the facility's administration.
A facility failed to respond appropriately to a pharmacist's recommendation to discontinue a PRN Atarax prescription for a resident due to nonuse. Although the resident's physician agreed with the recommendation, the facility did not act until questioned by a surveyor. The resident had an active order for Atarax for itching since earlier in the year. An interview with the DON confirmed the oversight.
A resident sustained multiple fractures after falling from bed due to inadequate supervision and assistance from a nurse aide. The aide, an agency staff member, was not informed of the resident's need for two-person assistance, as the facility's orientation packet lacked necessary information on accessing care needs. This deficiency resulted in actual harm to the resident.
Failure to Include Safe Meal Positioning in Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop comprehensive, person-centered care plans that addressed safe positioning during meals for 19 of 32 residents identified as needing to be out of bed during meals for swallowing safety. The facility’s Comprehensive Care Plan Policy required that care plans describe services needed to attain or maintain each resident’s highest practicable well-being. However, review of clinical records and care plans showed that residents with diagnoses and conditions such as diabetes, brain cancer, dysphagia, history of difficulty chewing, poor dentition, altered texture diets, thickened liquids, and CVA-related nutritional problems did not have care plan interventions specifying safe meal positioning, including being out of bed or seated upright during meals. For one resident admitted with diagnoses including diabetes, brain cancer, and dysphagia, a Speech Therapy discharge summary recommended the resident be out of bed for meals. The Director of Rehabilitation confirmed this resident needed to be out of bed and/or seated upright to consume meals safely. Despite this, the resident’s care plan for nutritional problems only directed staff to monitor for signs and symptoms of dysphagia and did not include interventions related to safe positioning for meals, and the Kardex lacked directions for assisting the resident out of bed for meals. Similar omissions were found for multiple other residents whose care plans addressed dysphagia, nutritional risk, inadequate oral intake, limited food acceptance, biting/chewing difficulty, altered texture diets, and potential chewing difficulties, but did not include specific interventions for safe positioning during meals. Review of Kardexes for these residents consistently showed no directions for assisting residents out of bed for meals, even though a list from the Director of Rehabilitation identified 32 residents who required staff to ensure they were out of bed during meals for swallowing safety. Nurse aides reported that they rely on the Kardex, the electronic hallway kiosk, or a paper census sheet to determine residents’ positioning requirements for meals. The census sheet reviewed did not document meal positioning requirements, and the Kardex entries lacked this information. During interviews, the Nursing Home Administrator and the DON confirmed that resident care plans did not consistently include meal positioning requirements, which prevented nurse aide staff from having accurate information available to provide safe care, and acknowledged that the facility failed to develop person-centered care plans related to safe positioning during meals for 19 of the 32 identified residents.
Failure to Recognize and Respond to Medication-Related Changes in Condition for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to appropriately respond to changes in condition for two residents. For one resident with hypertension, dementia, and a history of stroke, the clinical record showed a long-standing order for fluoxetine that was to be increased from 30 mg to 40 mg daily per a psychiatry note. Instead, a physician order was entered for duloxetine 40 mg daily, and the resident received duloxetine for three consecutive days. During this period, the resident was noted to have bloody tissues, a small blood clot on the tray table, and dried blood around the nares. Subsequent documentation identified that the resident had received the incorrect medication (duloxetine 40 mg for three doses), and the resident later developed active epistaxis with large blood clots, intermittent nosebleeds with increasing frequency and amount, and complaints of weakness and dizziness. Staff interviews revealed that multiple LPNs were aware that nosebleeds and excessive bleeding can be adverse effects of anticoagulant medications, but several of them were unaware that duloxetine carries a risk of abnormal or excessive bleeding. One LPN stated that she and other staff only learned about duloxetine’s bleeding risk after the resident was hospitalized and they looked up the side effects. The report notes that duloxetine’s prescribing information includes abnormal bleeding in the Warnings and Precautions section, and the facility’s change in condition policy requires notification of the resident, physician, and representative of changes in medical or mental status. The findings show that staff knowledge of duloxetine’s side effects was limited primarily to behavioral effects, and the facility did not appropriately recognize or respond to the resident’s change in condition in the context of the incorrect medication administration and subsequent bleeding episodes. For the second resident, who had diagnoses including anemia, urinary tract infection, and a pressure ulcer, staff discovered a bottle of mixed pills in the room and were unaware what the resident had taken. A CNA reported that the resident had slurred speech, was leaning to the side, and had pinpoint pupils. All medications in the room were removed and given to the RN supervisor, and the resident was educated that medications could not be kept at the bedside. Despite the resident’s neurologic and possible intoxication-type symptoms and the presence of multiple mixed medications including Tylenol 3, the RN supervisor directed that Creon be given and later provided pain medication, and the resident also received tramadol and gabapentin. Progress notes documented the perception that the resident may have independently taken Tylenol 3 and appeared to be under the influence, but the record did not show that the possibility of narcotic ingestion was addressed with the provider or that the provider was notified of possible consumption of narcotic pain medication in addition to the administered tramadol and gabapentin until the family voiced concerns about increased altered mental status and requested transfer to the ED.
Incorrect Antidepressant Ordered and Administered to Resident
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when an incorrect antidepressant was ordered and administered. A resident with diagnoses including hypertension, dementia, and a history of stroke had been on fluoxetine (Prozac) since 11/19/22, with continuous reorders through early 2026. A psychiatry progress note dated 1/26/26 documented a recommendation to increase the resident’s fluoxetine dose from 30 mg daily to 40 mg daily for major depressive disorder, and a progress note on 1/29/26 reiterated this recommendation. However, a physician’s order dated 1/30/26 was entered for duloxetine 40 mg once daily instead of fluoxetine. Review of the MARs for January and February 2026 showed that the resident received duloxetine on three consecutive days (1/30/26, 1/31/26, and 2/1/26). A progress note dated 2/2/26 documented that the resident had received the incorrect medication, duloxetine 40 mg, for three doses. The facility’s Medication Error Reporting policy required that medication errors be documented and reported to identify causes and develop prevention strategies. During interviews, the DON confirmed that duloxetine was inadvertently ordered in place of fluoxetine, and the Nursing Home Administrator and DON acknowledged that the facility failed to ensure residents were free of significant medication errors for one of five residents reviewed.
Failure to Assess, Obtain Consent, and Properly Install Bed Rail
Penalty
Summary
The facility failed to try alternative approaches before using a bed rail. When a bed rail was determined to be needed, the facility did not assess the resident for safety risk, did not review the risks and benefits with the resident or their representative, and did not obtain informed consent. Additionally, the facility did not ensure the bed rail was correctly installed and maintained.
Failure to Provide or Obtain Dental Services
Penalty
Summary
The facility failed to provide or obtain necessary dental services for a resident. This deficiency was identified during the survey process, indicating that the required dental care was not arranged or delivered as needed for the resident in question. No additional details regarding the resident's medical history or specific condition at the time of the deficiency are provided in the report.
Unsanitary Kitchen Conditions Due to Inadequate Cleaning and Maintenance
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in the main kitchen, as observed during a survey. The kitchen flooring was blackened with visible dirt and debris buildup in the grout and under equipment. Significant black buildup was noted under the dish machine area, which was also wet during dishwashing. The cove base molding around the kitchen had black buildup, and several floor tiles outside the dry storage room and corridor to the receiving dock were broken and cracked. The dietary manager acknowledged that the flooring and cove base had been a repeated issue and that cleaning efforts had not resolved the problem. These findings were confirmed through observation and staff interview, and were reviewed with the Nursing Home Administrator.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Implement Flu and Pneumonia Vaccination Policies
Penalty
Summary
The facility failed to develop and implement policies and procedures for administering flu and pneumonia vaccinations. This deficiency was identified during the survey process, indicating that the required protocols for ensuring residents receive these vaccinations were not established or followed as mandated.
Failure to Develop Comprehensive Care Plans for Residents with Pacemaker and Tracheostomy
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for two residents with specialized medical needs. For one resident with a cardiac pacemaker and a diagnosis of sick sinus syndrome, clinical and hospital records documented the presence of the pacemaker, but the resident's care plan did not address the device, associated checks, assessments, or necessary precautions. This omission was confirmed through review of the care plan and discussion with facility leadership. For another resident with a tracheostomy, the care plan included some interventions such as securing trach ties, elevating the head of the bed, providing oral care, and suctioning as needed. However, the care plan did not address potential complications like unplanned extubation or airway emergencies, nor did it include the requirement for an emergency tracheostomy tube at the bedside as specified in facility policy. Observations confirmed the presence of a tracheostomy, and staff interviews indicated the lack of an emergency kit at the bedside, further evidencing the incomplete care planning.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required.
Failure to Obtain Routine Vision Services for Resident with Eye Health Risks
Penalty
Summary
The facility failed to obtain routine vision services from an eye care professional for a resident with multiple diagnoses that increase the risk for eye health concerns, including diabetes, long-term use of non-steroidal anti-inflammatories, hypertension, and hyperlipidemia. The resident reported using eyeglasses only for reading and expressed a need for stronger glasses, but could not recall her last visit to an eye care professional. Clinical record review showed that two scheduled appointments with the facility's contracted eye care professional were cancelled, one due to time constraints and the other marked as refused, with no documentation of any attempt to obtain professional eye care services in the 12 months prior to or after these cancellations.
Failure to Provide Timely Podiatry Services for Resident with Foot Complications
Penalty
Summary
The facility failed to obtain timely professional podiatry services for a resident with diabetes, polyneuropathy, and peripheral angiopathy, who was at increased risk for foot complications. Clinical records showed that the resident had thickened nails, burning sensations in both feet, and extensive dry skin, with podiatry assessments documented in January and May. Despite daily application of prescribed lotions by licensed nursing staff, there was no evidence of podiatry services provided for over three months after the last assessment in May, even though the resident had ongoing symptoms and risk factors for wound development. The resident reported a painful, raised area on her right foot, believed to be a callous, and could not recall her last podiatry visit. Observation confirmed a hardened, calloused, and dry area on the right foot, which appeared to have developed over time. Staff interviews and record reviews confirmed that no staff had identified the change, notified a physician, or arranged for podiatry services in a timely manner, despite daily foot checks being required by physician order.
Failure to Assess and Intervene for Resident Continence Needs
Penalty
Summary
Facility staff failed to assess and implement interventions to maintain a resident's continence status. Upon admission, the resident had no history of bowel or bladder incontinence and was assessed as always continent, requiring only partial to moderate assistance for toilet transfers and ambulation. However, after admission, the resident experienced multiple episodes of urinary incontinence, primarily during evening and night shifts. The resident reported having to wait extended periods for staff assistance to use the bathroom, sometimes ringing the call bell early to compensate for delays, but staff did not always respond in time. On some occasions, staff turned off the call bell and did not return, resulting in the resident urinating in bed. The resident sometimes attempted to get up independently but required staff assistance when unable to do so. Clinical record review confirmed the resident's continence status changed after admission, with documented episodes of urinary and one episode of bowel incontinence. Despite these documented incidents, there was no evidence that facility staff evaluated or assessed the resident's incontinence episodes or developed a toileting plan to help maintain continence. Additionally, there was no ability to review call bell log activations to correlate with the timing of incontinence episodes. The deficiency was reviewed with the Nursing Home Administrator and Director of Nursing.
Failure to Maintain Required Tracheostomy Equipment at Bedside
Penalty
Summary
Facility staff failed to provide respiratory and tracheostomy care consistent with professional standards for a resident with a tracheostomy. The facility's policy required that a replacement tracheostomy tube be available at the bedside at all times. Clinical record review showed that the resident had a tracheostomy and physician orders for daily and as-needed tracheostomy care, including changing the inner cannula and checking skin integrity around the trach site and neck. The resident's care plan also included interventions such as ensuring trach ties are secured, elevating the head of bed, providing oral care, and suctioning as necessary. The resident was assessed as cognitively impaired. During observations on two separate dates, the resident was noted to have a tracheostomy present. However, when staff were asked to locate the emergency kit and replacement tracheostomy tube, neither could be found at the bedside or at the nurse's station. Both the LPN present and a second LPN were unable to locate the required items. This failure to have the necessary emergency tracheostomy equipment readily available at the bedside was confirmed during a meeting with facility leadership.
Failure to Provide Timely Financial Assistance and Social Services
Penalty
Summary
The facility failed to provide medically-related social services to assist a resident with financial matters. Upon admission following release from incarceration, the resident did not receive information about his personal funds, did not receive a statement, and was unaware of the location or status of any personal allowance funds. The facility determined that the resident had no resources and did not designate a responsible party, as the resident was his own responsible party. Despite having reasonable knowledge that the resident was entitled to monthly monetary benefits, the facility did not assist him in contacting the Social Security Administration (SSA) to reinstate his benefits immediately after his incarceration. The facility submitted documentation for Medicaid payment by indicating the resident had no income, but did not follow up on the reinstatement of Social Security or Medicare benefits until five months after admission, when it was discovered that the necessary documentation had likely not been submitted by prison staff. During this period, the resident was unable to access over $1,700 in deposited funds and did not receive monthly personal fund statements. The facility's inaction resulted in delayed access to entitled financial resources and lack of support in managing the resident's financial affairs.
Incorrect Medical Record Uploads Compromise Documentation Accuracy
Penalty
Summary
The facility failed to ensure accurate clinical documentation by erroneously uploading documents belonging to two other residents into the electronic health record (EHR) of a third resident. Specifically, a POLST (Physician Orders for Life-Sustaining Treatment) form for one resident and a medication clarification notice for another were found in the medical record of a different resident. This error was identified during a clinical record review and confirmed through staff interviews. The Nursing Home Administrator and Director of Nursing were notified of these findings, which demonstrated that the facility did not maintain accurate and resident-specific clinical records as required.
Failure to Timely Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the physician of a resident's change in condition in a timely manner, which required interventions. The clinical record review for the resident revealed that on March 1, 2025, at 9:35 PM, the resident was documented as unable to swallow. The following day, on March 2, 2025, at 10:11 AM, it was noted that the resident's medications were not administered due to safety concerns as the resident was not responding. Despite these significant changes, the physician was not notified until March 2, 2025, at 12:39 PM, when a Physician Call Report was faxed to the physician's office. This delay in communication occurred despite the resident's daughter requesting updates and eventually requesting the resident be sent to the emergency room due to the resident's deteriorating condition. The resident's condition included lethargy, unresponsiveness, and a high blood sugar level of 374 mg/dL, which was significantly above the normal range. The resident's vital signs were mostly within normal limits, but the blood pressure was unobtainable, and the resident exhibited coarse lung sounds and mouth breathing. The physician's response to send the resident to the emergency room was received after the resident had already been sent there by the facility. The Nursing Home Administrator confirmed the findings related to the untimely physician notification during an interview on March 6, 2025.
Failure to Transcribe Blood Sugar Monitoring Orders
Penalty
Summary
The facility failed to ensure complete and accurate clinical records for a resident admitted for a respite stay. The resident was admitted with physician orders from the community to have their blood sugar monitored four to five times a day. However, upon review, it was found that the order for blood sugar checks was not transcribed into the resident's physician orders upon admission, resulting in the resident's blood sugars not being monitored as required. This deficiency was confirmed during an interview with the Nursing Home Administrator.
Failure to Administer Medications and Monitor Weight
Penalty
Summary
The facility failed to provide the highest practicable care for three residents by not adhering to physician orders regarding weight monitoring and medication administration. For one resident, there were specific orders to monitor weight daily and administer Bumex if there was a significant weight gain. However, there were periods when the PRN Bumex was not available, and staff failed to notify the physician about the weight changes as required. This oversight occurred on multiple occasions, leading to a lack of appropriate intervention for the resident's weight fluctuations. Two other residents were affected by the facility's failure to administer prescribed Lidocaine patches for pain management. Despite physician orders to apply the patches daily, the medication was consistently unavailable, and there was no documentation explaining the unavailability or any communication with the medical provider about the issue. This lack of medication administration spanned several days, indicating a systemic issue with medication supply and communication within the facility. Interviews with the Director of Nursing revealed that the facility had not investigated the reasons behind the unavailability of the Lidocaine patches. The deficiencies were discussed with the Nursing Home Administrator, highlighting the facility's failure to ensure that residents received their prescribed treatments and the lack of documentation and communication regarding these issues.
Deficiency in Supplemental Oxygen Administration
Penalty
Summary
The facility failed to ensure the proper application of physician-ordered supplemental oxygen for two residents, leading to deficiencies in respiratory care. For Resident 47, there was an active physician order to apply supplemental oxygen at 5 liters per minute via a cool mist trach collar, with instructions to titrate the oxygen flow to maintain an SPO2 greater than 93 percent. However, observations revealed that Resident 47 was without a trach collar or supplemental oxygen on multiple occasions, despite documentation indicating an SPO2 of 92 percent, which was below the required threshold. Interviews with staff confirmed that the supplemental oxygen was not applied as ordered, and there was confusion regarding the documentation of oxygen application. For Resident 83, there was an active physician order for supplemental oxygen at 2 liters per minute as needed for an SPO2 less than 92 percent, with instructions to titrate the oxygen flow to maintain an SPO2 greater than 92 percent. However, the facility's care plans did not include any focus area or interventions related to respiratory failure with hypoxia or the use of supplemental oxygen. Additionally, there was a lack of documented SPO2 assessments or administration of supplemental oxygen in the resident's medical records, with only one assessment recorded over two months. The Director of Nursing confirmed the absence of necessary assessments to determine the need for supplemental oxygen.
Lack of Staff Competency Documentation for Specialized Care
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skill sets necessary for the care and assessment of residents with specific medical needs, including tracheostomy, peg tube, and catheter care. This deficiency was identified through a review of facility documentation, employee files, and staff interviews. The facility had five residents with urinary catheters, one resident with a tracheostomy, and two residents with peg tubes. However, the facility was unable to provide documentation verifying that four employees, including two registered nurses and two licensed practical nurses, possessed the required competencies to care for these residents. The Nursing Home Administrator confirmed the lack of documentation for these competencies during an interview.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an environment free from the potential spread of infection across two nursing units, affecting multiple residents. Enhanced Barrier Precautions (EBP) were not consistently implemented for residents with multidrug-resistant organisms (MDROs) or those with wounds and indwelling medical devices. For instance, Resident 22, who was positive for Klebsiella pneumoniae ESBL, did not have a portable commode in their shared room to mitigate potential transmission. Similarly, Resident 77, who was frequently incontinent and required EBP due to ESBL in her urine, shared a bathroom with other residents without evidence of laboratory testing to confirm she was no longer a contamination risk. The facility also failed to ensure proper use of personal protective equipment (PPE) during high-contact care activities. In the case of Resident 47, who required EBP due to a tracheostomy and peg tube, staff members did not don isolation gowns while performing wound care, despite being aware of the precautions. This oversight was confirmed through interviews with the involved staff members. Additionally, Resident 80, who required both EBP and Contact Precautions due to a knee wound infection, did not receive proper hand hygiene practices during wound care, as the staff member failed to change gloves or perform hand hygiene between steps. Furthermore, the facility did not display appropriate signage or provide PPE for Resident 85, who had a suprapubic catheter and required EBP. This lack of signage and PPE was confirmed during observations and interviews with the facility's administration. The report highlights repeated deficiencies in infection prevention and control, as similar issues were previously cited in earlier surveys.
Deficiency in Nurse Aide In-Service Training
Penalty
Summary
The facility failed to ensure that nurse aides received the required 12 hours of in-service training annually, as mandated by regulation 483.95(g). This deficiency was identified during a review of employee education records and staff interviews, which revealed that three nurse aides (Employees 2, 3, and 4) did not receive the necessary training. During a meeting with the Nursing Home Administrator and Director of Nursing, the surveyor requested documentation to confirm the completion of the training for these employees. However, an interview with the Nursing Home Administrator confirmed that there was no documented evidence of the required training being provided to the nurse aides in question.
Deficiencies in Environment and Property Management
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment in two nursing units. On the upper-level nursing unit, a shower gurney was found with a build-up of a dry, white substance and a used resident brief underneath the padding. Additionally, a handrail in a resident shower stall was loose, and the wall tile was cracked where the handrail met the wall. On the lower-level nursing unit, the cove base was detached from the wall outside a resident's room, exposing screws. Furthermore, the ceiling tiles in the locked brief room were stained with large black areas, which the Nursing Home Administrator identified as mold due to moisture accumulation after the removal of spray foam under the kitchen's walk-in freezer. The facility also failed to protect residents' property from loss. For Resident 60, there was no documentation of an inventory of personal belongings upon admission or discharge, as required by the facility's policy. Nursing documentation noted that Resident 60 was missing hearing aids and a second pair of eyeglasses, but there was no further documentation regarding these items. An interview with the Assistant Director of Nursing confirmed the facility could not locate Resident 60's personal property documentation. Similarly, for Resident 102, there was no evidence that staff inventoried her personal property on admission or discharge, as confirmed by the Nursing Home Administrator and the Director of Nursing. These deficiencies indicate a failure to adhere to the facility's policies regarding maintaining a safe and homelike environment and protecting residents' personal property. The issues were reviewed with the Nursing Home Administrator and the Director of Nursing, but the facility was unable to provide evidence that the necessary measures were followed to prevent these deficiencies.
Failure to Provide Bed-Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide written notice of its bed-hold policy to residents or their responsible parties upon transfer to a hospital, as required. This deficiency was identified for five out of thirteen residents reviewed for hospitalization concerns. Specifically, Residents 17, 65, 62, 80, and 83 were transferred to hospitals due to changes in their medical conditions, but there was no documentation that the facility provided the necessary written bed-hold notices to them or their responsible parties. The Nursing Home Administrator and Director of Nursing confirmed the lack of documentation for Residents 17 and 65. Additionally, the surveyor requested evidence of bed-hold notices for Residents 62, 80, and 83, but the facility could not provide any further information. The absence of these notices was confirmed during interviews with the Nursing Home Administrator and Director of Nursing, indicating a systemic issue in the facility's process for notifying residents or their representatives about bed-hold policies during hospital transfers.
Failure to Secure and Account for Medications
Penalty
Summary
The facility failed to properly secure and account for resident medications and biologicals, as evidenced by an unknown pill found on the floor of a resident's room. During an observation, a white, round pill was discovered on the floor next to the resident's bed, and the resident was unsure of its origin. An LPN was unable to identify the pill and disposed of it, indicating a lapse in medication security and accountability. Additionally, during a medication administration pass, the same LPN retrieved a controlled medication, Tramadol, for the resident without verifying the current controlled medication count before and after pouring the dose. The LPN was unaware of the facility's policy and procedures for controlled medication counts and did not verify the count using the electronic system. The Director of Nursing confirmed that staff are required to verify the controlled medication count when preparing medications for administration.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to assist two residents, identified as Residents 65 and 80, in obtaining routine dental services. Resident 65, who was admitted to the facility in November 2022 and is covered by Medicaid, was observed to have several broken teeth on October 22, 2024. His clinical records indicated that his last dental visit was on January 10, 2024, and he was due for a prophylactic dental cleaning six months later. However, there was no evidence that the facility offered him routine dental services as required by the state plan. Employee 8, a social worker, confirmed the lack of documentation for routine dental services for Resident 65. Resident 80, who has natural teeth and believed he might need a tooth extraction, had a care plan initiated in February 2023 to address his dental health. The plan included coordinating dental care and transportation. Despite a referral for dental services being forwarded on June 24, 2024, there was no evidence that Resident 80 received any professional dental services in the 11 months since the last standard survey. Employee 8, the director of social services, confirmed the absence of evidence for dental services or refusal of such services for Resident 80 in the past year.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that a resident received the pneumococcal immunization as required by their own policies and procedures. The policy, last reviewed in August 2024, mandates that residents be offered the pneumococcal vaccine unless medically contraindicated or previously vaccinated. During the pre-admission process, immunization records are to be obtained and verified, with updates made to the electronic medical record (EMR) for each offer, administration, or refusal of the vaccine. However, for Resident 96, who was admitted to the facility, there was no documentation of previous immunizations, nor was there any record of consent or declination for the pneumococcal vaccine. The clinical record review revealed that the Resident Pneumococcal and Influenza Immunization Consent/Declination form for Resident 96 was incomplete, with no sections marked for consent or declination. Despite a signed form by the resident's responsible party, there was no evidence of the resident's pneumococcal vaccination history or any offers or refusals documented. The facility's Infection Preventionist and Director of Nursing were unable to provide any additional documentation or written consent for the resident's immunization status, indicating a lapse in following the established procedures for immunization tracking and administration.
Failure to Educate and Document COVID-19 Vaccination for a Resident
Penalty
Summary
The facility failed to offer or provide education regarding the benefits, risks, and potential side effects of the COVID-19 vaccine to a resident identified as Resident 96. The policy titled COVID-19 Vaccination Administration, last reviewed in August 2024, mandates that the facility offer and administer COVID-19 vaccinations in accordance with state and federal guidelines. However, upon review of Resident 96's clinical records, there was no evidence of a COVID vaccination, vaccination history, or any documentation of offers, refusals, or contraindications related to the vaccination. During the survey, the Infection Preventionist, identified as Employee 7, was unable to provide any further documentation regarding Resident 96's COVID vaccination status. An interview with the Director of Nursing revealed that the facility was in the process of organizing an upcoming immunization clinic and was making phone calls to determine resident interest in the offered immunizations. Despite this, the facility could not provide any written consent, refusals, or vaccine history for Resident 96, indicating a lapse in following their vaccination policy and documentation requirements.
Facility Fails to Maintain Safe and Clean Laundry Area
Penalty
Summary
The facility failed to maintain a safe and clean environment in the main laundry area, as observed on October 25, 2024. The soiled linen room contained a large laundry bin with an extensive build-up of debris, including paper products, dirt, gloves, and washcloths. An active vent blowing air into the soiled area was covered in dust. A commode without a lid had debris and paper products discarded in it, with pillows and other items placed on top. Cobwebs were observed hanging from the ceiling where it met the wall. In the clean linen area, a ceiling tile was missing next to a fluorescent light fixture, exposing pipes and wires. Water stains were present on three ceiling tiles, with a garbage container and bucket partially filled with water underneath, and blankets on the floor to collect the water. Employee 9, a laundry aide, indicated that the ceiling had been leaking for a month due to showers located above the area. In the area where clothes are washed and dried, an electric heater affixed to the ceiling had a large black/brown stain with white fuzzy areas on the ceiling tile above it. A blood spill compliance center attached to the wall had kits labeled protective packs, all covered in dust. An insect glue trap on the electrical box was also covered in dust. These findings were reviewed with the Nursing Home Administrator, who noted that the facility was attempting to obtain a quote for repairs for the leak, but had not yet acquired it.
Failure to Honor Resident's Advance Directive
Penalty
Summary
The facility failed to honor a resident's right to refuse or discontinue advance directive treatment, specifically regarding artificial nutrition and hydration. Resident 80 had a POLST form signed by a physician indicating a preference for comfort measures only, without hydration or nutrition via a tube. This form lacked the resident or representative's signature but noted verbal consent from the responsible party. Additionally, a living will from 2005 confirmed the resident's wishes against life-sustaining treatment, including tube feeding. Despite these directives, a physician's order from October 2024 instructed staff to provide enteral feeding, contradicting the resident's documented wishes. The discrepancy was identified during a surveyor's review and discussed with the Director of Nursing and the Nursing Home Administrator. Following the surveyor's inquiry, the facility attempted to contact the resident's responsible party to confirm the POLST decisions but was unsuccessful. The facility began the process of obtaining an updated POLST to clarify the resident's wishes regarding artificial nutrition and hydration, but no updated document was provided by the end of the survey. This situation highlights a failure to ensure the resident's treatment preferences were respected and properly documented in accordance with their advance directives.
Failure to Provide Timely Medicare Coverage Notification
Penalty
Summary
The facility failed to provide timely notification to a resident whose payment coverage changed, as required by Medicare regulations. Specifically, the facility did not deliver the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 at least two calendar days before the end of Medicare-covered services for a resident. The clinical record review revealed that the resident's last covered day of Medicare A services was September 20, 2024, but there was no evidence that a written copy of the notice was mailed or provided to the resident's responsible party. Additionally, the section of the form that required a dated signature from the resident or their representative was left blank. Furthermore, the facility did not provide a signed Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) Form CMS-10055, which should have been issued to inform the resident of potential financial liability for non-covered services starting September 21, 2024. The form also lacked a dated signature from the resident or their representative, indicating that the notice was received and understood. During an interview with the Nursing Home Administrator and the Director of Nursing, the facility was unable to provide evidence of signed notices or attempts to obtain the necessary signatures, highlighting a deficiency in the facility's management of resident rights and notification procedures.
Deficiencies in Care Plan Implementation for Residents
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for two residents, leading to deficiencies in maintaining their highest practicable well-being. For Resident 68, the care plan did not address the specific care needs associated with the resident's indwelling foley catheter, despite physician orders indicating the necessity for regular catheter changes, flushing, and output documentation. The resident was observed with the catheter drainage bag improperly placed, and the care plan only noted bladder incontinence related to dementia without specific interventions for catheter care. For Resident 98, there was a discrepancy between the resident's documented advance directive and the care plan. The resident's POLST form and physician orders indicated a DNR status with comfort measures only, but the care plan inaccurately reflected a full code status. This inconsistency was not corrected until questioned by the surveyor, indicating a failure to update the care plan to reflect the resident's current wishes regarding their code status.
Failure to Provide Shaving Assistance to Residents
Penalty
Summary
The facility failed to provide necessary shaving assistance to two residents, both of whom were assessed as needing help with personal hygiene. Resident 85 was observed on two separate occasions with several days of facial hair growth, indicating a lack of shaving support. The resident's clinical records showed that he was dependent on staff for personal hygiene, including shaving, due to his cognitive status, which prevented him from expressing his shaving preferences. The Nursing Home Administrator confirmed these findings, acknowledging the facility's failure to provide the required assistance. Similarly, Resident 65 was observed with several days of facial hair growth, despite being assessed as requiring partial/moderate assistance for personal hygiene. The resident's clinical records indicated that he needed help with shaving, although he could shave himself with an electric razor if it was handed to him. The Nursing Home Administrator confirmed that the nurse aides responsible for his care did not provide the necessary support, resulting in the facility's failure to meet the resident's personal hygiene needs.
Failure to Apply Physician-Ordered Splint
Penalty
Summary
The facility failed to apply a physician-ordered splint for a resident with range of motion concerns. Resident 47, who has intellectual disabilities, cerebral palsy, and impaired mobility, had a physician order dated June 28, 2024, for a left grip splint to be applied in the morning and removed in the evening. The care plan initiated on July 22, 2019, specified that staff should apply the splint during morning care and remove it during evening care due to contractures of the left wrist and fingers. Observations on October 23 and 24, 2024, revealed that the splint was not applied as required, and it was found stored on the bedside furniture in the resident's room. Despite this, the treatment administration record indicated that staff had documented the application of the splint on those dates. An interview with an LPN revealed an assumption that skilled therapy staff were responsible for applying the splint, although the clinical record assigned this task to nursing staff. The issue was discussed with the Nursing Home Administrator and the Director of Nursing.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to properly assess the need for bed rails, evaluate the risk of entrapment, and obtain informed consent before installing bed rails for two residents. For Resident 60, the facility developed a care plan addressing his high risk for falls due to memory impairment and physical decline, but did not include the use of a bed rail. Despite this, a right-sided bed rail was observed in his room, and the facility could not provide evidence of informed consent, a risk assessment, or a physician's order for the bed rail. For Resident 80, a physician's order was present for a right-side bed rail to aid in bed mobility. However, the facility's assessment of potential entrapment zones was incomplete, failing to evaluate zones one, six, and seven, despite the presence of a headboard and footboard. The facility's policies and procedures did not include steps for obtaining informed consent for bed rail use, contributing to the deficiencies identified by the surveyors.
Failure to Implement Person-Centered Care Plans for Dementia
Penalty
Summary
The facility failed to develop and implement individualized person-centered care plans for two residents diagnosed with dementia. Resident 45 was admitted with Alzheimer's dementia and had a significant change Minimum Data Set Assessment indicating a diagnosis of dementia. Despite this assessment, there was no evidence of a person-centered care plan addressing the resident's dementia and cognitive loss. Similarly, Resident 65 was admitted with dementia with behavioral disturbance, and the facility's assessment confirmed the diagnosis. However, the care plan review showed no indication of a developed and implemented person-centered care plan for dementia and cognitive loss. These findings were confirmed by the Nursing Home Administrator and Director of Nursing, who acknowledged the lack of documentation for individualized care plans for both residents.
Failure to Respond to Pharmacist's Recommendation
Penalty
Summary
The facility failed to ensure an appropriate response to a consultant pharmacist's recommendation regarding a potentially unnecessary medication for one resident. A clinical record review revealed that a consultant pharmacist had recommended on December 4, 2023, that the facility evaluate the discontinuation of a PRN Atarax prescription for Resident 65 due to nonuse. Although the resident's physician agreed with the recommendation, the facility did not act on it until December 6, 2024, after being questioned by a surveyor. The resident had an active order for Atarax 25 mg, to be taken every eight hours as needed for itching, since January 30, 2023. An interview with the Director of Nursing confirmed that the facility did not respond appropriately to the pharmacist's recommendation, as the medication was only discontinued following the surveyor's inquiry. This oversight was a violation of the facility's obligation to respond to pharmacy recommendations in a timely manner, as outlined in the relevant state codes.
Failure to Prevent Accident Leads to Resident Harm
Penalty
Summary
The facility failed to provide necessary services to prevent accidents, resulting in actual harm to a resident who sustained multiple fractures. The incident occurred when a nurse aide, who was working independently, attempted to turn the resident during care. The resident, who required maximum assistance from two people and a bed rail for bed mobility, rolled off the bed and fell to the floor. The resident was diagnosed with a scalp hematoma, right hip fracture, multiple left-sided rib fractures, and a left scapular fracture following the fall. The nurse aide involved in the incident was an agency staff member who had not been adequately oriented to the facility's procedures for determining resident care needs. The aide was not informed of the resident's requirement for two-person assistance, as the facility's orientation packet lacked information on accessing the Point of Care system or the resident Kardex, which details care needs. The aide's lack of knowledge and the facility's failure to provide this critical information contributed to the resident's fall and subsequent injuries. The facility's management acknowledged that the orientation packet was incomplete and that the nurse aide had not received proper education or competency training to identify resident care needs. Despite the incident, another agency staff member was observed working without completing an orientation packet or demonstrating competency in accessing resident care information, indicating ongoing deficiencies in the facility's orientation and training processes.
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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